ESRD Network 5: Prevention Process Measure Training Christi Lines, MPH

ESRD Network 5: Prevention Process Measure Training Christi Lines, MPH January 26, 2016

Outline Overview of NHSN surveillance Brief review of Dialysis Event surveillance The value of auditing prevention process measures CDC Infection Prevention Tools Prevention Process Measures data entry how to

NHSN Dialysis Component Dialysis Component Four surveillance modules within the Dialysis Component Dialysis Event Prevention Process Measures Central Line Insertion Practices Patient Influenza Vaccination Participation in the Dialysis Component requires: 1. Users complete training for each module in use 2. Completion of the annual Outpatient Dialysis Center Practices Survey 3. Monthly Reporting Plans to indicate what surveillance the facility is doing according to NHSN protocol(s) Find reporting resources for each: http://www.cdc.gov/nhsn/dialysis/index.html

Required Reading: Dialysis Event Protocol The Dialysis Event Protocol is a document that provides instructions for reporting in NHSN All users must read the Dialysis Event Protocol to become familiar with instructions, definitions and procedures http://www.cdc.gov/nhsn/pdfs/pscmanual/8pscdialysiseventcurrent.pdf

Dialysis Event Surveillance The reporting protocol is designed to reliably capture data useful for informing quality improvement decisions. All participants are required to follow the protocol so data are uniformly collected and meaningful comparisons can be made. Dialysis Event Surveillance has FOUR requirements: 1. Outpatient Dialysis Center Practices Survey 2. Monthly Reporting Plan 3. Denominators for Dialysis Event Surveillance form 4. Dialysis Event form

Protocol Terminology and Components of a Rate Numerator = number of dialysis events Information from Dialysis Event forms Denominator = count of patients by vascular access type used to estimate number of patient-months considered at risk for dialysis events Info from Denominators for Dialysis Event Surveillance forms Rate = Dialysis Events (numerator) Patient-Months (denominator) x 100 Both numerator and denominator data must be correct to calculate valid rates

Dialysis Event Surveillance Protocol DENOMINATORS FOR DIALYSIS EVENT SURVEILLANCE

Protocol: Report Denominator Data Monthly Each month, report the number of hemodialysis outpatients by vascular access type who received hemodialysis at the center during the first two working days of the month. Report all hemodialysis outpatients, including transient patients. Exclude non-hemodialysis patients and exclude inpatients. Count each patient only once by vascular access type; if the patient has multiple vascular accesses, report only the vascular access with the highest risk of infection. This may not be the vascular access currently in use for dialysis. Higher Risk Nontunneled Central Line Tunneled Central Line Other Access Device AV Graft AV Fistula Lower Risk

Working Days The first two working days of the month are the days that provide the opportunity to capture all regularly scheduled hemodialysis shifts and patients. Count each patient only once! Example: A facility dialyzes patients 6 days a week, Monday - Saturday. If the 1 st day of the month falls on a Sunday, then Monday and Tuesday are the 1 st two working days of the month. Sun Mon Tue Wed Thu Fri Sat 1 Closed 2 3 4 5 6 7 Working Day 1 Working Day 2

Protocol: Report Denominator Data Monthly Each month, report the number of hemodialysis outpatients by vascular access type who received hemodialysis at the center during the first two working days of the month. Report all hemodialysis outpatients, including transient patients. Exclude non-hemodialysis patients and exclude inpatients. Count each patient only once by vascular access type; if the patient has multiple vascular accesses, report only the vascular access with the highest risk of infection. This may not be the vascular access currently in use for dialysis. Higher Risk Nontunneled Central Line Tunneled Central Line Other Access Device AV Graft AV Fistula Lower Risk

Refer to Protocol for Vascular Access Definitions Nontunneled central line: a central venous catheter that travels directly from the skin entry site to a vein and terminates close to the heart or one of the great vessels, typically intended for short term use. Tunneled central line: a central venous catheter that travels a distance under the skin from the point of insertion before entering a vein, and terminates at or close to the heart or one of the great vessels E.g., Hickman or Broviac catheters* Graft: a surgically created connection between an artery and a vein using implanted material (typically synthetic tubing) to provide a permanent vascular access for hemodialysis. Fistula: a surgically created direct connection between an artery and a vein to provide vascular access for hemodialysis. Other vascular access device: includes catheter-graft hybrid access devices (e.g., HeRO vascular access device*), ports, and any other vascular access devices that do not meet the above definitions. *Use of trade names and commercial sources is for identification only and does not imply endorsement.

Refer to Protocol for Vascular Access Definitions Nontunneled central line: a central venous catheter that travels directly from the skin entry site to a vein and terminates close to the heart or one of the great vessels, typically intended for short term use. When determining the patient s highest infection risk access for the denominator Tunneled central line: a central venous catheter that travels a distance under the skin from the point of insertion before entering a vein, and terminates at or close to the heart or one of the great vessels E.g., Hickman or Broviac catheters* Graft: a surgically created connection between an artery and a vein using implanted material (typically synthetic tubing) to provide a permanent vascular access Consider for hemodialysis. all of the patient s vascular accesses: even accesses that are not Fistula: a surgically created direct connection between an artery and a vein to provide used vascular for access dialysis, for hemodialysis. and accesses that are abandoned/non-functional. Other access device: includes catheter-graft hybrid access devices (e.g., HeRO vascular access device*), ports, and any other vascular access devices that do not meet the above definitions. *Use of trade names and commercial sources is for identification only and does not imply endorsement.

Dialysis Event Surveillance Protocol NUMERATORS: DIALYSIS EVENTS & REPORT NO EVENTS

Protocol: Report Numerator (Event) Data Throughout the month, monitor all outpatients who undergo hemodialysis at your facility for dialysis events. Even if they were not counted on that month s denominator form. Monitor transient patients and report dialysis events that occur at your facility. Report a dialysis event for any of the following: IV antimicrobial start Positive blood culture Pus, redness or increased swelling at the vascular access site On the event form under Risk Factors, report all of the patient s vascular accesses, regardless of whether they are in use for hemodialysis, abandoned/non-functional.

Protocol: Report Numerator Data Dialysis Event Types IV antimicrobial start: Report all starts of intravenous antibiotics or antifungals administered in an outpatient setting. A start is defined as a single outpatient dose or first outpatient dose of a course. Report regardless of the reason for administration or duration of treatment. Positive blood culture: Report all positive blood cultures from specimens collected as an outpatient or collected on the day of or the day following hospital admission. Report regardless of whether the infection is thought to be related to hemodialysis or whether or not a true infection is suspected. Pus, redness, or increased swelling at the VA site: Report each new outpatient episode where the patient has pus, >expected redness, and/or >expected swelling at any vascular access site. Report regardless of whether the patient receives treatment for infection. Always report pus. Report redness or swelling if greater than expected and suspicious for infection.

IV Antimicrobial Start Continuations Report all occurrences where IV antibiotics or antifungals are administered in an outpatient setting, regardless of the reason and duration of treatment Report outpatient starts that are continuations of inpatient treatment Sun Mon Tue Wed Thu Fri Sat INPATIENT IV Antimicrobial Start Continuing Inpatient Dose Continuing Inpatient Dose DISCHARGED Continuing Inpatient Dose OUTPATIENT IV Antimicrobial Start Although IV antimicrobial treatment was started in the hospital, report the OUTPATIENT IV antimicrobial start that is a continuation of the inpatient treatment

Protocol: Report Numerator Data Dialysis Event Types IV antimicrobial start: Report all starts of intravenous antibiotics or antifungals administered in an outpatient setting. A start is defined as a single outpatient dose or first outpatient dose of a course. Report regardless of the reason for administration or duration of treatment. Positive blood culture: Report all positive blood cultures from specimens collected as an outpatient or collected on the day of or the day following hospital admission. Report regardless of whether the infection is thought to be related to hemodialysis or whether or not a true infection is suspected. Pus, redness, or increased swelling at the VA site: Report each new outpatient episode where the patient has pus, >expected redness, and/or >expected swelling at any vascular access site. Report regardless of whether the patient receives treatment for infection. Always report pus. Report redness or swelling if greater than expected and suspicious for infection.

Reportable Positive Blood Cultures Report all positive blood cultures (PBC) Collected as an outpatient Collected within 1 calendar day after a hospital admission Sun Mon Tue Wed Thu Fri Sat OUTPATIENT Day of admission 1 calendar day after admission 1 2 3 4 5 6 7 8 9 DISCHARGED 10 11 12 13 OUTPATIENT REPORT PBC if specimen was collected during this time Do NOT report PBC if specimen was collected during this time 2 calendar days after admission

Protocol: Report Numerator Data Dialysis Event Types IV antimicrobial start: Report all starts of intravenous antibiotics or antifungals administered in an outpatient setting. A start is defined as a single outpatient dose or first outpatient dose of a course. Report regardless of the reason for administration or duration of treatment. Positive blood culture: Report all positive blood cultures from specimens collected as an outpatient or collected on the day of or the day following hospital admission. Report regardless of whether the infection is thought to be related to hemodialysis or whether or not a true infection is suspected. Pus, redness, or increased swelling at the VA site: Report each new outpatient episode where the patient has pus, >expected redness, and/or >expected swelling at any vascular access site. Report regardless of whether the patient receives treatment for infection. Always report pus. Report redness or swelling if greater than expected and suspicious for infection.

Dialysis Event 21 Day Rule An event reporting rule which reduces reporting of events likely related to the same patient problem. E.g., multiple positive blood cultures may result from a single infection The rule is that for each patient, 21 or more days must exist between two dialysis events of the same type for the second occurrence to be reported as a separate (new) dialysis event. If fewer than 21 days have passed since the last reported event of the same type, the subsequent event of the same type is NOT considered a new dialysis event and it is not reported. The 21 day rule applies across calendar months. Refer to each event definition in the protocol for instructions on applying the 21 day rule for each specific dialysis event type.

Applying the 21 Day Rule to Each Event Type Event Type IV Antimicrobial Start Positive Blood Culture Pus, Redness, or Swelling at VA Site Count 21 Days From the end of one IV antimicrobial course to the beginning of the next IV antimicrobial start (even if antimicrobials differ) Has it been 21 or more days since this patient received IV antimicrobial treatment? From the last reported PBC (specimen collection date) to the next PBC (even if microorganisms differ) Has it been 21 or more days since the specimen collection date of the last reported PBC? From first reported onset to next onset Has it been 21 or more days since this patient s last reported onset of PRS? If yes, report a new Dialysis Event. If no, do not report a new Dialysis Event.

PREVENTION PROCESS MEASURES

The Value of Auditing CDC Recommended Infection Prevention Practices Increased adherence to CDC recommended practices can prevent infections: Outpatient hemodialysis facilities that implemented the package of CDC recommended practices saw a 32% reduction in BSIs and a 54% reduction in access-related BSIs. 1 Auditing adherence to recommended practices: Promotes and reinforces recommended practices among staff. Ensures complete and correct implementation. 1. Am J Kidney Dis. August 2013, 62(2): 322 330

CDC Infection Prevention Audit Tools Facilities begin by learning recommended practices: CDC Recommended Interventions to Prevent Bloodstream Infections in Dialysis Settings: http://www.cdc.gov/dialysis/prevention-tools/core-interventions.html CDC recommended checklists: http://www.cdc.gov/dialysis/prevention-tools/index.html Simple reference tools useful for training staff. Then use the audit tools as part of a planned series of observations within their hemodialysis facility. Learn CDC Recommended Practices Implement CDC Recommended Practices Audit CDC Recommended Practices Provide Feedback on Adherence

Tips for Facilities to Successfully Implement New Practices Facilities should review current practices to identify discrepancies between current practices and CDC recommended practices. Facilities should develop an implementation strategy, they may consider: Input from patient care staff Training needs How to inform patients of changes Whether necessary supplies (e.g., chlorhexidine) are available Learn CDC Recommended Practices Implement CDC Recommended Practices Audit CDC Recommended Practices Provide Feedback on Adherence

Available CDC Dialysis Infection Prevention Audit Tools: http://www.cdc.gov/dialysis/prevention-tools/index.html Hand Hygiene HD Catheter Connection/ Disconnection AV Fistula/ Graft Cannulation/ Decannulation Although the audit tool includes both cannulation and decannulation, only cannulation is included in the QIA Learn CDC Recommended Practices Implement CDC Recommended Practices Audit CDC Recommended Practices Provide Feedback on Adherence

Data Collection All audits observer(s) should try to ensure that observations are as representative as possible of normal practice at the facility: Observe different staff members on different days and shifts. Consider observing during particularly busy times (e.g., shift change), when staff may be less attentive to proper practices.

How to Use the Audit Tool: Opportunities Each audit includes multiple observations. An observation is an opportunity to perform hand hygiene (when warranted) If an opportunity is observed and hand hygiene is performed, the observation is marked a success: The first two observations were successful because hand hygiene was warranted and was performed. The third observation was not successful because the warranted opportunity for hand hygiene was missed.

Tallying Opportunity Audit Results Number of Successful Opportunities: Sum of observed instances during which staff hand hygiene was warranted and was successfully performed. Total Number Opportunities: Total number of observed instances during which staff hand hygiene was warranted. 1 2 3 4 5

Audit Results Reported to NHSN Number of Successful Opportunities: Sum of observed instances during which staff hand hygiene was warranted and was successfully performed. These are the numbers reported to NHSN Total Number Opportunities: Total number of observed instances during which staff hand hygiene was warranted. 1 2 3 4 5

How to Use the Audit Tools: Procedures Each audit includes multiple observations. An observation is the review of a procedure to indicate which steps were performed correctly or incorrectly. If each step of a procedure is observed and correctly performed, the observation is marked a success: 1. 2. The first observation (catheter connection) was not successful because hub antiseptic was not allowed to dry. The second observation (catheter disconnection) was successful because all steps were observed and completed.

Tallying Procedure Audit Results Once all observations have been completed, add the successful observations and note the total number of observations performed: 1 2 3 4 5 6 7

Audit Results Reported to NHSN Once all observations have been completed, add the successful observations and note the total number of observations performed: 1 2 3 4 5 6 7 These are the numbers reported to NHSN

NHSN PREVENTION PROCESS MEASURES (PPM) MODULE INFORMATION FOR FACILITIES

Prevention Process Measures (PPM) Module How facilities add PPM to Monthly Reporting Plans How facilities report PPM data to NHSN How to interpret NHSN missing/incomplete data alerts How facilities Confer Rights to share data with Groups Differences for QIA vs. non-qia facilities Analysis: available reports and percent adherence

Facilities Report Audit Results to NHSN Audit results can be reported to NHSN either inplan or off-plan. In-plan refers to the selections made on the NHSN Monthly Reporting Plan: By making a selection on the Monthly Reporting Plan, facilities agree to follow the NHSN Protocol for monitoring and reporting of that prevention process measure. NHSN Dialysis Prevention Process Measures Protocol In-plan reporting requires a minimum number of observations for each audit each month and will generate alerts to remind facility users to report additional data In-plan reporting is suggested for QIA facilities.

Monthly Reporting Plan: Prevention Process Measures Facilities indicate which audits will be performed during the month by checking the corresponding box(es): By checking the box, the facility agrees to follow the NHSN protocol for monitoring and reporting of that prevention process measure. There are a minimum number of observations for in-plan reporting, specified below each checkbox. Tip Copy from the Previous Month to make the same selections as before.

How Facilities Report Audit Results to NHSN From the navigation bar, select Summary Data, then Add. Select Prevention Process Measures from the menu. Click the Continue button.

Numerators and Denominators Facilities report the sum of successful observations and the total number of observations that month on the Prevention Process Measures form in NHSN Numerators Denominators

Example of Reporting Audit Results to NHSN 5 7

Combine Multiple Audits of the Same Type, from the Same Month Successful Obs. = 5 + 2 + 5 = 12 Total Obs. = 7 + 4 + 6 = 17 12 17

NHSN Action Items and Alerts If facilities make a Prevention Process Measure (PPM) selection on the Monthly Reporting Plan, but do not: Report data for it, NHSN will show a Missing Summary Data alert Report the minimum number of total observations required by the Protocol, NHSN will show an Incomplete Summary Data alert

Prevention Process Measure Alerts Missing Summary Data alerts can be removed by: Reporting the additional data required by the Protocol Un-checking the surveillance option from that Monthly Reporting Plan (i.e., making the data off-plan )

Prevention Process Measure Alerts Incomplete summary data alerts can be removed by: Reporting the additional data required by the Protocol Un-checking the surveillance option from that Monthly Reporting Plan (i.e., making the data off-plan ) Selecting Dismiss Alert after the month has ended Alerts for 02/2015

Prevention Process Measure Alerts Incomplete summary data alerts can be removed by: Reporting the additional data required by the Protocol Un-checking the surveillance option from If that too Monthly few Reporting Plan (i.e., making the data off-plan ) observations were Selecting Dismiss Alert after the month collected has ended and the month has passed, incomplete alerts can be dismissed. Alerts for 02/2015

PPM Reports Line Listings that calculate percent adherence by month: Hand Hygiene Percent Adherence HD Catheter Connection/Disconnection Percent Adherence AV Fistula/Graft Cannulation/Decannulation Percent Adherence HD Catheter Exit Site Care Percent Adherence Dialysis Station Routine Disinfection Percent Adherence Injection Safety Percent Adherence All Prevention Process Measures

Interpreting NHSN PPM Reports Percent adherence is calculated by dividing the number of successful observations by the total number of observations and multiplying by 100. Percent Adherence = Number of Successful Observations Total Number of Observations x 100 Example NHSN Report for HD Catheter Connection/Disconnection Facility Org ID Summary Year/ Month HD Catheter Connection/ Disconnection # of Successful Observations HD Catheter Connection/ Disconnection Total # of Observations HD Catheter Connection/ Disconnection Percent Adherence 12345 2015M01 6 10 60.0 12345 2015M02 7 10 70.0 12345 2015M03 8 10 80.0

Online Reporting Resources Resources for PPM reporting are being updated E.g., Protocol, training, etc. http://www.cdc.gov/nhsn/dialysis/prevention-process-measures.html

Thank you! Questions? NHSN Helpdesk: nhsn@cdc.gov Specify dialysis in the subject line. For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.cdc.gov