Welcome and Instructions

Welcome and Instructions For audio, join by telephone at 877-594-8353, participant code 56350822# Your line is OPEN. Please do not use the hold feature on your phone but do mute your line by dialing *6. If you are having technical difficulties, email mmoch@kyha.com You may ask questions through the chat box or anytime through the call today 1

Kentucky Hospital Improvement Innovation Network Data Webinar

Agenda 1. HIIN Core and Additional Topics 2. Baseline Data 3. Monitoring Data 4. NHSN 5. Upcoming Data Webinars 3

HIIN Core and Additional Topics 1. Adverse Drug Events (ADE) 2. Catheter Associated Urinary Tract Infection (CAUTI) 3. Central Line Associated Blood Stream Infection (CLABSI) 4. Clostridium difficile (c-diff) 5. Falls 6. Pressure Ulcer (HAPU) 7. Readmissions 8. Sepsis 9. Surgical Site Infection (SSI) 10. Venous Thromboembolism (VTE) 11. Ventilator-Associated Events (VAE) Additional Required Topics 1. Methicillin-resistant Staphylococcus aureus (MRSA) 2. Culture of Safety Worker Safety 4

Core Measures By Topic ADE three measures Excessive Anticoagulation Hypoglycemia in Inpatients Receiving Insulin Adverse Drug Events due to Opioids 5

Excessive Anticoagulation due to Warfarin 6

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Hypoglycemia ADE 8

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ADE due to Opioids 10

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www.k-hen.com 12

Emily C Henderson, PharmD, LDE ehenderson@kyha.com 502-426-6220 13

CAUTI and CLABSI CAUTI and CLABSI six measures each as applicable SIR ICU Only and All Tracked Units Rate ICU Only and All Tracked Units Utilization Ratio ICU Only and All Tracked Units 14

CAUTI/CLABSI Applicability SIR ICU Only and All Tracked Units Applicable ONLY to facilities that report to NHSN and confer rights to KHA Quality Group CAUTI Rate/Utilization Ratio Applicable to ALL facilities CLABSI Rate/Utilization Ratio Applicable to all facilities that place and/or manage Central Lines ICU Rate/Utilization Ratio Applicable to facilities that have one or more Intensive Care Units 15

CAUTI/CLABSI Rate All Tracked Units All Tracked Units ICUs (excluding NICUs) + Other Inpatient Unit Numerator Total number of observed healthcare-associated CAUTI or CLABSI among patients in bedded inpatient care locations Denominator Total number of device (indwelling urinary catheter or central line) days for bedded inpatient care locations under surveillance 16

CAUTI/CLABSI Rate ICUs ICUs Only excluding NICUs Numerator Total number of observed healthcare-associated CAUTI or CLABSI among patients in ICU care locations Denominator Total number of device (indwelling urinary catheter or Central Line) days for ICU units under surveillance for the period 17

CAUTI/CLABSI Utilization Ratio - All Tracked Units All Tracked Units ICUs (excluding NICUs) + Other Inpatient Unit Numerator Total number of device (indwelling urinary catheter or central line) days for bedded inpatient care locations under surveillance (equals the Rate denominator) Denominator Total number of patient days for bedded inpatient care locations under surveillance 18

CAUTI/CLABSI Utilization Ratio ICU Units ICUs Only excluding NICUs Numerator Total number of device (indwelling urinary catheter or Central Line) days for ICU units under surveillance for the period (equals the Rate denominator) Denominator Total number of patient days for ICU units under surveillance for the period 19

CAUTI/ CLABSI Data Sources NHSN Lab-Microbiology Direct care givers Electronic Health Records 20

Clostridium difficile Two measures SIR applicable ONLY to facilities reporting to NHSN that have conferred rights Rate applicable to ALL facilities Numerator Total number of observed hospital onset C. difficile lab identified events among all inpatients in the facility, excluding well-baby nurseries and NICUs Denominator Patient days (facility-wide) 21

CDC NHSN Guidelines 22

NHSN Resources CAUTI CDC NHSN CLABSI CDC NHSN C. difficile and MRSA CDC NHSN Surgical Site Infection CDC NHSN Link on page 1 to a spreadsheet that lists ICD 10 codes for each procedure VAE CDC NHSN (VAC and IVAC) 23

Falls With Injury (Minor or Greater) N Q F # 0 2 0 2 Numerator - Total number of patient falls of injury level minor or greater (whether or not assisted by a staff member) by eligible hospital unit during the measurement period Classification None Minor Moderate Major Death Description Patient had no injuries (no signs or symptoms) resulting from the fall Resulted in application of a dressing, ice, cleaning of a wound, limb elevation, topical medication, pain, bruise, or abrasion Resulted in suturing, application of steri-strips/skin glue, splinting or muscle/joint strain Resulted in surgery, casting, traction, required consultation for neurological or internal injury or patients with coagulopathy who receive blood products as a result of the fall Patient died as a result of injuries sustained from the fall (not from the physiologic events causing the fall) 24

Falls with Injury (Minor or Greater) N Q F # 0 2 0 2 Denominator - Patient days in eligible units during the measurement period Included populations Inpatients, short stay patients, observation patients and same day surgery patients who receive care on eligible inpatient units for all or part of a day Adult critical care, step-down, medical, surgical, medicalsurgical combined, critical access and adult rehabilitation inpatient units. Patients of any age on an eligible reporting unit are included in the patient day count Excluded populations Other unit types (e.g. pediatric, psychiatric, obstetrical etc.) 25

Falls With Injury Data Sources Surveillance systems Medical records Billing systems 26

Hospital Acquired Pressure Ulcer/Injury Two Measures Prevalence Stage II and greater Applies to ALL facilities Must be reported monthly Rate Stage III and greater (AHRQ PSI 2) May not apply to Critical Access Hospitals because of length of stay exclusions KHA uses claims based facility data AHRQ specifications to obtain this data 27

HAPU Prevalence N Q F # 0 2 0 1 Numerator Patients that have at least one category/stage II or greater hospital-acquired pressure ulcer on the day of the prevalence measurement episode Denominator All patients surveyed for the measurement period Excluded populations Patients who Refuse to be assessed Are off the unit at the time of the prevalence measurement Are medically unstable at the time of the measurement for whom assessment would be contraindicated at the time of the measures (i.e. unstable blood pressure, uncontrolled pain, or fracture waiting repair) Are actively dying and pressure ulcer prevention is no longer a treatment goal 28

HAPU Prevalence Data Sources Ideal (Best) physical point prevalence surveillance Acceptable** Incident reporting Medical records Hospital discharge or administrative data **Denominator hospital admissions or discharges for the review period 29

Readmissions Hospital Wide/All Payor Hospital-wide 30-day all cause readmissions Numerator Unplanned inpatient admissions returning as an acute care inpatient to the same facility within 30 days of date of discharge of the index admission NOTE: you count the number of patients who are readmitted within 30 days not the number of readmissions 30

Readmissions Hospital Wide/All Payor Denominator Inpatient discharges Included populations patients equal to or greater than 18 years old Excluded populations Patient discharge status codes or primary admitting diagnosis as follows: Expired (UB04 Code: 20) Transferred to another acute care facility (UB04 Codes: 02, 05, 43, 66) Transferred to a rehab facility (UB04 Code: 62) Patients discharged AMA (UB04 Code: 07) Patients with medical treatment of cancer Patients for primary psychiatric disease 31 Rehabilitation care; fitting of prosthesis and adjustment devices

Readmissions Hospital Wide/Medicare Measure is a subset of the All Payor measure Specifications are the same except it applies only to Medicare patients Collect your data for All Payors first, then filter on only Medicare patients 32

Sepsis Three Measures 1. Postoperative Sepsis (AHRQ PSI-13) Not applicable to facilities that do not perform inpatient surgery KHA uses claims based facility data AHRQ specifications to obtain this data Post operative sepsis cases (secondary diagnosis) per 1,000 elective surgical discharges for patients 18 years and older 33

Sepsis 2. Hospital-Onset Sepsis Mortality Rate KHA uses claims based facility data Numerator Number of in-hospital deaths due to severe sepsis and septic shock (Diagnosis codes defined in AHRQ PSI-13) Denominator Number of patients with hospitalonset severe sepsis/septic shock. Hospital onset is an infection that is not present on admission Rate/1,000 discharges 34

Sepsis 3. Overall Sepsis Mortality Rate KHA uses claims based facility data Numerator Number of in-hospital deaths due to severe sepsis and septic shock (Diagnosis codes defined in AHRQ PSI-13) Denominator Number of patients with severe sepsis/septic shock Rate/1,000 discharges 35

Surgical Site Infection Surgical Site infection SIR and Rate Four Inpatient Procedures (if performed at your facility) Colon surgery Abdominal Hysterectomy Total Hip Replacement (voluntary NHSN reporting) Total Knee Replacement (voluntary NHSN reporting) SIR Applicable if reporting to NHSN and conferred rights 36

SSI Data Sources Surveillance period is 30 days post procedure Lab Emergency Department encounters Surgeons office NHSN 37

Venous ThromboEmbolism Post-Operative pulmonary embolism (PE) or Deep Vein Thrombosis (DVT) rate AHRQ PSI-12 Specific to surgical discharges Not applicable for facilities that do not do inpatient surgery KHA uses claims based facility data AHRQ specifications to obtain this data 38

Ventilator Associated Events (VAE) Applicable to facilities that manage care for mechanically ventilated inpatients meeting ALL of the following criteria 1. Provide care to at least one patient per month that is 2. In an inpatient unit and is 3. Patient is mechanically ventilated for at least 2 or more consecutive days (48 hours) Not required NHSN reportable Must indicate to KHA how facility will report NHSN vs. KQC 39

VAE VAC Ventilator Associated Condition (VAC) Numerator - Number of events that meet the criteria of VAC; including those that meet the criteria for infection-related ventilator-associated complication (IVAC) and possible/probable ventilator-associated pneumonia (VAP) Denominator number of ventilator days 40

VAE IVAC Infection-Related Ventilator-Associated Complication (IVAC) Numerator - Number of events that meet the criteria of infection-related ventilator-associated condition (IVAC); including those that meet the criteria for Possible/Probable VAP Denominator number of ventilator days 41

VAE Sources Direct care givers nurses, respiratory therapists NHSN 42

Data Sources Core Topic Site NHSN AHRQ ADE CAUTI CLABSI C. diff Falls Pressure Ulcer (Prevalence) (Rate) Readmissions Sepsis SSI * VTE VAE * 43

Data Sources Additional Topics Site NHSN AHRQ MRSA Culture of Safety Worker Safety* *Worker Safety measures are already collected on the OSHA Log 44

MRSA Hospital onset MRSA bacteremia events Numerator MRSA bacteremia events Denominator Patient days 45

Culture of Safety - Worker Safety Harm events related to patient handling Numerator Number of worker harm events related to patient handling for the time period Denominator Number of full-time equivalents (FTEs) for the time period Harm events related to workplace violence Numerator Number of worker harm events related to workplace violence for the time period Denominator Number of full-time equivalents (FTEs) for the time period 46

Worker Safety Data Sources Numerators obtain from the OSHA 300 log Recordable injuries include Death Loss of consciousness Days away from work Restricted work activity or job transfer or Medical treatment beyond first aid Denominator obtain from Human Resources 47

OSHA 300 Log 48

Baseline Periods Preferred Baseline Periods Calendar year 2014 except: SIRs Calendar year 2015 to be collected after the NHSN rebaseline is completed in Dec 2016 CAUTI & CLABSI Calendar year 2015 Alternate Baseline Periods Oldest 12, 9, 6, or 3 month consecutive period prior to Oct 2016 49

Baseline Periods 50

Data Submission MONTHLY Beginning Oct 2016 Site collected data will be entered into the KQC system by the hospital Site collected measures specific to your hospital will show up on your KQC data entry page 51

KY Quality Counts Data Collection System https://khaqualitydata.org 52

KY Quality Counts Data Collection System 53

NHSN Website Updated January 2017 Changes in reporting go into effect with the entry of January 2017 data NHSN Annual Training March 20 24, 2017 In-Person (limited attendees) Live Webinar K-HIIN NHSN Training Session April 2017 Webinar New to NHSN to address HIIN specific data entry issues/questions Questions regarding NHSN Deb Campbell, RN-BC, MSN, CPHQ Infection Prevention Improvement Advisor 502-992-4383 dcampbell@kyha.com 54

Upcoming Data Webinars: NHSN Training Session April 2017 Improvement Calculator Harm Across the Board Reports May 2017 Data Webinar June 2017 55

Questions 56