Benefits of Reporting in NHSN April 24, 2018
HealthInsight Team Donna Thorson Project Manager Nevada Leah Brandis Project Manager Oregon Shannon Cupka Project Manager New Mexico Shylettera Davis Project Manager Utah 2
HealthInsight Supports Lynn Kemper Assistant Director Long Term Care Eric Sather Multi-State Analyst Lisa Barton Project Coordinator 3
Objectives Participants will be able to Describe the benefits of reporting into NHSN Generate and interpret an NHSN report Discuss related regulations that impact nursing home operations 4
HealthInsight Overview of the CDI Cohort To determine if CDI is a problem in Nursing Homes Establish a state and national baseline Identify opportunities for preventing CDI 5
Benefits of Reporting into NHSN NHSN provides nursing homes a customized system for tracking infections in a streamlined and systematic way. Provides national rates for facilities to use as a baseline for assessing their own rates and prevention efforts. In addition, your facility can chose to share data with other partner facilities, corporate staff, or other entities (i.e., public health agencies) 6
Benefits of Reporting into NHSN (cont.) Can also report other data into NHSN (i.e., UTI, hand hygiene, PPE exposure and monitoring). You and your facility will already be prepared if this process becomes mandatory in your state. (NHSN reporting for CDI and UTI are already required in Nevada.) 7
Reports Available in NHSN Line Listing All CDI LabID Events Resident ID Current admission date Event date Specimen organism type Specimen source Location (within building) Transfer from Transfer from within last 4 weeks Line Listing for All Summary Data Number of resident days Number of catheter days Number of resident admissions 8
Additional Reports Rate Tables for CDI LabID Event Data Total CDI Rate CDI Treatment Prevalence on Admission Total CDI Percent that is Community-Onset (CO) Total CDI Percent that is LTCF-Onset (LO) and CDI LO Percent that is Acute Care Transfer (ACT LO) Total CDI Percent that is Recurrent LTCF-Onset (LO) CDI Rate LTCF-Onset (LO) Incident Rate Line Listing LTCF Adherence to Seven Core Elements of Nursing Home Antibiotic Stewardship Program Line Listing Antibiogram 9
Generating Reports in NHSN Before using the analysis function, make sure to clear alerts (incomplete/missing events, incomplete/missing summary items) Remember to generate a new data set to ensure all data is included Unresolved alerts will prevent data from showing up in Rate reports even if new data sets are generated 10
Tracking Tool National Nursing Home Quality Improvement Campaign 11
Data Entry 12
Process Tracking 13
State-Specific Data (NHSN CDI Cohort) State Baseline (Mar 2017-Dec 2017) Quarter 1 2018 Nevada 2.34 1.08 New Mexico 0.94 0.51 Oregon 1.50 1.66 Utah 0.59 0.29 14
Revised Data Reports 15
Connection to Regulations November 28, 2017 Regulation (SOM Appendix PP, 11-22-17) 483.80(a)(2) (i) A system of surveillance: routine, ongoing, and systematic collection, analysis, interpretation, and dissemination of surveillance data to identify infections. The facility s surveillance system must include a data collection tool and the use of nationally-recognized surveillance criteria such as but not limited to CDC s National Healthcare Safety Network (NHSN) Long Term Care Criteria to define infections or updated McGeer criteria. 483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. NHSN LTCF HAI Module Utilization of nationally-recognized surveillance criteria in NHSN Inputting data into NHSN as a data collection tool Running NHSN reports for analysis and interpretation Tracking CDI is a component of a good antibiotic stewardship program 16
Connection to Regulations November 28, 2019 Regulation (SOM Appendix PP, 11-22-17) 483.80(b) Infection preventionist 483.80(b)(4) Have completed specialized training in infection prevention and control. NHSN LTCF HAI Module NHSN facility administrator and NHSN user could be the infection preventionist Training to use NHSN for data collection, analysis and interpretation of infection data is a component of infection prevention and control training 17
Upcoming Infection Prevention Webinars Preventing the Spread of CDI Tuesday, June 26, 2018 11:30 a.m. PT / 12:30 p.m. MT What to Do if There Is a CDI Outbreak Tuesday, July 17, 2018 11:30 a.m. PT / 12:30 p.m. MT Be sure to invite any of your staff who would benefit from this information. 18
Action Items Go to NHSN to pull reports and review rates for trends What is it that is affecting your rates Present this information at your next QAPI meeting 19
Visit Us Online! HealthInsight s nursing home web pages provide many resources specific to nursing home staff. CDI / NHSN Material: https://healthinsight.org/nursing-home-resources#nationalhealthcare-safety-network-training Infection prevention and antibiotic stewardship: https://healthinsight.org/nursing-home-resources#infectioncontrol-and-antibiotic-stewardship Resident Safety Collaborative main page: http://healthinsight.org/nh-collaborative The Nursing Home Resource Library and Collaborative materials are linked in the right sidebar please explore! 20
Resources and References AHRQ Nursing Home Antimicrobial Stewardship Guide (Includes toolkits) https://www.ahrq.gov/nhguide/index.html NHSN training for nursing homes https://www.cdc.gov/nhsn/training/ltc/index.html The recording and handouts from today s webinar will be saved https://healthinsight.org/nursing-home-resources#nationalhealthcare-safety-network-training 21
Questions? 22
We want your feedback! Please complete the evaluation in the Chat Link 23
Contact information Donna Thorson, MS, CPHQ Project Manager DThorson@healthinsight.org 702-933-7327 Leah Brandis, RDN, CSG Project Manager LBrandis@healthinsight.org 503-382-3909 Shannon Cupka, EdM Project Manager SCupka@healthinsight.org Lisa Barton Multi-state Project Coordinator LBarton@healthinsight.org 503-382-3912 Shylettera Davis, BSN, RN Project Manager SDavis@healthinsight.org Lynn Kemper Assistant Director, Long-Term Care LKemper@healthinsight.org 503-382-3949 healthinsight.org/nh-collaborative 24
Thank you for your time and commitment! This material was prepared by HealthInsight, the Medicare Quality Innovation Network-Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-C2-18-36 4/24/18 25