HAI, NHSN and VBP: What’s New and What You Need To Know

Christine Martini-Bailey RN, BSN, CSSGB

Director, Quality Improvement and Patient Safety

Health Services Advisory Group (HSAG)

April 27, 2017

Objectives

• Review the 2017 updates to National Healthcare Safety Network (NHSN) Patient Safety Component for Healthcare Associated Infections (HAI)

• Understand the changes in NHSN due to the re-baselining

• Identify the impact of NHSN re-baselining on the Centers for Medicare & Medicaid Services (CMS) Value-Based Purchasing (VBP)

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2017 NHSN Patient Safety Component Updates

3

Updates to Organisms Lists

Updates and additions to:

• NHSN All Organism list

• NHSN Mucosal Barrier list

• NHSN Common Commensal list

Complete lists available from the Centers for Disease Control and Prevention (CDC):

https://www.cdc.gov/nhsn/acute-care-hospital/clabsi/index.html

(Under Supporting Materials section)

4

Flow Diagram—Event Determination

5 Source: CDC, available at https://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf

Building Blocks of NHSN Patient Component Surveillance Definitions

6 https://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf

*See SSI surveillance protocol ˄See LabID and VAE surveillance protocols N/A = Not applicable

SSI = Surgical Site infection VAE = ventilator-associated pneumonia prevention

Transfer Rule

If the date of the event is the day of transfer/discharge, or the next day, the infection is

attributed to the transferring location.

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Endocarditis (ENDO)

• Extended Infection Window Period (IWP) – 21 days

– 10 days before diagnostic test

– 10 days after the diagnostic test

• Extended Repeat Infection Timeframe (RIT) – Duration of admission

• Extended ENDO Secondary Bloodstream Infection (BSI) Attribution Period to the ENDO IWP and remaining duration of the admission for the organism that is used to meet the ENDO criterion

8

GIT (GI Tract) Criterion 2c Modification

• Patient has at least two of the following signs or symptoms compatible with infection of the organ or tissue involved: fever (>38˚ C), nausea, pain or tenderness, odynophagia or dysphagia

• And at least one of the following: – Organisms identified from blood by a culture or non-culture

based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment. The organism(s) identified in the blood must contain at least one MBI organism: See Appendix A of the BSI protocol.

– AND – Imagining test evidence suggestive of gastrointestinal

infection, which if equivocal is supported by clinical correlation.

9 MBI = mucosal barrier injury

Other Definitional Changes for 2017

ORAL—Added back to criterion 3a, “from mucosal scrapings or exudate”

3. Patient has at least one of the following signs or symptoms with no other recognized cause: ulceration, raised white patches on inflamed mucosa, or plaques on oral mucosa

And at least one of the following:

a. Virus identified from mucosal scraping or excaudate by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment.

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Other Definitional Changes for 2017

LUNG, SA, and NEC-provided guidance to allow clinical correlation to be used in cases where imaging tests are equivocal for infection.

• (LUNG 3) Patient has imaging test evidence of abscess or infection (excludes imaging test evidence of pneumonia) which if equivocal is supported by clinical correlation (i.e., physician documentation of antimicrobial treatment for lung infection).

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SA = Spinal abscess without meningitis NEC = Necrotizing enterocolitis

Pathogen Assignment

• Additional eligible pathogens identified within a RIT are added to the event.

• Pathogen exclusions for specific infection definitions (ex. UTI, PNEU) also apply to secondary BSI pathogen assignment.

– Excluded pathogens must be attributed to another primary site-specific BSI.

• A BSI pathogen may be reported for more than one infection source.

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UTI = urinary tract infection PNEU = pneumoccal

Central Line-Associated Bloodstream Infection (CLABSI) Changes

MBI Exclusion

• All facility types

• Exclude MBI-laboratory confirmed bloodstream infections (LCBIs)

Resources:

• MBI-LCBIs Guide: http://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/mbianalysis.pdf

• Summary Data Line List: http://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/summarylinelist.pdf

13 Source: CDC, available at https://www.cdc.gov/nhsn/pdfs/rebaseline/2015-rebaseline-sir-changes-applicable-to-cms-qrp.pdf

Surgical Site Infection (SSI) Changes

SSI Exclusions • Acute care hospitals • American Society of Anesthesiologists

(ASA) missing • BMI: If BMI>60 or BMI<12 • Gender is missing or gender is “O” • Medical affiliation is missing/incomplete (annual survey)

• Bed number missing (annual survey)

• Present at time of surgery (PATOS) • Age > 109 years • Procedure duration outliers • Closure technique missing

14

BMI = body mass index Source: CDC, available at https://www.cdc.gov/nhsn/pdfs/rebaseline/2015-rebaseline-sir-changes-applicable-to-cms-qrp.pdf

SSI Changes (cont.)

Resources

• Exclusion Criteria

http://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/ssi-sir_tips.pdf

• Line List of Procedures http://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/faq-procedure-line-list.pdf

• Analyzing Procedure Closure Technique

http://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/proceduresclosuretechnique.pdf

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Tools Available

• Electronic HAI Present on Admission (POA) Worksheet Generator – Requires user to ensure infection criterion are met and

to enter correct dates

– Generates worksheet with IWP, DOE, RIT, 2nd BSI Attribution Period

– Located under “Supporting Materials”

– Does not store information or send information to NHSN

16 Source: CDC, available at https://www.cdc.gov/nhsn/poa/index.html

American Journal of Infection Control NHSN Case-Study Series

• Additional educational tool

• Quarterly publication

• Addresses common surveillance scenarios

– CLABSI, CAUTI, VAE, SSI, MDRO/CDI

• Test your knowledge

• Quiz and answers via web link

17

CAUTI = catheter-associated urinary tract infections MDRO/CDI = multidrug-resistant organism & Clostridium difficile infection

Complete List Revisions

18 Source: CDC, available at https://www.cdc.gov/nhsn/pdfs/pscmanual/psc-january-2017-revisions.pdf

NHSN Changes and Re-baseline

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NHSN v8.6—Re-baseline Highlights

• Baseline 2 = “New Standard Population” • Significant changes with definitions and decreased incidence

of HAIs • Used calendar year (CY) 2015 in-plan data as baseline • No more “pooled means” • New predictive/risk models

– Multivariable Logistic Regression Models (risk-adjustment)

– Negative Binomial Regression (probability)

– Logistic Regression (predictive)

• Standard Infection Ratios (SIRs) for Critical Access Hospitals (CAHs)

• More SIRs for long-term acute care hospitals (LTACH) and Inpatient Rehabilitation Facilities (IRFs)

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Baseline Progression

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HAI Type

Original National Baseline Data

2015 Re-baseline Acute Care

Hospitals (ACH)

Long-term Acute Care Hospitals

(LTACH)

Inpatient Rehabilitation Facilities (IRF)

CLABSIs 2006–2008 2013 2013 2015

CAUTIs 2009 2013 2013 2015

SSIs 2006–2008 None None 2015 (ACH only)

Hospital-onset C. difficile

2010–2011 None None 2015

Hospital-onset MRSA bacteremia

2010–2011 None None 2015

VAE

New—No Previous National Baseline Data

2015

MBI 2015

Standardized Utilization Ratio (SUR) (all device types)

2015

MRSA = Methicillin-resistant Staphylococcus aureus

Measures By Facility

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HAI ACHs CAHs LTACHs IRFs

CLASBI (non-MBI)

Central Line SUR

MBI

CAUTI

Urinary Catheter SUR

VAE

Ventilator SUR

“All SSI” Models—Adults

“All SSI” Models—Peds

“Complex A/R” Models—Adults

“Complex A/R” Models—Peds

“Complex 30-day” Models—Adults (COLO and HYST)

MRSA Bacteremia LabID

CDI LabID

Separate from ACHs

COLO = Colon HYST = Hysterectomy A/R = Admission/Readmission

SSI SIR Model Review

• All SSI SIR Model – Inpatient only – Superficial, deep and organ/space SSI – Primary incision (superficial and deep) – On admission, readmission and post-discharge

• Complex A/R SSI Model (CDC HAI Progress Report) – Inpatient only – Only deep and organ/space SSI – On admission, readmission to facility

• Complex 30-Day SSI Model (CMS SSI Reporting) – In plan, Inpatient Colo and Hyster – Deep incisional primary and organ/space – Within 30 days of procedure

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Impacting SIRs

• Annual Survey

• CDI Test Type

• Other Potential Risk Factors:

– Facility bed size

– Medical school affiliation

– Status as a cancer hospital

– Intensive care unit (ICU) location

– Pediatric location

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Risk Variables

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Factor CLABSI CLABSI (NICU) CAUTI VAE CDI MRSA

CDC Location

Facility Type

Medical School Affiliation

Inpatient Quarterly CO Prevalence Rate

CDI Test Type

Birthweight

Length of Stay

Reporting from ED/Obs Locations

Facility Bedsize

ICU Beds

Risk Variables (cont.)

26

Factor COLO HYST

Cancer Hospital

Patient Level Factors

Age

ASA Score

BMI

Closure technique

Diabetes

Gender

SIR Reference

27 Source: CDC, available at https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/nhsn-sir-guide.pdf

New Locations Added

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Can now produce SIRs for the below units:

Mandatory CMS Reporting: • All Critical Care • All Medical Wards • All Surgical Wards • All Medical/Surgical Wards

CMS Value Based Purchasing FY 2018: • All Critical Care

IMPORTANT REMINDER!

CMS Value Based Purchasing FY 2019: • All Critical Care • Med, Surg, Med-Surg Wards

Standardized Utilization Ratio

• Summarized risk-adjusted measure

• Focuses on device use

• Uses multivariable logistic regression models

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• Predicted number = 1

• >1 is higher utilization

• <1 is lower utilization

SUR = # observed device days

# predicted device days

Coming Soon

Year # CAUTI # pred SIR P-value 95% CI Cath Days

2015 7 2.523 2.774 0.0193 1.213, 5.488 5,996

Implications To Data

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CAUTI – Example 1

Baseline 1:

New Baseline 2:

Year # CAUTI # pred SIR P-value 95% CI Cath Days

2015 7 10.401 0.673 0.2931 0.294,1.331 5,996

Implications To Data

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CAUTI – Example 2

Baseline 1:

New Baseline 2:

Year # CAUTI # pred SIR P-value 95% CI Cath Days

2015 30 60.650 0.495 <0.0001 0.340, 0.697 16,963

Year # CAUTI # pred SIR P-value 95% CI Cath Days

2015 30 26.772 1.121 0.5218 0.770, 1.580 16,963

Baseline By Year

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Do NOT use after CY 2016

Can use beginning CY* 2015

Only Use Baseline 2 CY 2017

and beyond

*Calendar Year

NHSN Changes and CMS

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Re-baseline SIRs Shared with CMS

Hospital IQR LTCHQR IRFQR

CLABSI CLABSI CAUTI

CAUTI CAUTI

CDI

MRSA

SSI Hyster

SSI Colon

*Please note: this table does not include Healthcare Provider (HCP) Flu, as it is not impacted by the re-baseline.

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The Old and New—What is CMS Seeing?

Baseline 1

Baseline 2

CMS will receive 6 quarters of data under Baseline 2.

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Hospital Compare

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Hospital Compare—Will use NHSN Baseline 2

“…data included in the December 2016 Quality Net Preview Reports will be calculated using the updated 2015 baseline and risk models.”

The Centers for Disease Control

https://www.cdc.gov/nhsn/pdfs/rebaseline/hospital-compare-verification-clabsi.pdf https://www.cdc.gov/nhsn/pdfs/rebaseline/hospital-compare-verification-ssi.pdf

Value-Based Purchasing

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FY 2018 and FY 2019 VBP

Domain I: PSI 90 Composite–15% – PSI 3: Pressure Ulcers

– PSI 6: Iatrogenic Pneumothorax

– PSI 7: CLABSI*

– PSI 8: Post-Op Hip Fx

– PSI 12: VTE/PE

– PSI 13:Post-op Sepsis

– PSI 14: Wound Dehiscence

– PSI 15: Accidental Puncture

Domain II: HAI (NHSN)–85% – CLABSI* – CAUTI – SSI Hysterectomy – SSI Colon – MRSA Bacteremia – CDI

25%

25% 25%

Safety 25%

VBP Program Thresholds: Safety Domain

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Measure VBP FY 2017 (Data CY 2015)

VBP FY 2018 (Data CY 2016)

VBP FY 2019 (Data CY 2017)

CAUTI 0.845 0.906 0.822*

CLABSI 0.457 0.369 0.860*

CDI 0.750 0.805 0.924

MRSA 0.799 0.767 0.854

SSI Hyster 0.698 0.710 0.762

SSI Colon 0.751 0.8244 0.783

PSI 90 0.777936 0.577321 0.774058

NHSN Re-baseline

*Note: FY2019 CAUTI and CLABSI = CC and MS Wards

VBP and NHSN Baselines

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Payment Year NHSN Baseline Used

FY 2018 VBP CY 2016 Data

NHSN Baseline 1

FY 2019 VBP CY 2017 Data

NHSN Baseline 2

1

Reminder: CMS IPPS Reports

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• “Snapshot” of what is being submitted on your behalf to CMS

• Validation of your submission • Only proof your data was entered

prior to the deadline • Means to verify data accuracy • Every submission, every time

CRITICAL

Important Reminders: CMS HAI Data

41

Every Journey Begins With a Good Map!

42

Avoids incorrect reporting to CMS

x http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf

Accurate mapping is critical

How Mapping Can Impact Your SIRs

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Unit Type IN:ACUTE:CC:ONC_M Critical Care Medical Oncology

IN:ACUTE:CC:M Critical Care Medical

Predicted CLABSI 4 1

Observed CLABSI 3 3

SIR 0.75 3.0

CAD* (Threshold: 0.369)

+1.24 +2.6

Correctly Map First: Improve Second!

*Cumulative Attributable Difference (CAD)

Mapping

• Re-evaluate at least annually – Location – Patient mix – Acuity

• Any changes in location – If just move a unit, you can remain. – If patient mix or acuity changes, you must map a new unit.

• Any changes in patient mix – Type of patient – Acuity of patients

• 80/20 rule – At least 80 percent of a particular patient type

• Virtual Units – When you don’t have 80 percent to map to a particular unit type, but enough

patients to skew your predicted number of infections – Example: a medical ward that routinely has a significant number of oncology

patients

44 Source: CDC, available at https://www.cdc.gov/nhsn/pdfs/pscmanual/15locationsdescriptions_current.pdf

NHSN Data Transition

45

Review: Baseline By Year

• Baseline 1 (old): Valid through CY 2016 data

• Baseline 2 (new): Valid beginning CY 2015 data

• CY 2017 and beyond, ONLY use Baseline 2 (new)

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SIR Confusion

47

FY 2018 VBP CY 2016

Baseline 1

? ? ? ?

Trending Data

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• You cannot continue trending from Baseline 1 into Baseline 2.

Incorrect

49

New Baseline Cannot continue trending beyond CY 2016

Correct Option

50

0

0.5

1

1.5

2

2.5

2012 2013 2014 2015 2016 2017 2018

SIR

Calendar Year

Community Memorial Hospital Trended CAUTI SIR

Baseline 1

Baseline 2

NHSN Re-baseline

Another Option

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NOTE: FY2018/CY2016 data will be calculated using Baseline 1. Producing 2016 data using Baseline 2, while valid, may cause some confusion.

Accessing Baseline Set 1 Reports

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“Old” Baseline Reports Baseline Set 1

Data Reporting

Facts: 1. For CY 2016 data, facilities will have more than one

“accurate” SIR. 2. VBP will use Baseline 1 and CY 2016 data. 3. Hospital Compare will use Baseline 2 and CY 2016 data. 4. You can go back to CY 2015 data using Baseline 2 for

trending purposes. 5. Select a baseline for internal reporting and stick to it for

CY 2016 data. 6. Only use Baseline 2 for CY 2017 data and beyond.

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Questions?

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Christine Martini-Bailey, RN, BSN, CSSGB Director, Quality Improvement and Patient Safety

cbailey@hsag.com | 614.307.2936

This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, California, Florida, Ohio, and the U.S. Virgin

Islands, 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. Publication No. QN-11SOW-D.1-04122017-01

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