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Minnesota NHSN User Group
Agenda
Thursday, November 19, 2015
1:00 – 2:00 p.m. CT
Welcome – Stratis Health
Update on MHA user group – MHA
CDC/NHSN updates - MDH
NHSN Graphs & TAP Reports
presentation – Michelle Nordwall
Stratis Health serves Minnesota in the Lake Superior Quality Innovation Network. | 952-854-3306 | www.stratishealth.org
NHSN 10TH YEAR ANNIVERSARY!
NHSN Updates
NHSN User Group November 2015
http://www.cdc.gov/nhsn/pdfs/newsletters/newsletter-sept-2015.pdf
NHSN Reporting Requirements for CMS
Looking Back This Year
o 2nd quarter data (April 1-June 30) for CLABSI, CAUTI, SSI COLO, SSI HYST, MRSA, and C. difficile were due November 15th for Acute Care hospitals that take part in the CMS Hospital IQR Program. Thank you!
Looking Forward to 2016
o There are no additions to the NHSN reporting requirements for Acute Care Hospitals for 2016.
o http://www.cdc.gov/nhsn/PDFs/CMS/CMS-Reporting-Requirements-Deadlines.pdf
o http://www.cdc.gov/nhsn/PDFs/CMS/CMS-Reporting-Requirements.pdf
Patient Safety Component
o Surveillance protocols for the NHSN 2016 Patient Safety Component are targeted for release November 1st, 2015.
o MDRO/CDI Lab ID Event Reporting-Optional fields will become “required”.
Last physical overnight location of patient immediately prior to arrival into facility
Has patient been discharged from another facility in past 4 weeks?
o Transition to ICD-10-PCS and CPT Codes- new supplemental mappings to NHSN in the “Supporting Materials” section of the SSI page. http://www.cdc.gov/nhsn/acute-care-hospital/ssi/index.html
New in NHSN-HAI Present on Admission Worksheet Generator
o Used for BSI, UTI, PNEU, IAB (not SSI, MDRO &CDI LabID Event, or VAE)
o Chapter 2 Identifying Healthcare-associated Infections (HAI) for NHSN Surveillance. It is not a calculator. It does identify:
7-day Infection Window Period Date of Event and POA or HAI determination 14-day Repeat Infection Timeframe (RIT) The Secondary BSI Attribution Period
o You must enter the date of admission and the date of the first diagnostic test
o The Generator will create a printable worksheet with the date of event and determines if the event is POA or HAI.
o Screen shots of the NHSN HAI Worksheet Generator are in the newsletter with instructions
Healthcare
associated
Infection
and POA
Worksheet
Generator
Data Quality
o Date of Admission is the date that the patient is physically admitted to an inpatient location. It is not the date that the admission order is written. Check for accuracy on since it effects the determination if the infection is present on admission.
o New locations for hospital outpatient departments and ASCs will be included in the CDC Location Labels and Location Descriptions” Chapter of the Patient Safety Manual.
o Sampling Denominator Method used for CLABSI and CAUTI. Eligible units include only ICU and ward locations with 75 or more device-days per month for the past 12 months.
New Helpdesk system
o Submit a question to [email protected]
o Email sent to you with a ticket number and the name of the team member
o The new system will:
Triage emails more efficiently
Give NHSN support staff the ability to retrieve emails sent
Provide a greater level of accountability to track emails
HEN 2.0 overview
Enter Date Here
• Fast paced project: Sept. 24, 2015 – Sept. 23, 2016• 17 of 26 base HENs received HEN 2.0 contract
• MHA’s goal 100% of Minnesota hospitals participating
• Overall HEN 2.0 goals remain:• Reduce HACs by 40 percent• Reduce readmissions by 20 percent
• Baseline: 4th Quarter 2010
• HEN 2.0 informational webinar recording: https://web.telspan.com/play/240mnhospitals/2108-10-7-15-mha
General questions: [email protected] support: [email protected]
HEN 2.0 overview Fewer HAIs in hospital programs led
by board certified infection preventionists
MHA will reimburse costs up to $250 to the first 10 who pass the certification
Reimbursement needs to be completed by Sept 2016
Must submit:
• reimbursement form
• copy of certificate of completion
• copy of receipts
Reimbursement form available on MHA website
http://www.mnhospitals.org/patient-safety/current-safety-quality-initiatives/mha-hen-20-mini-grant-proposals
Jill Kieser Andersen, Program Manager, Stratis Health
Lori Skinner, SSI Lead, Minnesota Hospital Association
Lisa Hesse, Infection Prevention Coordinator, Fairview Range
Janet Lilleberg, Senior Epidemiologist, MN Department of Health
Minnesota NHSN User Group
TAPping into NHSN Reports
Michelle Nordwall
MN NHSN User Group
November 19, 2015
13
Objectives
• Have a basic understanding of the Targeted
Assessment for Prevention (TAP) strategy
• Be able to locate and run National health care
Safety Network (NHSN) reports, including TAP
reports
• Understand how to interpret NHSN TAP reports
including a basic understanding of calculating a
Cumulative Attributable Difference (CAD)
14
TAP Strategy
15
TAP Strategy - Basic Understanding
• Method developed by the Centers for Disease
Control and Prevention (CDC) to use data for
action to prevent healthcare-associated
infections (HAIs)
• Targets health care facilities and specific units
within facilities with a disproportionate burden of
HAIs so gaps in infection prevention in the
targeted locations can be addressed
http://www.cdc.gov/hai/prevent/tap.html
16
TAP Strategy - Basic Understanding
• Uses a metric called the CAD , which is the
number of infections that must be prevented to
achieve a HAI reduction goal
• Allows for ranking of facilities, or locations within
individual facilities, by the CAD to prioritize
prevention efforts where they will have the
greatest impact
http://www.cdc.gov/hai/prevent/tap.html
17
TAP Strategy - Three-fold
• Identify and target facilities and/or
locations/units with a high CAD
• Assess prevention efforts and areas for quality
improvement in the targeted locations
• Implement known prevention strategies to
improve quality and lower infection rates
http://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/tap-glossary-current.pdf
18
NHSN Reports
19
NHSN Reports - Locate & Run
Generate datasets –
freezes your data at
a specific point in
time.
You must generate
datasets in order for
updates in your data
to be reflected.
http://www.cdc.gov/nhsn/pdfs/training/2015/introtoanalysis_da-2015.pdf
20
NHSN Reports - Locate & Run
Locate report of
interest under
Analysis
Output Options
http://www.cdc.gov/nhsn/pdfs/training/2015/introtoanalysis_da-2015.pdf
21
NHSN Reports - Locate & Run
Device-Associated Module
http://www.cdc.gov/nhsn/pdfs/training/2015/introtoanalysis_da-2015.pdf
22
NHSN Reports - Locate & Run
• Summary Data Line List – includes all summary
data of a certain type of HAI
• Line List – organized detailed list of each record
entered into NHSN
• Frequency Table – organized display of counts
and percentages
• Charts: Bar, Pie, Run – various graphical
representations of data
http://www.cdc.gov/nhsn/ps-analysis-resources/reference-guides.html
23
NHSN Reports - Locate & Run
• Rate Table – displays a facility’s calculated rates
as well as device-utilization ratios and other
data, where appropriate
• Standardized Infection Ration (SIR) Table –
displays a facilities SIR, which is a risk-adjusted
summary measure that compares the observed
(or actual) number of infections to the expected
(or predicted)
http://www.cdc.gov/nhsn/ps-analysis-resources/reference-guides.html
24
NHSN Reports - Locate & Run
http://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/tapreports_facilities.pdf
25
NHSN Reports - Locate & Run
http://www.cdc.gov/nhsn/pdfs/training/2015/runningtapreports_md.pdf
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NHSN Reports - Locate & Run
• TAP Reports – ranks health care facilities and
patient care locations within these facilities by
the CAD metric in descending order. These
reports also contain other applicable information
for prevention of HAIs such as count of HAIs,
SIRs, Device Utilization Ratios (DURs), and
pathogen distributions
http://www.cdc.gov/nhsn/ps-analysis-resources/reference-guides.html
27
TAP Reports
28
TAP Reports – Interpret
http://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/tapreports_facilities.pdf
29
TAP Reports - Understand CAD
• Number of infections that must be prevented
within a group, facility, or unit to achieve an HAI
reduction goal
• Observed – (Predicted * SIR target)
• CAD interpretation:
• Positive CAD = more infections than
predicted
• Negative CAD = fewer infections
http://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/tap-glossary-current.pdf
30
Resources
TAP Strategy:
http://www.cdc.gov/hai/prevent/tap.html
NHSN Analysis:
http://www.cdc.gov/nhsn/training/analysis/index.html
Analysis Quick Reference Guides:
http://www.cdc.gov/nhsn/ps-analysis-
resources/reference-guides.html
31
Resources
Guidance on mapping NHSN locations:
http://www.cdc.gov/nhsn/pdfs/pscmanual/15locations
descriptions_current.pdf
Webinar on NHSN Mapping Impact:
http://www.qualityreportingcenter.com/inpatient/vbp-
archived-events/
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Takeaways
• TAP Strategy – ability to target/assess specific
units for improvement
• Reports – Run a CAUTI rate report to find your
DUR and run your facilities’ TAP report
• Correct mapping = correct risk adjustment
• CAD – cumulative attributive difference is the
number of infections you need to prevent to
achieve a reduction
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Contact
Jill Kieser Andersen, Program Manager
Robyn Carlson, Quality Reporting Specialist
www.lsqin.org
This material was prepared by Lake Superior Quality
Innovation Network, under contract with the Centers for
Medicare & Medicaid Services (CMS), an agency of
the U.S. Department of Health and Human Services.
The materials do not necessarily reflect CMS policy.
11SOW-MN-C1-15-115 111315