NHSN: WHAT’S NEW, WHAT’S HOT…

WHAT’S NOT CDC ATLANTA CONFERENCE

December 5-6, 2011Cherylanne Zeumault

Jeanette Harris

THE HIGH POINTS SSI & CAUTI CAUTI…..not much is new – but if you

have questions…we can help SSI…..LOTS new in 2012

CMS: Colon surgeryCMS: Abdominal HysterectomyAlong with all the Washington MandatoryReportable surgeries

CARD,CBGB,CBGC,HPRO,HYST,KPRO,VHYS http://apps.leg.wa.gov/rcw/default.aspx?cite=43.70&full=true#43.70.056

RESOURCES The new NHSN Patient Safety

Component ManualNew this month

http://www.cdc.gov/nhsn/library.html

CMS REQUIREMENTS (COLONS & HYST) Add to your monthly reporting plan – a MUST Data Verification

800 hospitals Data Quality Output Options – check yourself Go to Output Options – Advanced – Data

Quality, CDC defined Output:

IF YOU HAVE NO SSI TO REPORT…

NEW REPORTING STEPS………….

Click on Event – Incomplete Click on Missing PA Events tab Check report NO EVENTS next to SSI then

“save”

WHY VALIDATE? It’s YOUR data It’s more meaningful, actionable EXTERNAL SCRUTINY Plus it helps everyone else for better

benchmarking Identified

Mis-mapped facility locations – leads to incorrect benchmarking

Incomplete denominators Misidentified linesMisconceptions of definitionsMissed/Overcalled cases

TIME TO DO YOUR ANNUAL CHECK Number of beds? Location mapping? New reporters? Are they all up do date?

Manual CountingElectronic Counting

Do spot checksSSI Procedures

Are they complete? Look for a secondary source for validation

How to find procedures NOT PRIMARILY CLOSED? Check procedure duration and ASA score for all

CBGB and CBGC IT can change things and you wouldn’t know it

PROCEDURE CHANGES FOR DENOMINATOR 1/1/2012 Non-autologous transplants –

No longer needed Estimated Blood loss for C-Sections –

No longer needed Implants: Temp or permanent

Porcine or synthetic valvesMechanical heartMetal rods, screws, sternal wires, cements,

internal staples, hemoclips, other

ADDITIONAL REQUIREMENTS FOR SPECIFIC PROCEDURES 5 procedures that have additional risk

CSEC, Fusion/RefusionHPROKPRO

Height in ft and inches or meters Weight in pounds or Kg C-Sections: Hours of labor in the hospital

Length of time beginning of active labor as an inpatient to delivery

MORE REQUIREMENTS FUSN/RFUSN

Diabetic Y/NSpinal LevelApproach

HPROWhich type - TP, PP, TR, PR

KPROWhich type – Primary, Revision (total or partial)

MORE THAN ONE PROCEDURE? Infection?

Determine which procedure could be associated

If it’s not clear, use the Principal Operative Procedure Selection Lists (Table 3 in the manual)

NUMERATOR CHANGE SSI “Detected” Field

No more “P” (post-discharge) Instead, “Detected” will have 2 values

RO: if SSI identified due to patient admission to a facility other than where the op was performed

RF: if SSI was identified due to patient readmission to the facility where the op was performed

Secondary BSI is required if there was a +BC

The organisms MUST be the same Linking

STANDARDIZED INFECTION RATIO (SIR)

The SIR is an indirect standardized method for summarizing HAI across any number of stratified groups of data.

The SIR is the number of observed infections divided by the predicted (or statistically expected) number of infections.

The expected number is based on the national NHSN average, the number of procedures performed by a hospital and the historical data for those procedures.

STANDARDIZED INFECTION RATIO (SIR)

A SIR of 1.0 means the observed number of infections is equal to the number of expected infections.

A SIR above 1.0 means that the infection rate is higher than that found in the "standard population." For HAI reports, the standard population comes from data reported by the hundreds of U.S. hospitals that use the NHSN system. The difference above 1.0 is the percentage by which the infection rate exceeds that of the standard population.

A SIR below 1.0 means that the infection rate is lower than that of the standard population. The difference below 1.0 is the percentage by which the infection rate is lower than that experienced by the standard population.

EXAMPLE IPist notices that “Hospital X” has a higher

number of KPRO infections than normal (more than one surgeon). IPist….PREPARES FOR BATTLE

During discussing with the Surgery Committee…Comments from surgeons “We have harder cases than hospital “Y” “We do more cases than hospital “Y” “We don’t like being compared to hospital “Y”!!

IPist notes: This is your SIR. It is 1.8 That means that you are 80% higher than other similar

hospitals – NATIONWIDE FYI….Hospital “Y” is not in your group (neener, neener) You are compared to other similar hospitals with similar

beds, risk factors, med school affiliation, etc.

EXAMPLE…CONTINUED Surgery rebuttle:

“What’s our rate compared to the National Rate? What’s the benchmark?

Ipist: There is no more “benchmark” There is only Standardized Infection Ratio This means that you are compared to other

surgeons/hospitals with patients with similar risk factors that include more than just ASA score and wound class

This is a BETTER and MORE ACURATE method of comparison

You’re SIR of 1.8 means that you have 80% more infections than similar hospitals across the nation

Surgery: So we really DO have more infections? Ipist: YES Surgery Committee Chair: I suggest we get a

team together to see what’s going on

MORAL OF THE STORY: RCA discovered that there were

variations in practices that contributed to these infections

Surgery Committee Report:More help during surgeryControl the number of staff in surgery suitePositioningDrapingDressingsStaff training

Outcome: no infection since (6 months)

HAPPY ENDING: