Understanding the Dialysis Event Protocol and Avoiding Common Reporting Mistakes Alicia Shugart, MA

Transcription

1 Understanding the Dialysis Event Protocol and Avoiding Common Reporting Mistakes Alicia Shugart, MA Public Health Analyst

2 Topics Dialysis Event Protocol Collecting data Reporting a numerator and denominator each month Selecting DE on the Monthly Reporting Plan Running reports Using help resources Avoiding common reporting errors

3 DIALYSIS EVENT PROTOCOL

4 Read the Dialysis Event Protocol The Dialysis Event Protocol is a document that provides instructions for reporting All users are required to read the Dialysis Event Protocol to become familiar with instructions, definitions and procedures

5 Data Reporting Requirements 1. Outpatient Dialysis Center Practices Survey Completed upon enrollment and annually thereafter 2. Monthly Reporting Plan Indicate what NHSN surveillance your facility will do each month 3. Denominators for Outpatient Dialysis form Completed once monthly 4. Dialysis Event form Completed monthly, one for each dialysis event that occurs

6 Outpatient Dialysis Center Practices Survey Completed during enrollment in NHSN and annually thereafter Survey includes questions about staff and patients during the first week of January It is recommended to complete the survey in January each year This is the best time to complete the survey, even if you plan to enroll later this year Print from the Dialysis Event homepage:

7 Outpatient Dialysis Center Practices Survey Example of questions about patients and staff in the first week of January

8 Vascular Access Definitions Fistula: A surgically created connection between an artery and a vein Graft: A surgically created connection between an artery and a vein created with implanted synthetic tubing Tunneled Central Line: Central venous catheter that travels a distance under the skin from the point of insertion before terminating at or close to the heart or one of the great vessels Nontunneled Central Line: Central venous catheter fixed in place at the point of insertion and travels directly from the skin entry site to a vein and terminates close to the heart or one of the great vessels Other Access Device: Includes hybrid access devices (e.g., HeRO TM vascular access device), ports, and any other access devices not meeting above definitions Use of trade names and commercial sources is for identification only and does not imply endorsement.

9 Infection Risk by Vascular Access Risk of infection varies by vascular access type: LOW RISK HIGH RISK Arteriovenous fistulas Arteriovenous grafts Other access devices (e.g., hybrids) Tunneled central lines Nontunneled central lines NHSN data are stratified by vascular access type

10 Denominators for Outpatient Dialysis form Report all maintenance hemodialysis outpatients treated at your facility on the first 2 working days of the month, stratified by 5 vascular access types Count each patient only once If they have more than 1 vascular access, count that patient under their highest infection risk access only Consider ALL vascular accesses present, not just those being used for dialysis If a patient is present on both working days (e.g., for a make-up appointment) do not count them twice Complete this form once per month

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12 Dialysis Events Dialysis events reported to NHSN by users IV antimicrobial starts Positive blood cultures Pus, redness or increased swelling at the vascular access site Dialysis events calculated in NHSN from reported data Local access site infection Access-related bloodstream infection Vascular access infection

13 Dialysis Event Form Monitor all maintenance hemodialysis outpatients who are treated at your facility at any time during the month for dialysis events: IV antimicrobial start Positive blood culture Pus, redness, or increased swelling at the vascular access site Complete a Dialysis Event form for each patient that has a dialysis event

14 Dialysis Event Form Any patient who receives maintenance hemodialysis treatment at your facility is included in dialysis event reporting Even if they were not counted on the denominator form Include transient patients who have a dialysis event while receiving hemodialysis treatment at your facility

15 Dialysis Event Form Patient demographics Risk Factors Dialysis Event type(s) & details Problems/ symptoms Outcomes

16 Dialysis Event Date Dialysis Event IV antimicrobial start Date Criteria Date of first outpatient administration Positive blood culture Date specimen was collected Pus, redness, or increased swelling at vascular access site Sign/symptom onset date Combination Earliest date of the three types

17 Dialysis Event Type: IV Antimicrobial Start Report all outpatient IV antimicrobial starts Include all IV antibiotics and antifungals, not just vancomycin Include starts that occur for any reason and duration, not just vascular access problems Exclude antivirals IV antimicrobials must be stopped for more than 21 days and then restarted to be considered a new event If IV antimicrobials are stopped for 21 days it is still the same event

18 Dialysis Event Type: Positive Blood Culture Include all positive blood cultures from specimens taken as an outpatient or within one (1) day after a hospital admission Even if the patient does not receive treatment Even if the infection is not related to dialysis treatment If you have > 1 positive blood culture, they must be more than 21 days apart to be considered separate dialysis events

19 Suspected Source of Positive Blood Culture Vascular access if there is objective evidence of vascular access infection and it is thought to be the source A source other than the vascular access if another source is thought to be the source and either: culture from another site has the same organism as the blood clinical evidence of infection at the site, but site is not cultured Contamination if organism is thought by the physician, Infection Preventionist, or nurse manager to be a contaminant Uncertain only if there is insufficient evidence to decide among the 3 previous categories

20 Positive Blood Culture Microorganisms On the back of the Dialysis Event form, report the microorganisms for positive blood cultures Suggestion: attach microbiology lab report to paper form List up to 3 microorganisms (in order of importance) Usually order of importance is indicated on the laboratory report For each microorganism, include antimicrobial susceptibility information i.e., susceptible, resistant, intermediate, or not tested Only certain bug/drug combinations are required

21 Dialysis Event Type: Pus, Redness or Increased Swelling at the Vascular Access Site Report all episodes of one or more symptoms of pus, redness or increased swelling at a vascular access site Even if the patient does not receive treatment Always report pus Report redness or swelling if they are more than expected and suspicious for infection at the time of onset There must be 21 or more days between the onset of a first and second episode of pus, redness, or increased swelling at a vascular access site to be considered separate dialysis events

22 21 Day Rule There must be 21 or more days between dialysis events of the same type Purpose of the rule is prevent over-reporting of what is likely the same patient problem

23 21 Day Rule Example A patient has two positive blood cultures within 21 days as a result of a bloodstream infection on January 1 st and January 9 th Report 1 dialysis event Event date is January 1 st The patient has a third positive blood culture on February 20 th Report a second dialysis event Because event date of this new positive blood culture is 21 or more days after the last reported positive blood culture

24 Dialysis Event Problems & Outcomes Specify problems associated with the dialysis event Fever, chills or rigors, drop in blood pressure Wound (not related to the vascular access) with pus or increased redness Cellulitis Pneumonia or respiratory infection Other problem Specify outcomes associated with either the dialysis event or problems Hospitalization Death

25 Dialysis Event Combinations 1 Dialysis Event report may have multiple parts, combining: IV antimicrobial start Positive blood culture Pus, redness or increased swelling at vascular access site For example, if a positive blood culture is the reason that a patient is treated with IV antimicrobials, this is part of the same group of events and they are reported together

26 CREATE A SYSTEM TO COLLECT DATA

27 Data Collection System Determine how will you capture all dialysis events: IV antimicrobial starts Positive blood cultures Onsets of pus, redness or increased swelling at the vascular access site And problem and outcome information for the form If frontline staff are aware of the dialysis event definitions, they can inform the primary data collector/reporter when an event occurs Follow-up on hospitalizations to determine if a positive blood culture resulted from a specimen collected within 1 calendar day after admission

28 Data Collection All resources are available on the public NHSN website: Protocol & forms Data Reporting NHSN is accessed through a secure website: Data entry/reporting

29 Using NHSN Forms Data are collected on forms according to the protocol Report Monthly Patient Census (denominator data) within 30 days of the end of the month Report Dialysis Events (numerator data) if they occur, within 30 days of the end of the month Using forms ensures all the required information needed is ready for data entry Saves time an incomplete event can t be saved, so if data are missing, it may be necessary to start over with data entry Improves data quality

30 REPORT A NUMERATOR AND A DENOMINATOR EACH MONTH

31 Numerator, Denominator and Rates Rates are used to standardize data and make them comparable across settings of different size To calculate a rate, you require a numerator and a denominator for each month Number of dialysis events over number of patient-months Rate = Dialysis Events (numerator) Patient Census (denominator) x 100

32 Monthly Reporting Plan Generates Alerts if Data are Not Reported on Time If a reporting plan is saved with DE selected for the outpatient hemodialysis clinic location, but either a numerator (events) or denominator (census) are not reported, an alert appears upon login after 30 days from the end of the month E.g., data for December should be reported before the end of January. Beginning February 1, any time a user logs in, they will see an alert for missing data

33 Reporting Zero Dialysis Events (Numerator is Equal to Zero) If no dialysis events occurred during a month, select Report No Events on the Denominators for Outpatient Dialysis form in NHSN No IV antimicrobial starts No positive blood cultures No pus, redness, or swelling at the vascular access site This indicates that the numerator (dialysis events) is equal to zero for this month/year The denominator (patient census information) is still reported for that month

34 Select Report No Events to report zero dialysis events for the month

35 Missing Summary Data Alert for Missing Denominator

36 Alert for Missing Numerator If no dialysis events are reported and the Report No Events checkbox has not been selected, there are two alerts for that month: Missing Events Incomplete Summary Data NHSN does not know if events need to be reported (so it alerts you that there are Missing Events ) or if Report No Events needs to be checked (so it also alerts you that there is Incomplete Summary Data ) If either an event is reported or if Report No Events is selected, a numerator for that month has been reported, so both alerts will disappear for that month

37 Missing Events Alert for Missing Numerator

38 Incomplete Summary Data Alert for Missing Numerator

39 ADD DE TO YOUR MONTHLY REPORTING PLAN BEFORE ADDING DATA

40 Monthly Reporting Plan Indicates what Patient Safety Component surveillance modules your facility intends to do: Device-Associated Module >> Dialysis Event DE If not doing surveillance for a specific month, select No NHSN Patient Safety Modules Followed this Month on the Monthly Reporting Plan You can submit up to one year of Monthly Reporting Plans in advance

41 Choose only if your facility is NOT doing any surveillance this month

42 Indicating DE on your reporting plan each month helps you to report correctly.

43 RUN REPORTS

44 Reviewing Your Data Monthly review is recommended to: Ensure all data have been reported and are accurate Review of quarterly data is recommended to: Detect problems in your facility Provide feedback to your staff Get staff engaged in quality improvement Allows for a better understanding of your facility s performance by comparing your facility s rates against NHSN aggregate rates

45 Creating Reports Experiment with the analysis function you can t break anything! Allow pop-ups from

46 Three Steps to Create a Report 1. Generate new data sets 2. Select a report ( output option ) from the list of templates Modify the report, if desired 3. Press Run button to create the report You can create a report with just a few clicks!

47 Step 1 Generate Data Sets First step: generate new data sets Generating data sets captures all of your facility s NHSN data so that reports will be created using complete, up-to-date information Each user has their own analysis data sets They may take several minutes to generate, but you can work elsewhere in NHSN while you wait

48 Step 1 Generate Data Sets From the navigation bar, select Analysis, then Generate Data Sets Select Generate New and OK, then wait for update

49 Step 2 Select a Report Once data sets are generated, select Output Options from the navigation bar Open folders to find dialysis event templates 1. Device-Associated Module folder 2. Dialysis Events folder 3. CDC Defined Output folder

50 Step 3 Run the Report Press Run button next to the report you want

51 USE HELP RESOURCES

52 Use Help Resources Refer to the Protocol and Tables of Instructions These can be found along with other reporting resources on the Dialysis Event Homepage Use the Help link to search the NHSN Online Manual Ask the NHSN Helpdesk at

53 AVOID COMMON REPORTING ERRORS

54 Population Dialysis event surveillance population includes pediatric patients Date of birth is a required event field, so age is captured for each dialysis event Dialysis event surveillance population does not include peritoneal dialysis patients Dialysis event surveillance population includes only maintenance hemodialysis outpatients

55 Vascular Accesses Include all central lines in Dialysis Event reporting, even those not being used for hemodialysis (e.g., a port for chemotherapy) Dialysis Event form: indicate all of the patient s vascular accesses Denominators for Outpatient Dialysis form: count the patient under the highest infection risk vascular access type that he has

56 Denominators for Outpatient Dialysis form Patients must be physically present for maintenance hemodialysis treatment on the first two working days of the month to be counted on the denominator form: Include transient patients Include pediatric patients Exclude acute/hospitalized patients Exclude peritoneal dialysis patients Exclude patients that miss their treatment appointment Report dialysis events that occur in patients receiving maintenance hemodialysis at your facility, regardless of whether or not the patient was counted in the denominator for that month

57 Report Dialysis Events Only A Dialysis Event form is completed only if a dialysis event occurs: IV antimicrobial starts Positive blood cultures Pus, redness, or increased swelling at the vascular access site Problems and outcomes on the Dialysis Event form are not reportable by themselves: Fever, chills or rigors, drop in blood pressure, wound, cellulitis, pneumonia, hospitalization and death are only reported if a dialysis event also occurs

58 CMS ESRD QIP NHSN Reporting Requirements In 2012, requires a minimum of 3 consecutive months of Dialysis Event reporting as defined in the Dialysis Event Protocol: Annual Dialysis Survey Monthly Reporting Plan with DE selected Dialysis denominator reported patient census information Dialysis numerator reported at least one dialysis event reported or Report No Events to indicate numerator is zero See our FAQs about NHSN and CMS ESRD QIP at

59 Questions? NHSN Helpdesk For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA Telephone, CDC-INFO ( )/TTY: Web: