NHSN Tips for CMS Hospital IQR Program: MRSA Bacteremia and CDI LabID Healthcare Personnel Influenza Vaccination Maggie Dudeck, MPH, CPH Epidemiologist National Provider Education Webcast May 1, 2013 National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion
Our Goal for Today Discuss tips for reviewing your facility s compliance in NHSN for CMS Hospital IQR Program MRSA Bacteremia and CDI LabID Events Healthcare Personnel Influenza Vaccination
MRSA BACTEREMIA AND CDI LABID
Online Resources CMS Related http://www.cdc.gov/nhsn/cms/index.html Operational Guidance How to Set Up NHSN Reporting for Facility-Wide Inpatient MRSA Bacteremia and C. difficile LabID events for the CMS Inpatient Quality Reporting Program Helpful Tips Using the SIRs
Online Resources NHSN Protocols http://www.cdc.gov/nhsn/acute-care-hospital/cdiff-mrsa/index.html One Stop Shopping On-Demand trainings NHSN Manual & Errata Data Collection Forms & Instructions CDC Location descriptions and guidance CMS-related documents Analysis guides FAQs
CHECKLIST One Stop Shopping Ensuring data are complete by the deadline and will be submitted to CMS: Confirm (and update if necessary) CCN in NHSN Review Monthly Reporting Plans and update if necessary Identify and enter all MRSA bacteremia and C. difficile LabID events into NHSN by location Enter overall FacWideIN denominator data for each month under surveillance Resolve Alerts, if applicable Use NHSN Analysis Output Options to verify accuracy and completion of data entry
Updating the CCN (1 of 3) Applies to ALL CMS-related reporting in NHSN Important to double- and triple-check this number! Must be completed by an administrative user (e.g., Facility Administrator)
Updating the CCN (2 of 3)
Updating the CCN (3 of 3)
CHECKLIST Review Monthly Plans Ensuring data are complete by the deadline and will be submitted to CMS: Confirm (and update if necessary) CCN in NHSN Review Monthly Reporting Plans and update if necessary Identify and enter all MRSA bacteremia and C. difficile LabID events into NHSN by location Enter overall FacWideIN denominator data for each month under surveillance Resolve Alerts, if applicable Use NHSN Analysis Output Options to verify accuracy and completion of data entry
Monthly Reporting Plan (1 of 7) The Monthly Reporting Plan informs CDC which modules a facility is following during a given month Referred to as In-Plan data The Plan also informs CDC which data can be used for aggregate analyses This INCLUDES sharing applicable data with CMS! A facility must enter a Plan for every month of the year Plans can be modified retrospectively
Monthly Reporting Plan (2 of 7) NHSN will only submit data for those complete months in which the following are indicated on the monthly reporting plan: FacWideIN MRSA LabID either Blood Specimens Only or All Specimens FacWideIN CDI LabID
Monthly Reporting Plan (3 of 7) To MODIFY a Plan:
Monthly Reporting Plan (4 of 7)
Monthly Reporting Plan (5 of 7)
Monthly Reporting Plan (6 of 7) Once saved, users can easily move to the next month s reporting plan
Monthly Reporting Plan (7 of 7) If your facility chooses to report LabID events for all MRSA specimens (e.g., wound, urine) - and indicates this in the plan - only those MRSA LabID events from blood specimens will be included in the data sent to CMS.
CHECKLIST MRSA and C. diff Ensuring data are complete by the deadline and will be submitted to CMS: Confirm (and update if necessary) CCN in NHSN Review Monthly Reporting Plans and update if necessary Identify and enter all MRSA bacteremia and C. difficile LabID events into NHSN by location Enter overall FacWideIN denominator data for each month under surveillance Resolve Alerts, if applicable Use NHSN Analysis Output Options to verify accuracy and completion of data entry
LabID Event s MDRO/CDI Protocol Use the MDRO/CDI protocol to identify MRSA bacteremia and C. difficile LabID events ALL identified MRSA bacteremia and C. difficile LabID events from all inpatient locations must be entered into NHSN The specific inpatient location where the patient was assigned at the time of specimen collection must be indicated! http://www.cdc.gov/nhsn/pdfs/pscmanual/12pscmdro_cdadcurrent.pdf
CHECKLIST Denominator Data Ensuring data are complete by the deadline and will be submitted to CMS: Confirm (and update if necessary) CCN in NHSN Review Monthly Reporting Plans and update if necessary Identify and enter all MRSA bacteremia and C. difficile LabID events into NHSN by location Enter overall FacWideIN denominator data for each month under surveillance Resolve Alerts, if applicable Use NHSN Analysis Output Options to verify accuracy and completion of data entry
Denominator Data (1 of 4) Denominator data must be entered each month. Go to Summary Data > Add Select MDRO/CDI option as summary data type.
Denominator Data (2 of 4) Select FACWIDEIN as the Location FACWIDEIN location is automatically available in NHSN this location does not have to be set up Select appropriate month and year
Denominator Data (3 of 4) http://www.cdc.gov/nhsn/pdfs/pscmanual/12pscmdro_cdadcurrent.pdf
Denominator Data (4 of 4)
CHECKLIST Resolve Alerts Ensuring data are complete by the deadline and will be submitted to CMS: Confirm (and update if necessary) CCN in NHSN Review Monthly Reporting Plans and update if necessary Identify and enter all MRSA bacteremia and C. difficile LabID events into NHSN by location Enter overall FacWideIN denominator data for each month under surveillance Resolve Alerts, if applicable Use NHSN Analysis Output Options to verify accuracy and completion of data entry
Report No Events (1 of 2) Facilities must appropriately Repor t No Event s for those months for which no LabID events of each type under surveillance were identified. If no LabID events have been reported and this box is not checked, your data will not be submitted to CMS.
Report No Events (1 of 2) On the MDRO and CDI Module summary data form, checkboxes for Report No Events are found underneath the patient day and admission count fields. If LabID events have already been reported for the specific organism, the Report No Events box will be disabled, preventing it from being checked. NOTE: If you identify and enter LabID events for an organism after checking Report No Events, the Report No Events box will automatically uncheck.
Denominator Data Report No Events (1 of 2)
Denominator Data Report No Events (2 of 2) Report No Events can also be accessed from the Alerts screen, under Missing Events
CHECKLIST NHSN Analysis Output Options Ensuring data are complete by the deadline and will be submitted to CMS: Confirm (and update if necessary) CCN in NHSN Review Monthly Reporting Plans and update if necessary Identify and enter all MRSA bacteremia and C. difficile LabID events into NHSN by location Enter overall FacWideIN denominator data for each month under surveillance Resolve Alerts, if applicable Use NHSN Analysis Output Options to verify accuracy and completion of data entry
NHSN Analysis Tools Analysis output options were created in order to allow facilities to review those data that would be submitted to CMS on their behalf. If you re not familiar with the NHSN Analysis functionality, please refer to our Analysis Resources and Trainings at: http://www.cdc.gov/nhsn/ps-analysis-resources/index.html
NHSN Analysis Tools (continued) SIRs are calculated for each hospital and LabID event type and can be obtained from NHSN Can obtain hospital-level SIRs f rom Advanced > CMS Repor t s
Standardized Infection Ratio for LabID Observed # of events SIR = Expected (Predicted) # of events Observed # of events the number of healthcare facility onset (HO) LabID events that you enter into NHSN Expected or predicted # of events risk adjustment is applied, comes from national baseline data LabID Risk Adjustment details published March 12, 2013: http://www.cdc.gov/nhsn/pdfs/mrsa-cdi/riskadjustment-mrsa-cdi.pdf
LabID SIRs (1 of 9) The data in these SIRs within NHSN will be current as of the last time you generated datasets. Data changes made in NHSN will be reflected in the next monthly submission to CMS EXCEPTION: Quarterly data are frozen as of the final submission date for a quarter. If you make changes to a quarter s deadline after the deadline, you will be able to see the changes reflected in the NHSN report, BUT The changes will not be reflected on Provider Participation reports or Hospital Compare
LabID SIRs (2 of 9) Within each output, there may be multiple tables. By default, SIRs are generated for each quarter, beginning with Q1 of 2013 Be sure to read the footnotes! The footnotes to each table provide valuable information regarding the data in each table. Data in the tables should be used to confirm accuracy and for quality checking of data, prior to t he CMS deadline for that quarter
LabID SIRs (3 of 9) Example: CDI The first table represents an overall, single SIR for your facility, per calendar-year quarter. This is the information that will be submitted to CMS for each IPPS-participating facility, as indicated by the facility s CCN. NOTE: If your facility shares a CCN with another facility, data will be submitted to CMS for the single CCN and therefore, the data within NHSN will represent only your facility s contribution to the combined SIR.
LabID SIRs (4 of 9) Example: CDI Looking at the data in this table: Have 3 months of data been reported for each quarter? If NO, check: Check that the all 3 months are included in the plans for the quarter Check that a FACWIDEIN summary record has been entered for each month If no LabID events of that type have been reported, check that the Report No Events box has been checked for each month
LabID SIRs (5 of 9) Example: CDI Looking at the data in this table: Are the # of the HO LabID events correct? If NO: Check the CDI LabID Line List and/or Frequency Table and include the variables onset and cdiassay; only HO Incident events will be counted for the # of observed infections Be sure to enter into NHSN any events that were identified but not yet reported
LabID SIRs (6 of 9) Example: CDI Looking at the data in this table: Are the patient days accurate? If NO: Check each month s summary record and edit, if necessary, any incorrect patient days reported for the LabID type (i.e., MRSA, CDI)
LabID SIRs (7 of 9) Example: CDI What if the event count, etc. appear to be missing for a designated quarter, as with 2013Q1? If the Quarter is listed in the SIR, but no data are calculated as with 2013Q1 above this means that there was an outlier prevalence rate and therefore, the SIR could not be calculated.
LabID SIRs (8 of 9) Example: CDI What if the event count, etc. appear to be missing for a designated quarter, as with 2013Q1? The second table in the SIR output will appear if there are any quarters with an outlier prevalence rate. These data should be checked to confirm that the number of admissions and the number of events for the quarter are correct. If the data in the second table are accurate, then the quarter would be considered complete for CMS purposes.
LabID SIRs (9 of 9) Example: CDI What if a quarter within the time frame analyzed is completely excluded from the first table? That quarter will be considered non-compliant. Review each month in the excluded quarter and complete data per the prescribed steps.
CHECKLIST Six It ems Ensuring data are complete by the deadline and will be submitted to CMS: Confirm (and update if necessary) CCN in NHSN Review Monthly Reporting Plans and update if necessary Identify and enter all MRSA bacteremia and C. difficile LabID events into NHSN by location Enter overall FacWideIN denominator data for each month under surveillance Resolve Alerts, if applicable Use NHSN Analysis Output Options to verify accuracy and completion of data entry
Resources CMS-related NHSN Documents: http://www.cdc.gov/nhsn/cms/index.html MDRO/CDI Module Protocol and supporting documents: http://www.cdc.gov/nhsn/acute-care-hospital/cdiff-mrsa/index.html Analysis Resources and Trainings: http://www.cdc.gov/nhsn/ps-analysis-resources/index.html
HEALTHCARE PERSONNEL INFLUENZA VACCINATION
Reporting Healthcare Personnel (HCP) Influenza Vaccination Summary Data The Centers for Medicare & Medicaid Services (CMS) added HCP influenza vaccination reporting to its quality reporting programs for acute care hospitals and ambulatory surgical centers Acute care hospitals began reporting data on January 1, 2013 (for the 2012-13 influenza season) Ambulatory surgical centers will begin reporting data on October 1, 2014 (for the 2014-15 influenza season) Facilities must enter their data into the HCP Vaccination Module in the National Healthcare Safety Network (NHSN) by May 15, 2013, for data to be transmitted to CMS.
CHECKLIST Activate HPS Component Ensuring data are complete by the deadline and will be submitted to CMS: Confirm (and update if necessary) CCN in NHSN Activate the Healthcare Personnel Safety (HPS) Component in NHSN (performed only once) Create Monthly Reporting Plan in the HPS Component Enter HCP influenza vaccination summary data for entire influenza season Use NHSN Analysis tools to verify accuracy and completion of data entry
Activating HPS Component for Existing NHSN Facilities Healthcare Personnel Influenza Vaccination data are reporting to NHSN through the Healthcare Personnel Safety Component. Only the NHSN Facility Administrator can activate a new component NHSN Facility Administrator adds users Users with administrative rights will be able to add additional HPS Component users and share data using the Group function for the HPS Component
Activating the HPS Component (1 of 2) Facility Administrator logs into https://sdn.cdc.gov Under My Applications select NHSN Reporting Log into any active component From the Home Page, click Facility then Add/Edit Component Check box next to Healthcare Personnel Safety Facility Administrator adds HPS Component Primary Contact Enter name, phone, e-mail, and address for person to be contacted if CDC/NHSN has updates or questions about the HPS Component
Activating the HPS Component (2 of 2) Facility Administrator adds HPS Component Primary Contact as a user within the NHSN facility Click Users on the navigation bar, then click Add Complete Add User screen mandatory fields User ID created by the facility First Name Last Name E-mail Address Must be an active/correct address for the user Other users are added by the Facility Administrator or new HPS Component Primary Contact
CHECKLIST Monthly Reporting Plan Ensuring data are complete by the deadline and will be submitted to CMS: Confirm (and update if necessary) CCN in NHSN Activate the Healthcare Personnel Safety (HPS) Component in NHSN (performed only once) Create Monthly Reporting Plan in the HPS Component Enter HCP influenza vaccination summary data for entire influenza season Use NHSN Analysis tools to verify accuracy and completion of data entry
Adding Monthly Reporting Plan in NHSN Click Reporting Plan then Add Select correct month and year from dropdown menus Check box next to Influenza Vaccination Summary
Adding Monthly Reporting Plan in NHSN (continued) Click Save when finished
CHECKLIST HCP Summary Ensuring data are complete by the deadline and will be submitted to CMS: Confirm (and update if necessary) CCN in NHSN Activate the Healthcare Personnel Safety (HPS) Component in NHSN (performed only once) Create Monthly Reporting Plan in the HPS Component Enter HCP influenza vaccination summary data for entire influenza season Use NHSN Analysis tools to verify accuracy and completion of data entry
HCP Influenza Vaccination Summary (1 of 2) Can be completed by going to Flu Summary > Add Single form, completed once per influenza season Must be completed by each season s reporting deadline Each time updated data are entered, all previously entered data for that season are overwritten.
HCP Influenza Vaccination Summary (2 of 2)
Denominator Categories Employee HCP Non-Employee HCP: Licensed independent practitioners (physicians, advance practice nurses, and physician assistants only) Non-Employee HCP: Adult students/trainees and volunteers HCP must be physically present in the acute care facility for at least 30 working days between October 1 and March 31
Numerator Categories The numerator includes HCP who received an influenza vaccination during the time from when the vaccine became available through March 31 of the following year Received at this healthcare facility or elsewhere Medical contraindications Declinations Unknown status
CHECKLIST NHSN Analysis Tools Ensuring data are complete by the deadline and will be submitted to CMS: Confirm (and update if necessary) CCN in NHSN Activate the Healthcare Personnel Safety (HPS) Component in NHSN (performed only once) Create Monthly Reporting Plan in the HPS Component Enter HCP influenza vaccination summary data for entire influenza season Use NHSN Analysis tools to verify accuracy and completion of data entry
NHSN Analysis Tools Line Listing HCP Flu Vaccinat ion Dat a for CMS IPPS was created to allow facilities to review those data that would be submitted to CMS on their behalf Can obtain hospital-level line list from Advanced > CMS Repor t s
HCP Flu Vaccination Line List (1 of 3) A single table titled Line Listing HCP Flu Vaccination Data for CMS IPPS will be presented in the pop-up HTML window. The table presents HCP vaccination data by influenza season, stratified by HCP category (employees, licensed independent practitioners, adult students/trainees and volunteers, and all three categories combined). This is the information that will be submitted to CMS for your facility.
HCP Flu Vaccination Line List (2 of 3) The first three rows of the table display the HCP influenza vaccination data for each individual HCP cat egory. The fourth row of the table displays the HCP influenza vaccination data for all three required HCP categories combined.
HCP Flu Vaccination Line List (3 of 3) If this table is not displayed when you click the Run button, be sure that you have included HCP influenza vaccination summary reporting in your HPS Component monthly reporting plan for the influenza season of interest and that you have entered HCP influenza vaccination data for the influenza season of interest.
CHECKLIST Complete for Five Items Ensuring data are complete by the deadline and will be submitted to CMS: Confirm (and update if necessary) CCN in NHSN Activate the Healthcare Personnel Safety (HPS) Component in NHSN (performed only once) Create Monthly Reporting Plan in the HPS Component Enter HCP influenza vaccination summary data for entire influenza season Use NHSN Analysis tools to verify accuracy and completion of data entry
The NHSN Website http://www.cdc.gov/nhsn/acute-care-hospital/hcpvaccination/index.html for training materials: Protocol (with Table of Instructions) Forms Operational Guidance Frequently asked questions (FAQs) Training slides and recorded webinars Facilities can contact NHSN with any questions at: nhsn@cdc.gov; please include HPS Flu Summary in the subject line of the e-mail.
Contact Information nhsn@cdc.gov For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.