January 21, 2016 Healthcare Associated Infection and Antimicrobial Resistance Unit

Transcription

1 NHSN Updates January 21, 2016 Healthcare Associated Infection and Antimicrobial Resistance Unit

2 Reminder! Data for CMS Quality Reporting Programs due Soon WHO: Acute care hospitals that participate in the CMS Hospital Inpatient Quality Reporting (IQR) Program: WHEN: Quarter 3 (July 1 September 30) data must be entered into NHSN by February 15, 2016 WHAT data is due: CLABSI and CAUTI data All ICU locations, Adult and pediatric medical, surgical, and medical/surgical wards Inpatient COLO and HYST SSI data MRSA Bacteremia and C. difficile LabID Events (all healthcare onset and community onset) FacWideIN,ED, and 24-hour observation locations Please note that February 15 th is a federal holiday and the NHSN Help Desk will not be available.

3 CMS reporting requirements starting January 1, 2016 Reporting Requirements and Deadlines in NHSN per CMS Current Rules: Requirements-Deadlines.pdf. Healthcare Facility HAI Reporting Requirements to CMS via NHSN - Current and Proposed Requirements: Requirements.pdf.

4 Patient Safety Protocols for 2016 NHSN v8.5 (January 2016) Not as many changes this year! Protocols have been posted to the NHSN website. The individual protocols are located on the site of the specific infection type (e.g., BSI protocol found under Protocols on the BSI surveillance webpage). The major changes to the protocols are listed in the Release Notes found at: These protocols should be used beginning on January 1, 2016 for data collected in 2016.

5 Changes to the Patient Safety Component Protocol LabID Event Reporting Two questions were changed from Optional to Required on the LabID Event screen. The questions are Last physical overnight location of patient immediately prior to arrival into facility and Has the patient been discharged from another facility in the past 4 weeks? Note: If collection of the data is too burdensome, use of the response option Unknown.

6 Changes to the Patient Safety Component Protocol Surgical Site Infections ICD-10 PCS and CPT transition ICD-9 CM procedure codes have been transitioned to ICD-10 PCS and CPT procedure codes in the NHSN application for procedures dated January 1, 2016 and going forward. For ICD-10 PCS and CPT, the current ICD-9 CM rules for HPRO/KPRO partials and revisions have been temporarily relaxed. And, KPRO/HPRO have supplemental ICD-10 PCS codes to help clarify revisions. Users will need to refer to the guidance for specific instructions to correctly input this data.

7 Changes to the Patient Safety Component Protocol Healthcare associated infections (HAI) and Present on Admission (POA) Worksheet Generator Release Delayed The Generator is designed to identify the: 7-day Infection Window Period Date of Event and POA or HAI determination 14-day Repeat Infection Timeframe (RIT) Secondary Bloodstream Infection Attribution Period This has been delayed due to compliance requirements

8 Changes to the Patient Safety Component Protocol UTI Defect is Fixed In 2015, a data entry defect did not allow entry of the symptoms of urinary urgency, frequency, or dysuria when an indwelling urinary catheter was indicated to be INPLACE, meaning that it was in place > 2 days and present on the date of event. Now when you select urgency, frequency, and dysuria a popup message warning will indicate these risk factors should only be selected if the urinary catheter was not in place at the time of the symptom. Justification if the catheter was removed on the date of event, it was still in place for some time, and therefore InPLACE will be selected. Now users may select urgency, and/or frequency, and/or dysuria, if the catheter had been removed before the symptom occurred.

9 National Risk Adjustment of HAI Data CDC will update the risk-adjustment of HAI data using the event and denominator data reported to NHSN for 2015 referred to as the Re-baseline of HAI data. The final analyses of 2015 data will occur in the summer of 2016, and the new risk-adjustment and SIRs will be available in NHSN in December 2016/January 2017.

10 SIR Calculations until the rebaselining To accommodate the CAUTI definition change until the rebaselining occurs at the end of 2016, you can customize CAUTI TAP reports using an SIR goal that closely represents or is below the current national CAUTI SIR. The preliminary estimate of the national CAUTI SIR from the first two quarters of CY2015 is Based on available national data, the CDC recommends using a customized SIR goal of less than or equal to 0.55 for the 2015 CAUTI TAP Reports.

11 2015 CAUTI Definition Changed and impacted SIRS and Rates Details regarding the use of the re-baselined SIRs for CMS programs (e.g., Hospital Value Based Purchasing) can be found in the Final Rule, as published in the Federal Register on August 17, 2015:

12 2015 Patient Safety Annual Facility Survey NHSN will release the annual patient safety facility survey in early This mandatory survey is completed by all facilities enrolled in NHSN to provide updated information on hospital characteristics and practices. NHSN has created a short, 5-minute Quick Learn video (formerly known as NHSN Hot Topics) that provides updates regarding all of the changes made to the 2015 Patient Safety Annual Facility Survey. Please remember, surveys must be completed and submitted in NHSN by March 1, Facilities that do not meet this deadline will be unable to complete monthly reporting plans.

13 2015 Patient Safety Annual Facility Survey NHSN Annual Hospital Survey: Antimicrobial Stewardship Questions (Q23-34) are aligned with the CDC s Core Elements of Hospital Antibiotic Stewardship Programs n/core-elements.html Data from the 2014 NHSN Annual Survey showed 21.2% of hospitals in Minnesota had antibiotic stewardship programs that incorporated ALL of the core elements

14 7 Core Elements 1. Leadership Commitment: Dedicate necessary human, financial, and IT resources. 2. Accountability: Appoint a single leader responsible for program outcomes. Physicians have proven successful in this role 3. Drug Expertise: Appoint a single pharmacist leader to support improved prescribing. 4. Act-Take at least one prescribing improvement action 5. Track: Monitor prescribing and antibiotic resistance patterns 6. Report: Regularly Report to staff prescribing and resistance patterns and steps to improve 7. Educate: Offer education about antibiotic resistance and improving prescribing practices

15 2014 Patient Safety Annual Facility Survey MN

16 2014 Patient Safety Annual Facility Survey MN

17 Core Elements of Hospital Antibiotic Stewardship Programs Checklist for Core Elements of Hospital Antibiotic Stewardship Programs mplementation/checklist.html

18 Minnesota Performance in CMS Incentive Programs NHSN User Group January 21, 2016

19 Objectives Identify current performance of Minnesota hospitals on value-based purchasing (VBP), hospital acquired conditions (HAC) and Readmission Reduction Program Share resources for CMS incentive programs and Minnesota measures

20 Value-Based Purchasing

21 VBP Fact Sheet

22 Fact Sheet Pie Charts

23 How to think about the years FY Baseline period 2016 Performance Period Fiscal Year adjustment factor

24 Where are we at? FY2016 Results complete Payment adjustment in effect FY2017 Results are being calculated Results will be shared with hospitals next summer FY2018 Performance period in effect through year

25 VBP Facts Now withhold is two percent o o o Could get some or all of it back Could get more than two percent back Could get a penalty Need to have enough cases to get a measure score If you don t have enough cases, other measures count more If you don t have enough measures in a domain, then other domains count more Payment adjustment impacts all Medicare billing

26 FY2016 VBP Total Performance Scores

27 FY2016 VBP Total Performance Scores Range =

28 FY2016 Results Overall MN hospitals have improved every year Both SSIs and CAUTI are our lowest performing measures Other improvement priorities are HCAHPS pain management and the new (to VBP) Care Transition Measure Medicare Spending per Beneficiary is also of interest to hospitals in our advisory group Five hospitals received a penalty

29 FY2018 & FY2019 HCAHPS Care Transition measure is new this year Hip/Knee complications will be added in next year Pediatric and adult medical ward locations will be included beginning with FY2019 results

30 Hospital-Acquired Condition Reduction Program

31 HAC Fact Sheet

32 HAC Facts Similar to VBP in how it is organized Except there is only a penalty, no incentive payment Hospitals in worst quartile will receive a one percent penalty New standard population will be used in FY2018 results Pediatric and adult medical ward locations will be included beginning with FY2018 results

33 HAC Facts SSI Colon and SSI Hysterectomy get one SIR rate If there are not enough predicted cases to calculate a SIR, then other measures will count more If no measures in domain, then other domain will determine the HAC score

34 FY2016 HAC Program

35 FY2016 Results 49 Minnesota hospitals were eligible Seventeen hospitals received a penalty CAUTI and SSI scores were the challenging measures

36 Readmission Reduction Program

37 RRP Fact Sheet

38 Readmission Reduction Program Facts Five Clinical Conditions AMI Heart Failure Pneumonia Hip/Knee COPD Now up to three percent penalty Twelve PPS hospitals had no penalty, 40 had some penalty

39 Excess Readmissions AMI

40 Excess Readmissions Heart Failure

41 Excess Readmissions Pneumonia

42 Excess Readmissions COPD

43 Excess Readmissions Hip and Knee

44 Statewide Quality Reporting and Measurement System (SQRMS) Minnesota Hospital Measures

45 Data Submission of VBP, RRP and HAC results Results in summer Final results in October Hospital Compare in December Required for MN in January 45

46 Hospital Slate of Measures Readmission Reduction (RRP) Program Medicare Beneficiary Quality Improvement Program (MBQIP) CAH Hospitals PPS Hospitals Value- Based Purchasing (VBP) Program Hospital Acquired Condition (HAC) Program Additional Measures for MN 46

47 Annual Measure Summary

48 Questions? Vicki Tang Olson, RN, MS Program Manager

49 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-D

50 Healthcare Personnel Influenza Vaccination NHSN Users group January 21, 2016

51 Objectives Understand current requirements for reporting Heathcare Personnel Influenza vaccination in critical access hospitals Identify resources for HCP reporting and improvement 51

52 Reporting Requirements 52

53 HCP Reporting For PPS hospitals, it is a requirement of the inpatient and outpatient reporting programs For Critical Access Hospitals (CAH), they have voluntarily signed up for the national Medicare Beneficiary Quality Improvement Program. This program has an annual cycle of September- August. This measure was added to MBQIP in September 2015 For CAH, this measure is required for SQRMS 53

54 Improvement Support MBQIP Update and the Healthcare Personnel Influenza Reporting conference call October 15, 2016 Robyn Carlson, Stratis Health Jennifer Health, Minnesota Department of Health Vicki Tang Olson, Stratis Health 54

55 Improvement Support SAFER Care virtual event for Critical Access Hospitals on November 18, 2015 Strategies to Improve Health Care Personnel Immunization Rates Denise Dunn, RN, MPH Supervisor, Vaccine Preventable Disease Section Minnesota Department of Health 55

56 Improvement Support At November 18 th webinar, also rolled out plan to have monthly data collection faxed to Stratis Health First submission was in December 2015 for months of October and November 32 CAH are participating and have received a blinded graph of comparison results We have just passed the deadline for the second month of data submission 56

57 Comparison Graphs Six graphs Three for percent completion for each of the three groups Three for percent for breakdown of immunizations categories for each group 57

58 Percent Vaccinated 58

59 Employee HCP Numbers 59

60 Q & A 60

61 Who to Count What about a contract service provider such as Access RN who places PICC lines? Where are ED Locum Tenens included in data? We have physician specialists that are contracted; however, they are not paid by our facility. They bill for themselves. Would they fall under this measure? What about healthcare professionals that practice in a specialty clinic that is connected to the hospital, but operate under a different CCN number and are not paid by our hospital payroll? This would include physicians, RNs, med assistants, etc. 61

62 Who to Count We have an attached clinic to our facility. Does that staff count in the denominator? Healthcare personnel working in inpatient or outpatient units of your critical access hospital which share the exact same CMS Certification Number (CCN) as the hospital should be included in your HCP influenza vaccination summary data reports. Assuming that this clinic does not have the same CCN as your facility and/or is not considered a unit of the hospital, you would not count individuals working in this attached clinic unless these individuals also physically work in the critical access hospital for one day or more from October 1 through March 31 and meet the definitions of one of the required denominator categories (employees, licensed independent practitioners, and adult students/trainees and volunteers). 62

63 Who to Count David mentioned registering satellite clinics, but the previous speaker said not to count LIPs who work only in outpatient satellite clinics. So which is it? Healthcare personnel working in inpatient or outpatient units of your critical access hospital which share the exact same CMS Certification Number (CCN) as the hospital should be included in your HCP influenza vaccination summary data reports. As noted above, an outpatient physician clinic would not meet these criteria. Outpatient satellite physician clinics should not be included in your CAH healthcare personnel influenza vaccination summary counts unless the healthcare personnel in these clinics also physically work in the CAH for one day or more from October 1 through March 31 and meet NHSN protocol definitions for an employee, licensed independent practitioner, or adult student/trainee or volunteer. 63

64 Who to Count If an off campus clinic has a different CCN and an employee only comes on hospital campus for meetings, are they still included in the numerator and denominator? If the healthcare personnel are physically present in the CAH during the reporting period of October 1 through March 31 to fulfill official work duties, then you would include these individuals in your numerator and denominator. Work-related meetings, including checking in to receive a work schedule, are considered official work duties; therefore, you would include these employees in the numerator and denominator if they physically enter an inpatient or outpatient unit of the CAH that is included in NHSN reporting for the meetings. 64

65 Who to Count If we have an attached Long term care facility that is separate from our CAH, do we include those employees? You would not include the employees of the long term care facility in your CAH counts, unless these employees also physically work for one day or more in the CAH from October 1 through March

66 Questions? Vicki Tang Olson, Program Manager

67 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-C

68 2 BSI Case Studies Lisa Hesse MLS CIC Case Study Coordinator

69 Primary (1 ) BSI Not related to an infection at another site

70 Secondary (2 ) BSI Associated with an infection at another site Associated infection must meet NHSN definition At least one matching organism OR blood culture used to meet criteria for infection Date of event is date of event of associated infection BSI falls within attribution period for infection [infection window + Repeat Infection Timeframe (RIT)] 2 BSI does NOT have an RIT

71 Secondary BSI 2 BSI does not have RIT CLABSI is never 2 BSI

72

73 Scenario 1a On day 13 of admission, patient has positive urine culture growing >100,000 cfu/ml E coli and suprapubic tenderness On day 18, patient has a positive blood culture growing E coli

74

75 Scenario 1a UTI? 1 or 2 Blood culture? Date of event?

76 X SUTI 1b E coli 2 BC E coli

77 Scenario 1b On day 13 of admission, patient has positive urine culture growing >100,000 cfu/ml E coli and >100,000 cfu/ml C. glabrata and has suprapubic tendernessmeets SUTI criteria for E coli, candida excluded On day 18, blood culture grows C glabrata and S aureus.

78

79 Scenario 1b Is there a UTI? Is there a BSI? 1 or 2? What is reported?

80 X SUTI 1b E coli X LCBI C glabrata and S aureus

81 Scenario 1b Is there a UTI? Is there a BSI? 1 or 2? What is reported? SUTI, DOE day 13 LCBI, C glabrata and S aureus DOE day 18

82 Scenario 2 Positive BC on day 8 of admit, E coli Fever day 8-12 Positive urine culture day 11, >100,cfu/ml E coli and >100,000cfu/ml S aureus

83

84 Scenario 2 Is there a UTI? DOE? Is there a BSI? 1 or 2? What is reported?

85 X SUTI 1b E coli and S aureus, 2 BSI E coli

86 Scenario 2 Is there a UTI? DOE? Is there a BSI? 1 or 2? What is reported? SUTI 1b, E coli and S aureus, secondary BSI E coli, date of event day 8

87 Scenario 2 cont BC on day 20 positive for S aureus 1 or 2 or not reported?

88

89 Scenario 2 cont, 2 BSI, within attribution period (infection window + RIT) DOE day 8

90 Questions?

91 Lisa Hesse