J-9__Healthcare-Associated_Infections_and_the_National_Healthcare_Safety_Network_07102015.docx

J Attachment 17

Attachment J.9

Patient Safety: Healthcare-Associated Infections and the National Healthcare Safety Network (NHSN)

Table of Contents

I. Introduction

The National Healthcare Safety Network (NHSN) is a secure, Internet-based surveillance system developed and maintained by the Centers for Disease Control and Prevention (CDC). NHSN tracks data on healthcare-acquired infections (HAIs) in the dialysis setting, known as “dialysis events” in NHSN.

NHSN collects data on 3 types of dialysis events (http://www.cdc.gov/nhsn/PDFs/pscManual/8pscDialysisEventcurrent.pdf :

Three types of dialysis events are reported by users: IV antimicrobial start; positive blood culture; and pus, redness, or increased swelling at the vascular access site. An additional four types of dialysis events are generated from the reported data: bloodstream infection (BSI), local access site infection (LASI), access-related bloodstream infection (ARB), and vascular access infection (VAI).

CDC defines BSI as “Any positive blood culture.” See http://www.cdc.gov/nhsn/PDFs/pscManual/8pscDialysisEventcurrent.pdf.

The Network shall support facility enrollment in NHSN and reporting of dialysis event data, serve as the group administrator for the NHSN database system for the facilities in the Network’s service area, and support NHSN data quality.

This Attachment describes how the Network shall support dialysis facilities in complying with CDC requirements for entering data into NHSN.

The reporting protocol, data collection forms, guidance documents, and other resources can be found at http://www.cdc.gov/nhsn/dialysis/dialysis-event.html.

The NSHN Helpdesk, available by e-mail at nhsn@cdc.gov, is available to provide support for NHSN enrollment and reporting.

II. NHSN Enrollment

When the Network learns that a new facility has opened, or is about to open, in the Network’s service area, the Network shall contact the new facility and train its staff on how to enroll in NHSN.

Instructions for the five-step facility enrollment process and associated documents are found at http://www.cdc.gov/nhsn/PDFs/dialysis/NHSN-de-New-User-Checklist.pdf. The Network shall educate facilities on the enrollment guide, checklist, FAQs, and other technical assistance documents provided by CDC.

III. Establishment and Use of NHSN Groups

The Network shall establish and use NHSN groups in order to view data for dialysis facilities in its service area. “Groups” are a database tool used to share select data with appropriate users. Each facility must identify its Network in NHSN for its facility data to appear in the Network’s reports. The Network shall obtain group administrator rights from every facility in the Network’s service area.

III.A. Group Administrator Instructions

The NHSN Group Administrator Guide can be accessed from the Dialysis Event home page or at http://www.cdc.gov/nhsn/PDFs/GroupAdminStartupGuideCurrent.pdf.

III.B. Obtaining Rights to Facilities

For instructions on how to join a group and confer rights to facility data, the Network can refer facilities to http://www.cdc.gov/nhsn/PDFs/dialysis/NHSN-Join-Group-Sharing-DE-data-1-2012.pdf.

IV. Dialysis Event Reporting in NHSN

As directed by CMS, the Network shall assist facilities to ensure that data are entered into NHSN accurately and in a timely manner.

IV.A. Tracking Reporting

The “Line Listing – CMS ESRD QIP Rule” report is available for the Network to run at any time; this report summarizes the completion of minimum NHSN Dialysis Event reporting requirements by facility and month. This report can be used to obtain a count of facilities that have reported NHSN dialysis event data for any given month. The Network can use this information to calculate Network-wide reporting rates and to follow up with facilities that have not yet reported. A quick reference guide, located at http://www.cdc.gov/nhsn/PDFs/dialysis/CMS-QIP-NHSN-report.pdf, summarizes how to run and interpret this report.

Additional information on analysis and reports is found in the Dialysis Event Surveillance Manual, available at http://www.cdc.gov/nhsn/PDFs/pscManual/Dialysis-Manual.pdf IV.B. Tracking Data Quality

For guidance on tracking data quality, see Appendix 3 of the NHSN Dialysis Event Surveillance & Reporting Data Quality Evaluation – Project Implementation Guide at http://www.cdc.gov/nhsn/PDFs/dialysis/DE-Data-Quality-Evaluation-Implementation-Guide.pdf.

Other reports available in NHSN can be used to identify data quality issues. Such reports include, but are not limited to:

Line Listing – All DE Denominators: This report provides a summary, by month, of each facility’s number of maintenance hemodialysis outpatients categorized by vascular access type, reported using the Denominators for Outpatient Dialysis Census Form. It provides an estimate of the number of maintenance hemodialysis patients at risk of a dialysis event, per facility, per month.

Line Listing – Frequency of Dialysis Events: This report provides a summary, by month, of each facility’s number of dialysis events (i.e., numerator data). It includes counts for the numbers of IV antimicrobial starts, bloodstream infections, local access site infections, access-related bloodstream infections, and vascular access infections reported by each facility.

Line Listing – Dialysis Events (detailed): This report lists dialysis events by facility, by row. Each row summarizes the information reported using a Dialysis Event form. It indicates event characteristics including patient’s vascular access type(s), transient status, dialysis event type(s) and details, and problems and outcomes associated with the event.

The NHSN Helpdesk, available by e-mail at nhsn@cdc.gov, can provide guidance on running and interpreting these reports.

IV.C. Creating Reports

Several NHSN reports are available to provide information on facilities in an NHSN group. Examples of reports that can be used to indicate which facilities have enrolled in NHSN and have joined the Network group are the “Rights Acceptance” report and the “Line Listing – Membership Rights” report. In addition to facility identification, the “Rights Acceptance Report” indicates whether the facility has accepted the Rights Template to share data with the group, and if accepted, the date on which it was accepted. The “Line Listing – Membership Rights” report indicates the type of data that the facility has agreed to share with the NHSN group and the timeframe in which data will be shared.

V. NHSN Data Checks

V.A. Quarterly Data Checklist

With the assistance of its Contracting Officer’s Representative (COR), the Network shall help facilities improve facility processes and resolve any identified data issues related to individual patients or the facility. The Network shall use the CDC-created checklist to perform quarterly NHSN data checks (see Table X).

Table X. Timeframe for completion and reporting of quarterly data checks

The Network shall provide feedback on the results from the checklist to CDC during bi-annual conference calls and follow up with facilities on an ongoing basis to correct data errors.

The following questions will be asked of Networks during the bi-annual calls, and Networks will be asked to participate in discussions related to these feedback items:

1. How did you define outliers for the different checklist elements?

2. Which checklist item(s) was most successful at helping to identify errors that warranted correction?

3. Any other comment on the value of these checklist items or other potential error types that should be assessed?

4. Do you have any suggestions for changes that could be made to NHSN educational materials or user interface to prevent future errors?

NHSN QUARTERLY DATA CHECKLIST

Denominator data review: Activity 1 provides instructions for reviewing denominator data to identify facilities with unusual monthly census data or unusual rates for individual vascular access types.

Numerator data review: Activities 2, 3 and 4 provide instructions for identifying any facilities that have not reported dialysis events for 3 or more consecutive months or that have a population at high risk for Blood Stream Infection but have not yet reported any BSIs.

#1: Identify facilities with unusual monthly vascular access data #2: Identify facilities with potential 21 day rule violations #3: Identify facilities that have not reported events for ≥3 months #4: Identify facilities with potentially erroneous BSI reporting.

Provide feedback in the monthly report to the COR (for the period as specified in the SOW).

Checklist Activity #1

· Identify facilities with unusual monthly denominator values for specific vascular access types

· Review vascular access rates in your Network service area that could indicate a potential data quality issue An unusually high or unusually low vascular access rate may represent a misunderstanding of the Dialysis Event Protocol or the use of an electronic report that does not match NHSN reporting definitions.

· Review changes in the percentage of each vascular access type reported by the facility from month to month A drastic change in the reported percentage of patients with each access type from one month to the next may represent an error.

Checklist Activity #2

· Identify facilities that have reported 2 dialysis events of the same type for the same patient whose event dates are less than 21 days apart Review the ‘Line Listing – 21 Day Rule Checks’ to identify facilities with potential 21 day rule violations

Checklist Activity #3

· Identify facilities that have reported no events for ≥3 consecutive months Depending on facility census, 3 consecutive months of reporting no dialysis events may represent poor surveillance or documentation practices, or a misunderstanding of the Dialysis Event Protocol.

This does not apply to facilities that have not yet reported, but only those facilities that have chosen to report no events by checking the box(es) on the denominator form.

Review the ‘Line Listing – 0 Dialysis Events (Any Type) >3 Months’ to identify facilities that have reported no events for >3 consecutive months

Checklist Activity #4

· Identify facilities with potentially erroneous BSI reporting

· First identify facilities in the top 25% of your Network’s distribution of % “Any CVC” The “Any CVC” category includes both tunneled and non-tunneled central lines.

· Next, determine whether any of the top 25% “Any CVC” facilities have reported 0 BSIs for 3 or more consecutive months

V.B. Facility Follow-Up

The Network shall choose the best way to follow up with facilities based on the number of facilities with potential data quality issues identified. When following up with facilities the Network shall:

Identify any misunderstanding of the Dialysis Event Protocol Investigate potential data entry errors Instruct the facility to correct errors Point the facility to CDC training resources.

VII. Quality Improvement Activity

By January March 31 of the base contract year, the Network shall begin a QIA focused on reducing BSIs. Revisions to the QIA will be completed by January 31st of each Option year as directed by the SOW. The QIA shall include at least 20% of Network facilities and Networks shall demonstrate a 5% or greater relative improvement in the pooled mean BSI of the QIA facilities at re-measurement compared to baseline. During the QIA, Networks shall educate facilities on implementation of the CDC recommended interventions to prevent BSIs in hemodialysis patients (http://www.cdc.gov/dialysis/prevention-tools/core-interventions.html).

VII.B. Guidance for Data Collection and Submission by the Network

The Network shall report monthly progress on the CMS Network DIF.

The NHSN Rate Table – Bloodstream Infection Data report can be used to identify the numerator (number of bloodstream infections) and denominator (patient-months) for each QIA facility for each quarter of the contract period. The numerator and denominator for each QIA facility should be pooled and the pooled mean BSI reported on the CMS dashboard input form. CDC will provide guidance on how to create the rate table report for monitoring QIA facilities.

Quarterly pooled mean BSI calculation for selected timeframe, per 100 patient-months:

(sum of QIA facility numerators/sum of QIA facility denominators) x 100

The Network shall report quarterly progress (see Table 1).

Table 1. Quarterly reporting of pooled mean BSI for QIA facilities.

The Network shall report baseline and remeasurement data for each contract year (see Table 2).

Table 2. Baseline and remeasurement reporting on CMS DIF.

Numerator (number of bloodstream infections) and denominator (patient-months) data can be found in the NHSN Rate Table – Bloodstream Infection Data report.

1st and 2nd quarter pooled mean BSI should be calculated using the following formula:

[(Sum of half year QIA facility numerators) / (Sum of half year QIA facility denominators)] x 100

VIII. Establish HAI LAN The primary focus of the HAI LAN is to improve information communication across care transitions, specifically between hospitals and dialysis centers caring for the same ESRD patients. The Network shall coordinate with its local QIO(s), state/local health departments, state survey agencies, and hospitals to support the communication and data quality improvement activity. More detail about the function of the LAN can be found in SOW Section C.4.3.B.

IX. Support Facilities in Completing Annual NHSN Dialysis Event Surveillance Training The Network shall provide education to all facilities regarding completing the annual online NHSN Dialysis Event Surveillance Training (http://nhsn.cdc.gov/nhsntraining/courses/C18/). To assist Networks with identifying users who have not yet completing the online training, CDC will provide Networks a quarterly report listing the facilities in their Network which have completed the online training requirement. At the end of 3rd quarter of each contract year, the Network shall report to CMS the percent of Network facilities who have completed the online training during that contract year. The Network should achieve at least 90% of Network facilities completing the online training by the end of 3rd quarter.

Percent of Network facilities completing training = (Number of eligible Network facilities with ≥1 facility-level staff completing training /Number of NHSN QIP-measure eligible facilities in Network) x 100

X. NHSN Data Quality Improvement Activity

Provide feedback to CMS bi-annually using the form provided by CDC.

Data for baseline, remeasurement, and monitoring reporting on the CMS DIF can be found in the NHSN Line Listing – Frequency of Dialysis Events report.