NHSN Training Hospital Infections Disclosure Act HIDA HAI ...

1. NHSN TrainingHospital Infections Disclosure Act (HIDA)HAI Update and Reporting RequirementsSeptember 1, 2010 Dixie Roberts, APRN, MPH Director, Healthcare Infections Section Division of Acute Disease Epidemiology

2. Objectives Discuss expansion & changes in NHSN Discuss HAI Prevention Plan and new resources for information Discuss current Hospital Infections Disclosure Act (HIDA) reporting requirements and expectations for hospital compliance

3. HAI Prevention Planshttp://www.cdc.gov/HAI/HAIstatePlans.html 1. Develop state public health infrastructure for HAI surveillance, prevention and control 2. Surveillance, Detection, Reporting, and Response 3. HAI Prevention 4. Evaluation and Communications

4. SC Public Health Resources 2.0 State funded positions: 1 filled, 1 vacant 3.5 Federally funded (ELC ARRA (exp. 12-11) & ELC Supplement (exp 12-10): Filled, 1.0 hourly FTE, 1.0 FTE Infection Preventionist requested, 0.25 hourly FTE Medical Consultant, 0.75 vacant Contracts SCHA & ORS (support HAI Plan implementation, training, and data needs) ELC Affordable Care Act: (generalists) (exp 12-11) Requested Lab support for HAI Outbreak investigations (PFGE) Surveillance for ARO – Facility reports for state level antibiograms.

5. ELC General Epi, Lab, and IT HAI: grant guidance received Detection and Reporting of Healthcare Associated Infection Data (HAI Surveillance) Improving Antimicrobial Use to Decrease Antimicrobial Use to Decrease Antimicrobial Resistant HAIs and Clostridium difficile infections Implementation of Laboratory Tests for Healthcare-Associated Infections and Antimicrobial-Resistant Pathogens Build Health Department capacity to provide infection control assistance to facilities with limited resources Identify best-value implementation strategies of evidence-based prevention interventions

6. HAI Prevention Resources http://www.cdc.gov/HAI/recoveryact/stateResources/stateResources.html Toolkits: (CLABSI, SSI, CDAD, CAUTI, ……) Criteria for Prevention Collaboratives The best approach to success is to bring aboard those knowledgeable and experienced in multicenter collaborative improvement projects (i.e., recruitment, training, communication). (*consultation available from groups such as: Institute for Healthcare Improvement (IHI) or Fieldstone Alliance .

7. SCHAIP Partnership State Agencies: SC Department of Health and Environmental Control (DHEC) Bureau of Disease Control (Surveillance- Response- Prevention) Bureau of Health Regulations (Licensing and Certifications) Legal Office SC Budget and Control Board - SC Office of Research and Statistics (ORS) SC Department of Health and Human Services (DHHS) -Hospital and LTC SC Department of Labor, Licensing, & Regulations Research Partnership: Health Sciences South Carolina (HSSC) Organizations/ Associations / Businesses: SC Hospital Association Association of Professionals in Infection Control and Epidemiology (APIC) – Palmetto Mothers Against Medical Error (MAME) AARP SC Healthcare Association – SCHCA (represents for profit LTC facilities) Aging Services of South Carolina (ASSC) (represents for profit and non-profit LTCs) Blue Cross/ Blue Shield (quality department) Carolinas Center for Medical Excellence (CCME) Quality Improvement Organization (QIO) Professions / Clinical Services– Individuals: Infectious Disease Physicians & Hospital Epidemiologists Critical Care Manager (CCM)

8. SC HAI Plan Prevention Collaboratives STOP BSI (CLABSI) – SCHA led -ongoing Clostridium difficile (C.diff) (pending resources) Surgical Site Infections (SSI) (pending resources) (future - CAUTI)

9. HAI Prevention Projects and Proposed Projects:  Operation Safe Surgery: SCHA with PHT Services, Ltd. Clean Hands Saves Lives Campaign (healthcare & community settings) MRSA - 9th Scope of Work: CCME (for CMS) is implementing the 9th Scope of Work (MRSA) Antimicrobial Stewardship – individual hospital efforts HICPAC Guidelines and Best Practices Workgroup: (Define, include Revised ARO Guidelines & ARO Strategic Plan) (DHEC, APIC, SCHA, (future)

10. HAI Infrastructure Development and Support Projects & Workgroups:  Lab Capacity and SC HAI Lab Response Network Information Technology HAI Prevention Training HAI Data Quality and Reports: validation, methods, routine reports HAI Outbreaks Surveillance and Response HAI Prevention Laws and Regulations HAI Prevention Research Initiatives HAI Prevention Incentives (future)

11. CDC NHSN NATIONAL Health Care Safety Network Expands HAI surveillance capacity Expands access to quality data –prospective payment rule (e.g. CMS) Provides national HAI Prevention Outcome Measures & Process Measures (clinical care, research) Allows Comparison (National SIR) Provides comparable data for public reporting (transparency) Provides HAI surveillance system for facilities (analysis, reports, trends)

12. Measures Required by States that Use NHSN for Mandatory Reporting (n=21)

14. HHS Action Plan Metrics – Appendix G

15. Patient Protection andAffordable Care Act - 2010

20. Impact of CMS Rule on State Mandated Reporting? HIDA is the law and no changes will be made in state mandates at this time Currently, there are more reporting requirements under HIDA than CMS will initially require Impact over time - to be determined

21. Stay Up To Date!NHSN features are changing frequently www.cdc.gov/nhsn NHSN Newsletters E-mails Communications Send questions via mail to: NHSN@cdc.gov DHEC: Healthcare Associated Infections (HAI) Section DHEC Division of Acute Disease Epidemiology E-mail: HAIPublicInformation@dhec.sc.gov Phone: (803) 898-0861 Dixie Roberts – robertdf@dhec.sc.gov Amber Taylor – tayloral@dhec.sc.gov Stan Ostrawski – ostrawsm@dhec.sc.gov Dr. Kathleen Antonetti – antonekl@dhec.sc.gov Katherine (Kate) Habicht- habichkl@dhec.sc.gov

22. Improvements Planned and Coming Soon CDA implemented for LabID Event Reporting Creating alerts for missing numerators and denominators Adding ability to report zero events Revised definitions for MDR-Klebsiella and MDR-Acinetobacter NHSN drug lists for specific reported organisms will be updated to collect most accurate susceptibility results Update to NHSN website with new area for posting detailed info on content of each release

23. Improvements -continued Developing audit trail for tracking user actions Removing forced regeneration of datasets Switch to Group set-up of templates for Confer Rights Easier creation and group use of Custom Fields Incomplete record notifications are being reconfigured for clearer messages to the user Migration to SAMS and away from Digital Certificates PS Annual Survey update for specific lab testing practices

24. Clinical Document Architecture (CDA) www.cdc.gov/nhsn Health Level 7 (HL7) standard provides framework for format of electronic documents. (electronic lab reporting –ELR) NHSN has been enabled to accept electronic infection reports, denominator data, and process of care data from commercial infection surveillance systems. “To implement CDA for NHSN, please contact your Infection Control Software vendor to inquire about the availability of generating CDA events records for importation into NHSN.” Technical guidance for vendors is on the NHSN web site.  

25. New HAI Information Resources CDC Safe Healthcare blog -multiple ongoing discussions - CAUTI, AR Stewardship, The One and Only campaign, listing of Medscape video's http://blogs.cdc.gov/safehealthcare/ What's new' section on the HICPAC homepage: http://www.cdc.gov/hicpac e.g. Medscape CAUTI video by Dr. Sanjay Saint

26. New HAI Information, cont. * Agency for Healthcare Research and Quality (AHRQ) New series, Best Practices in Public Reporting, No. 1. How To Effectively Present Health Care Performance Data To Consumers (http://www.ahrq.gov/qual/pubrptguide1.htm ) No. 2: Maximizing Consumer Understanding of Public Comparative Quality Reports: Effective Use of Explanatory Information ( http://www.ahrq.gov/qual/pubrptguide2.htm ) No. 3. How to Maximize Public Awareness and Use of Comparative Quality Reports Through Effective Promotion and Dissemination Strategies ( http://www.ahrq.gov/qual/pubrptguide3.htm )

27. HIDA Revisions May 14, 2010 DHEC will submit an annual report by April 15 of each year. HIDA requires reports every six months in the timeframe established by DHEC. Allows DHEC to levy a fine (previously only a condition of licensure HIDA Reporting Months Report Dates q 6 months Dec. 2009 – June 2010 (7 mos) Oct. 15, 2010 Dec. 2009 – Dec 2010 (13 mos) April 15, 2011 Jan 2011 – June 2011 (6 mos) Oct. 15, 2011 Jan 2011 – Dec 2011 (12 mos) April 15, 2012 Data for analysis is available 30 days following the end of the reporting period. The dates DHEC can access the full data set will be August 1 and February 1, leaving about 10 weeks before they are due instead of the previous 18 working days in January.

28. Reporting Compliance Must maintain NHSN enrollment Comply with NHSN Rules Must report infections and prevention processes as required by DHEC

29. 2010 SSI HIDA Reporting Requirements Surgical Site Infections (SSI) for the following procedures, in all hospitals where these procedures are performed (*except where designated only for hospitals < 200 beds). Coronary Artery Bypass Graft (CBGB) (both chest and donor site incisions) Coronary Artery Bypass Graft (CBGC) (with chest incision only) Hysterectomy (abdominal - HYST) Hip – prosthesis- (HPRO) Knee – prosthesis – (KPRO) *Colon (COLO) - (only report from hospitals of 200 beds or less)

30. Methicillin resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI) Microbiology laboratories are required to report all MRSA positive blood culture results, both inpatient and outpatient, with the associated *antibiograms. (DHEC links to discharge data) *Submit the susceptibility results for oxacillin, vancomycin and trimethroprim/sulfamethoxazole for the isolate Currently assessing this surveillance method for completeness of reporting and predictive value positive for the case definition Option if current system is not acceptable: NHSN MDRO Module.

31. CLABSI Reporting Requirements Central Line Associated Bloodstream Infections (CLABSI) in all hospital inpatient categories listed below must be reported into NHSN. Central line denominator data must be entered for all reportable locations as described in the NHSN Protocols. All inpatient units must be assigned a Location Code as defined in the CDC NHSN Protocols All units listed in the following categories are reportable inpatient units (locations). Adult Critical Care Pediatric Critical Care Inpatient Specialty Care Areas Inpatient Adult Wards Inpatient Pediatric Wards Step Down Units

32. New CLABSI Reporting Requirements: January 1, 2011 All hospitals with *Perinatal Centers approved to provide care in the following Neonatal Intensive Care Units (NICU) must report CLABSI into NHSN: Level III Nursery Level II / III Nursery Level II E Nursery (NHSN Location II / III) Current: Greenville Hospital System, McLeod Regional Medical Center, MUSC, Palmetto Health, Spartanburg Regional, Palmetto Health Baptist, Self Regional Health, Piedmont Medical Center; Plus any hospital approved by DHEC in the future to provide care in the reportable nursery categories. *SC State Health Plan – Requires CON – www.scdhec.gov

33. Facilities approved for Level II Nurseries New Reporting Requirement –under consideration All Level II Nurseries must report CLABSI cases in the DHEC Carolina Health Surveillance System (CHESS) on the web or mail reports to DHEC. Incident cases only: name, DOB, specimen collection date, lab results No denominator data is required Hospital responsible for reporting is the one that the infection is attributed to

34. Infection Prevention Processes Reporting Requirements HIDA Report links to SCIP Measures Infection Prevention Process Survey - will be sent out late 2010 or early 2011 Employee Influenza Vaccine Coverage – mandatory reporting under consideration.

35. Infection PreventionistsTHANK YOU FOR ALL YOU DO TO PROTECT US FROM HARM!

36. Combines All locations: Significant decline from 50% above the national SIR to 8% below the national. Critical Care reporting started in 2008 with Inpatient Wards added in 2009 – possibly explaining the difference between the All Locations graph and the Critical Care graph. Combines All locations: Significant decline from 50% above the national SIR to 8% below the national. Critical Care reporting started in 2008 with Inpatient Wards added in 2009 – possibly explaining the difference between the All Locations graph and the Critical Care graph.

37. Critical Care only. Will be important to look at these CLABSI reports by different location categories. Decline from 49% and significantly above the national to 8 % above but statistically not different than the national. Critical Care only. Will be important to look at these CLABSI reports by different location categories. Decline from 49% and significantly above the national to 8 % above but statistically not different than the national.

38. Essential Actions to Comply with HIDA Reporting Requirements True / False 1. Must report all SSIs into NHSN 2. Must maintain NHSN enrollment 3. Must comply with NHSN Rules 4. Must report VAPs into NHSN 5. Must report infections and prevention processes as required by DHEC 6. Must assign rights to DHEC