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Presentation to: Georgia Hospital Association

NHSN Reporting for Laboratory-identified Clostridium difficile Infection (CDI) and Methicillin-resistant Staphylococcus aureus (MRSA) (Bacteremia). Presentation to: Georgia Hospital Association Presented by: Jeanne Negley, MBA, Healthcare Associated Infection Coordinator

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Presentation to: Georgia Hospital Association

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  1. NHSN Reporting for Laboratory-identified Clostridiumdifficile Infection (CDI) and Methicillin-resistant Staphylococcus aureus (MRSA) (Bacteremia) Presentation to: Georgia Hospital Association Presented by: Jeanne Negley, MBA,Healthcare Associated Infection Coordinator Date: November 15, 2012

  2. Purpose of MDRO and CDI Lab ID Event Reporting • To calculate proxy measures of MDRO and CDI events, exposures, and healthcare acquisition. • Provide a monitoring method that enables a facility to rely almost exclusively on data obtained from the laboratory. • Also provide a mechanism for facilities to report and analyze MDRO and CDI data to inform infection control staff of impact of targeted prevention efforts.

  3. CMS Reporting Requirements • Laboratory-Identified (Lab-ID) MRSA (bacteremia) and CDI in NHSN • Begins January 2013 for Inpatient Quality Reporting Program for hospitals • Overall Facility-Wide Inpatient (LabID, Method C) • Laboratory-Identified (Lab-ID) module • Not an infection event surveillance module • Lab-ID is a laboratory driven surveillance process

  4. We are not following CDI infection event surveillance module

  5. LAB ID MDRO/CDI Reporting References NHSN MDRO/CDI Module: http://www.cdc.gov/nhsn/mdro_cdad.html MDRO/CDI NHSN Protocol: http://www.cdc.gov/nhsn/PDFs/pscManual/12pscMDRO_CDADcurrent.pdf CDC Location Labels and Location Descriptions: http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf Table of Instructions: (Make sure you review instructions for Lab ID for MRSA and CDI.) http://www.cdc.gov/nhsn/PDFs/pscManual/14pscForm_Instructions_current.pdf NHSN definitions can change; consult on-line references.

  6. Reporting Forms Enter Online. Hardcopy Paper Forms Available.(http://www.cdc.gov/nhsn/mdro_cdad.html) • Monthly Reporting Plan • Laboratory-Identified MDRO/CDAD Event Form • This is the numerator: one form per LabID event • MDRO and CDAD Prevention Process and Outcome Measures Monthly Monitoring Form • This is the denominator: Inpatient – total patient days, admissions

  7. Starting with Reporting Plans and Denominators • Input Monthly Reporting Plans • Recommend input for entire year • Incorrect /incomplete reporting plans affect reporting to CMS • Map all inpatient locations • Both Lab ID MRSA (blood only) and CDI (stool) are for entire facility (all locations)

  8. Patient Safety Monthly Reporting Plan Reporting PlanAdd. Input Month and Year. Scroll down page.

  9. Reporting Plan (Cont.) 1 2 4 5 3 6 Input “FacWideIn” for MRSA. Check Lab ID Event Blood Specimen Only Add Row to input CDI plan Input “FacWideIn” for CDI Check Lab ID Event All Specimens for CDI Select “Copy from Previous Month” to input multiple reporting plans.

  10. Summary Data Requirements MRSA Blood Cultures:FacWideIn = Total inpatient admissions and total inpatient days for the month. CDI: FacWideIn = Total inpatient admissions and total inpatient days minus admission/pt days accrued in a NICU or well baby nursery.

  11. MRSA Overall Facility-Wide Inpatient Patient Days = 2950, Admissions = 300 MICU Wards SICU Pediatric ICU and Wards Well Baby Nurseries & NICUs Reference: CDC location list

  12. CDI Overall Facility-Wide Inpatient Patient Days = 2600, Admissions = 250 MICU Wards SICU Pediatric ICU and Wards Reference: CDC location list Exclude well baby nurseries & NICUs. Include maternity patients and newborn readmitted to pediatricunit. Exclude Well Baby Nursery& NICU

  13. Locations not included in Facility-Wide Inpatient • Outpatient Dialysis • Operating Rooms • Clinics • Outpatient lab results • Do NOT include: • Emergency Department • Observation Units (<24 hour stay) • Outpatient Surgery • Outpatient Radiology • Outpatient Chemotherapy/Infusion Service ADDITIONAL RULES: Emergency Department: If ED pt is admitted as inpatient and lab collected same day as admit, you can report result. Applies to any outpatient location. Observation Bed Patients in Inpatient Setting: These patients are counted as inpatients.

  14. Inputting Denominator Data (1 of 2) Summary DataAdd. Select “MDRO and CDI Prevention Process and Outcome Measure Monthly Monitoring. Input denominator data every month; even if you do not have infection events.

  15. Inputting Denominator Data (2 of 2) For MRSA For CDI

  16. MRSA Bacteremia Events(Numerator)

  17. MRSA Definitions • MRSA: S. aureus testing oxacillin-resistant, cefoxitin resistant, or methicillin-resistant by standard • susceptibility testing methods, or by a laboratory test • that is FDA-approved for MRSA detection from isolated • colonies • MRSA Isolate: Specimen obtained for clinical • decision making that tests positive for MRSA • Active surveillance testing specimens (e.g., nasal screen) do not count as clinical specimens • MUST have a method to differentiate clinical vs. • surveillance cultures (speak with lab)

  18. MRSA Definitions—Blood Culture Only • MRSA Blood Isolate LabID Event: All non-duplicate MRSA blood isolates • Duplicate MRSA Blood Isolate: MRSA+ blood culture from the same patient and location, following a previous positive MRSA-positive blood culture within the past 2 weeks (14 days) • There should be a full 14 days with no MRSA-positive blood culture for the patient and location before another blood isolate LabID event is entered into NHSN for that patient

  19. Identifying a Lab ID MRSA Event (+) MRSA blood culture test result (taken for clinical purposes) Prior (+) in< 2 weeks? No Yes Lab ID Event Duplicate MRSA Test Not a Lab ID Event

  20. MRSA Event Example (1 of 3) As part of the data review, Betty Brown (infection preventionist) identifies new MRSA Lab Events (blood cultures only). For example, Ms. Doe has 5 blood samples reported (+) for MRSA. Applying the 14-day rule, only 3 of the 5 samples will be reported.

  21. MRSA Event Example (2 of 3) Betty proceeds to complete a Lab ID MDRO or CDI event for each of the three unique events. EventAdd.

  22. MRSA Event Example (3 of 3) Always the same Always the same Location = where specimen collected Auto-fill If pt. d/c in past 3 months, input yes and d/c date. Save.

  23. Lab ID Event CDI(Numerator)

  24. Definitions Laboratory-Identified (Lab-ID) CDI event: Any non-duplicate CDI-positive assay on unformed stool. CDI-positive Lab Assay: Positive lab assay for C. difficile toxin A and/or B, or toxin-producing organism detected from stool culture or other lab means. Duplicate C. difficile-positive test: CDI-positive assay from same patient within 2 weeks of previous positive assay.

  25. Identifying a Lab ID CDI Event (+) C. difficile test result(on unformed stool) Prior (+) in< 2 weeks? No Yes Lab ID Event Duplicate C. difficile Test Not a Lab ID Event

  26. CDI Event Example (1 of 3) As part of the data review, Betty Brown identifies new cases of C. diff. Applying the 14-day rule, only the first of the 2 (+) stool specimens will be reported as a LabID event.

  27. CDI Event Example (2 of 3) EventAdd Auto-fill

  28. CDI Event Example (3 of 3) Always the same Always the same Always the same Auto-fill Auto-fill Location = where specimen collected Auto-fill If pt. d/c in past 3 months, input yes and d/c date. Save.

  29. Lab ID Event Categories You do not have to calculate these rates. NHSN will do this for you!

  30. CDI Only LabID Events Categorized through NHSN Calculations as • Incident CDI Assay: new cases (specimen obtained >8 weeks after the most recent LabID Event). • Recurrent CDI Assay: CDI LabID Event from specimen obtained > 2 weeks and < 8 weeks after the most recent LabID Event.

  31. LabID Events Categorized through NHSN Calculations as Healthcare Facility-Onset (HO): LabID Event from specimen collected >3 days after admission to the facility (= on or after day 4) Discharge Admission CO* HO 2 d < 4 weeks 4-12 weeks >12 weeks CO CO-HCFA Indeterminate * Depending upon whether patient was discharged within previous 4 weeks, CO-HCFA vs. CO (CDI only) Day 1 Day 4

  32. LabID Events Categorized through NHSN Calculations as 2) Community-Onset (CO): LabID Event from specimen collected from an outpatient or inpatient ≤ 3 days after admission to the facility (Day 1, 2 or 3 with date of admission as Day 1) Discharge Admission CO* HO 2 d < 4 weeks 4-12 weeks >12 weeks CO CO-HCFA Indeterminate * Depending upon whether patient was discharged within previous 4 weeks, CO-HCFA vs. CO (CDI Only) Day 1 Day 4

  33. CDI Only LabID Events Categorized through NHSN Calculations as 3) CO Healthcare Facility-Associated (CO-HCFA): CO LabID Event collected from a patient who was discharged from this facility ≤ 4 weeks prior to stool collection Discharge Admission CO* HO 2 d < 4 weeks 4-12 weeks >12 weeks CO CO-HCFA Indeterminate * Depending upon whether patient was discharged within previous 4 weeks, CO-HCFA vs. CO Day 1 Day 4

  34. Facility Healthcare Facility-Onset Incidence for Lab ID Event # of all Incident HO LabID Events per month in the facility # of patient days for the facility X 1,000 for MRSAor X 10,000 for CDI Note: There are several prevalence and other incident metrics not included in this presentation.

  35. MRSA Blood Lab ID FacWideIn Risk Adjustment Variables

  36. CDI Lab ID FacWideIn Risk Adjustment Variables

  37. Using Electronic Surveillance Systems (1 of 3) • Includes data mining software (MedMined, Safety Surveiller, Theradoc, etc.). • Use a positive culture listing; not HAI listing. • Emergency Department: may need to designate as “Inpatient & Outpatient” location. • Watch for duplicates (within the same month or month to month). • Once you retrieve data, you can manually enter into NHSN or prepare to upload electronically.

  38. Validating Electronic Data (2 of 3) • VALIDATE your Electronic Reporting System • Compare your electronic IC system totals for patient days and admissions against alternate source, like a financial report, using NHSN definitions. • Does your system count each transfer between units during same admission as a new admission? • Does your system count only the Mom or both Mom & Baby (for CDI)? • Does your system count a patient as discharged from your facility within the last 3 months if they were in for outpatient Lab work last week, but had no inpatient admission/discharge for over a year?

  39. Validating Electronic Data (3 of 3) • Before submitting your data: • Confirm your Positive Culture List against selected patients for download. • If they don’t match, you may need to manually add or delete cases. • Verify report is complete and fix any issues found during validation • For example, discharged from facility within last 3 months

  40. FAQ (1) 1) What is the most important action to prepare to report Lab-ID MRSA and CDI? Obtain a listing of MRSA (bacteremia) and CDI from your laboratory. Smaller hospitals that have fewer events can request a list of organisms. This is the best method to know that your data are correct; it is not recommended that you rely on reports to the Infection Prevention team. Sample Spreadsheet for Lab Line ListDirections to Use Lab Line List

  41. FAQ (2) 2) What if a smaller hospital admits a pt to a larger hospital in the same health system, and this pt has a positive CDI assay from the smaller hospital? You can report the positive lab if the admission to the new location is on the same day the specimen was collected. This applies to transfers from any other facility or outpatient location.

  42. FAQ (3) 3) If we have a number of admits for each unit, would you count a transfer from one unit to another as an admit? No. Facility-Wide Inpatient Admission Count: Include any new patients that are assigned to a bed in any inpatient location within the facility at the time of the facility-wide admission count. Qualification as a new patient means that the patient was not present on the previous calendar day at the time of the patient day count. The daily admission counts are summed at the end of the calendar month for a monthly facility-wide inpatient admission count. http://www.cdc.gov/nhsn/PDFs/PatientDay_SumData_Guide.pdf

  43. FAQ (4) 4) What if I have a patient that completed his stay at my hospital and then a week later as an outpatient had a specimen drawn that was positive for CDI? We are reporting Lab ID CDI or MRSA for facility-wide inpatient (FacWideIn). Inpatient and outpatient reporting for Lab ID CDI cannot be mixed. Therefore, you do not include outpatient specimens in your reporting for FacWideIn. (You may include this data in your internal reporting system, but do not input into NHSN.)

  44. FAQ (5) 5) When counting patient days and admissions, do we include “observation” patients? As long as a patient is on an outpatient observation unit, you would not count the observation days as patient days. The date of admission will be the date of admission to an inpatient unit. However, if an observation patient is located on an inpatient unit (like a medical ward), you would count the observation days as patient days, with the date of admission being the date of admission to the inpatient unit.

  45. FAQ (6) 6) A patient had a MRSA-positive blood culture obtained in the ED and was admitted to an inpatient unit on the same day. How do I report this LabID event? If the date of specimen collection in the ED and the date of admission to the inpatient unit are the same calendar date, report the LabID event for the ED and the inpatient unit. If the patient was admitted to the inpatient unit on a later date, you report the event for the ED only.

  46. FAQ (7) 7) My facility has a rehab unit with a different CMS Certification Number than the rest of the facility. Should this unit be included in LabID surveillance? If a unit is considered a part of the facility (not just sharing walls) and there is potential for patient and staff contact across units, the unit should be included in FacWideIN LabID surveillance.

  47. FAQ (8) 8) As a follow-up to the previous question, my facility discharges patients before counting them as new admissions to the rehab unit. If I include rehab admissions in my monthly FacWideIN summary data, patients who went from the hospital to the rehab unit will be counted twice. What should I do? We don’t want to double-count admissions. If it’s not possible to distinguish between patients who arrived from the facility and those who arrived from elsewhere, exclude rehab admissions in your FacWideIN counts. Continue to include rehab patients in patient-day counts.

  48. Announcement 1 CDC expects to release version 7.1 of NHSN on February 16, 2013. New release will include updated protocol (e.g., present on admission, etc.) We suggest you wait until new release before entering 2013 data.

  49. Announcement 2 Get Smart About Antibiotics Week (November 12-18, 2012). Tools for your antibiotic stewardship program: http://www.cdc.gov/getsmart/healthcare/ Get CME/CE on antibiotic stewardship: http://www.cdc.gov/getsmart/healthcare/learn-from-others/CME/antimicrobial-resistance.html#Stewardship

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