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HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM

Introduction to NHSN

Basics of Infection PreventionHealthcare-Associated Infections Program

Center for Health Care QualityCalifornia Department of Public Health

Last Updated 2017

Objectives

• Describe National Healthcare Safety Network (NHSN) and key terms

• Review mandatory HAI surveillance and reporting requirements

• Demonstrate how to use NHSN

• Review how to interpret NHSN reports

• Report numerator and denominator data monthly per NHSN protocol for:• Central line associated bloodstream infections (CLABSI)• MRSA bloodstream infections • VRE bloodstream infections • C. difficile infections (CDI)• Surgical site infections for 28 procedures (SSI)

• Report central line insertions practices (CLIP) adherence data for each line inserted in critical care areas

California Required HAI Reporting by Hospitals

Additional Federal HAI Reporting Requirements

• All U.S. acute care and long-term acute care (LTAC) hospitals required by CMS to report into NHSN for Medicare reimbursement

• HAI reportable for CMS but not in CA mandates• CAUTI in hospital ICUs and medical, surgical, and

med/surg wards• Ventilator-associated events (VAE) in LTAC ICUs and wards

Healthcare Facility HAI Reporting Requirements to CMS via NHSNhttps://www.cdc.gov/nhsn/PDFs/CMS/CMS-Reporting-Requirements.pdf

Federal HAI Reporting in Non-Hospital Settings

Required by CMS • Outpatient hemodialysis• Inpatient free standing rehabilitation facilities• Inpatient free standing psychiatric facilities• Ambulatory surgery centers

Healthcare Facility HAI Reporting Requirements to CMS via NHSN http://www.cdc.gov/nhsn/PDFs/CMS/CMS-Reporting-Requirements.pdf

National Healthcare Safety Network

• Centers for Disease Control and Prevention (CDC) surveillance system for HAI reporting from hospitals, long term care facilities, and hemodialysis clinics• Provides standardization • Used by CDPH, CMS, and others to receive HAI data• Data used for HAI public reporting and pay for

performance programs• Accessed through a secure, web-based interface; open to all

U.S. healthcare facilities at no charge

NHSN Strengths

• Provides standards for surveillance across health care facilities

• Data is risk-adjusted for comparison to national data• Web-based; data housed remotely• Includes data quality checks• Data analysis tools are built-in• Allows electronic reporting using national electronic health

record standards (e.g., HL7, CDA)• Expandable to many health care settings

NHSN Data AccessFacilities own their NHSN surveillance data and:• May edit data at any time to improve accuracy and

completeness• May join NHSN groups to confer rights for data access

• Healthcare organizations, CDPH (join one or more)• Facilities within a group cannot see each other’s data

• Are mandated to allow CDPH access to specific NHSN data• Signed a data use agreement with CDC which allows CMS

access to specific NHSN data

Enrolling Hospitals into NHSN• Hospitals enroll on the NHSN website www.cdc.gov/nhsn• California hospitals should already be enrolled

Accessing NHSN

• Each hospital must assign a Facility Administrator (FA)• Receives all NHSN communications• Assigns new users• Has full rights and can assign user rights as needed• Can create user groups

• To become an NHSN user• FA must request NHSN for new user via e-mail• NHSN then invites the new user via e-mail

• All NHSN users must apply for a Security Access Management Services (SAMS) card to access NHSN

NHSN Information for Enrolled Facilities

• Educational modules

• CMS requirements• Links to emails and

newsletters• Training protocols,

forms, support materials, analysis resources, FAQ

NHSN Websitehttps://www.cdc.gov/nhsn

NHSN Structure

NHSN Overviewwww.cdc.gov/nhsn/PDFs/pscManual/1PSC_OverviewCurrent.pdf

NHSN Structure: Patient Safety Component

NHSN Overviewwww.cdc.gov/nhsn/PDFs/pscManual/1PSC_OverviewCurrent.pdf

NHSN Structure: Healthcare Personnel Safety Component

NHSN Healthcare Personnel Safety Componenthttps://www.cdc.gov/nhsn/pdfs/hps-manual/hps_manual-exp-plus-flu-portfolio.pdf

NHSN Structure – Long Term Care Facility Component

NHSN Long-term Care Componenthttps://www.cdc.gov/nhsn/ltc/index.html

Access NHSN via Secure Web Portal Using SAMS Card

CDC Location Mapping• Each NHSN patient care area is defined by the type of

patients receiving care in that location

• Define (or redefine) a patient care location:

• Step 1: Determine the acuity level (e.g., critical care, ward)

• Step 2: Determine the type of service (e.g., burn, surgical, cardiac)

• Hospital designates the location type

• Important to review location mapping yearly to ensure correct risk adjustments by NHSN for each location

NHSN Patient Safety Manual: Chapter 15

Determining NHSN Location

• Apply 80% Rule to designate patient type in most locations• Patient care area is comprised of at least 80% patients

of the same acuity level

• Apply 60% Rule for medical/surgical mixed units • If more than 60% are medical patients, define as a

medical location • If more than 60% are surgical patients, define as a

surgical location

NHSN Patient Safety Manual: Chapter 15

Add Your Monthly Reporting Plan19

Add Monthly Summary Data - CLABSI

Add Monthly Summary Data – MDRO / CDI21

Add Monthly Surgical Procedure Data22

Add Event - CLABSI, MRSA/VRE BSI, CDI, SSI, CLIP

Key Terms - 1

• Colonization and inflammation are NOT infections

• Colonization – presence of microorganisms on skin, mucous membranes, in open wounds, or in excretions or secretions but are not causing adverse clinical signs or symptoms

• Inflammation – results from tissue response to injury or stimulation by noninfectious agents, such as chemicals

Key Terms - 2

• Inpatient vs Outpatient

• NHSN Inpatient: a patient whose date of admission to the healthcare facility and the date of discharge are different calendar days

• NHSN Outpatient: patient whose date of admission to the healthcare facility and the date of discharge are the same day

NHSN Standardized Infection Ratio (SIR)

• Driven by need for a summary measure• Replaces multiple rate comparisons for SSI

• Adjusts for differences in infection risk• e.g., by type of procedure and associated risk factors of

patients undergoing that procedure in your hospital

NHSN Standardized Infection Ratio (SIR) - 2

• SIR compares the number of HAI reported by your hospital with the predicted number of HAI derived from NHSN referent data from 2015

• CLABSI • MRSA BSI • CDI• SSI • CAUTI

Interpreting SIR• SIR= 1.0

• Number of HAI observed in your hospital is the same as the predicted number of HAI for your hospital as derived from NHSN national referent data

• SIR <1.0• Fewer HAI observed than predicted

• SIR >1.0 • More HAI observed than predicted

Note: The SIR will only be calculated, in NHSN, for your hospital if the predicted is >1 because you cannot have less than one whole person infected

NHSN: A Guide to the SIR

NHSN: A Guide to the SIRhttps://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/nhsn-sir-guide.pdf

• How to interpret SIR• How SIR is calculated• Risk adjustment factors

for specific HAI

Calculating SIR

Examples:• If your hospital has 2 CLABSI per 1000 line days and national

data predict 2.0 CLABSI per 1000 line days: SIR = 2 = 1.0

• If your hospital has 4 SSI per 100 hip prosthesis procedures and national data predict 2.5 SSI:

SIR = 4 = 1.62.5

Determine if an SIR is Significantly Different than NHSN Data

The observed difference is not statistically significant if: • The p-value >0.05, or • The 95% confidence interval includes 1.0

• If the p-value is not significant, the confidence interval won’t be significant either and vice versa

• The confidence interval indicates precision as well as significance.

SIR Interpretation

Describe findings: 1. “We had 9 CLABSI in 2016; 7.2 were expected. Our SIR is 1.25 or 25%

higher than what would be predicted from national data.”2. “However, this difference is not significantly different than that predicted

by the national hospital data because our estimate is not very precise.” *3. “In fact, our SIR may be anywhere from 35% below to more than double

the predicted value (.65 – 2.2).” 4. “We will continue to monitor CLABSIs. Observations over time (and more

line days) will help us better understand how we compare. Our ultimate goal is to prevent all CLABSIs.”

* Due to limited surveillance experience, e.g., too few line days across hospital units with predicted low rates.

SIR Interpretation - 2

Describe findings: 1. “We saw 74 CLABSI in 10,065 line days; 26.6 were predicted.” 2. “The SIR is 2.78, or nearly 3 times higher than what would be

predicted from national data.”3. “This is significantly different than the national hospital data.”4. “In fact, the precision of this estimate shows that our hospital is

between 2 and 3 ½ times higher than predicted (C.I. 2.2 – 3.5).” 5. “We need to implement a CLABSI prevention program immediately.”

SSI Risk Adjustment• Models have been developed for each NHSN operative

procedure• Specific factors found to increase SSI risk for that

procedure• Every patient undergoing a procedure in your hospital has a

calculated SSI risk probability• Predicted number of SSI calculated by summing risk

probabilities for your hospital’s surgical patients

SSI Risk Adjustment - 2Example: HYSTFactors in the risk adjustment model that add to SSI risk are: • Diabetes• ASA score • Hospital bed size (from the annual survey)• Scope• Age• Duration of procedure• BMI

NHSN: A Guide to the SIRhttps://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/nhsn-sir-guide.pdf

SSI Risk Adjustment - 3This table represents a partial list of 100 hypothetical patients who have undergone a HYST procedure and the risk factors present for each

Retrieve Your Facility’s Data• Generate a data set after all data are entered before running

a report• Generating a data set retrieves a copy of your hospital data

from NHSN• Data sets are specific to each NHSN user

HEALTHCARE-ASSOCIATED INFECTIONS PROGRAMNHSN Analysis Options and Reports• Analysis Reports are available

only if you have generated a data set

• “Analysis Reports” are reports developed by NHSN

• Reports are present in a series of expandable folders

• To view report options– Choose a module– Choose “Modify Report”

This allows you to choose a date range and other

options– If you select “Run Report”,

all relevant data for the last several years will be included in the report

Modifying a CDC “Canned” Report

• Check “Show descriptive variable names” • Easier to read

• Choose what you want to modify• Title or Format• Time Period

Modifying a CDC “Canned” Report - 2

• Filters

• Allows more variables to be added to the report

• Display Options

• Choose how you want the data displayed in the report

Sample Rate Table41

• Review your data findings• Check that all infections and denominator data are listed for each

Sample Standardized Infection Ration (SIR) Table for One Year – by Location

Sample Standardized Utilization Ratio (SUR)

The number of central line days/the number of predicted central line days = SUR

Targeted Assessment for Prevention (TAP) Reports

• Available for CDI, CLABSI, CAUTI• Identifies number of infections that need to be prevented to

reach targeted goal• Called the cumulative attributable difference (CAD) in NHSN• Lists results by location for CLABSI and CAUTI

• Assists in deciding where to focus infection prevention efforts

NHSN Help• Use NHSN website

www.cdc.gov/nhsn• Email NHSN questions

to nhsn@cdc.gov

CDPH HAI Program NHSN Support

• For issues specific to California, NHSN help is also available from the CDPH HAI Program at HAIProgram@cdph.ca.gov

Summary

• NHSN is a surveillance system used for recording data which meets the regulatory reporting requirements for CDPH and CMS

• NHSN has many analysis features to assist users in interpreting and presenting their data

• Resources are available for interpretation and analysis of NHSN data

• CDC at www.cdc.gov/nhsn

• CDPH at www.cdph.ca.gov/HAI

Questions?

For more information, please contact any

HAI Program Team member

Or emailHAIProgram@cdph.ca.gov

Introduction to NHSN - CDPH Home Document Library… · HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM...

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