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March 27 th & 31 th, 2015
INFECTIONWATCH2015
Introduction to Network 14 HAI TeamShare goals of InfectionWatch2015Discuss focus facility selectionExplain project componentsProvide project and training material:
Hand Hygiene observation auditsCatheter Connection and Disconnection observation audits
AVF/G Cannulation observation auditsFacility NHSN data entry and reporting
Best practices for reporting
OBJECTIVES
*Please utilize the chat function for questions*2
Jason Simmington, QI Specialist* [email protected]
Kelly Shipley, QI Director [email protected] MRB Workgroup Advisors
Nathan Muzos, IM Director PAC Advisors [email protected]
Aparna Biradar, QI Analyst [email protected]
Dany Anchia, QI Coordinator [email protected]
*Project Lead for InfectionWatch2015’s CDC Audits reporting in NHSN
NETWORK 14 HAI TEAM
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NETWORK 14 MISSION STATEMENT
We support equitable patient- and family-centered quality dialysis
and kidney transplant health care through the provision of patient
services, education, quality improvement, and information
management.
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Reduce blood stream infections (BSI) in dialysis facilities by correctly implementing/performing infection control. Network 14 facilities will do this by: Encouraging/promoting CDC established BSI prevention
practices and resources Identify areas for improvements Engage staff with regular feedback
Increase familiarity with CDC-recommended practicesEncourage habitual attention to and assessment of
infection control and prevention practices Identify and address barriers to recommended practicesEngage patients in HAI awareness/reduction/elimination
activitiesShare and spread best practices by participating in the
HAI LAN
GOALS
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STRATEGY ALIGNED WITH METRICS
BLOODSTREAM INFECTIONS AND THE QIP
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INFECTIONWATCH2015 COMPONENTS
Patient Engageme
nt
Regional HAI LAN
CDC Monthly Audits
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NHSN Eligible facilities for 2015, n= 542
Network analysis of Blood Stream Infection
(BSI) rate per 100 patient months,
Q2-Q3 2014
New facilities eligible to report in 2015n=33
Remaining Facilities, n=509
Facilities with 0
BSI rates
by “Any CVC”
Group2
Group1
Facilities with BSI rates in the range of 3.21(±1) by “Any CVC”
2015 HAI Focus Facility SelectionNHSN data cross reference with corporate facility selection
Corporate selection:-High BSI-Low BSI-Suspected NHSN data accuracy issues
SOW requirement: 20% Network facilities
132 facilities chosen (25% over sampled)combination of Group 1 and 2 after facilities with no catheter patients and no NHSN access were removed
• 23 new facilities• 100 corporate selected facilities -
some from Network NHSN analysis
• 9 non-batch submitting facilities from Network NHSN analysis
HAND HYGIENE AUDIT TOOL: PAGE 1
Numerator
Denominator
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HH AUDIT TOOL: PAGE 2
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WHO 5 MOMENTS FOR HH
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CATH CONNECT/DISCONNECT AUDIT TOOL
Numerator
Denominator
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AUDIT TOOL CORRESPONDS TO CDC CHECKLIST
http://www.cdc.gov/dialysis/PDFs/collaborative/CL_Hemodialysis-Catheter-Connection-508.pdfhttp://www.cdc.gov/dialysis/PDFs/collaborative/CL-Hemodialysis-Catheter-Disconnection-508.pdf
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AVF/G CANNULATION AUDIT TOOL
Numerator
Denominator
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AUDIT TOOL CORRESPONDS TO THE CDC AVF/G CANNULATION
CHECKLIST
http://www.cdc.gov/dialysis/PDFs/collaborative/AV-Fistula-Graft-Cannulation-Observations.pdf17
TRAINING INFORMATIONFOR QIA FACILITIES
CDC can assist with PPM facility
training!18
The Value of Auditing CDC Recommended Infection Prevention
Practices
Increased adherence to CDC recommended practices can prevent infections: Outpatient hemodialysis facilities that implemented the
package of CDC recommended practices saw a 32% reduction in BSIs and a 54% reduction in access-related BSIs.1
Auditing adherence to recommended practices: Promotes and reinforces recommended practices among
staff. Ensures complete and correct implementation.
1. Am J Kidney Dis. August 2013, 62(2): 322–330
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CDC Infection Prevention Audit Tools
Facilities begin by learning recommended practices: CDC Recommended Interventions to Prevent
Bloodstream Infections in Dialysis Settings:• http://www.cdc.gov/dialysis/prevention-tools/core-interventi
ons.html CDC recommended checklists:
• http://www.cdc.gov/dialysis/prevention-tools/index.html • Simple reference tools useful for training staff.
Then use the audit tools as part of a planned series of observations within their hemodialysis facility.Learn CDC Recommende
d Practices
Implement CDC
Recommended Practices
Audit CDC Recommended Practices
Provide Feedback on
Adherence
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Tips for Facilities to Successfully Implement New Practices
Facilities should review current practices to identify discrepancies between current practices and CDC recommended practices.
Facilities should develop an implementation strategy, they may consider: Input from patient care staff Training needs How to inform patients of changes Whether necessary supplies (e.g., chlorhexidine) are
availableLearn CDC
Recommended Practices
Implement CDC
Recommended Practices
Audit CDC Recommended Practices
Provide Feedback on
Adherence
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Available CDC Dialysis Infection Prevention Audit Tools:
http://www.cdc.gov/dialysis/prevention-tools/index.html
HD Catheter Connection/ Disconnecti
on
Hand Hygiene
Learn CDC Recommende
d Practices
Implement CDC
Recommended Practices
Audit CDC Recommended Practices
Provide Feedback on
Adherence
AV Fistula/ Graft
Cannulation/ Decannulati
on
Although the audit tool includes both cannulation and
decannulation, only cannulation is included in the QIA
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Data Collection
All audits – observer(s) should try to ensure that observations are as representative as possible of normal practice at the facility: Observe different staff members on different days and
shifts. Consider observing during particularly busy times (e.g.,
shift change), when staff may be less attentive to proper practices.
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How to Use the Audit Tool: Opportunities
Each audit includes multiple observations. An observation is an opportunity to perform hand hygiene
(when warranted) If an opportunity is observed and hand hygiene is
performed, the observation is marked a success:
The third observation was not successful because the warranted opportunity for hand hygiene was
missed.
The first two observations were successful because hand hygiene
was warranted and was performed.
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Tallying Opportunity Audit Results
Number of Successful Opportunities: Sum of observed instances during which staff hand hygiene was warranted and was successfully performed.
Total Number Opportunities: Total number of observed instances during which staff hand hygiene was warranted.
12345
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Audit Results Reported to NHSN
Number of Successful Opportunities: Sum of observed instances during which staff hand hygiene was warranted and was successfully performed.
Total Number Opportunities: Total number of observed instances during which staff hand hygiene was warranted.
12345
These are the
numbers reported to
NHSN
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How to Use the Audit Tools: Procedures
Each audit includes multiple observations. An observation is the review of a procedure to indicate
which steps were performed correctly or incorrectly. If each step of a procedure is observed and
correctly performed, the observation is marked a success:
The first observation (catheter connection) was not successful because hub antiseptic was not
allowed to dry.
The second observation (catheter disconnection) was successful
because all steps were observed and completed.
1.2.
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Tallying Procedure Audit Results
Once all observations have been completed, add the successful observations and note the total number of observations performed:
1234567
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Once all observations have been completed, add the successful observations and note the total number of observations performed:
Audit Results Reported to NHSN
1234567
These are the
numbers reported to
NHSN
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NHSN PREVENTION PROCESS MEASURES (PPM) MODULE – INFORMATION FOR FACILITIES
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Prevention Process Measures (PPM) Module
How facilities add PPM to Monthly Reporting Plans
How facilities report PPM data to NHSN How to interpret NHSN missing/incomplete
data alerts How facilities Confer Rights to share data
with Groups Differences for QIA vs. non-QIA facilities
Analysis: available reports and percent adherence
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Facilities Report Audit Results to NHSN
Audit results can be reported to NHSN either “in-plan” or “off-plan.”
In-plan refers to the selections made on the NHSN Monthly Reporting Plan: By making a selection on the Monthly Reporting Plan,
facilities agree to follow the NHSN Protocol for monitoring and reporting of that prevention process measure.• NHSN Dialysis Prevention Process Measures Protocol
In-plan reporting requires a minimum number of observations for each audit each month and will generate alerts to remind facility users to report additional data
In-plan reporting is suggested for QIA facilities.
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Monthly Reporting Plan: Prevention Process Measures
Facilities indicate which audits will be performed during the month by checking the corresponding box(es): By checking the box, the facility agrees to follow the NHSN
protocol for monitoring and reporting of that prevention process measure.
There are a minimum number of observations for in-plan reporting, specified below each checkbox.
Tip – “Copy from the Previous Month” to make the same
selections as before.
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How Facilities Report Audit Results to NHSN
From the navigation bar, select “Summary Data,” then “Add.”
Select “Prevention Process Measures” from the menu.
Click the “Continue” button.
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Numerators and Denominators
Facilities report the sum of successful observations and the total number of observations that month on the Prevention Process Measures form in NHSN
Numerators
Denominators
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Example of Reporting Audit Results to NHSN
5 7
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Combine Multiple Audits of the Same Type, from the Same Month
12 17
Successful Obs. = 5 + 2 + 5 = 12
Total Obs. = 7 + 4 + 6 = 17
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NHSN Action Items and Alerts
If facilities make a Prevention Process Measure (PPM) selection on the Monthly Reporting Plan, but do not: Report data for it, NHSN will show a Missing Summary
Data alert Report the minimum number of total observations
required by the Protocol, NHSN will show an Incomplete Summary Data alert
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Prevention Process Measure Alerts
Missing Summary Data alerts can be removed by: Reporting the additional data required by the Protocol Un-checking the surveillance option from that Monthly
Reporting Plan (i.e., making the data “off-plan”)
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Prevention Process Measure Alerts
Incomplete summary data alerts can be removed by: Reporting the additional data required by the Protocol Un-checking the surveillance option from that Monthly
Reporting Plan (i.e., making the data “off-plan”) Selecting “Dismiss Alert” after the month has ended
Alerts for 02/201540
Prevention Process Measure Alerts
Incomplete summary data alerts can be removed by: Reporting the additional data required by the Protocol Un-checking the surveillance option from that Monthly
Reporting Plan (i.e., making the data “off-plan”) Selecting “Dismiss Alert” after the month has ended
If too few observations
were collected and the month
has passed, incomplete
alerts can be dismissed.
Alerts for 02/201541
“Confer Rights” Alert for Facility Users with Administrator Rights
When Groups request these new data, a
Confer Rights alert will
display on the facilities’
homepage.
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“Confer Rights” Alert for Facility Users with Administrator Rights
Facility users should click “not accepted” to see all Groups that have modified their data sharing requests
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“Confer Rights” Not Accepted List
Facility administrative users should click on the Group’s name to view the new request
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Facilities “Confer Rights” to Share PPM Data with Group(s)
Facility users should review their Confer Rights screen to see which data the Group is requesting.
All changes are marked:
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Facilities “Confer Rights” to Share PPM Data with Groups
If the facility agrees to share all data specified on the Confer Rights page, they should scroll to the bottom and click the “Accept” button.
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New PPM Reports
Scheduled for April 2015 – Line Listings that calculate percent adherence by month: Hand Hygiene Percent Adherence HD Catheter Connection/Disconnection Percent
Adherence AV Fistula/Graft Cannulation/Decannulation Percent
Adherence HD Catheter Exit Site Care Percent Adherence Dialysis Station Routine Disinfection Percent Adherence Injection Safety Percent Adherence
Scheduled for July 2015 – Line Listing to review what’s been reported: All Prevention Process Measures
For QIA
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Interpreting NHSN PPM Reports
Percent adherence is calculated by dividing the number of successful observations by the total number of observations and multiplying by 100.
𝑃𝑒𝑟𝑐𝑒𝑛𝑡 h𝐴𝑑 𝑒𝑟𝑒𝑛𝑐𝑒¿𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑆𝑢𝑐𝑐𝑒𝑠𝑠𝑓𝑢𝑙𝑂𝑏𝑠𝑒𝑟𝑣𝑎𝑡𝑖𝑜𝑛𝑠
𝑇𝑜𝑡𝑎𝑙 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑂𝑏𝑠𝑒𝑟𝑣𝑎𝑡𝑖𝑜𝑛𝑠𝑥100
Facility Org ID
Summary Year/
Month
HD Catheter Connection/
Disconnection # of Successful Observations
HD Catheter Connection/
Disconnection Total # of
Observations
HD Catheter Connection/
Disconnection Percent
Adherence12345 2015M01 6 10 60.012345 2015M02 7 10 70.012345 2015M03 8 10 80.0
Example NHSN Report for HD Catheter Connection/Disconnection
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Online Reporting Resources
Resources for PPM reporting are being updated E.g., Protocol,
training, etc.
http://www.cdc.gov/nhsn/dialysis/prevention-process-measures.html49
Barriers Performing 50 audits is time consuming Many patients do not want to wash their access prior to
treatment Staff issues
Lessons learned Schedule your time Bad habits in facilities happen over time and auditing is a
way to catch and correct Raised awareness in doctors of their own practices Assisted facilities stay survey ready
The most successful facilities were those that embraced the project and had fun with it.
WHAT WE LEARNED
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≥ 30 hand hygiene observations Collect data using CDC audit tool Report data to Network via entering results into NHSN
≥ 10 catheter connection/disconnection observations Collect data using CDC audit tool Report data to Network via entering results into NHSN
≥ 10 fistula/graft cannulation observations Collect data using CDC audit tool Report data to Network via entering results into NHSN
MONTHLY FACILITY ACTIONS
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PROJECT TIMELINE
INFECTIONWATCH2015 FOCUS FACILITY (FF) TIMELINE
DESCRIPTION MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
Introductory Project Webinar 3/27 or 3/31
FF deadline to accept Network 14 NHSN confer rights template 4/3
FF designate auditors 4/3
FF auditors review CDC audit protocols/guidelines 4/3
Focus Facility InfectionWatch2015 CDC audits begin 4/1
Hand Hygiene audit tallies due in NHSN
Cath Connection audit tallies due in NHSN
AVF/G audit tallies due in NHSN Patient Engagement HAI Activity Webinar and Selection X
Patient Engagement HAI Activity Submission X
Regional HAI LAN Webinars – 1 X 3Q15, 1X 4Q15 TBD
Wrap-Up Project Webinar TBD
SEE MONTHLY DUE DATES FOR ENTERING AUDIT TALLIES INTO NHSN
Monthly Reporting Due Dates of Audit Tallies in NHSN>= 30 Hand Hygiene observations per month
>= 10 Catheter Connection observations per month > = 10 AVF/AVG Cannulation observations per month
Audit Month May Jun Jul Aug Sep Oct Nov Dec
April 1-May
May 1-Jun
June 1-Jul
July 31-Jul
August 1-Sep
September 1-Oct
October 30-Oct
November 1-Dec
MONTHLY DUE DATES FOR ENTERING AUDITS INTO NHSN
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http://esrdnetwork.org/patients-families/patient-representatives/
PATIENT ENGAGEMENT ASPECT
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GEORGIA NORTH CAROLINASOUTH CAROLINA MISSISSIPPIALABAMATENNESSEE TEXAS
REGIONAL HAI LEARNING AND
ACTION NETWORK (LAN)
https://youtu.be/zUnEzRijSBk
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PROJECT LOCATION ON WEBSITEHTTP : / /ESRDNETWORK.ORG/PROFESS IONALS/QUAL ITY- IMPROVEMENT/HA I-L AN
/
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Best Practices Video Covers hand hygiene, catheter connection/disconnection,
and fistula/graft cannulation Procedure steps mirror the checklists http://www.cdc.gov/dialysis/prevention-tools/training-video.
htmlCatheter Scrub-the-hub Protocol
Key step in catheter connection/disconnection http://www.cdc.gov/dialysis/PDFs/collaborative/Hemodialysi
s-Central-Venous-Catheter-STH-Protocol.pdfChecklist tools
http://www.cdc.gov/dialysis/prevention-tools/index.htmlHand Hygiene Observation Protocol
http://www.cdc.gov/dialysis/prevention-tools/Protocol-hand-hygiene-glove-observations.html
ADDITIONAL RESOURCES FOR FACILITIES
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Introduction to Network 14 HAI TeamShare goals of InfectionWatch2015Discuss how focus facilities were selectedExplain project componentsProvide training material for
Hand HygieneCatheter Connection & DisconnectionAVF/G CannulationFacility NHSN data entry
Best practices for reporting
OBJECTIVES
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Thank you for participating!
POLLING QUESTIONS
Kelly Shipley, RHIAQuality Improvement Director
Jason Simmington, MHSQuality Improvement
Specialist469-916-3806
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