Transcript National Healthcare Safety Network: Central Line

Performing CAUTI Surveillance for Participation in
the CMS IRF Quality Reporting Program
Katherine Allen-Bridson, RN, BSN, MScPH, CIC,
Centers for Disease Control and Prevention
National Center for Emerging and Zoonotic Infectious
Diseases
Training for Inpatient Rehabilitation Facilities
May 2, 2012
Nothing to Disclose
Division of Healthcare Quality Promotion
Objectives
1.
State the purposes of the Centers for Disease Control and
Prevention’s (CDC) National Healthcare Safety Network (NHSN).
2.
Define methodology for Catheter-associated Urinary Tract Infection
(CAUTI) surveillance.
3.
Define the CAUTI data required and method to report through the
NHSN in order to meet requirements for the Centers for Medicare
and Medicaid Services Quality Reporting Program (QRP) for
Inpatient Rehabilitation Facilities (IRFs).
4.
Identify basic steps required for facility enrollment in NHSN.
5.
Identify the rehabilitation location types for which CAUTI
surveillance can be performed.
What is NHSN?
www.cdc.gov/nhsn
Web-based system launched by CDC in
2005 for surveillance of healthcareassociated infections (HAI), other adverse
events, and prevention practices.
Technical design enables manual data
entry or electronic reporting.
Purposes of NHSN

Comply with legal requirements – including but not limited to state
or federal laws, regulations, or other requirements – for mandatory
reporting of healthcare facility-specific adverse event, prevention
practice adherence, and other public health data.

Enable healthcare facilities to report HAI and prevention practice
adherence data via NHSN to the U.S. Center for Medicare and
Medicaid Services (CMS) in fulfillment of CMS’s quality
measurement reporting requirements for those data.

Provide state departments of health with information that identifies
the healthcare facilities in their state that participate in NHSN.

Provide to state agencies, at their request, facility-specific, NHSN
patient safety component and healthcare personnel safety
component adverse event and prevention practice adherence data
for surveillance, prevention, or mandatory public reporting.
Three Main NHSN Components

Patient Safety Component (will discuss in detail)

Healthcare Personnel Safety Component


Blood / Body Fluids Exposure Module

Influenza Vaccination and Exposure Management
Module
Biovigilance Component

Hemovigilance Module (Blood Safety)
Patient Safety Component
5 Modules
Patient Safety
Component
Deviceassociated
Module
Procedureassociated
Module
Antimicrobial
Use &
Resistance
(AUR)
Module
MDRO & CDI
Module
Vaccination
Module
Device-associated Module: 5 Events
Device-associated Module
CLABSI
CLIP
VAP
CAUTI
DE

CLABSI
Central line-associated bloodstream
infection
Central line insertion practices
Ventilator-associated pneumonia


CLIP
VAP

CAUTI
Catheter-associated urinary tract
infection

DE*
Dialysis event
*For outpatient dialysis only
NHSN Surveillance Methodology
ACTIVE vs. PASSIVE

ACTIVE Trained personnel use standard
definitions and a variety of data sources to
investigate and identify events.

PASSIVE
Personnel, such as staff
nurses, not trained to do surveillance may
report events. No purposeful investigation for
infections occurs.
NHSN Surveillance Methodology2
PATIENT-BASED vs. LABORATORY-BASED

PATIENT-BASED Monitoring patients for events,
risk factors, and procedures and practices related
to patient care
– Visit patient care areas
– Review patient charts
– Discuss with caregivers

LABORATORY-BASED Case-finding based on
positive lab findings
NHSN Surveillance Methodology3
PROSPECTIVE vs. RETROSPECTIVE

PROSPECTIVE Monitoring patients while
still in the institution; includes post-discharge
period for surgical site infections (SSI)

RETROSPECTIVE Case-finding based
solely on chart review after patient discharged
Healthcare-associated Infection (HAI)
A localized or systemic condition
resulting from an adverse reaction
to the presence of an infectious
agent(s) or its toxin(s) that
• Occurs in a patient in a
healthcare setting
And
• Was not present or incubating
at the time of admission, unless
the infection was related to a
previous admission
NHSN and CMS
Quality Reporting Program
Healthcare Facility HAI Reporting to CMS via NHSN –
Current and Proposed Requirements DRAFT (11/14/2011)
HAI Event
Facility Type
Reporting Start Date
CLABSI
Acute Care Hospitals
Adult, Pediatric, and Neonatal ICUs
January 2011
CAUTI
Acute Care Hospitals
Adult and Pediatric ICUs
January 2012
SSI
Acute Care Hospitals
Colon and abdominal hysterectomy
January 2012
I.V. antimicrobial start
Dialysis Facilities
January 2012
Positive blood culture
Dialysis Facilities
January 2012
Signs of vascular access infection
Dialysis Facilities
January 2012
CLABSI
Long Term Care Hospitals *
October 2012
CAUTI
Long Term Care Hospitals *
October 2012
CAUTI
Inpatient Rehabilitation Facilities
October 2012
MRSA Bacteremia LabID Event
Acute Care Hospitals
January 2013
C. difficile LabID Event
Acute Care Hospitals
January 2013
HCW Influenza Vaccination
Acute Care Hospitals
January 2013
HCW Influenza Vaccination
ASCs
October 2014
SSI (future proposal)
Outpatient Surgery/ASCs
TBD
* Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN
NHSN and CMS

CMS Final Rules in Federal Register published
August 18, 2011.

Must follow NHSN CAUTI protocol exactly and report
complete and accurate data.

Data must be reported to NHSN by means of manual
data entry into NHSN web-based application or via
file imports using the Clinical Document Architecture
(CDA) file format.

Pass quality control acceptance checks that assess
the data for completeness and accuracy.
NHSN and CMS, cont’d

NHSN requires data to be submitted monthly (within
30 days of the end of the month in which it is
collected) so it has the greatest impact on infection
prevention activities.

Data must be entered into NHSN no later than 4 ½
months after the end of the quarter to be shared
with CMS.
– E.g. Q1 (January-March) data must be entered into
NHSN by August 15; Q2 by November 15; Q 3 by
February 15 and Q4 by May 15

Does not preempt any state mandates for CAUTI
reporting to NHSN.
NHSN and the CMS Annual Payment Update (APU) Hospital/IRF
Inpatient Quality Reporting (IQR) Program

Hospitals/IRFs enter quarterly HAI data into NHSN

< 4 ½ months following the end of the reporting quarter

CDC prepares facility-specific HAI summary statistics that
are submitted in monthly and quarterly files to CMS using a
secure QualityNet exchange account

Hospitals/IRFs can view their own HAI summary statistics at
a secure CMS website where the APU Dashboard is posted
(for more information see
http://www.qualitynet.org/dcs/ContentServer?c=Page&page
name=QnetPublic%2FPage%2FQnetBasic&cid=122869434
6716)
ENROLLMENT INTO NHSN
http://www.cdc.gov/nhsn/enroll.html
Facility Administrators & Users
should complete all
required NHSN Trainings
before beginning Enrollment
http://www.cdc.gov/nhsn/training.html
NHSN Facility Administrator
Enrollment Guide
http://www.cdc.gov/nhsn/PDFs/FacilityAd
minEnrollmentGuideCurrent.pdf
NHSN Facility Administrator

Only one Facility Administrator per facility

Only person who can enroll a facility

Responsible for initial set-up
– Adding locations
– Adding users and assigning user rights
– Joining and conferring rights to groups
Enrollment into NHSN
NHSN Registration http://nhsn.cdc.gov/RegistrationForm/index.jsp
2 IRF Enrollment Options


Freestanding, separately licensed facility
Location within an Acute Care Facility
Enrollment Requirements:
IRFs Requiring Unique NHSN orgID

Enroll in NHSN as a separate facility if:
– Free standing licensed IRF with a CCN (CMS
Certification Number) with the last four digits
between 3025-3099

Identify as “HOSP-REHAB” facility type
Enrollment Requirements:
IRFs Requiring Unique NHSN orgID

Annual survey required
– Complete new, rehabilitation specific annual
survey for calendar year 2011
– Use whole numbers without decimal points

Two locations: Adult and Pediatric IRF
Rehabilitation Facility Locations
CDC
Definitions
Page 15-13 of NHSN Patient Safety Component Manual
Enrollment Requirements:
IRF Units Within a Hospital

Set-up as Inpatient Rehabilitation Ward location
within an enrolled acute care or critical access
facility type if:
– IRF unit within a hospital and 3rd character of CCN is
either a “T” or an “R”

Additional questions are required for licensed
IRF units within hospitals to be identified for
CMS reporting.
Rehabilitation Locations
Within Hospital
CDC
Definitions
Page 15-8 of NHSN Patient Safety Component Manual
Beyond Enrollment
Annual Survey: IRF

Annual survey
required for HOSP
REHAB facility type:
– Must complete a new
IRF-specific annual
survey for calendar
year 2011.
– Use whole numbers
without decimal
points.
Monthly Reporting Plan

CAUTI must be included in Monthly Reporting Plan for data
to be reported on behalf of the facility to CMS.
 Locations: Inpatient Adult and Pediatric Rehabilitation
Wards
Example for
freestanding IRF
Add
Locations
Monthly Reporting Plan, cont’d

The Monthly Reporting Plan informs CDC
which modules a facility is following during a
given month.

A facility must enter a Plan for every month of
the year, even those in which no modules are
followed.

A facility may enter data only for
months in which Plans are on file.
Reporting Numerator and Denominator Data

Report each CAUTI detected or indicate that no CAUTI occurred
for reporting locations. (Found on Denominator screen).

Report total device days and total patient days for reporting
locations, including months in which no CAUTIs were identified
and/or no patient days or urinary catheter days occurred.
RESOURCES
Resources for NHSN
http://www.cdc.gov/nhsn/index.html
Resources for Surveillance

NHSN Patient Safety Component
Manual, January 2012
– Ch 3: Monthly Reporting Plan
– Ch 7: CAUTI Protocol (January 2012)
– Ch 14: Tables of Instructions
– Ch 16: Key Terms
http://www.cdc.gov/nhsn/TOC_PSCManual.html
Resources for Surveillance, cont’d

NHSN Forms (June 2011)
– 57.106: Monthly Reporting Plan
– 57.114: Urinary Tract Infection
– 57.118 Denominators for Intensive
Care Unit (ICU)/ Other locations (not
NICU or SCA)
http://www.cdc.gov/nhsn/forms/Patient-Safety-forms.html
Available Training

Training
– Device Associated Module
– Pre-recorded Webinars
– Lectoras
http://www.cdc.gov/nhsn/training/
Available Training, cont’d

NHSN Enrollment & Facility Set-up (Slidesets [PDFs])

Overview of the Patient Safety Component, Deviceassociated module (Slideset [PDF])

Data Entry, Surveillance, Analysis, Data Entry, Import,
and Customization (Slideset [PDF])

Introduction to the Device-associated Module (Training
Course with quiz)

Catheter-associated Urinary Tract Infection (CAUTI)
(Training Course with quiz)
http://www.cdc.gov/nhsn/training/