Transcript VAP Data Collection - K-HEN

Ventilator-Associated Pneumonia
K-HEN Data Collection
& Submission
Dolores Hagan, RN BSN
K-HEN Education and Data Manager
August 2012
Objectives
• Review reporting requirements
• Review K-HEN recommended measures
• Review the specifications for monitoring
data (Inclusion and exclusion criteria)
• Discuss requirements for baseline data
• Define data entry and submission timeline
• Identify measures that may be pulled
from other systems where data is
currently being entered
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Reporting Requirements
• For each topic area chosen, hospitals are
required to submit data for at least
– One process measure AND
– One outcome measure
• Hospitals are strongly encouraged to
report on the K-HEN recommended
measures
• Additional outcome and/or process
measures may be selected and reported as
desired
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K-HEN Recommended Measures
• Purpose—standardize reporting on the same
measures across the state for robust
benchmarking capability
• Measures selected based on polling data from
the KHA Quality Conference in March 2012
• Have continued to evolve with your feedback
(Keep it coming! )
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HRET HEN Encyclopedia of Measures
• Lists all measures available in the CDS
• Defines the numerator and denominator for
each measure
• Provides a link to the source of the measure
• http://www.khen.com/Portals/16/Documents/HRET_HEN_
Encyclopedia_of_Measures_v3.pdf
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VAP: Outcome Measure
• Preferred measure: #92 or 95 ICU or High
Risk Nursery (HRN) Ventilator-associated
pneumonia rate (ventilator days
denominator)
• Alternate measure: #93 or 94 All non-ICU
units or all units, ventilator-associated
pneumonia rate (ventilator days
denominator)
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# 92 or # 95 VAP Criteria
• Numerator—The number of ventilatorassociated pneumonia in ICU or HRN
• Denominator—Number of ventilator days
(collected daily)
– #92—ICU ventilator days
– #95—HRN ventilator days
• Equation—(Number of VAP/Number of
ventilator days in specified unit) * 1000
# 93 or # 94 VAP Criteria
• Numerator—The number of ventilatorassociated pneumonia within the specified
unit or units
• Denominator—Number of ventilator days
within the specified unit
– #93—All non-ICU units patient days
– #94—All units
• Equation—(number of VAPs in specified
units/number of ventilator days in same
specified units)*1000
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Source: CDC NHSN VAP
VAP: Process Measure
• Preferred Measure: #90 Ventilator Bundle
Adherence Rate
• Alternate Measure: #91 Hand hygiene
adherence rate (VAP)
Source: CDC NHSN & Joint Commission Hand Hygiene Reference
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#90 Ventilator Bundle Use Criteria
Numerator—Number of patients on mechanical
ventilation at the time of survey for whom all four
elements of the bundle are documented in place.
• HOB elevation ≥ 30 degrees or contraindication; noted on
2 different shifts within a 24-hour period
• Daily sedation interruption and assessment of readiness
to extubate; complete documentation required
• Peptic ulcer disease prophylaxis
• DVT prophylaxis
Denominator—Total number of patients on
ventilators at the time of observation
Source: NQF Ventilator Bundle Use
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#91 VAP Hand Hygiene Compliance
• Numerator—Hand hygiene performed
consistent with guidelines
• Denominator—Total number of hand
hygiene observation opportunities
• Equation—(Total number of acts of hand
hygiene consistent with guidelines/total
number of observed hand hygiene
opportunities) X 100
Source: Joint Commission Hand Hygiene Reference
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Baseline Data
• Only submitted one time
• For all topic areas except Readmissions:
– Baseline data is from 2011 prior to January 1, 2012
– May be the entire calendar year of 2011 or any other
period within the year (a month, a quarter, etc)
– Enter your specific period beginning and ending
dates
• Readmission Baseline Data
– Preferably CY 2011
– May use Jan – Jun 2012 if 2011 data is not available
• If no baseline data is available, do not enter anything for
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baseline—begin with monitoring data
VAP Baseline Data
Complete baseline data
entry by August 15!
• NHSN data will be extracted once rights are
conferred
• Data should be entered on a monthly basis
as much as possible
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2012 VAP Monthly Data Entry Schedule
Monitoring Month
Data Entry Available
Data Entry Complete
January
Immediately
As soon as possible*
February
Immediately
As soon as possible*
March
Immediately
As soon as possible*
April
Immediately
As soon as possible*
May
Immediately
As soon as possible*
June
Immediately
As soon as possible*
July
August 1, 2012
August 31, 2012
August
September 1, 2012
September 30, 2012
September
October 1, 2012
October 31, 2012
October
November 1, 2012
November 30, 2012
November
December 1, 2012
December 31, 2012
December
January 1, 2013
January 31, 2013
*If data is available
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Comprehensive Data System (CDS)
• Link to HRET training webinar for CDS
located on K-HEN website under Data Page
• https://www.hretcds.org/Login.aspx
• Data coordinator receives initial login and
creates hospital’s users
– At least two data administrators
– As many data entry users as needed
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Measure Selection
• Review the K-HEN Recommended
Measures and the HRET Encyclopedia of
Measures
• Determine which measures you will report
Remember you MUST report on at least one
process and one outcome measure
per topic area selected
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Measure Enrollment
• Enroll in the measures that you are
reporting
• Select Admin  Measure Enrollment
– Select the topic area
– Select/deselect and save the measures that
you will be reporting on
– This will narrow your choices for data entry to
only those selected
– You may reselect those measures at a later
time if desired
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Data Collection & Entry
• Review the numerator and denominator
criteria for the measures selected
• Collect and compile the data
• Sign on to the CDS
– Select Data Entry tab
– Select the topic from the drop  Select Next
– Find the appropriate measure  Select Enter
Data
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Baseline Data Entry
• Defaults to the Baseline tab
• Enter the Measurement start and end dates  Select
‘Add’
• Under ‘Data Entry’ column, Select ‘Go’
• Was data collected for this measurement period? 
Select Yes or No
– If No, enter reason (e.g. data not available)
– If Yes, enter the numerator and denominator
– Select Save or Submit
• Save holds data in ‘temporary’ area and is not available for
reporting within the CDS
• Data may be edited by the hospital until it is submitted
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Monitoring Data Entry
• Select the Monitoring tab
• Under the Data Entry column, Select ‘Go’ for
the appropriate month
• Was data collected for this measurement
period?  Select Yes or No
• If No, enter reason (e.g. data not available)
• If Yes, enter the numerator and denominator
• Select Save or Submit
– ‘Save’ holds data in ‘temporary’ area and is available for
reporting within the CDS
– Data may be edited by the hospital until it is submitted
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Data Tidbits
• Each month should have data entered or a
reason it was not collected
• Additional training will be provided after data
has been entered and reporting is available
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Monthly Progress Report
•
•
•
•
Due to K-HEN by the 10th of each month
Use template provided
One report per topic area
Report template and sample complete
report located on K-HEN website (www.khen.com) under Tools and Resources
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Project Title: ______________________________
Hospital Name: ____________________________
Date: _____________
State: _____________
Self Assessment Score, 1-5 (see AHA/HRET Assessment Scale document) = <enter score here>
Aim Statement
Aim?: (Including your How
Good and By When
statement)
Why is this project
important?:
Changes being Tested,
Implemented or Spread
(For each listed change,
indicate whether it is being
tested (T), Implemented (I)
or Spread (S))
Run Charts
Lessons Learned
(Make fonts large, title, labels, dates
and notes very simple on graphs
prior
to shrinking graphs. Should be able
to
fit 6-8 readable graphs here.
If no data are available for a particular
measures either create “empty” run
list
the name of the measure(s) to be
collected.)
(Enter summary here)
Recommendations and
Next Steps
• Enter summary here (what
do you need from Executive
Project Champion, Sponsor
at this time to move
project?)
• Recommendations
• Next steps for testing
Team Members
(Name of Project
Champion, Senior Leader
Sponsor & all other names
& roles)
© 2012 Institute for Healthcare Improvement
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Project Assessment Scale
• http://www.khen.com/Portals/16/Documents/HRETHEN
ProjectAssessmentScale.pdf
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Homework
• Set up CDS users for your site
• Collect and enter baseline data by Aug 15
• Enter monitoring data for Jan - Jun 2012 as
available and time permits
• Enter monitoring data for Jul 2012 by Aug
31
• Complete July progress report by Aug 10
and email to [email protected]
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Questions
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