NHSN Reporting for
Critical Access Hospitals
Allison Murad, MPH
Surveillance for Healthcare-Associated and Resistant Pathogens (SHARP) Unit
Michigan Department of Health and Human Services (MDHHS)
Why NHSN?
• The “Gold Standard” for HAI Reporting and Surveillance
• Clinical vs. Surveillance Definitions:
• Clinical:
• Individualized
• Used for making therapeutic decisions
• Surveillance
• Population-based
• Must be applied uniformly and consistently
The Essentials of Infection Surveillance
• Know protocol/criteria
• Consistently apply the criteria
• Report events meeting criteria; exclude those that don’t
• Failure to do so:
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Breach of NHSN Rules of Behavior
Decreased usefulness of national comparative data
Unfair comparisons between facilities
Possible validation discrepancies
Potential impact of CMS Inpatient Quality Reporting score & facility
reimbursement
Components of NHSN
Not Enrolled in NHSN?
• Start here: https://www.cdc.gov/nhsn/acute-care-hospital/enroll.html
Already Enrolled in NHSN for HCP?
• If you’ve enrolled your facility in NHSN in order to report Healthcare
Personnel Influenza Vaccination Data, you can activate the Patient
Safety Component by going to: Facility – Add/Edit Component
Add additional users to your facility!
• Users – Add
Patient Safety Component
• Device-Associated Module
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CLABSI
CLIP
CAUTI
VAE
VAP
• Procedure-Associated Module
• SSI
• Antimicrobial Use and Resistance Module (AUR)
• Multidrug-Resistant Organism and Clostridium difficile Infection (MDRO/CDI)
Module
• MRSA LabID
• CDI LabID
MDRO/CDI Reporting
“The NHSN MDRO/CDI Module offers a means for facilities to meet
criteria and metrics that are outlined in several organizational guidelines
to control and measure the spread of MDROs and CDI within their
healthcare system.”
“As outlined in the HICPAC guideline, these MDRO and C.difficile
pathogens may require specialized monitoring to evaluate if intensified
infection control efforts are required to reduce the occurrence of these
organisms and related infections. The goal of this module is to provide a
mechanism for facilities to report and analyze these data that will inform
infection prevention professionals of the impact of targeted prevention
efforts.”
LabID Reporting
• LabID Event reporting is based strictly on laboratory testing data
without clinical evaluation of the patient, allowing for a much less
labor intensive method to track C. difficile and MDROs, such as MRSA.
• Advantages of LabID Event Reporting
• Objective laboratory-based metrics
• Estimate infection burden
• Estimate exposure burden
• Assess need for and effectiveness of interventions
• Standardized case definitions
• Increased comparability between settings
Categorization of CDI LabID Events
• Incident: Event from a specimen obtained >56 days (8 weeks) after the
most recent CDI LabID Event (or with no previous CDI LabID Event
documented)
• Day 1 = date of first specimen collection
• Recurrent: Event from a specimen obtained >14 days (2 weeks) and ≤ 56
days (8 weeks) after the most recent CDI LabID Event
• Day 1 = date of first specimen collection
• Duplicate: Event from the same patient AND location, following a previous
lab result within the past two weeks (14 days), even across calendar
months and readmissions to the same facility.
• Duplicate events will prompt a pop-up message that will not allow you to enter
Categorization of CDI LabID Events
• Healthcare-Onset (HO): Positive toxin tests collected >3 days after
admission to the facility (i.e., on or after hospital day 4)
• Community-Onset (CO): LabID Event collected in an outpatient location or
an inpatient location ≤3 days after admission to the facility (i.e., days 1, 2,
or 3 of admission).
• Community-Onset Healthcare Facility-Associated (CO-HCFA): CO LabID
Event collected from a patient who was discharged from the facility ≤4
weeks prior to current date of stool specimen collection. Data from
outpatient locations (e.g., outpatient encounters) are not included in this
definition.
Best part of categorization?
• NHSN categorizes for you!
• Running and exporting data will show the rates and ratios of each
categorized event type facility-wide
What can you do with the data?
MDHHS Feedback
Reports
National NHSN Use
• As of March 2017:
CMS Reporting
Requirements
MDHHS SHARP Unit
• Validation Activities
• Statewide NHSN User Group Webinars, Next Call: Wednesday, June 28th at 10am
• ICAR Assessments/Infection Control Consulting:
Noreen Mollon, [email protected]
• CRE Surveillance and Prevention Initiative:
Brenda Brennan, [email protected]
• Antimicrobial Resistance:
Sara McNamara, [email protected]
Thank you!
Allison Murad, MPH
Surveillance for Healthcare-Associated and Resistant
Pathogens (SHARP) Unit, MDHHS
[email protected]
www.michigan.gov/hai