Introduction to NHSN - CDPH Home Document Library… · 15.09.2017 · HEALTHCARE-ASSOCIATED...

HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM

Basics of Infection PreventionHealthcare-Associated Infections Program

Center for Health Care QualityCalifornia Department of Public Health

Introduction to NHSN

Last Updated 2015


Objectives

• Describe National Healthcare Safety Network (NHSN) key terms

• Demonstrate how to use NHSN

• Review how to interpret NHSN reports

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National Healthcare Safety Network

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• Nationwide surveillance system for reporting HAI from hospitals, long term care facilities, and hemodialysis clinics– Provides transparency and accountability in healthcare– Used by CDPH, other state health departments, and

CMS for HAI reporting– Data used for HAI public reporting, pay for 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 healthcare

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• Adapt to electronic reporting using national electronic

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

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NHSN Limitations

• Data validation methods in development• Requires following all NHSN protocols which are

detailed and lengthy• Not easily integrated with electronic medical

record for data import

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Recommended Practices for Surveillance and NHSN

1. Assess the population2. Select the outcome or process for surveillance 3. Use surveillance definitions and protocols4. Collect surveillance data

You may be required by regulation to perform surveillance for specific HAI and specific patient populations.

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Recommended Practices for Surveillance and NHSN - 2

5. Calculate and analyze infection rates6. Apply risk stratification methodology7. Report and use surveillance data

Can all be done within the NHSN system!

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CDPH Mandatory HAI Reporting• California acute care hospitals (including LTACH) are

required by CDPH to meet mandated HAI reporting requirements– CLIP in ICU– CLABSI facility-wide (from all inpatient locations)– SSI from 28 operative procedures (per AFL 11-32)

Reference NHSN Patient Safety Manual

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CDPH Mandatory HAI Reporting - 2

– C. difficile from inpatient locations, including ED and observational units

– MRSA and VRE bacteremia from inpatients• If inpatient MRSA BSI is related to a

central line, also report the event as CLABSI (i.e., enter in both NHSN modules)

Reference NHSN Patient Safety Manual

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CMS Mandatory HAI ReportingRequired by CMS for reporting specific infections for Medicare reimbursement from all U.S. acute care and LTAC hospitals:• CLABSI in hospital ICUs, 2011• CAUTIs in hospital ICUs, 2012• SSI from colon and abdominal hysterectomies, 2012• MRSA bacteremia and C.difficile , 2013 • HCP Influenza Vaccination, 2013 • CLABSI & CAUTI in hospital wards , 2015

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

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https://www.cdc.gov/nhsn/PDFs/CMS/CMS-Reporting-Requirements.pdf


CMS Mandatory HAI Reporting -2

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Required by CMS for reporting:• Outpatient hemodialysis, 2012

– Inpatient rehabilitation facilities– CAUTI, all wards, 2012

• Healthcare provider (HCP) influenza vaccination, October 2014– Ambulatory surgery centers

• HCP influenza vaccination, October 2014

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

https://www.cdc.gov/nhsn/PDFs/CMS/CMS-Reporting-Requirements.pdf


NHSN Data AccessFacilities…• 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

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NHSN Structure

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NHSN Structure: Patient Safety Component

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NHSN Structure: HCP Safety Component

NHSN Healthcare Personnel Safety Component(http://www.cdc.gov/nhsn/PDFs/training/HCP-flu-Vaccination-Summary-Reporting-ASC-Training-slides.pdf)

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http://www.cdc.gov/nhsn/PDFs/training/HCP-flu-Vaccination-Summary-Reporting-ASC-Training-slides.pdf

HEALTHCARE-ASSOCIATED INFECTIONS PROGRAM 16

NHSN Structure – Long Term Care Facility Component


Clinical vs Surveillance DefinitionsClinical criteria used by physicians for patient care and management may differ from surveillance criteria

• Clinical– Patient centered– Used for therapeutic decisions

• Surveillance– Population based – Applied exactly the same way each time– Physician diagnosis of infection is acceptable for some

infections


In NHSN, infection is not

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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


NHSN HAI Surveillance Definitions

• Look for annual CDC updates to definitions(https://www.cdc.gov/nhsn/)

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https://www.cdc.gov/nhsn


NHSN Surveillance Reporting for Enrolled Facilities

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• Educational modules• CMS requirements• Links to emails and past

newsletters• SSI surveillance

(highlighted)• Training protocols,

forms, support materials, analysis resources, FAQ


NHSN Newsletters Provide Updated Guidance

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NHSN 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

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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)

• Apply 80% Rule to designate patient type

NHSN Patient Safety Manual, Chapter 15

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CDC Location Mapping

Exception to the 80% Rule

• Medical/surgical locations (ICU and wards)– Define medical/surgical mixed units– If more than 60% medical patients, define as a

medical location – If more than 60% surgical, define as a surgical location

NHSN Patient Safety Manual, Chapter 15

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Access the NHSN Facility Home Page via Secure Web portal

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NHSN Rate Table

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Review your Data Findings!First, check that all your infections are listed AND

denominator data for each month


Sample Rate Table

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NHSN Standardized Infection Ratio (SIR)

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• Driven by need for a summary measure– (e.g., 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

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

– CLABSI (2006-2008)– MRSA BSI (2010-2011)– SSI (2006-2008)– CDI (2010-2011)– CAUTI (2009)


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

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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

2.0

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

SIR = 4 = 1.62.5

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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.

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SIR Interpretation

Describe findings: 1. “We had 9 CLABSI; 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.

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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.”

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SSI Risk Adjustment

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• 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• Based on the surgical patient population, the

expected (predicted) number of SSI can be calculated


SSI Risk Adjustment - 2

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Example: HYSTFactors in the risk adjustment model that add to SSI risk are: • Age ≤44 years• ASA score of 3, 4, or 5• Duration of surgery longer than 100 minutes

(incision to close time)• Procedure done at major teaching hospital (from

NHSN Annual Survey)


SSI Risk Adjustment -3


Generate a Data Set in NHSN

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• Generate a data set prior to performing analysis

• “Generating a data set” retrieves a copy of your hospital data from NHSN

• Data sets are specific to each NHSN user


NHSN Analysis Options and Reports

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Modifying a CDC “Canned” Report

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NHSN Help

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• Use NHSN website (www.cdc.gov/nhsn)

• Email NHSN questions to [email protected]

http://www.cdc.gov/nhsn

mailto:[email protected]


HAI Program and NHSN

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• For issues specific to California, NHSN help is also available from the CDPH HAI Program at [email protected]

• HAI Program Website (www.cdph.ca.gov/hai) has tailored guides, slide sets and implementation tools.

mailto:[email protected]

http://www.cdph.ca.gov/hai

http://www.cdph.ca.gov/hai


Summary

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

• Resources are available for interpretation and analysis of NHSN data

– CDC at cdc.gov/nhsn

– CDPH at cdph.ca.gov/hai

https://www.cdc.gov/nhsn

https://www.cdph.ca.gov/hai


Questions?

For more information, please contact any

HAI Liaison Team member.

Thank you.

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Introduction to NHSN - CDPH Home Document Library… · 15.09.2017 · HEALTHCARE-ASSOCIATED...

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Transcript of Introduction to NHSN - CDPH Home Document Library… · 15.09.2017 · HEALTHCARE-ASSOCIATED...