Mandatory Reporting of Mandatory Reporting of Healthcare Associated Healthcare Associated

Infections in Texas Infections in Texas

Jennifer Steinhausen, MPH, CICHealthcare Associated Infections

Clinical Specialist 512.458.7111 ext. 3773

Jennifer.Steinhausen@dshs.state.tx.us

Presentation Overview1. Identify the HAI Problem

2. HAI Legislation

3. Anticipated Reporting Requirements

4. Anticipated Reporting Time-Line

5. National Healthcare Safety Network (NHSN)

6. Preparation for NHSN reporting

The HAI Problem

United States1.7M infections/year99,000 deaths/year $25-$33B in healthcare costs Texas 130K-160K infections/year8K-9K deaths/yearCosts to patient & family,

HCW, etc.

http://www.apic.org/downloads/legislation/HAI_map.gif

Patient Empowerment

5 Reasons for HAI Reporting

Consumer’s right to know

Improve healthcare quality by reducing

HAI

Help to identify facility needs for

DSHS support

Establish standards for comparability of

data

Disclosure of PHIwww.dshs.state.tx.us/hipaa/webmessage.shtm

Legislation Background

78th legislative Session (2005) passed study bill• Advisory Panel, White Paper

79th legislative Session (2007) passed SB 288• Reporting provisions but no appropriation

80th legislative Session (2009) passed SB 203: Amended SB 288 (Chapter 98)• Added two members to AP• 28 PAE• Included appropriation• BUT does not allow data sharing with CDC

Chapter 98 Requirements

Establish 18 member Advisory Panel Establish Healthcare Associated Infections (HAI) reporting system Compile and make available to the public a data summary, by

health care facility, at least annually Allow health care facilities to submit concise written comments Provide education and training Ensure confidentiality & legal protections Verify the accuracy and completeness of the data reported Receiving reports from the public Enforcement

Link to Legislation: www.HAITexas.org

Caveats to Reporting

Proposed changes to the legislation

Staffing/Funding issues

Composition of the Advisory Panel will and is changing

Please bear with us. This is still a work in progress…

So, what does this really mean?

Reporting Requirements

Who is required to report?• Ambulatory Surgical Centers

o Licensed under Chapter 243• General Hospitals

o Licensed under Chapter 241 o Hospital that provides surgical or obstetrical services

that is maintained or operated by the state.o INCLUDES LTACs and CAHs with ICU/CCU/NICU

• DOES NOT INCLUDE COMPREHENSIVE MEDICAL REHABILITATION HOSPTIAL

Reporting Requirements

Reportable healthcare-associated infections• Central line-associated bloodstream infections in the

following special care settings: adult, pediatric and/or adolescent ICUs & CCUs, NICUs (Level II/III & Level III Nurseries)

• Surgical site infectionso PEDS/ADOLESCENT HOSPITALS: Cardiac procedures, spinal

surgery with instrumentation, and ventriculoperitoneal shunt procedures

o ALL OTHER HOSPITALS: Colon surgeries, hip & knee arthroplasties, abdominal & vaginal hysterectomies, vascular procedures, and coronary artery bypass grafts

SSI Reporting Requirements

Facilities shall report HAI data on patients who are admitted to the facility for inpatient treatment of a surgical site infections associated with a reportable procedure within 30 calendar days of the procedure or within 1 year of the procedure if the procedure involved an implant.

Facilities will be required to report surgical site infections back to the originating facility, if identified.

Originating facility will be required to report the SSI, using NHSN.

Reporting Requirements

Alternative for surgical site infections• A facility that does not perform a least a monthly

average of 50 of any combination of the listed reportable procedures, shall report the surgical site infections relating to the three (3) most frequently performed NHSN procedures.

What to Report?

Report Ventriculoperitoneal shunts including revision and removal of shunt in 2011

Alternative Reporting Selection of surgical procedures to report (example)

• Identify NHSN procedures (http://www.cdc.gov/nhsn/PDFs/ImportingProcedureData_current.pdf)

o Cesarean section: 2o Gallbladder surgery: 12Gallbladder surgery: 12o Knee prosthesis: 1o Open reduction of fracture: 5o Colon surgery: 7Colon surgery: 7o Hip prosthesis: 1o Pacemaker surgery: 3o Appendix surgery: 6Appendix surgery: 6

• Select 3 highest volume surgical procedures to report using NHSN

4 categories for SSI reportingPhase 1

Are you licensed as a general hospital under Ch 241? Are a

licensed ASC under Ch 243? Or state/government run?

STOP: No State reporting

No

Do you perform at least 50 of any combination of procedures

required?

No Report 3 highest volume NHSN

procedures

Yes

Do you perform Knee Arthroplasties?

Yes

Report Knee Arthroplasties to

NHSN for 1st phase of reporting

No

Yes

STOP: Nothing to report

for 1st phase

Proposed Rules

Phase in reporting, beginning July 2011* All facilities report CLABSIs in specialty care areas Surgical centers and general hospitals report knee

arthroplasties• Knee arthroplasties ICD-9th Revision codes; Knee prosthesis –

00.80-00.84, 81.54 and 81.55 Pediatric hospitals report ventriculoperitoneal shunts

• Ventriculoperitoneal shunts ICD-9th Revision codes; Ventriculoperitoneal shunts including revision and removal of shunt – 02.2, 02.32-02.35, 02.39, 02.42, 04.43 and 54.95

* Tentative date. May include reporting of previous quarter

Proposed Rules

Beginning in January 2012*• Surgical centers and general hospitals report hip

arthroplasties, coronary artery bypass grafts• Pediatric hospitals report cardiac procedures

Beginning January 2013*• Surgical centers and general hospitals report

abdominal & vaginal hysterectomies, colon surgeries, and vascular procedures

• Pediatric hospitals report spinal surgeries with instrumentation

* Tentative date.

Proposed Reporting Time Line

Reporting Quarter Jan 1 – Mar 31

April 1 – June 1

July 1 – Sept 30

Oct 1 – Dec 31

Facility data submission deadline

31-May 31-Aug 30-Nov 28-Feb

DSHS data reconciliation performed

15-Jun 15-Sep 15-Dec 15-Mar

Facility corrections due 30-Jun 30-Sep 31-Dec 31-Mar

DSHS data summary to facilities

NA 15-Oct NA 15-Apr

Facility comment period NA 30-Oct NA 30-Apr

DSHS review of comments

NA 15-Nov NA 15-May

Public posting of summary

NA 1-Dec NA 1-Jun

HAI Reporting

National Healthcare Safety Network (NHSN) developed and sustained by the Centers for Disease Control & Prevention is the anticipated designated reporting system.

CMS

Texas vs. CMS Reporting: 2011

Texas CMS

Who?

–General hospitals (adult, pediatric, adolescent) with ICU and/or that perform NHSN surgeries. Includes LTACs & CAHs

–ASCs that perform NHSN surgical procedures

Hospitals that receive Medicare reimbursement through (IPPS).

Excludes?Comprehensive medical rehabilitation hospitals

Department of Veterans Affairs/ Department of Defense hospitals.

Rehab, cancer, children’s, psych, VA/DOD hospitals; LTACs; CAH

What?CLABSIs in ICU of general hospitals.

General hospitals and ASCs will report SSI data.

CLABSI in ICUs and high risk nurseries

When?

Q2 or Q3 2011: CLABSIs in ICUs and knee arthroplasties, VP shunts or 3 highest volume NHSN procedures (not due until Aug/Nov 2011)

Q1 2011: CLABSI in ICUs & high-risk nurseries (not due until Aug 2011)

HAI Reporting: NHSNhttp://www.cdc.gov/nhsn/

NHSN 5 Steps to Get Startedhttp://www.cdc.gov/nhsn/cms-ipps-rule_training.html

Advantages of NHSN Training is very thorough and explains, in detail, the

“rules” for complying with NHSN surveillance protocols.

National comparative data is available when reporting infection rates

Surgical denominator data can be uploaded all at once rather than individually entered (IF the user has an electronic surgical record & all required data elements are present)

Vendors have developed compatible software for uploading facility data

Challenges using NHSN

Enrollment & Training process may take 10 – 15 hours

Digital certificate installation can be cumbersome • Will be replaced by SAMS in 2011

Many data elements are required for input into NHSN

NHSN page is extensive

NHSN Data Entry – Summary Data

Establish processes to gather necessary data• Summary Data

o Collection of line days in ICUs– NICU: separate by birth weight, umbilical vs CVC

• Event Datao CLABSIo SSI

• Procedure Datao For each reportable surgery performed

Collecting Summary Data

Collecting Event Data

Preparation for NHSN Data Entry

Establish processes to gather data• Collection of surgical denominator data –

includes patient specific details about EACH procedure preformed for risk stratification.

o http://www.cdc.gov/nhsn/PDFs/ImportingProcedureData_current.pdf

o http://www.cdc.gov/nhsn/forms/57.121_DenomProc_BLANK.pdf

• THIS IS NOT AN AGGREGATE NUMBER OF SURGICAL PROCEDURES!

Collecting Procedure Data

Required for inpatients

Required for Knee

Arthroplasties

Data Mining Vendors

The following vendors completed a HL7 CDA pilot project with NHSN

http://www.apic.org/AM/Template.cfm?Section=News_Releases&CONTENTID=9707&TEMPLATE=/CM/ContentDisplay.cfm

NHSN Preparation

Enroll your facility in NHSN, using CMS #• May need to request Registration ID from NHSN

Establish facility contact for TEXAS: Primary and secondary contacts who coordinate communications related to data submissions, verifications and approval of data summary to NHSN and DSHS. • Encourage use several contacts and a general facility

email (i.e. IP@YourHospital.com)

APIC NHSN Trainingwww.apic.org/TexasNHSN

Location Dates Property Name

Lubbock Friday, 1/7/2011 Radisson Lubbock (505 Ave Q)

Abilene Friday, 1/14/2011 Hilton Garden Inn (4449 Ridgemont Drive)

Tyler Friday, 1/21/2011 Holiday Inn South Broadway (5701 South Broadway)

Conroe Monday, 1/31/2011 The Woodlands Resort(2301 North Millbend Drive, The Woodlands)

Beaumont Monday, 2/4/2011 MCM Elegante Hotel and Convention Center(2355 I-10 South)

Houston Friday, 2/11/2011 Holiday Inn near the Galleria (3131 West Loop South)

Waco Saturday, 2/19/2011 Clarion Inn Near Baylor University(801 South 4th Street)

San Antonio Monday, 2/28/2011 Embassy Suites (125 E. Houston Street)

El Paso Friday, 3/4/2011 Embassy Suites (6100 Gateway Blvd. East)

McAllen Monday, 3/14/2011 Spring Hill Suites by Marriott for faculty rooms(1800 South Ware Road)

(700 Convention Center Blvd)

Corpus Christi Friday, 3/18/2011 Holiday Inn (1102 South Shoreline Blvd)

Austin Monday, 3/28/2011 Wyndham Garden Hotel (3401 S Ih-35)

Midland Friday 4/8/11 Courtyard Marriott (1505 Tradewinds Boulevard)

Dallas Monday, 4/18/2011 Magnolia Hotel (1401 Commerce Street)

Look towards the future…

What we are not doing… (yet?)Receiving reports from the public Preventable adverse events

• An event included in the list of serious events identified by the National Quality Forum

• An event or condition for which the Medicare program will not provide additional payment to the facility

RSV in pediatric inpatient units

www.HAITexas.org

TO DO LIST

Reporting could

begin with April

2011* data* Tentative date

Complete NHSN enrollm

ent

Begin

collecting

denominator

data

Plan to

attend

NHSN

training

(www.HAI

Texas.org)

Breathe!

Contact Information

Jennifer Steinhausen, Clinical Specialist Email

• Jennifer.Steinhausen@dshs.state.tx.us• HAITEXAS@dshs.state.tx.us

Office: 512.458.7111, extension 3773

Important Websites: • www.HAITexas.org • www.cdc.gov/nhsn• https://sdn.cdc.gov/