NHSN Updates Linda R Greene RN, MPS, CIC linda.greene@urmc.rochester.edu

Objectives

• Describe changes to NHSN definitions

• Explain how these changes are consistent with the HHS action plan

• Identify new prevention practices or implementation strategies related to SSIs,

CAUTIs, C difficile and CLABSIs

Feelings of Helplessness

Broken escalator

General Changes in NHSN Reporting

Requiring Medicare Number

Surgical Site Infections (SSIs) • Data Source: National Healthcare Safety Network (NHSN)

• Metric: Standardized Infection Ratio (SIR) = Observed # of HAIs

Predicted # of HAIs

• Baseline Period: 2006-2008

• 5 year target: 25% reduction in SSIs following SCIP-like procedures on admission or readmission (SIR=.75)

• 2012 Preliminary: 20% reduction (SIR=.80)

Source: Excerpted from Presentation of Paul Malpiedi, Health Scientist, CDC

Overall .80 Colon Surgery .80 Abdominal Hysterectomy .89 Knee Replacement .76 Hip Replacement .84 Coronary Artery Bypass .71 Other Cardiac .68 Vaginal Hysterectomy .90 Rectal Surgery .76 Peripheral Vascular Bypass .74

2012 Procedure Specific SIR

Changes to Reporting

CPT Codes used for billing Not readily available in inpatient

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=1PWiyILAfQKI_M&tbnid=OCN5h0gH7mLmwM:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.funnyjunksite.com%2Ffunny-cartoons%2Ffunny-surgery%2F&ei=_sKMUv7jE-upsATUuoHgBw&bvm=bv.56643336,d.cWc&psig=AFQjCNH_Rcq9R8XUoRzlCuUPqZE7fCNTDA&ust=1385043015722514�

Reporting Requirements- SSI

• Will require height and weight

• Diabetes ( definition: oral agent or insulin)

• Include procedures not primarily closed- indicate if not primarily closed for risk adjustment

• Musculoskeletal Disease Society definition- SSI PJI will replace SSI JNT (Periprosthetic)

• HPRO and KPRO ( additional details hemi, total, resurfacing)

Challenges

•Denominator data readily available?

•Redesigning collection forms

•ICD-10 may be challenging

OK , I’m no statistician what’s all this mumbo jumbo about?

In simple terms- you are compared to the average of a referent population adjusted for risk. In this case it is a historical control.

The SIR

What about CMS?

Rate reported as a SIR (Deep and Organ space only)

Risk adjusted Expected/Observed

Complex risk adjusted methodology

Simply Put

• A SIR of 1.0 means the observed number of infections is equal to the

number of expected infections.

• A SIR above 1.0 means that the infection rate is higher than that found in the "standard population." For HAI reports, the standard population comes from data reported by the hundreds of U.S. hospitals that use the NHSN system. The difference above 1.0 is the percentage by which the infection rate exceeds that of the standard population.

• A SIR below 1.0 means the infection rate is lower than that of the standard population. The difference below 1.0 is the percentage by which the infection rate is lower than that experienced by the standard population

The SIR

PROS CONS

Surgical risk adjustment is a significant improvement

Risk adjustment still suboptimal – especially with CLABSI data

Consistent with other types of data such as mortality

Not designed to compare 1 institution t another- only to compare with national average

Advantages with rare events

Potential problems with ranking ,etc

Overall rates can cloud the big picture

NHSN Current National Results

25 facilities had SIRs significantly higher than 1.0 for surgical site infections associated with hip arthroplasty

30 facilities had SIRs significantly higher than 1.0 for surgical site infections associated with knee arthroplasty

20 facilities had SIRs significantly higher than 1.0 for surgical site infections associated with colon surgery

15 facilities had SIRs significantly higher than 1.0 for surgical site infections associated with abdominal hysterectomy

Ambulatory Surgery Centers

Coming soon: • Identify a set of ASC procedures for which HAI

definitions and measures should be developed

• Support a plan for routine surveillance that can be consistently be implemented

• Reporting through NHSN

summaryYprocCount infCountComplexnumExpComplexSIRComplex SIRComplex_pvaSIRComplex95CI proccode months2012H1 813 12 9.467 1.268 0.245 0.655, 2.2142012H1 90 4 2.605 1.536 0.265 0.418, 3.932 COLO 62012H1 379 1 3.792 0.264 0.108 0.007, 1.469 HPRO 62012H1 343 7 3.055 2.291 0.036 0.921, 4.721 HYST 6

Where is my greatest opportunity for improvement? What is your interpretation of my overall SIR? Where am I performing well?

Hospital Analysis

How about evidence on prevention ?

New HICPAC guidelines on SSI – public comment soon. • No post-operative doses of antibiotics for clean and clean-

contaminated cases

• Re-dose if procedure exceeds half life of antibiotic, excessive blood loss or extensive burns

• Alcohol based prep

• Do not use antimicrobial sutures to prevent SSI

• Maintain normothermia – No method suggested

• Antimicrobial dressings- unresolved issue

CAUTI • Proposed CAUTI definitional changes with anticipated implementation in NHSN in 2015 • Two approaches in consideration includes:

o Simplified approach; more stream-lined; more specific/ less sensitive o Correlated with Clinical determination utilizing treatment for UTI as element of

criteria • Moving ahead to look at symptoms with spinal cord injury for a stream-lined definition • Allow for fever with other recognized cause • Pilot the criteria and definitions and pilot both approaches(comparing to current CAUTI

definition) • ‘Mini pilot’ and will tweak to the data collection form and then expand to more settings • Any changes would be made by January, 2015

Other Issues

Lab Survey

Looking at Candiduria

CAUTI

States with SIR above 1 Colorado — 1.001 Iowa — 1.012 California — 1.014 Michigan — 1.066 Mississippi — 1.089 Indiana — 1.095 Kentucky — 1.098 Illinois — 1.103 North Carolina — 1.126 Arizona — 1.138 Washington — 1.142 Idaho — 1.149 Nevada — 1.208 Montana — 1.226 Arkansas — 1.234 Delaware — 1.235 Oregon — 1.239 New York — 1.38 Rhode Island — 1.385 Vermont — 1.408 New Hampshire — 1.444 Tennessee — 1.453 Nebraska — 1.499 District of Columbia — 1.514 Minnesota — 1.575 Massachusetts — 1.603 South Carolina — 1.719 Connecticut — 1.771 Maine — 1.892 Utah — 1.9

Concern over CAUTI – HHS Action Plan Basic and/or Laboratory Science

• Facilitate research to enhance our understanding of factors leading to the development of CAUTI and the optimal modes of prevention, diagnosis, and

therapy. A logical area for attention is biofilms. • Identify methods to differentiate bladder colonization from CAUTI in patients with catheters.

Epidemiology • Explore the epidemiology of CAUTI and asymptomatic bacteriuria, including

incidence, outcomes, and relative contributions to the use of antimicrobials. • Identify methods to improve the surveillance of CAUTI, including determining

the accuracy of surveillance definitions in select populations (e.g., elderly patients) and developing methods for electronic capture of CAUTI.

• Study the epidemiology of antimicrobial resistance in uropathogens, considering the role of different urinary catheter systems as reservoirs for resistant bacteria and the presence of resistance to antimicrobial/antiseptic coatings.

• Quantify the unnecessary use of urinary catheters and its consequences (trauma, encrustation).

Other concern over CAUTIs

• Most significant reductions in Non- ICU settings

• Device utilization in ICUs has not decreased dramatically

• Thought that all critical care patients should have a catheter

• HICPAC Guidelines non specific on this issue

• Work underway to improve precision on this metric

Historically – No Respect for CAUTIs

Long Term Care

New NHSN reporting in Long Term Care Facilities is currently available for certified skilled nursing facilities/nursing homes and intermediate/chronic care facilities for the developmentally disabled.

http://www.cdc.gov/nhsn/PDFs/LTC/LTCF-UTI-protocol_FINAL_8-24-2012.pdf

What is new since HICPAC Guidelines ?

• Technical evidence – minimal

• Pickard Study ( RCT) – no support for antiseptic catheters

• Much more evidence on socio- adaptive aspects of prevention and on hard wiring insertion and removal protocols ( nurse-driven protocols, stop orders, indications for insertion)

• Connection to other causes of patient harm

Connect the Safety Dots

Falls?

Antibiotic

Resistance

DVT?

C Diff infection

Urinary Catheter

Harm

CAUTI

Immobility

Decubs?

Trauma

Discomfort Satisfaction

Delays,

LOS

Cost$

Challenges

While rounding in the ICU, one of the nurses notes that Ms. X no longer requires a urinary catheter

The physician replies “ Why don’t you just leave it in”, it makes life easier for the nurses.

What is the issue?

How can we resolve it ?

31

CLABSI • In 2014 , an additional field will be added to the CLABSI

module, indicating an inpatient dialysis unit

• This will still be attributed to the inpatient unit , but will give organizations the opportunity to analyze these infections and Identify opportunities not specific to their unit.

• Expand electronic capture of data

Research Priorities

• Understand Role of Biofilm

• Understand barriers to implementation of evidence based practices

• Optimal strategies for catheter maintenance

Focus

More focus outside of ICU

2015- Report in non ICU location

Challenges:

Daily review for necessity of line

Maintenance issues

C difficile- NHSN Reporting

• Continue to use lab ID Event

• For C difficile SIR- report lab testing type on quarterly basis to allow for changes in testing

methodology through the year ( this is used for

the risk adjustment)

• New lab ID calculator coming

• Data module for long term care

C difficile

Goals:

1. Improve Antimicrobial Stewardship

2. Improve environmental contamination

C difficile bundle

• A- Antibiotic Stewardship

• B- Barrier Precaution

• C- Compulsive Hand washing

• D- Disinfection of Environment

• E- Executive Sponsorship

summaryYQ

CDIF HO Count

numExpCDI

SIR SIR_pval sir95ci

2012Q1 14 18.615 0.752 0.1705 0.411, 1.262 2012Q2 25 18.625 1.342 0.0909 0.868, 1.982 2012Q3 20 18.018 1.110 0.3504 0.678, 1.714 2012Q4 16 17.938 0.892 0.3805 0.509, 1.449

Which statement is not correct ? A. The table demonstrates a possible opportunity for

improvement A. The yearly SIR is below 1

C. The Hospital performed well the first quarter D. The second quarter contributes the most to the determination of the yearly SIR

Summary

• Ongoing changes in NHSN

• Attempting electronic capture

• Role of the EHR

• Implementation science is the greatest challenge