Nhsn workshop new apic meeting october 7 2011
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NHSN Workshop NEW APIC Meeting October 7, 2011. Wisconsin Department of Health Services. Agenda. Status of NHSN use in Wisconsin CMS reporting via NHSN Next version release: October NHSN data analysis SIR Committee reports Q & A. NHSN Use in Wisconsin. Live users February 2010: 24

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NHSN Workshop NEW APIC Meeting October 7, 2011

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Nhsn workshop new apic meeting october 7 2011

NHSN WorkshopNEW APIC MeetingOctober 7, 2011

Wisconsin Department of Health Services


Agenda

Agenda

  • Status of NHSN use in Wisconsin

  • CMS reporting via NHSN

  • Next version release: October

  • NHSN data analysis

    • SIR

    • Committee reports

  • Q & A


Nhsn use in wisconsin

NHSN Use in Wisconsin

  • Live users

    • February 2010: 24

    • September 2011: 100

    • 26 CAH (45%), 70 PPS (100%), 1 VA, 1 Children’s, 2 LTAC

  • 6 more enrolling

  • 10 more training


Eligible facilities

Eligible Facilities


How do i get started

How Do I Get Started?

NHSN public site: http://www.cdc.gov/nhsn/


Enrollment

Enrollment

  • CDC training http://www.cdc.gov/nhsn/training.html

  • Obtain digital certificate

  • Complete facility survey/contact info

  • Submit facility consent form

  • Set up facility account on NHSN – locations, reporting plans, etc.


Cms hai reporting

CMS HAI Reporting


Healthcare facility hai reporting to cms via nhsn current and proposed requirements draft 8 5 2011

Healthcare Facility HAI Reporting to CMS via NHSN – Current and Proposed RequirementsDRAFT (8/5/2011)


Submission timelines

Submission Timelines


Updates with the next nhsn version release in october

Updates with the Next NHSN Version Release in October


Planned for the october 2011 release

Planned for the October 2011 Release

  • Alerts for missing numerators and denominators

  • Ability to report zero events for a month

  • Updates to custom fields – more fields, easier to use


October 2011 release cont d

October 2011 Release, Cont’d.

  • Ability for groups to send messages to facilities within NHSN

  • Analysis updates (dialysis comparative rates, rates to 3 places, etc.)

  • Module specific to LTC facilities and relevant reporting (start with LabID Events and UTI)


Nhsn data analysis

NHSN Data Analysis


Generating data sets

Generating Data Sets


Accessing your data

Accessing Your Data


Analysis reports tree view

Analysis Reports Tree View


Cdc s pre configured reports

CDC’s Pre-Configured Reports


Default report

Default Report


Modify your report

Modify Your Report


Customized control chart

Customized Control Chart

Name the new report

Choose variable labels for more description in the headings

Select a time period


Customized control chart cont d

Customized Control Chart, Cont’d.

Apply any necessary filters

Choose the type of data used in the chart

Configure your chart to include reference lines (control limits and smoothing are not available at this time)

Run or save your chart or export your data


Customized control chart cont d1

Customized Control Chart, Cont’d.


Standardized infection ratio sir

Standardized Infection Ratio (SIR)

  • Similar to a standardized mortality ratio

  • Compares observed infections with expected number of infections (using 2006-2008 NHSN aggregate data as the standard population)

  • SIR < 1: Observed are less than expected

  • SIR = 1: Observed equals expected

  • SIR > 1: Observed are more than expected


Ssi sir report

SSI SIR Report


Ssi sir report output by orgid

SSI SIR Report Output – By OrgID


Ssi sir report output changing time period to obtain sir

SSI SIR Report Output – Changing Time Period to Obtain SIR


Ssi sir report output by orgid procedure code

SSI SIR Report Output – By OrgID/Procedure Code


Ssi sir report output by orgid procedure code outpatient

SSI SIR Report Output – By OrgID/Procedure Code/Outpatient


Ssi sir report output procedures not included in sir

SSI SIR Report Output – Procedures Not Included in SIR


Ssi sir report output procedures not included in sir cont d

SSI SIR Report Output – Procedures Not Included in SIR, Cont’d.


Ssi sir report output procedures not included in sir cont d1

SSI SIR Report Output – Procedures Not Included in SIR, Cont’d.

Duration = 0 excludes the procedure

Approach = N (not specified) for FUSN or RFUSN excludes the procedure


Reasons for procedure exclusion

Reasons for Procedure Exclusion

  • Missing required field/risk factor

  • Procedure duration outlier

  • Procedure date ≤ patient’s DOB

  • Patient’s age at procedure ≥ 109 yrs

  • Wound class = U

  • Approach = N (for FUSN or RFUSN only)

  • Spinal level = N (for FUSN only)

Source: http://www.cdc.gov/nhsn/PDFs/Newsletters/NHSN_NL_OCT_2010SE_final.pdf, Appendix C


Compare two sirs

Compare Two SIRs


Compare two sirs1

Compare Two SIRs


Compare two sirs cont d

Compare Two SIRs, Cont’d.

Statistically significant


Wisconsin data aggregates

Wisconsin Data Aggregates


Conferred rights n 84

Conferred Rights (n = 84)

*Numbers among 3 prevention collaboratives are not unique. 65 unique hospitals participate in these projects.


Dph data use agreement

DPH Data Use Agreement

Offers added protection

  • Share data with DPH staff while asking questions

  • Confer rights to data for inclusion in statewide aggregates

  • Allow DPH staff to see plans/data for selected topics to troubleshoot any inconsistencies, issues


Nhsn tutorials

NHSN Tutorials

  • http://www.dhs.wisconsin.gov/communicable/HAI/Tutorials.htm

  • 5-10 minutes each

  • Screenshots with voiceover for navigation/functionality topics including entering data, setting up facility, and analysis


Questions

Ashlie DowdellSurveillance Coordinator HAI Prevention Project [email protected](608) 266-1122

Questions?


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