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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
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.



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 Current and Proposed Requirements



Planned for the october 2011 release
Planned for the October 2011 Release Current and Proposed Requirements

  • 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. Current and Proposed Requirements

  • 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 Current and Proposed Requirements


Generating data sets
Generating Data Sets Current and Proposed Requirements


Accessing your data
Accessing Your Data Current and Proposed Requirements


Analysis reports tree view
Analysis Reports Tree View Current and Proposed Requirements


Cdc s pre configured reports
CDC’s Pre-Configured Reports Current and Proposed Requirements


Default report
Default Report Current and Proposed Requirements


Modify your report
Modify Your Report Current and Proposed Requirements


Customized control chart
Customized Control Chart Current and Proposed Requirements

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. Current and Proposed Requirements

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. Current and Proposed Requirements


Standardized infection ratio sir
Standardized Infection Ratio (SIR) Current and Proposed Requirements

  • 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 Current and Proposed Requirements


Ssi sir report output by orgid
SSI SIR Report Output – By OrgID Current and Proposed Requirements







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 Cont’d.

  • 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 Cont’d.


Compare two sirs1
Compare Two SIRs Cont’d.


Compare two sirs cont d
Compare Two SIRs, Cont’d. Cont’d.

Statistically significant



Conferred rights n 84
Conferred Rights (n = 84) Cont’d.

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


Dph data use agreement
DPH Data Use Agreement Cont’d.

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 Cont’d.

  • 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 Dowdell Cont’d. Surveillance Coordinator HAI Prevention Project [email protected](608) 266-1122

Questions?


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