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NHSN Reporting

NHSN Reporting. C-diff Lab ID event MRSA Lab ID event HCW influenza vaccination. C-diff Lab ID event. Acute care hospitals to start reporting facility wide IN c-diff Lab ID events 1/1/2013.

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NHSN Reporting

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  1. NHSN Reporting C-diff Lab ID event MRSA Lab ID event HCW influenza vaccination

  2. C-diff Lab ID event • Acute care hospitals to start reporting facility wide IN c-diff Lab ID events 1/1/2013. • This monitoring method enables a facility to rely almost exclusively on data obtained from the laboratory. • Have you completed the NHSN training yet? http://www.cdc.gov/nhsn/wc_MDRO_CDAD_ISlabID.html

  3. C-diff monthly Lab ID event • Every month – put in your reporting plan (FACWIDE IN) Go to reporting plan on NHSN

  4. C-diff monthly NHSN Lab ID event • Every month – to do this monthly surveillance you need to have a way to get the + c-diff toxin assays. • How do you get this information at your facility? • Lab calls you all + c-diff results? • Computerized report?

  5. C-difficile Lab ID patient and event (Use the MR# or ID # that remains the same for the patient across all visits and admissions) • Mr. Doe admitted to your facility medical/surgical unit for congestive heart failure on August 1, 2012, MR #33442, DOB 5/23/1943. • He was transferred with a “history of c-diff”. There is no paperwork that shows the last C-diff testing results, but the patient is on po Flagyl. • The patient continues his stay at your hospital for CHF; their oral Flagyl for the c-diff is complete on 8/3/2012 and the patient has semi-formed stool. • On August 19, 2012 the patient starts having diarrhea again and another loose stool is tested positive for c-diff • What do you enter into NHSN? • Let’s use the NHSN algorithm to see…..

  6. Yes, on 8/19/2012 Last + c-diff toxin assay unknown (> than 2 weeks) – must enter into NHSN

  7. NHSN data entry!

  8. C-diff Lab ID patient and event • Mrs. Smith is admitted to your facility orthopedic unit for a total knee replacement on August 1, 2012. MR# is 88773 and her DOB is 1/29/58. • She develops a fever of 101.6 and a post operative pneumonia is diagnosed, the patient is started on oral Levaquin and q 4 hour respiratory treatments on 8/5/2012. • 8/9/2012 – the nurses note that she has 3 loose stools. • 8/10/2012 – 2 loose stools • 8/11/2012 – C-diff PCR is + ,diarrhea continues, po Flagyl is started. • 8/15/2012 - the patient improves and is discharged to a rehabilitation facility.

  9. Yes, on 8/11/2012 No previous +

  10. NHSN Data entry!

  11. C-diff Lab event? • Mr. Staph is seen in the ER for nausea, vomiting and diarrhea on 8/8/2012. the patient has a low grade fever while in the ER of 99.6, the ER orders fluids and zofran which gets the nausea and vomiting under control. Blood cultures and a c-diff PCR are ordered prior to discharge, he is to follow up with his PCP for further issues. • 8/10/2012 you note that that 3 of 4 of the patients blood cultures grew E-coli and his c-diff PCR was +. MR # was 99984 and DOB 8/12/74. • What do you enter into NHSN? • If you are following CMS mandatory reporting – No, they mandate FACWIDE IN. • But your facility could decide to voluntarily input FACWIDE OUT too, if this is the case it should be added.

  12. NHSN Data entry!

  13. C-diff monthly Lab ID event summary data • At the end of the month you must put in your summary data so that data/rates can be calculated. • Go to NHSN – Add summary data. (For FACWIDE IN you will need patient days, admissions. IF you are entering FACWIDE OUT then you need encounters too.) • IF you did not have any Lab ID events you must enter this information here!!!

  14. Enter Summary Data into NHSNAugust patient days – 2500August admissions – 822ER encounters – 187No NICU or Out patient dialysis…

  15. Monthly NHSNMRSA Bacteremia Lab ID event • Every month – put in your reporting plan (FACWIDE IN) Go to reporting plan on NHSN

  16. Monthly MRSA Bacteremia Lab ID event surveillance…… • Every month – have a way to get the + MRSA blood culture information. • How do you get this information at your facility? • Lab calls you all + MRSA results? • Computerized report?

  17. MRSA unique blood source monthly Lab ID event? • Mr. Black admitted on 8/7/2012 to the ICU with fever. Blood cultures taken on arrival. • 8/10/2012 4/4 blood cultures + for MRSA. • What do you enter into NHSN? • MR#55565, DOB 8/16/88. Because this was the first blood isolate obtained from this patient, also called unique blood source, aLabID Event form needs to be completed. • Go to NHSN reporting

  18. MRSA monthly Lab ID event? • 8/1/2012 Mrs. Barr (MR#67823, DOB 3/23/66) was admitted to the medical surgical unit of your hospital with an open wound that was cultured. The culture was positive for MRSA. Appropriate antibiotics and wound care was initiated during the hospitalization. • 8/5/2012 the patient spiked a fever and blood cultures were taken. • 8/7/2012 ¾ Blood cultures + for MRSA. • What do you enter into NHSN?

  19. Don’t forget to add “Summary Data”!!!! • Go to NHSN “Add Summary Data” • Be sure and have the following data…. Patient Days Patient Admissions ER Encounters (IF voluntarily choosing to enter FACWIDE OUT) If you did not have MRSA Unique Blood source Lab ID event – this is where you document that.

  20. Right from the CDC NHSN Training!!!!

  21. Did you do your NHSN MDRO training yet? • http://www.cdc.gov/nhsn/wc_mdro_labID.html

  22. NHSN Health Care Influenza Vaccination Reporting

  23. Influenza Vaccination Reporting • Reporting required for Acute Care Hospitals starting January 2013 and ASCs starting October 2014. • Reporting will be done through NHSN’s Healthcare Personnel Safety Component. • This component has 2 modules: • Healthcare Personnel Exposure • Healthcare Personnel Vaccination

  24. Influenza Vaccination Reporting • CDC encourages that HCP influenza vaccination summary counts be updated on a monthly basis within 30 days of the end of each month. However, entering a single influenza vaccination summary at the conclusion of the measure reporting period will meet the minimum data requirements for NHSN participation.

  25. Influenza Vaccine Reporting • You must complete the monthly plan for this module. Healthcare Personnel Safety Monthly Reporting Plan

  26. Healthcare Personnel Influenza Vaccination Summary

  27. Question 1 (Denominator) Notes: • Include all HCP who have worked at the facility for at least 30 working days during the reporting period, regardless of clinical responsibility or patient contact. This includes HCP who joined after October 1 or left before March 31, or who were on extended leave during part of the reporting period. Working for any number of hours a day counts as one working day. • Include both full-time and part-time persons. If an HCW works in two or more facilities, each facility should include the HCW in their denominator. Count HCP as individuals rather than full-time equivalents. • Licensed practitioners who receive a direct paycheck from the reporting facility, or who are owners of the reporting facility, should be counted as employees. • The HCP categories are mutually exclusive. Each HCP should be counted only once in the denominator (question 1).

  28. Questions 2-6 (Numerator) Notes • Questions 2-6 are mutually exclusive. The sum of the HCP in questions 2-6 should equal the number of HCP in question 1 for each HCP category. Questions 2-6 are to be reported separately for each of the three HCP categories. • Only the following HCP should be counted in question 4: HCP with (1) a severe allergic reaction to eggs or other vaccine component(s) or (2) a history of Guillian-Barre Syndrome within 6 weeks after a previous influenza vaccination. • The following should be counted in question 5 (declined to receive influenza vaccine): • HCP who declined vaccination because of conditions other than those included in question 4. • HCP who declined vaccination and did not provide any other information. • HCP who did not receive vaccination because of religious exemptions. • HCP who deferred vaccination for the entire influenza season (i.e. from October 1 to March 31).

  29. Question #1 • When are LIP counted as “Employees” and when are they counted as LIP? • A. Always count them as LIP • B. Count them as employees unless they are a physician • C. Count them as Employee if they receive a paycheck regardless of their job duties.

  30. Answer #1 • An “employee” is anyone on the payroll and receiving a paycheck from the facility. Regardless of their job duties, if they work at the facility for at least 30 days from October 1 to March 31, these HCP are reported as “employees.”

  31. Question #2 • What type of nurses are considered LIP? • A. Any nurse the rounds with or works for a Physician • B. Only Advanced Practice Nurses • C. Nurses that are Credentialed

  32. Answer #2 • All advanced practice nurses should be included in the licensed independent practitioner category. Advanced practice nurses include nurse practitioners, nurse midwives, clinical nurse specialists, and nurse anesthetists.

  33. Question #3 • In an employee works a half a day 5 times a month, this should be counted as: • A. 2.5 days • B. 5 days

  34. Answer #3 • If a HCW is physically present in the facility for any part of a day, this is counted as working one day. Therefore, the employee would be counted as working five days a month. The measure reporting period lasts for six months (October 1 to March 31), so you would include this employee in the denominator since he/she will have worked at least 30 days during the reporting period.

  35. Question #4 • A hospital is part of a multi-hospital system that has one corporate payroll. Each hospital has its own NHSN number. Some HCP work at multiple facilities. How should they report total number of HCP? • A. Lump them all together • B. Report HCP in each facility they work • C. Report HCP in the main facility they work

  36. Answer #4 • Each facility should report the total number of HCP who physically work in that facility. If a healthcare worker (HCW) physically works in multiple facilities in the hospital system for 30 days or more from October 1 to March 31, this individual should be counted in the total number of HCP for each facility where he/she works.

  37. Links FAQs • http://www.cdc.gov/nhsn/faqs/FAQ-Influenza-Vaccination-Summary-Reporting.html • Questions • NHSN@cdc.gov

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