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nhsn reporting of cms required hai hcp measures acute care hospital

NHSN Reporting of CMS Required HAI & HCP MeasuresAcute Care Hospital

This material was prepared by Masspro, the Medicare Quality Improvement Organization for Massachusetts, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily represent CMS policy. 10-ma-ptcare-14-268-nhsn-hai-hcp-qdr012913-ppt-Jan14

required cms quality data reporting
Required CMS Quality Data Reporting

To comply with the CMS Quality Data Reporting, CMS requires acute care hospitals to report on 6 HAI measures in addition to Healthcare Personnel Vaccination measure.

These data sets are to be entered into the CDC NHSN database. NHSN will upload your facility data to CMS to comply with each quarterly deadline.

If your facility data is not complete and present at this time you will fail submission. And be non-compliant with reporting requirements.

cms required hai reporting
CMS Required HAI Reporting
  • Central Line Blood Steam Infections (CLABSI)

Reporting required ICU Locations

  • Catheter Associated Urinary Tract Infections (CAUTI)

Reporting required ICU Locations

  • Surgical Site Infection (SSI) Colon and Abdominal Hysterectomy surgeries

All inpatient colon and abdominal hysterectomy procedures

cms required hai hcp reporting
CMS Required HAI & HCP Reporting
  • Clostridium Difficile Infection (CDI) by Lab ID event

Reporting facility wide inpatient population (* with exclusions)

  • Methicillin-Resistant Staphylococcus Aureus (MRSA) bacteremia by Lab ID event

Reporting facility wide inpatient population

  • Healthcare Personnel (HCP) Influenza Vaccination

Reporting includes both hospital paid employees and non- hospital employees *Conditions do apply

additional data points required january 2014
Additional Data Points RequiredJanuary 2014


Extending CLABSI and CAUTI beyond the ICU has been postponed. New start date is January 1, 2015

  • CMS suggests all facilities use the additional time for preparation to report these events throughout their facilities
cy 2014 nhsn changes
CY 2014 NHSN Changes
  • As of July 1, 2014, all events entered for Medicare beneficiaries must include the Medicare Beneficiary Number.

***This is not an option! Even though leaving the field blank will not hold back your record.

  • Clostridium Difficile Infection (CDI) by Lab ID

You will be required to report your facility test type quarterly. The test type is utilized in the risk adjustment of the CDI Standard Infection Ratio (SIR)

Instructions pending release by NHSN

cy 2014 nhsn changes1
CY 2014 NHSN Changes
  • Surgical Site Infection (SSI)
  • Incisional closure type to included those that were not primarily closed
  • NHSN will adopt the Muscular Skeletal Infection Society’s (MSIS) definitions of periprosthetic joint infection as a new organ/space infection site for knee and hip replacement procedures
  • NHSN will adopt the Association of Anesthesia Clinical Directors definition of Procedure/Surgery start time and Procedure/Surgery Finish for calculating operative duration
  • Patient height, weight and diabetes status will be required on all procedures entered into NHSN
  • Additional field will be required when reporting knee and hip replacement procedures
cy 2014 nhsn changes2
CY 2014 NHSN Changes
  • Beginning January 1, 2014 participation in the NHSN Central Line-associated Bloodstream Infection (CLABSI) module will require surveillance for, and reporting of, Mucosal Barrier Injury-Laboratory Confirmed Bloodstream Infection (MBI-LCBI) events.
  • In 2013, reporting of this type of LCBI was optional for in-plan reporting.
changes to clabsi reporting in 2014
Changes to CLABSI Reporting in 2014
  • The definition of neutropenia in the MBI-LCBI criteria will be expanded to include the 3 calendar days after the positive blood culture.
  • The neutropenia definition used for 2014 will be: 2 days of absolute neutrophil count (ANC) or white blood cell (WBC) count less than 500 cells/mm3 within the following time period surrounding the positive blood culture - the 3 calendar days before, the day of, and the 3 calendar days after. In 2013, the time period was limited to the 3 calendar days before and the day of positive blood culture.
  • In 2014, there will be a new optional question on the BSI form: “Any hemodialysis catheter present?” The purpose of this optional field is to help track the proportion of CLABSIs that are potentially related to CVCs used for hemodialysis.
ssi updates
SSI Updates
  • NHSN is working on an ICD-9 CM mapping tool for the new HPRO and KPRO denominator for procedure data fields. As soon as this tool is complete we will share this with our NHSN users via an email and we will also make this tool available on the NHSN website in the SSI section under “Supporting Materials”.
  • Please note that the new 2014 procedure import specifications, as well as a sample procedure import file, are available on the SSI section of the NHSN webpage under “Supporting Materials”:
surgical site infection ssi 2014 changes
Surgical Site Infection (SSI) 2014 Changes
  • Height and weight for all procedures

Begins January 1, 2014

  • Diabetes status ~ starts now with the allowance for electing No if you are unable to find the diabetic status

*Begins without exception January 1, 2015

  • Incisional closure type (primary vs. non-primary)
  • Modified definition of procedure duration.
patient safety component
Patient Safety Component
  • After January 1, 2014 you will begin to see an alert on your NHSN home screen reminding you to complete a 2013 annual survey.
  • The Patient Safety annual surveys must be completed by March 1st. Facilities will not be able to create a March 2014 monthly reporting plan without completing a 2013 facility survey.
  • The questions on the annual surveys are identical to those asked on the 2012 survey. The annual survey forms are available on the NHSN website (on each specific HAI webpage) under ‘Data Collection Forms’. Updated instructions addressing common questions for the annual hospital survey will soon be posted under ‘Data Collection Forms’.
healthcare personnel safety component
Healthcare Personnel Safety Component
  • For those following the Influenza Vaccination Summary module, NHSN encourages users to complete the (optional) "Seasonal Survey on Influenza Vaccination Programs for Healthcare Personnel".
  • The data collected in this brief survey, including methods a facility uses to deliver influenza vaccine to its HCP, are very helpful to CDC personnel. If electing to complete this survey, only one survey should be completed during the influenza season
ventilator associated reporting
Ventilator-Associated Reporting
  • Reporting ventilator associated events is not currently required by CMS.
  • All facilities are encouraged to use this reporting component to establish a baseline as well as utilize the standard reporting criteria.
  • This will give you the opportunity to evaluate your SIR as well as frank rates.
utilizing nhsn data for improvement
Utilizing NHSN Data for Improvement

NHSN data reporting functions are robust and can be an asset to internal performance improvement activities

All the data you enter is ready for analysis as soon as it is entered.

Entering data within the requested 30 days will allow you to confirm that your data is complete, accurate and ready for CMS upload each quarter

You will be able to follow your rates as well as Standard Infection Ratio (SIR)

Using the SIR you will have a better idea if your infection incidence is higher or lower than predicted

standard infection ratio sir
Standard Infection Ratio (SIR)

A SIR of 1.0 or less is good

It means that you had less than predicted infections

If you had 2 infections and 3.4 were expected your SIR would be .59

2 / 3.4 = 0.5882

If you had 4infections and 3.4 were expected your SIR would be 1.18

2 / 3.4 = 1.1765

what you c an d o n ow
What You Can Do Now
  • Make sure that all the data fields required are part of your electronic record
  • Involve your IT department to amend current reports and automate other to upload data. This may give your facility back many clinical hours!
  • Keep informed by visiting the CDC NHSN website
  • Check your Hospital Compare reports for accuracy during the preview period
  • Use your data, know what your SIR rates are for all components
  • Assess your facility’s processes to assure the most effective and cost efficient way to report accurately and timely