Katherine Allen-Bridson, RN, BSN, MScPH, CIC, Centers for Disease Control and Prevention

National Center for Emerging and Zoonotic Infectious Diseases

Performing CAUTI Surveillance for Participation in the CMS IRF Quality Reporting Program

Division of Healthcare Quality Promotion

Training for Inpatient Rehabilitation FacilitiesMay 2, 2012

Nothing to Disclose

Objectives1. State the purposes of the Centers for Disease Control and Prevention’s

(CDC) National Healthcare Safety Network (NHSN).

2. Define methodology for Catheter-associated Urinary Tract Infection (CAUTI) surveillance.

3. Define the CAUTI data required and method to report through the NHSN in order to meet requirements for the Centers for Medicare and Medicaid Services Quality Reporting Program (QRP) for Inpatient Rehabilitation Facilities (IRFs).

4. Identify basic steps required for facility enrollment in NHSN.

5. Identify the rehabilitation location types for which CAUTI surveillance can be performed.

What is NHSN?

Web-based system launched by CDC in 2005 for surveillance of healthcare-

associated infections (HAI), other adverse events, and prevention practices.

Technical design enables manual data entry or electronic reporting.

www.cdc.gov/nhsn

Purposes of NHSN Comply with legal requirements – including but not limited to state

or federal laws, regulations, or other requirements – for mandatory reporting of healthcare facility-specific adverse event, prevention practice adherence, and other public health data.

Enable healthcare facilities to report HAI and prevention practice adherence data via NHSN to the U.S. Center for Medicare and Medicaid Services (CMS) in fulfillment of CMS’s quality measurement reporting requirements for those data.

Provide state departments of health with information that identifies the healthcare facilities in their state that participate in NHSN.

Provide to state agencies, at their request, facility-specific, NHSN patient safety component and healthcare personnel safety component adverse event and prevention practice adherence data for surveillance, prevention, or mandatory public reporting.

Three Main NHSN Components

Patient Safety Component (will discuss in detail)

Healthcare Personnel Safety Component

Blood / Body Fluids Exposure Module Influenza Vaccination and Exposure Management

Module

Biovigilance Component

Hemovigilance Module (Blood Safety)

Patient Safety Component5 Modules

Device-associated Module: 5 Events

CLABSI Central line-associated bloodstream

infection CLIP Central line insertion practices VAP Ventilator-associated pneumonia CAUTI Catheter-associated urinary tract

infection DE* Dialysis event

*For outpatient dialysis only

NHSN Surveillance Methodology

ACTIVE vs. PASSIVE

ACTIVE Trained personnel use standard definitions and a variety of data sources to investigate and identify events.

PASSIVE Personnel, such as staff nurses, not trained to do surveillance may report events. No purposeful investigation for infections occurs.

NHSN Surveillance Methodology2

PATIENT-BASED vs. LABORATORY-BASED PATIENT-BASED Monitoring patients for events,

risk factors, and procedures and practices related to patient care– Visit patient care areas– Review patient charts– Discuss with caregivers

LABORATORY-BASED Case-finding based on positive lab findings

NHSN Surveillance Methodology3

PROSPECTIVE vs. RETROSPECTIVE

PROSPECTIVE Monitoring patients while still in the institution; includes post-discharge period for surgical site infections (SSI)

RETROSPECTIVE Case-finding based solely on chart review after patient discharged

Healthcare-associated Infection (HAI)

A localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that

• Occurs in a patient in a healthcare setting

And• Was not present or incubating

at the time of admission, unless the infection was related to a previous admission

NHSN and CMSQuality Reporting Program

Healthcare Facility HAI Reporting to CMS via NHSN – Current and Proposed Requirements DRAFT (11/14/2011)

HAI Event Facility Type Reporting Start Date

CLABSIAcute Care Hospitals

Adult, Pediatric, and Neonatal ICUsJanuary 2011

CAUTIAcute Care Hospitals

Adult and Pediatric ICUsJanuary 2012

SSIAcute Care Hospitals

Colon and abdominal hysterectomyJanuary 2012

I.V. antimicrobial start Dialysis Facilities January 2012

Positive blood culture Dialysis Facilities January 2012

Signs of vascular access infection Dialysis Facilities January 2012

CLABSI Long Term Care Hospitals * October 2012

CAUTI Long Term Care Hospitals * October 2012

CAUTI Inpatient Rehabilitation Facilities October 2012

MRSA Bacteremia LabID Event Acute Care Hospitals January 2013

C. difficile LabID Event Acute Care Hospitals January 2013

HCW Influenza Vaccination Acute Care Hospitals January 2013

HCW Influenza Vaccination ASCs October 2014

SSI (future proposal) Outpatient Surgery/ASCs TBD

* Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN

CMS Final Rules in Federal Register published August 18, 2011.

Must follow NHSN CAUTI protocol exactly and report complete and accurate data.

Data must be reported to NHSN by means of manual data entry into NHSN web-based application or via file imports using the Clinical Document Architecture (CDA) file format.

Pass quality control acceptance checks that assess the data for completeness and accuracy.

NHSN and CMS

NHSN requires data to be submitted monthly (within 30 days of the end of the month in which it is collected) so it has the greatest impact on infection prevention activities.

Data must be entered into NHSN no later than 4 ½ months after the end of the quarter to be shared with CMS.

– E.g. Q1 (January-March) data must be entered into NHSN by August 15; Q2 by November 15; Q 3 by February 15 and Q4 by May 15

Does not preempt any state mandates for CAUTI reporting to NHSN.

NHSN and CMS, cont’d

NHSN and the CMS Annual Payment Update (APU) Hospital/IRF Inpatient Quality Reporting (IQR) Program

Hospitals/IRFs enter quarterly HAI data into NHSN

< 4 ½ months following the end of the reporting quarter

CDC prepares facility-specific HAI summary statistics that are submitted in monthly and quarterly files to CMS using a secure QualityNet exchange account

Hospitals/IRFs can view their own HAI summary statistics at a secure CMS website where the APU Dashboard is posted (for more information see http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetBasic&cid=1228694346716)

ENROLLMENT INTO NHSN

http://www.cdc.gov/nhsn/enroll.html

Facility Administrators & Usersshould complete all

required NHSN Trainingsbefore beginning Enrollment

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

NHSN Facility AdministratorEnrollment Guide

http://www.cdc.gov/nhsn/PDFs/FacilityAdminEnrollmentGuideCurrent.pdf

NHSN Facility Administrator

Only one Facility Administrator per facility Only person who can enroll a facility Responsible for initial set-up

– Adding locations

– Adding users and assigning user rights

– Joining and conferring rights to groups

Enrollment into NHSNNHSN Registration http://nhsn.cdc.gov/RegistrationForm/index.jsp

2 IRF Enrollment Options

Freestanding, separately licensed facility Location within an Acute Care Facility

Enrollment Requirements:IRFs Requiring Unique NHSN orgID

Enroll in NHSN as a separate facility if:

– Free standing licensed IRF with a CCN (CMS Certification Number) with the last four digits between 3025-3099

Identify as “HOSP-REHAB” facility type

Enrollment Requirements:IRFs Requiring Unique NHSN orgID

Annual survey required

– Complete new, rehabilitation specific annual survey for calendar year 2011

– Use whole numbers without decimal points

Two locations: Adult and Pediatric IRF

Rehabilitation Facility Locations

Page 15-13 of NHSN Patient Safety Component Manual

CDC Definitions

Enrollment Requirements: IRF Units Within a Hospital

Set-up as Inpatient Rehabilitation Ward location within an enrolled acute care or critical access facility type if:

– IRF unit within a hospital and 3rd character of CCN is either a “T” or an “R”

Additional questions are required for licensed IRF units within hospitals to be identified for CMS reporting.

Rehabilitation Locations Within Hospital

Page 15-8 of NHSN Patient Safety Component Manual

CDC Definitions

Beyond Enrollment

Annual Survey: IRF

Annual survey required for HOSP REHAB facility type:

– Must complete a new IRF-specific annual survey for calendar year 2011.

– Use whole numbers without decimal points.

Monthly Reporting Plan CAUTI must be included in Monthly Reporting Plan for data

to be reported on behalf of the facility to CMS.

Locations: Inpatient Adult and Pediatric Rehabilitation Wards

Example for freestanding IRF

AddLocations

Monthly Reporting Plan, cont’d

The Monthly Reporting Plan informs CDC which modules a facility is following during a given month.

A facility must enter a Plan for every month of the year, even those in which no modules are followed.

A facility may enter data only for months in which Plans are on file.

Reminder!

Reporting Numerator and Denominator Data Report each CAUTI detected or indicate that no CAUTI occurred

for reporting locations. (Found on Denominator screen).

Report total device days and total patient days for reporting locations, including months in which no CAUTIs were identified and/or no patient days or urinary catheter days occurred.

RESOURCES

Resources for NHSN

http://www.cdc.gov/nhsn/index.html

Resources for Surveillance

NHSN Patient Safety Component Manual, January 2012

– Ch 3: Monthly Reporting Plan

– Ch 7: CAUTI Protocol (January 2012)

– Ch 14: Tables of Instructions

– Ch 16: Key Terms

http://www.cdc.gov/nhsn/TOC_PSCManual.html

Resources for Surveillance, cont’d

NHSN Forms (June 2011)

– 57.106: Monthly Reporting Plan

– 57.114: Urinary Tract Infection

– 57.118 Denominators for Intensive Care Unit (ICU)/ Other locations (not NICU or SCA)

http://www.cdc.gov/nhsn/forms/Patient-Safety-forms.html

Available Training

Training

– Device Associated Module

– Pre-recorded Webinars

– Lectoras

http://www.cdc.gov/nhsn/training/

Available Training, cont’d

NHSN Enrollment & Facility Set-up (Slidesets [PDFs])

Overview of the Patient Safety Component, Device-associated module (Slideset [PDF])

Data Entry, Surveillance, Analysis, Data Entry, Import, and Customization (Slideset [PDF])

Introduction to the Device-associated Module (Training Course with quiz)

Catheter-associated Urinary Tract Infection (CAUTI) (Training Course with quiz)

http://www.cdc.gov/nhsn/training/