National Healthcare Safety Network (NHSN) in 2015 Ashlie Dowdell HAI Surveillance Coordinator SEW APIC, February 5, 2015 Wisconsin Department of Health Services

Agenda Review the 2015 definition change highlights. Recap state and federal NHSN reporting requirements. What’s coming in 2015 for: Ambulatory surgery centers (ASC). Long-term care (LTC) facilities. ICD-10.

When Do I Need To Incorporate These Changes? All definition/surveillance protocol changes took effect January 1, 2015. Changes to fields/reporting rules will be part of the database after the first 2015 version update (January 31). Wait until after the version update to enter 2015 reporting plans, data and the annual facility survey for CY 2014.

Patient Safety Component Protecting and promoting the health and safety of the people of Wisconsin

General NHSN Changes NHSN Infection Window Event Date Repeat Infection Timeframe Secondary Bloodstream Infection (BSI) Attribution Period CDC/NHSN Surveillance Definitions for Specific Types of Infections (aka Chapter 17) Note: These general changes do not apply to Long-Term Care Component users.

NHSN Infection Window Replaces “gap day” methodology from 2014. All elements of the criteria must be part of this window. For criteria that include diagnostic testing: Day the first positive diagnostic test included in the infection criteria was obtained. Three calendar days before the test. Three calendar days after the test. Day -3 Day -2 Day -1 Day of first positive test Day 1 Day 2 Day 3

Event Date 2014: Date the last element of the criteria was met. 2015: Date the first element of the criteria occurs for the first time within the seven-day infection window. Event date still determines whether an infection is present on admission (POA) or healthcare-associated. Event dates on the date of admission, two days before and the day after are POA. Events dates on or after hospital day 3 (hospital admission day is day 1) are HAIs for NHSN surveillance.

Repeat Infection Timeframe (RIT) 14-day period during which repeat infections of the same type cannot be reported. Any additional pathogens collected during this timeframe should be added to the original infection report. Event date for the first infection is day 1 of the RIT.

Secondary BSI Attribution Period Must meet the Secondary BSI Guideline criteria and fall during this time period. 14-17-day period (depending on where the event date falls within the Infection Window): 7-day Infection Window of the primary infection. 14-day Repeat Infection Timeframe of the primary infection.

Sun Mon Tue Wed Thu Fri Sat Nov 23 Nov 24 Nov 25 Nov 26 Nov 27 Nov 28 Day -3 before culture = Beginning of Infection Window Nov 29 Day -2 before culture Nov 30 Day -1 before culture Dec 1 Fever, + culture = CAUTI Date of Event Day 1 of RIT Dec 2 Day 1 after culture Day 2 RIT Dec 3 Day 2 after culture Day 3 RIT Dec 4 Day 3 after culture (End of IW) Day 4 RIT Dec 5 Day 5 RIT Dec 6 Day 6 RIT Dec 7 Day 7 RIT Dec 8 Day 8 RIT Dec 9 Day 9 RIT Dec 10 Day 10 RIT Dec 11 Day 11 RIT Dec 12 Day 12 RIT Dec 13 Day 13 RIT Dec 14 Day 14 RIT (End of RIT) Dec 15 Dec 16 Dec 17 Dec 18 Dec 19 Dec 20 Infection Window Repeat Infection Timeframe Secondary BSI Attribution Window

Excluded Modules for Certain General HAI Rules Protecting and promoting the health and safety of the people of Wisconsin

Specific HAI Definitions/ Chapter 17 HAI definitions for anything without a devoted module. First significant update since the 1990s. Bring them up to date and make them consistent with other NHSN changes over the years. Available at: http://www.cdc.gov/nhsn/PDFs/pscManual/17pscNosInfDef_current.pdf

BSI Protocol Secondary BSI Guide Will no longer ask whether blood culture organism is a logical pathogen for the primary site of infection. Introduction of the Secondary BSI Attribution Period (Infection Window + Repeat Infection Timeframe for the primary infection). Core temperatures no longer required for infant fevers. Use the documented temperature and do not convert.

UTI Protocol No longer included: Colony counts less than 100,000 CFU/ml. Urinalysis results. Cultures positive only for yeast, mold, dimorphic fungi, or parasites. Uropathogen list for asymptomatic bacteremic UTI (ABUTI) (will use the same list as for symptomatic UTI). Protecting and promoting the health and safety of the people of Wisconsin

New Denominator Sampling Option Alternate method for collecting CLABSI and CAUTI denominator data. Can only be used in ICUs and wards with 75 or more device-days per month. Collect patient days and device days one day per week (e.g., every Tuesday) at the same time and provide the total number of patient days for the month. NHSN will estimate the device days based on the collected data for use as the denominator.

Ventilator-Associated Events (VAE) Protocol Combine possible VAP and probable VAP into one event: PVAP. Exclude typically environmental pathogens (i.e., community-associated fungal pathogens) not known/rarely acquired in healthcare for PVAP. New optional denominator: Episodes of Mechanical Ventilation. Vent days and APRV days continue to be required. Daily minimum PEEP/FiO2 when there is no value documented as maintained for 1 hour during the calendar day: Use the lowest value documented in that calendar day.

Pneumonia/Ventilator- Associated Pneumonia Changes Bringing testing, pathogens in line with VAE definitions. Cannot report pathogens or attribute secondary BSIs for PNU1 definition. If blood cultures are collected and pathogens identified within the required period, modify the designation to PNU2. Protecting and promoting the health and safety of the people of Wisconsin

SSI Protocol Inpatient/outpatient procedures. **Changed 2/3/15**: Back to the 2014 definitions. Inpatient procedure – different dates of admission and discharge. Outpatient procedure – same date of admission and discharge. Infection present at the time of surgery (PATOS). SSIs with PATOS excluded from SSI SIRs beginning in 2016 with the new baseline.

SSI Protocol, cont. Prior infection at the index joint for HPRO/KPRO revisions. Primary closure: Any portion closed at the skin level rather than all tissue levels. Diabetes: Medication-based definition of diabetes or ICD-9 discharge codes. Scope field: Y if the procedure was coded as a lap procedure performed using a laparoscope/robotic assist.

MDRO/CDI Protocol: Denominator Be prepared to exclude unit-based inpatient rehab facilities (IRF), inpatient psychiatric facilities (IPF) and skilled nursing facilities (SNF) with a different CMS Certification Number (CCN) than the acute care hospital. New denominator screen will walk through that removal: Total patient days/admissions = all locations. MDRO patient days/admissions = exclude IPF/IRF/SNF. CDI patient days/admissions (if reporting CDI) = exclude IPF/IRF/SNF and NICU/well baby counts.

MDRO/CDI Protocol: New Locations Map ERs and dedicated 24-hour observation locations. Any time you use FACWIDEIN as a location, you also need to report the same organism for the ER and observation. Attribute cultures taken in the ER to the ER (not the admitting inpatient unit as was done in 2014).

CRE Changes CRE = E. coli, Klebsiella pneumoniae/oxytoca, and Enterobacter. Definition changes: Ertapenem has been added. Only includes pathogens testing resistant to a carbapenem (intermediates will no longer count). CRE-Klebsiella will be limited to Klebsiella oxytoca and Klebsiella pneumoniae.

New CRE Definition Any Escherichia coli, Klebsiella oxytoca, Klebsiella pneumoniae, or Enterobacter testing resistant to imipenem, meropenem, doripenem, or ertapenem by standard susceptibility testing methods (i.e., minimum inhibitory concentrations of ≥ 4 mcg/mL for doripenem, imipenem, and meropenem or ≥ 2 mcg/mL for ertapenem) or by production of a carbapenemase (i.e., KPC, NDM, VIM, IMP, OXA-48) demonstrated using a recognized test (e.g., PCR, metallo-β-lactamase test, modified-Hodge test, Carba-NP). Protecting and promoting the health and safety of the people of Wisconsin

MDRO/CDI Protocol Optional questions to be added to LabID Event form: Last physical location of patient immediately prior to arrival to facility (if specimen is community-onset). Has patient been discharged from another facility in the past four weeks? (this includes NH, rehab, other hospitals, LTACs, etc.). Protecting and promoting the health and safety of the people of Wisconsin

Dialysis Component Protecting and promoting the health and safety of the people of Wisconsin

2015 Changes (All Optional – Not Part of CMS Reporting) 5 new process measures: Hemodialysis catheter connection/disconnection. Hemodialysis catheter exit site care. Arteriovenous fistula and graft cannulation/decannulation. Dialysis station routine disinfection. Injection safety. Influenza vaccination for dialysis patients. Analysis – data quality reports.

Dialysis Events Form New question: “Where was this positive blood culture collected?” Responses include dialysis clinic, hospital (day of or day following hospital admission) or ER, and other location. Loss of vascular access field under the outcomes section will now be required.

LONG-TERM CARE Facility Component Protecting and promoting the health and safety of the people of Wisconsin

New Required Denominator Fields Enter the monthly total for each new field when entering the monthly total resident days: If reporting UTI: Number of new antibiotic starts for UTI indication. If reporting CDI: Number of admissions on CDI treatment. Protecting and promoting the health and safety of the people of Wisconsin

General HAI Surveillance Definitions New terms used in the Patient Safety Component (infection window, repeat infection timeframe, etc.) do not apply to the LTC Component and should not be used at this time. Refer back to the LTC module protocols instead. Updated LTC Component protocols and training slides available now at http://www.cdc.gov/nhsn/LTC/index.html.

NHSN Reporting Requirements Protecting and promoting the health and safety of the people of Wisconsin

CMS Healthcare Facility NHSN HAI Reporting Requirements Reporting Specifications Existing Requirement New Requirement for 2015 Acute Care Hospitals (Prospective Payment System – PPS) CLABSI (ICUs, PICUs, NICUs) CAUTI (ICUs, PICUs) SSI (COLO and HYST) MRSA Bacteremia LabID Event C. difficile LabID Event HCP Influenza Vaccination CLABSI and CAUTI Expansion (Medical, Surgical and Medical/Surgical Wards) Outpatient Dialysis IV antimicrobial start Positive blood culture Signs of vascular access infection Long-Term Acute Care (LTAC) Hospitals CLABSI CAUTI Ventilator-Associated Events (2016) Inpatient Rehabilitation Facilities (IRF) Ambulatory Surgery Centers (ASC) None Inpatient Psychiatric Facilities (IPF) Long-Term Care (LTC) Facilities

State Reporting Requirements Medicaid P4P Program. CAUTI. PPS and CAH. April 2014 – March 2015 due September 30, 2015. HCP Influenza Vaccination. PPS, CAH, psych and children’s. 2014-15 season due May 15, 2015. CRE. PPS, CAH, children’s and LTAC hospitals. Data reported monthly even if no positive cultures have been identified.

Reminder: NHSN 2015 Changes Training 10-minute videos available now at http://www.cdc.gov/nhsn/Training/patient-safety-component/index.html February 17-19 via live webstream, includes overview of each module and case studies. DPH January 7 webcast recording available at http://dhsmedia.wi.gov/main/Play/8d1fc0a5fb8347fe8d79601709d381c41d.

What’s coming in 2015 for ambulatory surgery, long-term care and ICD-10? Protecting and promoting the health and safety of the people of Wisconsin

ASCs in 2015 All should be enrolled or enrolling. Finishing up the first season of flu reporting (2014-15). Due May 15. Outpatient Component due to launch in the summer. Protecting and promoting the health and safety of the people of Wisconsin

Outpatient Component - ASCs Focus on SSIs, same day adverse events, and IV antibiotic prophylaxis timing initially. Start with ASCs, open up to hospital outpatient departments later. Start with 10 procedures (breast, colon, hernia, abdominal hyst, laminectomy, gallbladder, fractures, hip and knee replacements, vaginal hyst). Denominators will be aggregate numbers of procedures, admissions, etc. Risk adjustment/analysis still TBD.

LTC Participation in NHSN 13 Wisconsin facilities live (206 across the country). 3 have conferred rights to DPH so far. Per the surveillance workshops last fall: 64 facilities plan to use the protocols outside NHSN. 57 facilities plan to enroll in the near future. Protecting and promoting the health and safety of the people of Wisconsin

Current LTC Reporting Options MDRO/C. difficile – laboratory-identified events Urinary tract infections Prevention process measures Hand hygiene Gown and glove use Staff flu vaccination Protecting and promoting the health and safety of the people of Wisconsin

LTC in 2015 Pilot for interested facilities in 2015. Enroll (see checklist http://www.cdc.gov/nhsn/LTC/enroll.html). Start reporting at least CRE. Determine the LTC-specific questions, road blocks, tools, etc. for enrolling and participating. Protecting and promoting the health and safety of the people of Wisconsin

Why NHSN for LTC? Standardized definitions. NHSN = McGeer’s criteria. National standard - try to use protocols, even if you’re not ready to enroll. Start to build data for comparison, both locally and nationally. Helps with the survey/QAPI process. 2013 National HAI Goal to enroll 5% of nursing homes by 2017.

Transitioning to ICD-10 NHSN ICD-10 code mapping is expected to be available by March 2015. ICD-10 coding starts October 2015. ICD-10 codes will be accepted into NHSN starting January 2016 after the version update. Between October and January, omit the ICD code in the procedure record to avoid error messages. Protecting and promoting the health and safety of the people of Wisconsin

Questions? Ashlie Dowdell HAI Surveillance Coordinator Wisconsin Division of Public Health 608-266-1122 ashlie.dowdell@wi.gov Protecting and promoting the health and safety of the people of Wisconsin