1. NHSN Reporting for Critical Access Hospitals
Allison Murad, MPH
Surveillance for Healthcare-Associated and Resistant Pathogens (SHARP) Unit
Michigan Department of Health and Human Services (MDHHS)

2. Why NHSN? The “Gold Standard” for HAI Reporting and Surveillance
Clinical vs. Surveillance Definitions:
Clinical:
Individualized
Used for making therapeutic decisions
Surveillance
Population-based
Must be applied uniformly and consistently

3. The Essentials of Infection Surveillance
Know protocol/criteria
Consistently apply the criteria
Report events meeting criteria; exclude those that don’t
Failure to do so:
Breach of NHSN Rules of Behavior
Decreased usefulness of national comparative data
Unfair comparisons between facilities
Possible validation discrepancies
Potential impact of CMS Inpatient Quality Reporting score & facility reimbursement

4. Components of NHSN

5. Not Enrolled in NHSN?
Start here:

6. Already Enrolled in NHSN for HCP?
If you’ve enrolled your facility in NHSN in order to report Healthcare Personnel Influenza Vaccination Data, you can activate the Patient Safety Component by going to: Facility – Add/Edit Component

7. Add additional users to your facility!
Users – Add

8. Patient Safety Component
Device-Associated Module
CLABSI
CLIP
CAUTI
VAE
VAP
Procedure-Associated Module
SSI
Antimicrobial Use and Resistance Module (AUR)
Multidrug-Resistant Organism and Clostridium difficile Infection (MDRO/CDI) Module
MRSA LabID
CDI LabID

9. MDRO/CDI Reporting
“The NHSN MDRO/CDI Module offers a means for facilities to meet criteria and metrics that are outlined in several organizational guidelines to control and measure the spread of MDROs and CDI within their healthcare system.”
“As outlined in the HICPAC guideline, these MDRO and C.difficile pathogens may require specialized monitoring to evaluate if intensified infection control efforts are required to reduce the occurrence of these organisms and related infections. The goal of this module is to provide a mechanism for facilities to report and analyze these data that will inform infection prevention professionals of the impact of targeted prevention efforts.”

10. LabID Reporting
LabID Event reporting is based strictly on laboratory testing data without clinical evaluation of the patient, allowing for a much less labor intensive method to track C. difficile and MDROs, such as MRSA.
Advantages of LabID Event Reporting
Objective laboratory-based metrics
Estimate infection burden
Estimate exposure burden
Assess need for and effectiveness of interventions
Standardized case definitions
Increased comparability between settings

11. Categorization of CDI LabID Events
Incident: Event from a specimen obtained >56 days (8 weeks) after the most recent CDI LabID Event (or with no previous CDI LabID Event documented)
Day 1 = date of first specimen collection
Recurrent: Event from a specimen obtained >14 days (2 weeks) and ≤ 56 days (8 weeks) after the most recent CDI LabID Event
Duplicate: Event from the same patient AND location, following a previous lab result within the past two weeks (14 days), even across calendar months and readmissions to the same facility.
Duplicate events will prompt a pop-up message that will not allow you to enter

12. Categorization of CDI LabID Events
Healthcare-Onset (HO): Positive toxin tests collected >3 days after admission to the facility (i.e., on or after hospital day 4)
Community-Onset (CO): LabID Event collected in an outpatient location or an inpatient location ≤3 days after admission to the facility (i.e., days 1, 2, or 3 of admission).
Community-Onset Healthcare Facility-Associated (CO-HCFA): CO LabID Event collected from a patient who was discharged from the facility ≤4 weeks prior to current date of stool specimen collection. Data from outpatient locations (e.g., outpatient encounters) are not included in this definition.

13. Best part of categorization?
NHSN categorizes for you!
Running and exporting data will show the rates and ratios of each categorized event type facility-wide

14. What can you do with the data?

15. MDHHS Feedback Reports

16. National NHSN Use
As of March 2017:

17. CMS Reporting Requirements

18. MDHHS SHARP Unit Validation Activities
Statewide NHSN User Group Webinars, Next Call: Wednesday, June 28th at 10am
ICAR Assessments/Infection Control Consulting: Noreen Mollon,
CRE Surveillance and Prevention Initiative: Brenda Brennan,
Antimicrobial Resistance: Sara McNamara,

19. Thank you!
Allison Murad, MPH Surveillance for Healthcare-Associated and Resistant Pathogens (SHARP) Unit, MDHHS