1. NHSN Data Submission Requirements 2013 Health Care Excel Cathie Pritchard LPN, RHIT Quality Data Reporting Technologist October 12, 2012

2. Important Dates  Data must be submitted monthly (within 30 days of the end of the month which is collected).  For data to be shared with Centers for Medicare & Medicaid Services (CMS), each quarter’s data must be entered into NHSN no later than 4 ½ months after the end of the quarter. 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. 2 Reminder!

3. Hospital Inpatient Quality Reporting Program HAI Requirements  January 2011 CLABSI data from adult, pediatric, and neonatal intensive care units  January 2012 CAUTI from adult and pediatric intensive care units SSI from inpatient colon and abdominal hysterectomy procedures  January 2013 Methicillin Resistant Staphylococcus Aureus(MRSA) Bacteremia Clostridium Difficile (C.Diff) Healthcare Personnel Influenza Vaccination 3

4. Health Care Facility HAI Reporting to CMS via NHSN—Current and Proposed Requirements DRAFT (11/23/2011) 4

5. CMS Reporting Requirements LabID Event for FacWideIN 5

6. Facility-wide Inpatient FacWideIN Includes all inpatient locations, including observation patients housed in an inpatient location 6

7. CMS 2013 What Data Will NHSN Report to CMS? MRSA Blood and C. difficile Healthcare Facility-Onset (HO) LabID Events CDI: All non-duplicate, non-recurrent LabID Event specimens collected > 3 days after admission to the facility MRSA Blood: All non-duplicate, LabID Event specimens collected >3 days after admission to the facility 7

8. CMS 2013 MRSA Bacteremia LabID Event  Organism: Methicillin-Resistant Staphylococcus aureus (MRSA)  Data Collection: CDC NHSN - MDRO/CDI Module  Required Locations All inpatient locations (=FacWideIN) for LabID Events  Required Data Community-Onset (CO) and Healthcare-Onset (HO) Event MRSA blood specimens at the facility-wide inpatient level 8

9. CMS 2013 C. difficile LabID Event  Organism: Clostridium difficile (C. diff )  Data Collection: CDC NHSN - MDRO/CDI Module (LabID Event)  Required Locations: All inpatient locations at Facility-wide Inpatient level (FacWideIN) minus NICU, SCN, or other Well Baby locations (e.g. Nurseries, babies in LDRP)  Required Data Community-Onset (CO) and Healthcare-Onset (HO) Events All C. difficile LabID Events on unformed stool specimens at the facility-wide Inpatient level 9

10. Validation Process  Combines random and targeted sampling approach Abstract CLABSI data for candidate CLABSI medical records Abstract CLABSI data for all currently requested quarterly medical records being validated for other topics: -Acute Myocardial Infarction (AMI), Heart Failure (HF), Pneumonia (PN), Surgical Care Improvement Project (SCIP), Emergency Departments (ED) / Immunization (IMM) If your hospital is being validated for core measures, you also are being validated for CLABSI 10

11. Validation Process (Continued)  Basics ICU patients Positive blood culture results  Complete the positive blood culture template  Selection is a two-step process Step one—Identify candidate CLABSI patients Step two—Randomly sample up to three candidate CLABSI patients from the template 11

12. Validation Process (Continued)  Positive blood culture templates are due quarterly, 15 days prior to clinical submission deadlines November 15, 2012 February 15, 2013 May 15, 2013 12

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14. Training on how to complete the blood culture temple. 14

15. Validation Process (Continued)  Validation process will continue as additional HAI measures are added  CAUTI and SSI data will be validated next (final rule page 1138)  New measures will be added starting with 1 st quarter 2013 (final rule page 1114) 15

16. Submitting the Blood Culture Template  Submitted using My QualityNet Secure File Exchange  Infection Preventionists should work with Quality staff who have a QualityNet Account  Validation for hospitals selected for FY 2014 continues through 3 rd Quarter 2012 16

17. Questions? Cathie Pritchard, LPN, RHIT cpritchard@inqio.sdps.org 812-234-1499, extension 229 17 This material was prepared by Health Care Excel, the Medicare Quality Improvement Organization for Indiana, 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 reflect CMS policy. 10SOW-IN-INDPAT-12-017 08/30/2012