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

1. Performing CAUTI Surveillance for Participation in the CMS IRF Quality Reporting Program Katherine Allen-Bridson, RN, BSN, MScPH, CIC, Centers for Disease Control and Prevention National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion Training for Inpatient Rehabilitation Facilities May 2, 2012 Nothing to Disclose

2. Objectives • State the purposes of the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN). • Define methodology for Catheter-associated Urinary Tract Infection (CAUTI) surveillance. • 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). • Identify basic steps required for facility enrollment in NHSN. • Identify the rehabilitation location types for which CAUTI surveillance can be performed.

3. What is NHSN? www.cdc.gov/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.

4. 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.

5. 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)

6. Patient Safety Component5 Modules

7. Device-associated Module: 5 Events • CLABSI Central line-associated bloodstream infection • CLIPCentral line insertion practices • VAPVentilator-associated pneumonia • CAUTICatheter-associated urinary tract infection • DE* Dialysis event *For outpatient dialysis only

8. NHSN Surveillance Methodology ACTIVE vs. PASSIVE • ACTIVETrained personnel use standard definitions and a variety of data sources to investigate and identify events. • PASSIVEPersonnel, such as staff nurses, not trained to do surveillance may report events. No purposeful investigation for infections occurs.

9. NHSN Surveillance Methodology2 PATIENT-BASED vs. LABORATORY-BASED • PATIENT-BASEDMonitoring patients for events, risk factors, and procedures and practices related to patient care • Visit patient care areas • Review patient charts • Discuss with caregivers • LABORATORY-BASEDCase-finding based on positive lab findings

10. NHSN Surveillance Methodology3 PROSPECTIVE vs. RETROSPECTIVE • PROSPECTIVE Monitoring patients while still in the institution; includes post-discharge period for surgical site infections (SSI) • RETROSPECTIVECase-finding based solely on chart review after patient discharged

11. 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

12. NHSN and CMSQuality Reporting Program

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

14. NHSN and CMS • 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.

15. NHSN and CMS, cont’d • 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.

16. 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)

17. ENROLLMENT INTO NHSN http://www.cdc.gov/nhsn/enroll.html

18. Facility Administrators & Usersshould complete allrequired NHSN Trainingsbefore beginning Enrollment http://www.cdc.gov/nhsn/training.html

19. NHSN Facility AdministratorEnrollment Guide http://www.cdc.gov/nhsn/PDFs/FacilityAdminEnrollmentGuideCurrent.pdf

20. 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

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

23. 2 IRF Enrollment Options • Freestanding, separately licensed facility • Location within an Acute Care Facility

24. 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

25. 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

26. Rehabilitation Facility Locations CDC Definitions Page 15-13 of NHSN Patient Safety Component Manual

27. 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.

28. Rehabilitation Locations Within Hospital CDC Definitions Page 15-8 of NHSN Patient Safety Component Manual

29. Beyond Enrollment

30. 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.

31. 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

32. 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!

33. 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.

34. RESOURCES

35. Resources for NHSN http://www.cdc.gov/nhsn/index.html

36. 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

37. 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

38. Available Training • Training • Device Associated Module • Pre-recorded Webinars • Lectoras • http://www.cdc.gov/nhsn/training/

39. 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/