What Do I Report and When and To Who Do I Report It?

1. What Do I Report and When and To Who Do I Report It? APIC Indiana Fall Conference October 2014 By Susan Kraska, RN,CIC

2. Oxford English dictionary definition of reporting: re·port/ingverb • give a spoken or written account of something that one has observed, heard, done, or investigated. • present oneself formally as having arrived at a particular place or as ready to do something. • be responsible to (a superior or supervisor).

3. 1972 (APIC was born): Infection Control Committee Quality Assurance SENIC Study NNISS Others per your facility 2011-2014: Patient Care Unit Specific Physician(s) Quality Management Leadership Hospital Board Health Grades Indiana State Dept of Health NHSN/CDC CMS 3rd Party Payers QIO’s PATIENTS Timeline of Reporting

4. What’s Required? Federal and ISDH Reporting 2014 • Acute Care: CLABSI (ICU’s), CAUTI (ICU’s), SSI, C. Diff, MRSA Bacteremia, HCP Influenza Vaccination • LTCH: CLABSI,CAUTI, HCP Influenza Vaccination • IRF: CAUTI, HCP Influenza Vaccination • Cancer Hospitals: CLABSI, CAUTI, SSI • ESRD: Dialysis Events • ASC’s, Outpt Hospital Depts.: HCP Influenza Vaccination

5. 2015-2016 Additions • CLABSI & CAUTI: Acute Care Med Surg • MRSA Bacteremia: LTCH, IRF • C. Diff: LTCH, IRF • HCP Vaccination: Inpt Psych, ESRD, (proposed) • VAE: LTCH

6. Centers for Disease Control http://www.cdc.gov/nhsn/cms/ Operational Guidance for Acute Care Hospitals Operational Guidance for PPS-Exempt Cancer Hospitals Operational Guidance for Long Term Acute Care Hospitals Operational Guidance for Inpatient Rehabilitation Facilities Outpatient Dialysis Facilities CMS Reporting - CLABSI CMS Reporting - CAUTI CMS Reporting - SSI CMS Reporting - MRSA/CDI Healthcare Personnel Influenza Vaccination FAQs

7. What Do I Report? Simple answer: Always report what is required and what can make a difference for patient outcomes.

8. 2014 CAUTIs by Location No change from last report. May not include most recent infections due to micro issues.

9. CLABSIs: 2014 Note: Previously reported CLABSI in the PICU in June 2014 removed from CLABSI as related to Femoral Art line which does not meet definition for central line.

10. CLABSIs by Line Type

11. CLABSIs: NICU 1 year without a CLABSI!

12. Cdiff LabID Events: 2014

13. MRSA Bacteremia LabID Events: 2014

14. SSI Trends: 2010- 2014(by date of procedure)

15. When Do I Report ? • Mandatory deadlines • Scheduled committee meetings • Bi-monthly • Quarterly • Annually • To prevent harm • Requests

16. Who Do I Report To? • NHSN- current mandatory requirements • Board- meaningful data that gives the big picture • President- meaningful data that gives more specific info; how are we doing • Chief Financial Officer- what does it cost • Committees- where are there issues • Physicians- who has the issue • Specific Units/Departments- is training or education needed • Staff- how does my care affect my patient • Patients

17. Other Things to Consider • Annual Report • Physician and Department Specific Rates • Drilling Down • Mini Root Cause Analysis • Unit-based Infection Prevention Committees • Publish In-house Successes and Failures

18. We Do All This for One Reason!

19. Thank You for Your Attention! QUESTIONS? Skraska@beaconhealthsystem.org

20. And Finally………………..