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NHSN Workshop NEW APIC Meeting October 7, 2011

NHSN Workshop NEW APIC Meeting October 7, 2011. Wisconsin Department of Health Services. Agenda. Status of NHSN use in Wisconsin CMS reporting via NHSN Next version release: October NHSN data analysis SIR Committee reports Q & A. NHSN Use in Wisconsin. Live users February 2010: 24

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NHSN Workshop NEW APIC Meeting October 7, 2011

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  1. NHSN WorkshopNEW APIC MeetingOctober 7, 2011 Wisconsin Department of Health Services

  2. Agenda • Status of NHSN use in Wisconsin • CMS reporting via NHSN • Next version release: October • NHSN data analysis • SIR • Committee reports • Q & A

  3. NHSN Use in Wisconsin • Live users • February 2010: 24 • September 2011: 100 • 26 CAH (45%), 70 PPS (100%), 1 VA, 1 Children’s, 2 LTAC • 6 more enrolling • 10 more training

  4. Eligible Facilities     

  5. How Do I Get Started? NHSN public site: http://www.cdc.gov/nhsn/

  6. Enrollment • CDC training http://www.cdc.gov/nhsn/training.html • Obtain digital certificate • Complete facility survey/contact info • Submit facility consent form • Set up facility account on NHSN – locations, reporting plans, etc.

  7. CMS HAI Reporting

  8. Healthcare Facility HAI Reporting to CMS via NHSN – Current and Proposed RequirementsDRAFT (8/5/2011)

  9. Submission Timelines

  10. Updates with the Next NHSN Version Release in October

  11. Planned for the October 2011 Release • Alerts for missing numerators and denominators • Ability to report zero events for a month • Updates to custom fields – more fields, easier to use

  12. October 2011 Release, Cont’d. • Ability for groups to send messages to facilities within NHSN • Analysis updates (dialysis comparative rates, rates to 3 places, etc.) • Module specific to LTC facilities and relevant reporting (start with LabID Events and UTI)

  13. NHSN Data Analysis

  14. Generating Data Sets

  15. Accessing Your Data

  16. Analysis Reports Tree View

  17. CDC’s Pre-Configured Reports

  18. Default Report

  19. Modify Your Report

  20. Customized Control Chart Name the new report Choose variable labels for more description in the headings Select a time period

  21. Customized Control Chart, Cont’d. Apply any necessary filters Choose the type of data used in the chart Configure your chart to include reference lines (control limits and smoothing are not available at this time) Run or save your chart or export your data

  22. Customized Control Chart, Cont’d.

  23. Standardized Infection Ratio (SIR) • Similar to a standardized mortality ratio • Compares observed infections with expected number of infections (using 2006-2008 NHSN aggregate data as the standard population) • SIR < 1: Observed are less than expected • SIR = 1: Observed equals expected • SIR > 1: Observed are more than expected

  24. SSI SIR Report

  25. SSI SIR Report Output – By OrgID

  26. SSI SIR Report Output – Changing Time Period to Obtain SIR

  27. SSI SIR Report Output – By OrgID/Procedure Code

  28. SSI SIR Report Output – By OrgID/Procedure Code/Outpatient

  29. SSI SIR Report Output – Procedures Not Included in SIR

  30. SSI SIR Report Output – Procedures Not Included in SIR, Cont’d.

  31. SSI SIR Report Output – Procedures Not Included in SIR, Cont’d. Duration = 0 excludes the procedure Approach = N (not specified) for FUSN or RFUSN excludes the procedure

  32. Reasons for Procedure Exclusion • Missing required field/risk factor • Procedure duration outlier • Procedure date ≤ patient’s DOB • Patient’s age at procedure ≥ 109 yrs • Wound class = U • Approach = N (for FUSN or RFUSN only) • Spinal level = N (for FUSN only) Source: http://www.cdc.gov/nhsn/PDFs/Newsletters/NHSN_NL_OCT_2010SE_final.pdf, Appendix C

  33. Compare Two SIRs

  34. Compare Two SIRs

  35. Compare Two SIRs, Cont’d. Statistically significant

  36. Wisconsin Data Aggregates

  37. Conferred Rights (n = 84) *Numbers among 3 prevention collaboratives are not unique. 65 unique hospitals participate in these projects.

  38. DPH Data Use Agreement Offers added protection • Share data with DPH staff while asking questions • Confer rights to data for inclusion in statewide aggregates • Allow DPH staff to see plans/data for selected topics to troubleshoot any inconsistencies, issues

  39. NHSN Tutorials • http://www.dhs.wisconsin.gov/communicable/HAI/Tutorials.htm • 5-10 minutes each • Screenshots with voiceover for navigation/functionality topics including entering data, setting up facility, and analysis

  40. Ashlie DowdellSurveillance Coordinator HAI Prevention Project ashlie.dowdell@wi.gov(608) 266-1122 Questions?

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