Mandatory Reporting of Healthcare Associated Infections in Texas

1. Mandatory Reporting of Healthcare Associated Infections in Texas Jennifer Steinhausen, MPH, CIC Healthcare Associated Infections Clinical Specialist 512.458.7111 ext. 3773 Jennifer.Steinhausen@dshs.state.tx.us

2. Presentation Overview • Identify the HAI Problem • HAI Legislation • Anticipated Reporting Requirements • Anticipated Reporting Time-Line • National Healthcare Safety Network (NHSN) • Preparation for NHSN reporting

3. The HAI Problem United States • 1.7M infections/year • 99,000 deaths/year • $25-$33B in healthcare costs Texas • 130K-160K infections/year • 8K-9K deaths/year • Costs to patient & family, HCW, etc.

4. http://www.apic.org/downloads/legislation/HAI_map.gif

5. 5 Reasons for HAI Reporting Improve healthcare quality by reducing HAI Consumer’s right to know Establish standards for comparability of data Help to identify facility needs for DSHS support Patient Empowerment

6. Disclosure of PHIwww.dshs.state.tx.us/hipaa/webmessage.shtm

7. Legislation Background • 78th legislative Session (2005) passed study bill • Advisory Panel, White Paper • 79th legislative Session (2007) passed SB 288 • Reporting provisions but noappropriation • 80th legislative Session (2009) passed SB 203: Amended SB 288 (Chapter 98) • Added two members to AP • 28 PAE • Included appropriation • BUT does not allow data sharing with CDC

8. Chapter 98 Requirements • Establish 18 member Advisory Panel • Establish Healthcare Associated Infections (HAI) reporting system • Compile and make available to the public a data summary, by health care facility, at least annually • Allow health care facilities to submit concise written comments • Provide education and training • Ensure confidentiality & legal protections • Verify the accuracy and completeness of the data reported • Receiving reports from the public • Enforcement

9. Link to Legislation: www.HAITexas.org

10. Caveats to Reporting • Proposed changes to the legislation • Staffing/Funding issues • Composition of the Advisory Panel will and is changing Please bear with us. This is still a work in progress…

11. So, what does this really mean?

12. Reporting Requirements • Who is required to report? • Ambulatory Surgical Centers • Licensed under Chapter 243 • General Hospitals • Licensed under Chapter 241 • Hospital that provides surgical or obstetrical services that is maintained or operated by the state. • INCLUDES LTACs and CAHs with ICU/CCU/NICU • DOES NOT INCLUDE COMPREHENSIVE MEDICAL REHABILITATION HOSPTIAL

13. Reporting Requirements • Reportable healthcare-associated infections • Central line-associated bloodstream infections in the following special care settings: adult, pediatric and/or adolescent ICUs & CCUs, NICUs (Level II/III & Level III Nurseries) • Surgical site infections • PEDS/ADOLESCENT HOSPITALS: Cardiac procedures, spinal surgery with instrumentation, and ventriculoperitoneal shunt procedures • ALL OTHER HOSPITALS: Colon surgeries, hip & knee arthroplasties, abdominal & vaginal hysterectomies, vascular procedures, and coronary artery bypass grafts

14. SSI Reporting Requirements Facilities shall report HAI data on patients who are admitted to the facility for inpatient treatment of a surgical site infections associated with a reportable procedure within 30 calendar days of the procedure or within 1 year of the procedure if the procedure involved an implant. Facilities will be required to report surgical site infections back to the originating facility, if identified. Originating facility will be required to report the SSI, using NHSN.

15. Reporting Requirements • Alternative for surgical site infections • A facility that does not perform a least a monthly average of 50 of any combination of the listed reportable procedures, shall report the surgical site infections relating to the three (3) most frequently performed NHSN procedures.

16. What to Report? Report Ventriculoperitoneal shunts including revision and removal of shunt in 2011

17. Alternative Reporting • Selection of surgical procedures to report (example) • Identify NHSN procedures (http://www.cdc.gov/nhsn/PDFs/ImportingProcedureData_current.pdf) • Cesarean section: 2 • Gallbladder surgery: 12 • Knee prosthesis: 1 • Open reduction of fracture: 5 • Colon surgery: 7 • Hip prosthesis: 1 • Pacemaker surgery: 3 • Appendix surgery: 6 • Select 3 highest volume surgical procedures to report using NHSN

18. 4 categories for SSI reportingPhase 1 STOP: NoState reporting Are you licensed as a general hospital under Ch 241? Are a licensed ASC under Ch 243? Or state/government run? No Yes Do you perform at least 50 of any combination of procedures required? Report 3 highest volume NHSN procedures No Yes STOP: Nothing to report for 1st phase Do you perform Knee Arthroplasties? No Report Knee Arthroplasties to NHSN for 1st phase of reporting Yes

19. Proposed Rules Phase in reporting, beginning July 2011* • All facilities report CLABSIs in specialty care areas • Surgical centers and general hospitals report knee arthroplasties • Knee arthroplasties ICD-9th Revision codes; Knee prosthesis – 00.80-00.84, 81.54 and 81.55 • Pediatric hospitals report ventriculoperitoneal shunts • Ventriculoperitoneal shunts ICD-9th Revision codes; Ventriculoperitoneal shunts including revision and removal of shunt – 02.2, 02.32-02.35, 02.39, 02.42, 04.43 and 54.95 * Tentative date. May include reporting of previous quarter

20. Proposed Rules • Beginning in January 2012* • Surgical centers and general hospitals report hip arthroplasties, coronary artery bypass grafts • Pediatric hospitals report cardiac procedures • Beginning January 2013* • Surgical centers and general hospitals report abdominal & vaginal hysterectomies, colon surgeries, and vascular procedures • Pediatric hospitals report spinal surgeries with instrumentation * Tentative date.

21. Proposed Reporting Time Line

23. HAI Reporting • National Healthcare Safety Network (NHSN) developed and sustained by the Centers for Disease Control & Prevention is the anticipated designated reporting system. CMS

24. Texas vs. CMS Reporting: 2011

25. HAI Reporting: NHSN http://www.cdc.gov/nhsn/

26. NHSN 5 Steps to Get Started http://www.cdc.gov/nhsn/cms-ipps-rule_training.html

27. Advantages of NHSN • Training is very thorough and explains, in detail, the “rules” for complying with NHSN surveillance protocols. • National comparative data is available when reporting infection rates • Surgical denominator data can be uploaded all at once rather than individually entered (IF the user has an electronic surgical record & all required data elements are present) • Vendors have developed compatible software for uploading facility data

28. Challenges using NHSN • Enrollment & Training process may take 10 – 15 hours • Digital certificate installation can be cumbersome • Will be replaced by SAMS in 2011 • Many data elements are required for input into NHSN • NHSN page is extensive

29. NHSN Data Entry – Summary Data • Establish processes to gather necessary data • Summary Data • Collection of line days in ICUs • NICU: separate by birth weight, umbilical vs CVC • Event Data • CLABSI • SSI • Procedure Data • For each reportable surgery performed

30. Collecting Summary Data

31. Collecting Event Data

32. Preparation for NHSN Data Entry • Establish processes to gather data • Collection of surgical denominator data – includes patient specific details about EACH procedure preformed for risk stratification. • http://www.cdc.gov/nhsn/PDFs/ImportingProcedureData_current.pdf • http://www.cdc.gov/nhsn/forms/57.121_DenomProc_BLANK.pdf • THIS IS NOT AN AGGREGATE NUMBER OF SURGICAL PROCEDURES!

33. Collecting Procedure Data Required for inpatients Required for Knee Arthroplasties

34. Data Mining Vendors The following vendors completed a HL7 CDA pilot project with NHSN http://www.apic.org/AM/Template.cfm?Section=News_Releases&CONTENTID=9707&TEMPLATE=/CM/ContentDisplay.cfm

35. NHSN Preparation • Enroll your facility in NHSN, using CMS # • May need to request Registration ID from NHSN • Establish facility contact for TEXAS: Primary and secondary contacts who coordinate communications related to data submissions, verifications and approval of data summary to NHSN and DSHS. • Encourage use several contacts and a general facility email (i.e. IP@YourHospital.com)

36. APIC NHSN Trainingwww.apic.org/TexasNHSN

37. Look towards the future… What we are not doing… (yet?) • Receiving reports from the public • Preventable adverse events • An event included in the list of serious events identified by the National Quality Forum • An event or condition for which the Medicare program will not provide additional payment to the facility • RSV in pediatric inpatient units

38. www.HAITexas.org

39. TO DO LIST • Reporting could begin with April 2011* data • * Tentative date • Complete NHSN enrollment • Plan to attend NHSN training (www.HAI Texas.org) Breathe! • Begin collecting denominator data

40. Contact Information Jennifer Steinhausen, Clinical Specialist • Email • Jennifer.Steinhausen@dshs.state.tx.us • HAITEXAS@dshs.state.tx.us • Office: 512.458.7111, extension 3773 Important Websites: • www.HAITexas.org • www.cdc.gov/nhsn • https://sdn.cdc.gov/