C. difficile Data Entry What’s in it for me?

1. C. difficile Data Entry What’s in it for me? Date: May 9, 2017 Presented by: Marilee Johnson, MT (ASCP) MBA Technical Advisor, Infection Prevention 3/15/2018 1

2. CMS Clostridium Difficile Infection (CDI) Reporting and Reduction Project • Partnersin the project: • You= 3000 Nursing Homes (NC-62 & GA-53) • QIN-QIO National Coordinating Center (NCC) and your local QIO, Alliant Quality • National Healthcare Safety Network (NHSN)

3. Goals of the Collaborative • To create a baseline and measure success on Clostridium difficile infection (CDI) reduction efforts in Nursing Homes • Aggregate data can be used as an opportunity for quality improvement purposes Report C. diff data by the 15th of each month!

4. Report C. diff for 10 months March-December 2017 Report by the 15th of the Month!

5. How do I Report LabID Events to NHSN? • Login to the SAMS Portal and the NHSN application https://sams.cdc.gov/ • Verify that the locations in your facility have been correctly mapped into NHSN • Review Monthly Reporting Plan and add or update as necessary • Identify and enter all C. difficile infection (CDI) LabID events into NHSN by location • Enter denominator data for each month

6. Login to the SAMS Portal Go to https://sams.cdc.gov/ Click on the SAMS Grid Card login button, and enter your username and password

7. Login to the SAMS Portal and NHSN Application Then, enter your grid card information 3 W 6

8. NHSN Landing Page Select the Componentyou want to report data to: Long-term Care Facility Healthcare Personnel Safety Select your Facilityname Click Submit

9. Application Portal Select NHSN Reporting to submit your facility’s data to NHSN

10. NHSN Long Term Care Facility Component Home Page NHSN Home toolbar Reporting Plan Resident Event Summary Data Surveys Analysis Facility Group Logout

11. Verify Locations in NHSN Go to Facility Select Locations Click Find to show all locations currently entered Review locations and edit or add if necessary

12. Monthly Reporting Plan: Review • A Plan must be completed for every month (even when not following a module) • Monthly Reporting Plan can be modified retrospectively • Can enter Plans for up to one year in advance

13. Monthly Reporting Plan: Add a Reporting Plan Go to Reporting Plan Select Add Enter the Monthand Year

14. Monthly Reporting Plan: Select Organism for LABID Event reporting Select Organism Type from drop-down menu (i.e., C. difficile) Check “Lab ID Event All Specimens” Click C. difficile ClickSave

15. Monthly Reporting Plan: Finda Reporting Plan View all months previously entered

16. CDILabID Events: Requirements • The NHSN MDRO/CDI LabID Event Module protocol must be used to identify C. difficile LabID Events • Surveillance must occur for ALL resident locations in the LTCF • A NHSN Monthly Reporting Plan for the LTCF must be completed for March-December 2017 • For each month, the facility must report numerators (CDI LabID Events) and denominators (number of resident admissions, number of resident-days, and number of admissions on C. difficile treatment) for the entire facility

17. CDILabID Events: Requirements • Testing performed on unformed/loose stool specimens • Lab results obtained before a resident’s admission to the LTCF or during an admission to another facility are excluded • Lab results obtained from an ED or outpatient setting (doctors office or clinic) may be included only if: • The specimen is collected on the calendar day or the next calendar day that the resident leaves the facility AND • The resident returns to the LTCF on the calendar day of transfer or the following calendar day (i.e., no change in current admission date for LTCF)

18. CDILabID Event or Not? Mr. T is a resident in your LTCF. He does not have a history of C. difficile. On March 1, he was transferred to the local emergency department for evaluation of diarrhea and fever. While in the emergency department, a loose stool specimen tested positive for C. difficile. He received IV fluids and was transferred back to the LTCF on March 2. Was this a CDI LabID event for your facility?

19. CDILabID Event or Not? Mr. T is a resident in your LTCF. He does not have a history of C. difficile. On March 1, he was transferred to the local emergency department for evaluation of diarrhea and fever. While in the emergency department, a loose stool specimen tested positive for C. difficile. He received IV fluids and was transferred back to the LTCF on March 2. YES: Since the specimen was collected in an ED and during Mr. T’s current admission in the LTCF, the C. difficile specimen should be entered into NHSN as a CDI LabID Event for the LTCF.

20. CDI Definitions CDI LabID Event: • All non-duplicate C. difficile positive laboratory assays obtained while a resident is receiving care in the LTCF * Remember:Lab results from outside facilities before a resident’s admission should not be included in LabID event reporting * Tip:Keep a log of all positive C. difficile tests sent from your facility so you can track duplicate results to ensure they are not incorrectly entered as CDI LabID Events

21. CDI LabID Events: Add an event Go to Event Three options – Add, Find, and review Incomplete events

22. CDI LabID Events: Event Type Date of specimen collection

24. Entering Denominator Data into NHSN • Enter the month and year • Remainder of form will populate based on plan on file

25. Entering Denominator Data into NHSN Check Box will appear for each in-plan organism

26. Don’t Forget to Save your Summary Denominator Data!

27. Key Points to Remember • Only results from unformed/loose stool specimens should be included • Duplicate C. difficile lab assays should NOT be reported when applying LabID Event rules, the date of specimen collection is considered Day 1 of the count • LabID Event rules apply to specimens collected while the resident is receiving care by the LTCF, and may include specimens collected from an ED of OP setting only if collected during the resident’s currentadmission • In such cases, Resident Care Location and Primary Resident Service Type should reflect the patient’s information PRIOR to the ED or OP visit

28. Recap • Access to the NHSN Database (SAMS) • Track residents with C. diff in your facility • Report by the 15th of the Month • March 2017 – December 2017 • Reporting required even if NO C. diff events • Use data for Quality Improvement Report by the 15thof each month!

29. Thank you for partnering with Alliant Quality! Alliant Quality Marilee H. Johnson, MT (ASCP), MBA Technical Advisor, Infection Prevention 919-695-8331 marilee.johnson@alliantquality.org • Sources: • National Healthcare System Network (NHSN) LabIDEvent Reporting Review, Updates and Tips, District of Columbia’s NHSN Cohort Faculty Advisors, February 16, 2017 • Centers for Disease Control & Prevention, NHSN LTCF Module For More Information Contact:

30. This material was prepared by GMCF, for Alliant Quality, the Medicare Quality Innovation Network – Quality Improvement Organization for Georgia and North Carolina, 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. Publication No. 11SOW-GMCFQIN-GA-C2-17-17