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NHSN Data Submission Requirements 2013 Health Care Excel

NHSN Data Submission Requirements 2013 Health Care Excel. Cathie Pritchard LPN, RHIT Quality Data Reporting Technologist October 12, 2012. Important Dates. Reminder !. Data must be submitted monthly (within 30 days of the end of the month which is collected).

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NHSN Data Submission Requirements 2013 Health Care Excel

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  1. NHSN Data Submission Requirements 2013Health Care Excel Cathie Pritchard LPN, RHIT Quality Data Reporting Technologist October 12, 2012

  2. Important Dates Reminder! • Data must be submitted monthly (within 30 days of the end of the month which is collected). • For data to be shared with Centers for Medicare & Medicaid Services (CMS), each quarter’s data must be entered into NHSN no later than 4 ½ months after the end of the quarter. • 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.

  3. Hospital Inpatient Quality Reporting Program HAI Requirements • January 2011 • CLABSI data from adult, pediatric, and neonatal intensive care units • January 2012 • CAUTI from adult and pediatric intensive care units • SSI from inpatient colon and abdominal hysterectomy procedures • January 2013 • Methicillin Resistant Staphylococcus Aureus(MRSA) Bacteremia • Clostridium Difficile (C.Diff) • Healthcare Personnel Influenza Vaccination

  4. Health Care Facility HAI Reporting to CMS via NHSN—Current and Proposed RequirementsDRAFT (11/23/2011)

  5. CMS Reporting RequirementsLabID Event for FacWideIN

  6. Facility-wide InpatientFacWideIN Includes all inpatient locations, including observation patients housed in an inpatient location

  7. CMS 2013What Data Will NHSN Report to CMS? MRSA Blood and C. difficile Healthcare Facility-Onset (HO) LabID Events CDI: All non-duplicate, non-recurrent LabID Event specimens collected > 3 days after admission to the facility MRSA Blood: All non-duplicate, LabID Event specimens collected >3 days after admission to the facility

  8. CMS 2013MRSA Bacteremia LabID Event • Organism: Methicillin-Resistant Staphylococcus aureus (MRSA) • Data Collection: CDC NHSN - MDRO/CDI Module • Required Locations • All inpatient locations (=FacWideIN) for LabID Events • Required Data • Community-Onset (CO) and Healthcare-Onset (HO) Event • MRSA blood specimens at the facility-wide inpatient level

  9. CMS 2013C. difficile LabID Event • Organism: Clostridium difficile (C. diff ) • Data Collection: CDC NHSN - MDRO/CDI Module (LabID Event) • Required Locations: All inpatient locations at Facility-wide Inpatient level (FacWideIN) minus NICU, SCN, or other Well Baby locations (e.g. Nurseries, babies in LDRP) • Required Data • Community-Onset (CO) and Healthcare-Onset (HO) Events • All C. difficile LabID Events on unformed stool specimens at the facility-wide Inpatient level

  10. Validation Process • Combines random and targeted sampling approach • Abstract CLABSI data for candidate CLABSI medical records • Abstract CLABSI data for all currently requested quarterly medical records being validated for other topics: • Acute Myocardial Infarction (AMI), Heart Failure (HF), Pneumonia (PN), Surgical Care Improvement Project (SCIP), Emergency Departments (ED) / Immunization (IMM) • If your hospital is being validated for core measures, you also are being validated for CLABSI

  11. Validation Process (Continued) • Basics • ICU patients • Positive blood culture results • Complete the positive blood culture template • Selection is a two-step process • Step one—Identify candidate CLABSI patients • Step two—Randomly sample up to three candidate CLABSI patients from the template

  12. Validation Process (Continued) • Positive blood culture templates are due quarterly, 15 days prior to clinical submission deadlines • November 15, 2012 • February 15, 2013 • May 15, 2013

  13. Training on how to complete the blood culture temple .

  14. Validation Process (Continued) • Validation process will continue as additional HAI measures are added • CAUTI and SSI data will be validated next (final rule page 1138) • New measures will be added starting with 1st quarter 2013 (final rule page 1114)

  15. Submitting the Blood Culture Template • Submitted using My QualityNet Secure File Exchange • Infection Preventionists should work with Quality staff who have a QualityNet Account • Validation for hospitals selected for FY 2014 continues through 3rd Quarter 2012

  16. Questions? Cathie Pritchard, LPN, RHIT cpritchard@inqio.sdps.org 812-234-1499, extension 229 This material was prepared by Health Care Excel, the Medicare Quality Improvement Organization for Indiana, 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. 10SOW-IN-INDPAT-12-017 08/30/2012

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