NHSN Data Quality QIA January, 2017
Mission Statement The Mission of the IPRO End Stage Renal Disease (ESRD) Network Program is to promote health care for all ESRD patients that is safe, effective, efficient, patient-centered, timely, and equitable.
Objectives Requirements of NHSN Data Quality QIA? CMS Expectations CDC Expectations Data Submission Requirements Gaps Identified Activities of the QIA How Can You Find Us? 3 3
Network Data Department Krystle Gonzalez Jaya Bhargava, PhD, CPHQ Sr. Data Coordinator Operations Director 203-285-1225 203-285-1215 kgonzalez@nw1.esrd.net jbhargava@nw1.esrd.net 1952 Whitney Avenue, 2 nd Floor, Hamden, CT 06517 Phone: (203) 387-9932 Fax: (203) 389-9902
NHSN Data Quality QIA Criteria Minimum of 20 facilities and 5 hospitals; 3 cohorts spanning 3 years Project Period Baseline January – June 2016 Re-measure is January - June 2017 Requirements “PBCcollHospEDCt” field used for analysis Identify dialysis facilities without EMR access and affiliated hospitals Goals Improve communication of key information between hospitals and facilities Improvement in BSI reported in hospital setting Data Source NHSN 5 5
CDC Expectation: NHSN Data Quality QIA BSI’s lead to serious complications and death 30,000 BSI’s reported in 2014 Cost 23,000 / incident Quality Incentive Program Requirements Follow CDC “Dialysis Event Protocol” Identified gaps Dialysis facility is unaware of BSI Insufficient information transfer ● Surveillance ● Quality of care for patient 6 6
CDC Expectation: Protocols Dialysis Event Reporting Positive Blood Cultures from specimens collected in an outpatient facility Collected within one calendar day after a hospital admission. ● Includes specimens collected on the day of or the day following admission to the hospital. Reported regardless of whether or not a true infection is suspected Whether the infection is thought to be related to hemodialysis Event Reporting Protocol for Hospitals CDC defines “Date of the Event” CDC also defines “Present on Admission (POA)” Hospitals report BSI after the 3rd calendar day of admission 7 7
NHSN Data QIA Measure Calculation (CountofBSIsidentifiedinthehospitalorE.D.)/(AllBSIsreport edinNHSN)x 100 ‘Count of BSIs identified in the hospital’ is captured by the variable PBCcollHospEDCt 8
Barriers Hospital staff not aware of the dialysis facility requirement Hospital staff do not report positive blood culture data to dialysis facility (HIPAA) Do not consistently providing records Facility only requesting discharge summary No dialysis facility person assigned to follow up on hospitalizations 9
Interventions Improve communication of key information Identify tool Hospital/ Dialysis Facility Communication Forms Relationships / contact with hospital infection preventionists Gaining access to hospital EMR Use RCA / PDSA cycle Adapt one strategy that works best 10
Hospital Infection Preventionist Report to Dialysis Center Hospital Infection Preventionist Report to Dialysis Center Hospital Name: ________________ Location: _________________ Date: __________ Person completing form: ________________________ Title: __________ Phone #: ____________ Print Clearly Patient Name: _____________________/ ID: ______________________ DOB: / / Print Clearly Admission Date: _____________ Discharge Date: _______________ Date of Culture: ______________ Within first day of admission: Yes No CDC – “One calendar day after hospital admission includes positive blood cultures collected on the day of or the day following admission to the hospital.” Culture Site: __________________________ Organism(s): ___________________________________________________ Is organism a Multidrug Resistant Organism? (MDRO): Yes No Fax a list of sensitivities to enter in NHSN: Yes No Were any antibiotics administered during this hospitalization? Yes No Date: ___________ Name of Antibiotic: _____________ Dose: _________ Frequency: ___________ Name of Antibiotic: _____________ Dose: _________ Frequency: ___________ Continue antibiotic as an outpatient? Yes No Vascular Access Were there any changes to the vascular access during this hospitalization? Yes No Was a new vascular access placed? (Circle correct answer) Fistula Graft HeRO Catheter Was a non-dialysis vascular access placed? (Circle correct answer) PICC Port Other ________ Any follow-up appointments or tests required? Yes No List: _________________________ Reported to: ______________________________RN Dialysis Unit: __________________________ Attention: This electronic message contains information that may be legally confidential and/or privileged. The information is intended solely for the individual or entity named above and access by anyone else is unauthorized. If you are not the intended recipient, any disclosure, copying, distribution, or use of the contents of this information is prohibited and may be unlawful. If you have received this electronic transmission in error, please reply immediately to the sender that you have received the message in error, and delete it. Thank you for your cooperation. 11
Dialysis Center Report to Hospital Infection Preventionist Dialysis Unit Name: ________________ Location: _________________ Date: __________ Fax: __________ Person completing form: ________________________ Title: __________ Phone #: ____________ Print Clearly The patient listed below receives regularly scheduled dialysis at our faciltiy on: M-W-F T-T-S 1 st shift _____ 2 nd shift _____ 3 rd shift _____ 4 th shift _____ Patient Name: _____________________/ ID: ______________________ DOB: / / Print Clearly History of recent infection: Yes No History of MDRO: Yes No Type: ____________ Site of Recent infection: ______________________ Culture Date: _________ Organism(s): ___________________ Antibiotics administered: Yes No Name of antibiotic(s): _________________________ Medication allergy: Yes No Allergic to: ___________________________________ Vascular Access Current usable vascular access is: Fistula / Graft / Catheter /HeRO Special instructions related to vascular access: • Last Access/ no other option for vascular access _______________ • Multiple problems recently _________________ clotting, infections, poor blood flow • Good vascular access, please preserve _____________________ Does the patient have other sources of possible infection? (wounds, PICC, decubitus, foot ulcers, other) ______________________________________________________________________________________ Reported to: ____________________________ Hospital: ___________________ Telephone # ___________ Attention: This electronic message contains information that may be legally confidential and/or privileged. The information is intended solely for the individual or entity named above and access by anyone else is unauthorized. If you are not the intended recipient, any disclosure, copying, distribution, or use of the contents of this information is prohibited and may be unlawful. If you have received this electronic transmission in error, please reply immediately to the sender that you have received the message in error, and delete it. Thank you for your cooperation. 12
Hospital Infection Preventionists Yale New Haven Hospital Hartford Hospital St. Francis Medical Center St. Mary’s Medical Center Rhode Island Hospital Miriam Hospital 13
Gaining Access to EMR Request Access to EMR Only to Discharge Summery ?? 14
PDSA Tool Dialysis Clinic Insert Your NHSN Data Reporting Quality Improvement Project Peritoneal Facility Hemo QAPI Month reviewed Start Date Reviewed Dates Completion Date Estimated Actual November-16 December-16 January-17 February-17 March-17 Project Team Members Project Leader: 1. id not report any positive blood cultures collected outside of the dialysis clinic on the day of, and on the day after hospitalization in National Healthcare Safety Network (NHSN) 2. Problem Statement: 3. S pecifi c 4. M easurable GOAL: A ction Oriented 5. R ealistic 6. T ime Bound 7. Root Cause(s): 8. External Team Members 1. Barriers: 2. 3. Brainstorm possible solutions: Review BSI data from NHSN and identify if reporting is correct. Do you have patients admitted to the hospital? Do you know to report any positive blood cultures collected outside of the dialysis clinic on the day of, and on the day after hospitalization in National Healthcare Safety Network (NHSN)? Do you have a method to collect data from the hospital? Do you know the contact person at the hospital to obtain data? Check if any patients were admitted to the hospital when the BSI was reported? Status Act ( Changes/ additions to plan on Plan ( recommendations ) Do ( Progress on plan ) Study ( Analysis) Date (Adopt/ Adapt/ analysis) Abandon) Nov-16 15
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