NYS HAI Reporting Program Audit and Validation

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NYS HAI Reporting Program Audit and Validation

• Rachel L. Stricof
• rls01_at_health.state.ny.us

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Data Validity Checks - Process

• Central office generates bi-weekly reports
• By region
• For each hospital
• Regional staff review
• Contact hospitals
• Data verified
• If indicated, NHSN data corrected by hospital

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Data Validity ChecksColon Surgery Indicators

• Clean colon procedures
• Outpatient colon procedures
• Colon procedures without general anesthesia
• Colon surgery duration less than 30 minutes or
  more than 15 hours

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Data Validity ChecksCABG Surgery (CBGB and CBGC)

• Outpatient CABG surgery
• CABG procedures without the use of general
  anesthesia
• American Society of Anesthesiologists (ASA)
  Classification of Physical Status score of 1 or 2
• CABG surgery duration less than 30 minutes or
  more than 15 hours
• CABG surgery designated as trauma case

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Data Validity Checks Central Line-Associated
Blood Stream Data

• Monthly summaries in which CL Days Patient Days
• Recognized pathogens designated as a skin
  contaminant (added recently)

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Audit Objectives

• Determine the reliability and consistency of
  surveillance definitions
• Evaluate current surveillance methods used to
  detect infections
• Evaluate current risk adjustment methods and
  determine if additional factors need to be
  considered for public reporting purposes
• Evaluate intervention strategies designed to
  reduce or eliminate specific infections
• Provide on-site education on the definitions,
  surveillance mechanisms and use of the NHSN

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Hospital Audits

• 180 hospital site visits between July 2007 and
  January 2008
• 320 - ICU surveys conducted
• 1162 - ICU charts reviewed
• 213 - CABG charts reviewed
• 664 - Colon charts reviewed

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Selection of CLABS Medical Records

• Evaluation of 1st quarter reporting
• All reporting ICUs were evaluated
• Review microbiology lab reports
• Select 5 10 positive blood cultures from each
  ICU
• Review medical record
• Determine if a central line was in place on date
  of culture
• If yes, continue audit and collect NHSN data and
  supplemental information
• A standardized data collection form
• HAI staff were blind to case status (reported or
  not) until after the chart reviews were completed

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Selection of Surgical Patients

• Central office created list of medical records
• All SSI cases reported for 1/1/07 3/31/07
• Two controls per case Internal and External
• CABG Gender, Age within 10 years, CBGB or CBGC,
  Multiple procedure status
• Colon Duration above or below 3 hour cut point,
  trauma, emergency, ASA, age / 1 year
• HAI regional staff blind to case/control status
• After review, sealed envelope opened
• Discrepancies reconciled with hospital ICP
• If indicated, hospital revised data in NHSN

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CABG Chart Audits, 35 NYS Hospitals
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CABG Chart Audits, 35 NYS Hospitals
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CABG Chart Audits, 35 NYS Hospitals
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CABG Chart Audits, 35 NYS Hospitals
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Colon Chart Audits, 153 Hospitals
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Colon Chart Audits, 153 NYS Hospitals
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Audit Challenges

• Age of Transition
• Information going from paper to electronic
• Every hospital has a different system(s)
• Within a hospital, systems not integrated
• Password protection issues
• Even with focus on limited variables, factors,
  and infection indicators chart reviews took 30
  minutes 1 hour to review on average

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Cardiac Surgery Reporting System (CSRS)

• Developed to assess hospital and surgeon-specific
  risk-adjusted mortality rates
• Deep surgical site infections involving bone are
  supposed to be reported
• HAI data reconciliation with CSRS
• CRSR had 25 infections not in NHSN under
  evaluation
• 1 associated with procedure in 2006
• 1 duplicate in CRSR
• 5 should have been in NHSN
• ICP stated she thought she had entered the SSIs

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Cardiac Surgery Reporting System

• The following factors were associated with SSIs

Patient Risk Factors Surgical Risk
Factors Female Gender Emergency
Procedure COPD Bleeding Requiring
Re-operation Diabetes Immunodeficiency Bod
y Mass Index Post-operative Respiratory
Failure Post-operative Renal Failure Post-operativ
e GI Bleeding
Pre-operative risk factors to be evaluated for
potential risk adjustment
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Risk Factors Next Steps

• To determine if individual patient risk factors
  influence hospital rankings
• If high risk patients are evenly distributed,
  rankings will not change
• If high risk patients are seen in select
  facilities, we will need to adjust
• Provide public with better understanding of
  their individual risk factors

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Post-Discharge Surveillance Survey

• PHL revised to require reporting of infections
  between hospitals
• Readmission facility must notify hospital where
  surgery performed
• Original surgery hospital to report SSI in NHSN
• 87 percent of facilities have a mechanism to
  identify readmissions
• 55 percent of facilities had active
  post-discharge surveillance system for outpatient
  settings

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CABG Chest Site Infections by Extent and
Detection Time, 40 NYS Hospitals
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Colon SSIs by Extent and Detection Time,182 NYS
Hospitals, 2007
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CABG Donor Vessel Site Infections by Extent and
Detection Time, 40 NYS hospitals
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NYSDOH Decision re PDS

• Do not require or mandate a universal,
  post-discharge surveillance mechanism
• Continue to monitor the severity of these events
• For hospital-specific comparisons, only include
  patients identified post discharge if they were
  readmitted to another hospital
• Patients readmitted to the same facility already
  included
• Established custom field in the NHSN reporting
  system to identify SSI events detected following
  readmission to another hospital

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Validation is ?

• Being at once relevant and meaningful
• Being well grounded provide direction for
  improvement
• Conforming to accepted principles of sound
  biological classification
• Ensuring appropriateness
• Having legal efficacy or force

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It Takes a Village

• Carole Van Antwerpen, Program Manager
• Peggy Hazamy Buffalo and Rochester Region
• Diana Doughty Syracuse Region
• Betsy Todd Hudson Valley
• Marie Tsivitis Long Island
• Kate Gase NYC
• Boldt Tserenpuntag Data Manager
• Kamal Nan Siag MPH Student
• Edgar Manukian MPH Student
• Andrea Fischer MPH Student
• Mary Andres and Teresa Horan Always there to
  support and defend us.