Katherine Allen-Bridson, RN, BSN, MScPH, CIC,

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Performing CAUTI Surveillance for Participation
in the CMS IRF Quality Reporting Program

• Katherine Allen-Bridson, RN, BSN, MScPH, CIC,
• Centers for Disease Control and Prevention

• National Center for Emerging and Zoonotic
  Infectious Diseases

Training for Inpatient Rehabilitation
Facilities May 2, 2012
Nothing to Disclose

• Division of Healthcare Quality Promotion

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Objectives

1. State the purposes of the Centers for Disease
   Control and Preventions (CDC) National
   Healthcare Safety Network (NHSN).
2. Define methodology for Catheter-associated
   Urinary Tract Infection (CAUTI) surveillance.
3. Define the CAUTI data required and method to
   report through the NHSN in order to meet
   requirements for the Centers for Medicare and
   Medicaid Services Quality Reporting Program (QRP)
   for Inpatient Rehabilitation Facilities (IRFs).
4. Identify basic steps required for facility
   enrollment in NHSN.
5. Identify the rehabilitation location types for
   which CAUTI surveillance can be performed.

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What is NHSN?
www.cdc.gov/nhsn

• Web-based system launched by CDC in 2005 for
  surveillance of healthcare-associated infections
  (HAI), other adverse events, and prevention
  practices.
• Technical design enables manual data entry or
  electronic reporting.

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Purposes of NHSN

• Comply with legal requirements including but
  not limited to state or federal laws,
  regulations, or other requirements for
  mandatory reporting of healthcare
  facility-specific adverse event, prevention
  practice adherence, and other public health data.
• Enable healthcare facilities to report HAI and
  prevention practice adherence data via NHSN to
  the U.S. Center for Medicare and Medicaid
  Services (CMS) in fulfillment of CMSs quality
  measurement reporting requirements for those
  data.
• Provide state departments of health with
  information that identifies the healthcare
  facilities in their state that participate in
  NHSN.
• Provide to state agencies, at their request,
  facility-specific, NHSN patient safety component
  and healthcare personnel safety component adverse
  event and prevention practice adherence data for
  surveillance, prevention, or mandatory public
  reporting.

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Three Main NHSN Components

• Patient Safety Component (will discuss in detail)
• Healthcare Personnel Safety Component
• Blood / Body Fluids Exposure Module
• Influenza Vaccination and Exposure Management
  Module
• Biovigilance Component
• Hemovigilance Module (Blood Safety)

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Patient Safety Component5 Modules
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Device-associated Module 5 Events

• CLABSI Central line-associated bloodstream
• infection
• CLIP Central line insertion practices
• VAP Ventilator-associated pneumonia
• CAUTI Catheter-associated urinary tract
  infection
• DE Dialysis event

For outpatient dialysis only
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NHSN Surveillance Methodology

• ACTIVE vs. PASSIVE
• ACTIVE Trained personnel use standard definitions
  and a variety of data sources to investigate and
  identify events.
• PASSIVE Personnel, such as staff nurses, not
  trained to do surveillance may report events. No
  purposeful investigation for infections occurs.

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NHSN Surveillance Methodology2

• PATIENT-BASED vs. LABORATORY-BASED
• PATIENT-BASED Monitoring patients for events,
  risk factors, and procedures and practices
  related to patient care
• Visit patient care areas
• Review patient charts
• Discuss with caregivers
• LABORATORY-BASED Case-finding based on positive
  lab findings

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NHSN Surveillance Methodology3

• PROSPECTIVE vs. RETROSPECTIVE
• PROSPECTIVE Monitoring patients while still in
  the institution includes post-discharge period
  for surgical site infections (SSI)
• RETROSPECTIVE Case-finding based solely on
  chart review after patient discharged

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Healthcare-associated Infection (HAI)

• A localized or systemic condition resulting from
  an adverse reaction to the presence of an
  infectious agent(s) or its toxin(s) that
• Occurs in a patient in a healthcare setting
• And
• Was not present or incubating at the time of
  admission, unless the infection was related to a
  previous admission

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NHSN and CMSQuality Reporting Program
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Healthcare Facility HAI Reporting to CMS via NHSN
Current and Proposed Requirements DRAFT
(11/14/2011)
HAI Event Facility Type Reporting Start Date
CLABSI Acute Care Hospitals Adult, Pediatric, and Neonatal ICUs January 2011
CAUTI Acute Care Hospitals Adult and Pediatric ICUs January 2012
SSI Acute Care Hospitals Colon and abdominal hysterectomy January 2012
I.V. antimicrobial start Dialysis Facilities January 2012
Positive blood culture Dialysis Facilities January 2012
Signs of vascular access infection Dialysis Facilities January 2012
CLABSI Long Term Care Hospitals October 2012
CAUTI Long Term Care Hospitals October 2012
CAUTI Inpatient Rehabilitation Facilities October 2012
MRSA Bacteremia LabID Event Acute Care Hospitals January 2013
C. difficile LabID Event Acute Care Hospitals January 2013
HCW Influenza Vaccination Acute Care Hospitals January 2013
HCW Influenza Vaccination ASCs October 2014
SSI (future proposal) Outpatient Surgery/ASCs TBD
Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN
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NHSN and CMS

• CMS Final Rules in Federal Register published
  August 18, 2011.
• Must follow NHSN CAUTI protocol exactly and
  report complete and accurate data.
• Data must be reported to NHSN by means of manual
  data entry into NHSN web-based application or via
  file imports using the Clinical Document
  Architecture (CDA) file format.
• Pass quality control acceptance checks that
  assess the data for completeness and accuracy.

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NHSN and CMS, contd

• NHSN requires data to be submitted monthly
  (within 30 days of the end of the month in which
  it is collected) so it has the greatest impact on
  infection prevention activities.
• Data must be entered into NHSN no later than 4 ½
  months after the end of the quarter to be shared
  with CMS.
• 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
• Does not preempt any state mandates for CAUTI
  reporting to NHSN.

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NHSN and the CMS Annual Payment Update (APU)
Hospital/IRF Inpatient Quality Reporting (IQR)
Program

• Hospitals/IRFs enter quarterly HAI data into NHSN
• lt 4 ½ months following the end of the reporting
  quarter
• CDC prepares facility-specific HAI summary
  statistics that are submitted in monthly and
  quarterly files to CMS using a secure QualityNet
  exchange account
• Hospitals/IRFs can view their own HAI summary
  statistics at a secure CMS website where the APU
  Dashboard is posted (for more information see
  http//www.qualitynet.org/dcs/ContentServer?cPage
  pagenameQnetPublic2FPage2FQnetBasiccid122869
  4346716)

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ENROLLMENT INTO NHSN

• http//www.cdc.gov/nhsn/enroll.html

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Facility Administrators Usersshould complete
allrequired NHSN Trainingsbefore beginning
Enrollment

• http//www.cdc.gov/nhsn/training.html

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NHSN Facility AdministratorEnrollment Guide

• http//www.cdc.gov/nhsn/PDFs/FacilityAdminEnrollme
  ntGuideCurrent.pdf

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NHSN Facility Administrator

• Only one Facility Administrator per facility
• Only person who can enroll a facility
• Responsible for initial set-up
• Adding locations
• Adding users and assigning user rights
• Joining and conferring rights to groups

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Enrollment into NHSN

• NHSN Registration http//nhsn.cdc.gov/Registration
  Form/index.jsp

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2 IRF Enrollment Options

• Freestanding, separately licensed facility
• Location within an Acute Care Facility

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Enrollment RequirementsIRFs Requiring Unique
NHSN orgID

• Enroll in NHSN as a separate facility if
• Free standing licensed IRF with a CCN (CMS
  Certification Number) with the last four digits
  between 3025-3099
• Identify as HOSP-REHAB facility type

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Enrollment RequirementsIRFs Requiring Unique
NHSN orgID

• Annual survey required
• Complete new, rehabilitation specific annual
  survey for calendar year 2011
• Use whole numbers without decimal points
• Two locations Adult and Pediatric IRF

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Rehabilitation Facility Locations
CDC Definitions
Page 15-13 of NHSN Patient Safety Component Manual
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Enrollment Requirements IRF Units Within a
Hospital

• Set-up as Inpatient Rehabilitation Ward location
  within an enrolled acute care or critical access
  facility type if
• IRF unit within a hospital and 3rd character of
  CCN is either a T or an R
• Additional questions are required for licensed
  IRF units within hospitals to be identified for
  CMS reporting.

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Rehabilitation Locations Within Hospital
CDC Definitions
Page 15-8 of NHSN Patient Safety Component Manual
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Beyond Enrollment
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Annual Survey IRF

• Annual survey required for HOSP REHAB facility
  type
• Must complete a new IRF-specific annual survey
  for calendar year 2011.
• Use whole numbers without decimal points.

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Monthly Reporting Plan

• CAUTI must be included in Monthly Reporting Plan
  for data to be reported on behalf of the facility
  to CMS.
• Locations Inpatient Adult and Pediatric
  Rehabilitation Wards

Example for freestanding IRF
AddLocations
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Monthly Reporting Plan, contd

• The Monthly Reporting Plan informs CDC which
  modules a facility is following during a given
  month.
• A facility must enter a Plan for every month of
  the year, even those in which no modules are
  followed.
• A facility may enter data only for months in
  which Plans are on file.

Reminder!
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Reporting Numerator and Denominator Data

• Report each CAUTI detected or indicate that no
  CAUTI occurred for reporting locations. (Found
  on Denominator screen).
• Report total device days and total patient days
  for reporting locations, including months in
  which no CAUTIs were identified and/or no patient
  days or urinary catheter days occurred.

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RESOURCES
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Resources for NHSN
http//www.cdc.gov/nhsn/index.html
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Resources for Surveillance

• NHSN Patient Safety Component Manual, January
  2012
• Ch 3 Monthly Reporting Plan
• Ch 7 CAUTI Protocol (January 2012)
• Ch 14 Tables of Instructions
• Ch 16 Key Terms

http//www.cdc.gov/nhsn/TOC_PSCManual.html
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Resources for Surveillance, contd

• NHSN Forms (June 2011)
• 57.106 Monthly Reporting Plan
• 57.114 Urinary Tract Infection
• 57.118 Denominators for Intensive Care Unit
  (ICU)/ Other locations (not NICU or SCA)

http//www.cdc.gov/nhsn/forms/Patient-Safety-forms
.html
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Available Training

• Training
• Device Associated Module
• Pre-recorded Webinars
• Lectoras

http//www.cdc.gov/nhsn/training/
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Available Training, contd

• NHSN Enrollment Facility Set-up (Slidesets
  PDFs)
• Overview of the Patient Safety Component,
  Device-associated module (Slideset PDF)
• Data Entry, Surveillance, Analysis, Data Entry,
  Import, and Customization (Slideset PDF)
• Introduction to the Device-associated Module
  (Training Course with quiz)
• Catheter-associated Urinary Tract Infection
  (CAUTI) (Training Course with quiz)

http//www.cdc.gov/nhsn/training/
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