NHSN Data Quality QIA January, 2017 Mission Statement The Mission - - PowerPoint PPT Presentation

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NHSN Data Quality QIA January, 2017 Mission Statement The Mission - - PowerPoint PPT Presentation

Sep 10, 2023 301 likes •534 views

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

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NHSN Data Quality QIA

January, 2017

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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.

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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?
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Jaya Bhargava, PhD, CPHQ Operations Director 203-285-1215 jbhargava@nw1.esrd.net Krystle Gonzalez

  • Sr. Data Coordinator

203-285-1225 kgonzalez@nw1.esrd.net

1952 Whitney Avenue, 2nd Floor, Hamden, CT 06517 Phone: (203) 387-9932 Fax: (203) 389-9902

Network Data Department

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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
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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
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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
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  • (CountofBSIsidentifiedinthehospitalorE.D.)/(AllBSIsreport

edinNHSN)x 100

  • ‘Count of BSIs identified in the hospital’ is captured by the

variable PBCcollHospEDCt

NHSN Data QIA Measure Calculation

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  • 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

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Barriers

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Interventions

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  • 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
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Hospital Infection Preventionist Report to Dialysis Center

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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.
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Dialysis Center Report to Hospital Infection Preventionist

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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 1st shift _____ 2nd shift _____ 3rd shift _____ 4th 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.
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Hospital Infection Preventionists

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  • Yale New Haven Hospital
  • Hartford Hospital
  • St. Francis Medical Center
  • St. Mary’s Medical Center
  • Rhode Island Hospital
  • Miriam Hospital
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Gaining Access to EMR

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  • Request Access to EMR
  • Only to Discharge Summery
  • ??
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PDSA Tool

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December-16 January-17 February-17 March-17 1. 2. 3. 4. 5. 6. 7. 8. 1. 2. 3.

Date Status

(Adopt/ Adapt/ Abandon)

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Dialysis Clinic  Peritoneal  Hemo QAPI Month reviewed

November-16

Start Date Reviewed Dates Completion Date

Estimated Actual

Root Cause(s): GOAL:

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)

Project Leader: Problem Statement:

External Team Members

Act (Changes/ additions to plan on

analysis)

Barriers:

Plan (recommendations) Do (Progress on plan)

Study (Analysis) Brainstorm possible solutions: Do you have a method to collect data from the hospital? Do you know the contact person at the hospital to obtain data? NHSN Data Reporting Quality Improvement Project Project Team Members 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)? Review BSI data from NHSN and identify if reporting is correct. Check if any patients were admitted to the hospital when the BSI was reported?

S pecific M easurable A ction Oriented R ealistic T ime Bound

Insert Your Facility

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Positive Blood Culture FAQs

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  • Part 1: Data Collection

https://www.cdc.gov/nhsn/pdfs/dialysis/newsblasts/dec15newsblastpbcfaqspart1.pdf

  • Part 2: Reporting Pathogen Information

https://www.cdc.gov/nhsn/pdfs/dialysis/newsblasts/newsblast-pbc-faqs-part2.pdf

  • Part 3: Reporting Antimicrobial Susceptibility

https://www.cdc.gov/nhsn/pdfs/dialysis/newsblasts/newsblast-pbc-faqs-part3.pdf

  • Part 4: Using NHSN Data for Improvement

https://www.cdc.gov/nhsn/pdfs/dialysis/newsblasts/newsblast-pbc-faqs-part4.pdf

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Knowledge Base Customer Portal

  • Level 1 (Self Help): New customer support portal

http://help.esrd.ipro.org/support/home

  • Level 2 (Email Technical Assistance): questions submitted

NW1Help@iproesrdnetwork.freshdesk.com

  • Level 3 (One-on-One Technical Assistance): Use of WebEx

“Meet Now” method for real-time assistance

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How Can You Find Us?

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IPRO ESRD Program Website http://esrd.ipro.org

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IPRO ESRD Program Facebook Page https://www.facebook.com/IPROESRDProgram

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For more information:

IPRO ESRD Network of New England (Network 1) info@nw1.esrd.net

IPRO ESRD Network of New England 1952 Whitney Avenue Hamden, CT 06517 Main: 203-387-9332 Fax: 203-389-9902