ami shah, mph alicia shugart, ma priti patel, md christi lines, mph november 19, 2014 disclaimer:...
TRANSCRIPT
Ami Shah, MPHAlicia Shugart, MA
Priti Patel, MDChristi Lines, MPH
November 19, 2014
Disclaimer: The findings and conclusions in this report/presentation are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
The Past, Present, and Future: NHSN Analysis Resources and How to
Make Them Work for You
National Center for Emerging and Zoonotic Infectious Diseases
Division of Heatlhcare Quallity Promtoion
Analysis in NHSN - Outline
A brief history of NHSN Value of analysis
What Analysis tools are presently available? Finding and using Analysis tools Tailoring reports to your needs
Future expectations for NHSN Analysis
A BRIEF HISTORY OF NHSN
Dialysis Surveillance Early On
Via annual survey, CDC conducted surveillance of hemodialysis associated hepatitis since the early 1970s
1999: CDC established the Dialysis Surveillance Network (DSN) A voluntary national surveillance system that monitored:
• IV Antimicrobial Starts• Positive Blood Cultures• Hospitalization
DSN was designed for dialysis center personnel, NOT infection control professionals
Dialysis Surveillance Early On
2005: Providers using DSN transitioned to using the National Healthcare Safety Network (NHSN) Approximately 100 dialysis facilities voluntarily
participated in the early years of NHSN Most were hospital-affiliated dialysis units
2008: First publication of NHSN outpatient dialysis facility data Dialysis Surveillance Report: National Healthcare Safety
Network (NHSN)—Data Summary for 2006. Seminars in Dialysis—Vol 21, No 1 (January–February) 2008 pp. 24–28
2009: CDC Dialysis BSI Prevention Collaborative established Facilities used NHSN for prevention initiatives
NHSN Changes and QIP
2011: Dialysis Event Reporting Changed “Hospitalization” event type was discontinued New dialysis event type introduced: Pus, redness, and
increased swelling at the vascular access site (PRS) Hospitalization and death were included as outcomes
related to dialysis events
End of 2011: Centers for Medicare and Medicaid Services (CMS) published the End Stage Renal Disease (ESRD) Quality Incentive Program (QIP) Rule Calendar Year 2012 (Payment Year 2014) QIP incentivized NHSN enrollment and reporting Anticipated a dramatic increase in NHSN enrollment
Outpatient Hemodialysis Facility Enrollment in NHSN, 2010 -
Present
0
1000
2000
3000
4000
5000
6000
7000
First CMS ESRD QIP final rule published in November 2011 for participation in CY
2012.
791
6,0275,694
NHSN Growth
2012: First year of CMS ESRD QIP incentivized participation in NHSN Over 5,500 additional outpatient dialysis facilities enrolled
2014: CDC implemented the NHSN Dialysis Component to tailor the user interface for dialysis facility users
NHSN continues to improve with updates a few times per year Addition of new surveillance options Improvements to the user interface in response to user
feedback Introduction of new and improved analytical tools
Development of Analytical Tools for Dialysis Users
Dialysis reports initially based upon hospital reports Reports were mixed among hospital reports
CDC developed the Centers for Medicaid and Medicare Services End Stage Renal Disease Quality Incentive Program Report (CMS ESRD QIP) with dialysis users in mind Facilities needed help to ensure that criteria were met
for reporting requirements mandated by CMS 2012 – Present: CDC has observed a large uptake in the
use of the QIP report and other analysis tools• 2012: 100’s of QIP reports run• After 2012 - Present: 45,000+ QIP reports run
Finding Dialysis Analysis Tools Early On
NHSN Dialysis Event Reporting and Analysis was housed in the Patient Safety Component
Dialysis reports were mixed in with hospital reports in the “Device-Associated Module” folder
Establishing NHSN Aggregate Rates
Current NHSN aggregate data are from facilities that entered data between January 2007 — April 2011.
CDC’s intention is to update and publish new aggregate rates once a clean and complete year of data becomes available.
Location Access TypeSummary
Yr/Qtr Months
Number Bloodstream
InfectionsPatient- months
Bloodstream Infection Rate/100
patient-months
NHSN Bloodstream
Infection Pooled Mean
Rate/100 patient-months
Incidence Densityp-value
Incidence Density
Percentile
123456 All 2014Q1 2 4 114 3.42 1.27 0.4998 .
123456 Fistula 2014Q1 3 0 54 0.00 0.48 0.6271 25
123456 Graft 2014Q1 3 1 55 1.82 0.88 0.5750 50
123456 Other Access 2014Q1 3 0 1 0.00 . . .
123456 Tunneled 2014Q1 3 1 4 25.00 3.24 0.0572 46
123456 Nontunneled 2014Q1 3 0 1 0.00 2.78 0.0799 100
123456 Any CVC 2014Q1 3 1 5 20.00 3.21 0.4551 69
Most Dialysis Rate Tables provide aggregate data from all of NHSN. This information can be used to compare each facility to the rest
of NHSN.
NHSN and Analysis Beginnings
To summarize… The Dialysis Surveillance Network preceded the
introduction of NHSN and monitored different dialysis event types
NHSN was created in 2005 • In 2012 as a result of QIP, enrollment increased
exponentially• All analytical resources were found under the Patient Safety
Componento A single analysis tree view was used to address the
needs of both hospitals and dialysis facilitieso CDC developed the QIP report with dialysis users in
mindo CDC’s ability to update aggregate rates annually
depends on data quality of NHSN NHSN continues to grow and improve
NHSN ANALYSIS: TODAYFinding and using available NHSN tools…
NHSN Analysis: Today In August 2014, the new Dialysis Component was launched
and all Analysis options related to Dialysis moved out of the Patient Safety Component! Analysis output options are presented in a streamlined and user-
friendly layout Reports are separated into pertinent categories Reports can be run as-they-are or modified to better suit your needs
NHSN Analysis: Today
The report type determines how data are displayed
Report types include: Line Listings Frequency Tables Pie Charts Rate Tables Run Charts
CREATE A REPORT IN 3 STEPS
Creating Reports in NHSN
Experiment with the Analysis function – You won’t break anything!
NHSN does the work for you!
Create a Report in 3 Steps
1. Generate Data Sets
2. Select a Report
Modifying the report is optional
3. ‘Run’ the Report
Step 1 - Generate Data Sets
Data sets are the files NHSN uses to run reports
Generating new data sets captures all of your facility’s NHSN data so that reports are created using complete, up-to-date information
Each user has their own analysis data sets
May take several minutes to generate
Step 1 - Generate Data Sets From the navigation bar, select ‘Analysis,’ then ‘Generate
Data Sets’ If data sets exist, the date generated is shown
Only information in NHSN before the “Date Last Generated” will be included in the reports.
Step 1 - Generate Data Sets Click “Generate New” and then select ‘OK’ to replace
existing data sets Wait for update
Step 2 – Select a Report
Once data sets are generated, select ‘Output Options’ from the navigation bar
“Expand All” or select the appropriate folder to find the relevant report
i.e., Output Options > Dialysis Events > Numerators > CDC Defined Output > “Line Listing – Frequency of Dialysis Events”
Step 3 – ‘Run’ the Report Press the “Run” button next to the report you want
Step 3 – ‘Run’ the Report
The report will open in a separate window
ALLOW POP-UPS!
OPTIONAL REPORT MODIFICATIONS(OPTIONAL)
Modifying Reports is Optional
Some suggestions to modify reports: Restrict the report to a certain time period Choose what variables appear and how they are organized in
reports you run
Click the ‘Modify’ button next to the template you’d like to change
The Modify Screen
The modify screen has several components that users can experiment with.
A couple of easy modification options:1. Filter by date
2. Specify variables that appear and adjusting the order in which they appear in the output.
Modifying Reports: Filtering by Date
Filter by time period Try “eventDate” for a report that includes all dialysis
events that occurred during a specific time interval
Different reports have differing filtering options
Modifying Reports: Filtering by Date
Filter by “eventDate” Use MM/DD/YYYY date format
In the example below, the report will include all dialysis events that occurred on or between October 1, 2011 and October 31, 2011
Modifying Reports: Filtering by Date
Common date variable is SummaryYM
SummaryYM = Summary of data by Year and Month Enter date(s) in MM/YYYY format
• E.g., the report will include data from Oct 1, 2013 to Dec 31, 2013
Modifying Reports – Filtering by Date
Another common date variable is SummaryYQ SummaryYQ = Summary of data by Year and Quarter Enter date(s) in YYYYQ# format (e.g. 2014Q1 = the 1st
quarter of 2014)
E.g., the report will include data from the 3rd quarter of 2013 through the 2nd quarter of 2014 (or July 2013 – June 2014)
Modifying Reports – Changing Variable Display and Output Order
The bottom of the modify screen allows you to specify what data will be displayed in the output and the order in which they will appear
Click the link next to the “Modify Variables to Display by Clicking” option.
Note: Modification and display options vary by report
Modifying Reports – Changing Variable Display and Output Order
Modifying Reports – Changing Variable Display and Output Order
To modify which variables are included in the report output, select a variable from the “Available variables” column and press the to move it to the “Selected variables” column.
Modifying Reports – Changing Variable Display and Output Order
Click the ‘Up’ and ‘Down’ buttons to change the display order in the “Selected variables” column
Click ‘Save’ and run the report when done
Modifying Reports – Changing Variable Display and Output Order
The report will pop-up in a new dialogue box with the variable added in the position you assigned.
READING NHSN REPORTS
Understanding Basic NHSN Terminology
In-Plan vs. Off-Plan Reporting: Selecting the checkbox next to a surveillance option on the “Monthly Reporting Plan” indicates the facility will report data in-plan, according the corresponding NHSN protocol
Numerator = number of dialysis events Information from “Dialysis Event” form Numerator = 0 if the “Report No Events” box is checked
on the “Denominators for Outpatient Dialysis” form The top number in a rate calculation
Denominator = number of at-risk patient-months Information from “Denominators for Outpatient Dialysis”
form The bottom number in a rate calculation
HOW TO READ NHSN REPORTS Example 1: CMS ESRD QIP Line Listing
Line Listing - CMS ESRD QIP Rule Report
Aim of the report is to show if minimum QIP NHSN reporting requirements have been met for a given month Have data been reported in-plan? Has a complete numerator been reported? Has a complete denominator been reported?
Line Listing - CMS ESRD QIP Rule Report
Generate Data Sets
Locate the report under Output Options in the “CMS Reports” folder
Click “Run”
Org IDCMS
Certification Number
Facility Name LocationSummary
Year/Month
DE on Reporting
Plan
Dialysis Event
Numerator Reported
Dialysis Event
Denominator Reported
Criteria Met this Month
10856 123456 Dialysis Test Facility OPDIAL 2014M01 Y N Y N
10856 123456 Dialysis Test Facility OPDIAL 2014M02 Y Y Y Y
10856 123456 Dialysis Test Facility OPDIAL 2014M03 N N N N
10856 123456 Dialysis Test Facility OPDIAL 2014M04 Y Y N N
Example: Line Listing - CMS ESRD QIP Rule
Data are reported to CMS by CCN. Verify that a CCN is listed and that it is correct.
CCN = CMS Certification Number CCN can be added or edited on the
Facility Info screen
Org IDCMS
Certification Number
Facility Name LocationSummary
Year/Month
DE on Reporting
Plan
Dialysis Event
Numerator Reported
Dialysis Event
Denominator Reported
Criteria Met this Month
10856 123456 Dialysis Test Facility OPDIAL 2014M01 Y N Y N
10856 123456 Dialysis Test Facility OPDIAL 2014M02 Y Y Y Y
10856 123456 Dialysis Test Facility OPDIAL 2014M03 N N N N
10856 123456 Dialysis Test Facility OPDIAL 2014M04 Y Y N N
Example: Line Listing - CMS ESRD QIP Rule
Summary Year/Month column indicates which month is represented by the row Looking down the column, you can determine if
consecutive months are represented
Example: Line Listing - CMS ESRD QIP Rule
Org IDCMS
Certification Number
Facility Name LocationSummary Year/
Month
DE on Reporting
Plan
Dialysis Event
Numerator Reported
Dialysis Event
Denominator Reported
Criteria Met this Month
10856 123456 Dialysis Test Facility OPDIAL 2014M01 Y N Y N
10856 123456 Dialysis Test Facility OPDIAL 2014M02 Y Y Y Y
10856 123456 Dialysis Test Facility OPDIAL 2014M03 N N N N
10856 123456 Dialysis Test Facility OPDIAL 2014M04 Y Y N N
Y = Reporting Plan saved with “DE” selected for the month
Dialysis Events will be reported “in-plan”
Org IDCMS
Certification Number
Facility Name LocationSummary
Year/Month
DE on Reporting
Plan
Dialysis Event
Numerator Reported
Dialysis Event
Denominator Reported
Criteria Met this Month
10856 123456 Dialysis Test Facility OPDIAL 2014M01 Y N Y N
10856 123456 Dialysis Test Facility OPDIAL 2014M02 Y Y Y Y
10856 123456 Dialysis Test Facility OPDIAL 2014M03 N N N N
10856 123456 Dialysis Test Facility OPDIAL 2014M04 Y Y N N
Example: Line Listing - CMS ESRD QIP Rule
Did the facility report the number of at-risk patient-months (denominator) in January and February 2014?
Y = Denominators for Outpatient Dialysis form was completed for the month
Example: Line Listing - CMS ESRD QIP Rule
Report the number of highest risk vascular access types
Check off the “Report No Events” boxes on the Denominator Form as necessary.
Reporting a Numerator
Each month, each dialysis event type needs to be accounted for.
This can be done by :1. Reporting an event via the Dialysis Event form, or…2. Checking off the “report no events” box for specific event
types on the “Denominators for Outpatient Dialysis” form to confirm that no events (i.e., zero events) of that type occurred during the month.
Numerator = 0 when the “report no events” checkbox is checked
Org IDCMS
Certification Number
Facility Name LocationSummary
Year/Month
DE on Reporting
Plan
Dialysis Event
Numerator Reported
Dialysis Event
Denominator Reported
Criteria Met this Month
10856 123456 Dialysis Test Facility OPDIAL 2014M01 Y N Y N
10856 123456 Dialysis Test Facility OPDIAL 2014M02 Y Y Y Y
10856 123456 Dialysis Test Facility OPDIAL 2014M03 N N N N
10856 123456 Dialysis Test Facility OPDIAL 2014M04 Y Y N N
Adding an Event Can Satisfy the Numerator RequirementReport dialysis
events using the “Dialysis Event” form
Complete all required fields and click “Save”
Org IDCMS
Certification Number
Facility Name LocationSummary
Year/Month
DE on Reporting
Plan
Dialysis Event
Numerator Reported
Dialysis Event
Denominator Reported
Criteria Met this Month
10856 123456 Dialysis Test Facility OPDIAL 2014M01 Y N Y N
10856 123456 Dialysis Test Facility OPDIAL 2014M02
Y Y Y Y
10856 123456 Dialysis Test Facility OPDIAL 2014M03
Y N N N
10856 123456 Dialysis Test Facility OPDIAL 2014M04
Y Y N N
“Reporting No Events” Can Satisfy the Numerator Requirement
The “Report No Events” checkboxes are found on the Denominators Form.
Y = No events reported, report no events boxes appropriately checkedN = No events reported, report no events boxes have NOT been appropriately checked
Example of Reporting No Events: No IV Antimicrobial Starts in January and February
2012
January 2012: - Numerator Reported = “N – NO”
because no IV antimicrobial start events were reported, AND the “Report No Events: No IV Antimicrobial Start Events” was NOT checked off on the Denominator form.
February 2012: - Numerator Reported = “Y – YES”
because no IV antimicrobial start events were reported, AND the “Report No Events: No IV Antimicrobial Start Events” WAS checked off on the Denominator form.
Summary Year/
Month
DE on Reporting
Plan
Dialysis Event
Numerator Reported
Dialysis Event
Denominator Reported
Criteria Met this Month
2014M01 Y N Y N2014M0
2Y Y Y Y
Org IDCMS
Certification Number
Facility Name LocationSummary
Year/Month
DE on Reporting
Plan
Dialysis Event
Numerator Reported
Dialysis Event
Denominator Reported
Criteria Met this Month
10856 123456 Dialysis Test Facility OPDIAL 2014M01 Y N Y N
10856 123456 Dialysis Test Facility OPDIAL 2014M02
Y Y Y Y
10856 123456 Dialysis Test Facility OPDIAL 2014M03
Y N N N
10856 123456 Dialysis Test Facility OPDIAL 2014M04
Y Y N N
Example: Line Listing - CMS ESRD QIP Rule
Verify NHSN reporting requirements are met for the month, reflected by a “Y” (Yes) in each field To meet CMS criteria, all other Yes/No fields in the
same row must be “Y” “N” indicates that action is needed
ESRD QIP Resources
http://www.cdc.gov/nhsn/PDFs/dialysis/CMS-QIP-NHSN-report.pdf
HOW TO READ NHSN REPORTSExample 2: Bloodstream Infection (BSI) Rate Table
Components of a Rate
Numerator = number of dialysis events Information from “Dialysis Event” form Numerator = 0 if the “Report No Events” box is checked
on the Denominators for Outpatient Dialysis form
Denominator = number of at-risk patient-months Information from “Denominators for Outpatient Dialysis”
form
Rate (per 100 patient-months)
NHSN dialysis event rates are calculated per 100 patient-months
Typically rates are stratified by vascular access type
=Dialysis Events (numerator)
Patient-Months (denominator)x 100
Most Dialysis Rate Tables are interpreted similarly.
Aggregate Rates are provided for comparison for the following Rate Table reports: Rate Table – IV Antimicrobial Start Data Rate Table – IV Vancomycin Start Data Rate Table – Bloodstream Infection Data Rate Table – Access Related Bloodstream Infection
Percent Adherence measurements are provided for the following Rate Table reports: Rate Table for Hand Hygiene Adherence Rate Table – All Practice Adherence (CLIP) Rate Table – Flu Vaccine Adherence Rate Table – Flu Vaccine Declination
In 2015, additional reports will be added for newly introduced surveillance options.
Example: Bloodstream Infection Data Rate Table
Aim of the report is to provide the rate of bloodstream infections over time for the facility and provide NHSN aggregate data for comparison
Bloodstream Infection Any positive blood culture
Note: This example has been modified to specify a distinct time interval: 2nd quarter of 2012
Example: Bloodstream Infection Data Rate Table
Generate data sets Locate the report
under Output Options:1. ‘Dialysis Events’
folder2. ‘Rates’ folder3. ‘CDC Defined
Output’ folder• Rate Table –
Bloodstream Infection Data
Click “Run”
Location Access Type SummaryYr/Qtr Months
Number Bloodstream
Infections
Patient-Months
Bloodstream Infection Rate/100 patient-months
NHSN Bloodstream
Infection Pooled Mean
Rate/100 patient-months
Incidence Densityp-value
Incidence Density
Percentile
123456 All 2012Q2 3 2 211 0.948 1.27 0.4998 . 123456 Fistula 2012Q2 3 0 97 0 0.48 0.6271 25 123456 Graft 2012Q2 3 0 63 0 0.88 0.5750 50 123456 Other Access 2012Q2 3 0 3 0 . . . 123456 Tunneled 2012Q2 3 1 45 2.222 3.24 0.0572 46 123456 Nontunneled 2012Q2 3 1 3 33.333 2.78 0.0799 100
123456 Any CVC 2012Q2 3 2 48 4.167 3.21 0.4551 69
Example: Bloodstream Infection Data Rate Table
Non-shaded (white) area is
the facility data.
Shaded (yellow) area is aggregate data from all of
NHSN. Use this information to compare each facility to the
rest of NHSN.
Location Access Type SummaryYr/Qtr Months
Number Bloodstream
Infections
Patient-Months
Bloodstream Infection Rate/100 patient-months
NHSN Bloodstream
Infection Pooled Mean
Rate/100 patient-months
Incidence Densityp-value
Incidence Density
Percentile
123456 All 2012Q2 3 2 211 0.948 1.27 0.4998 . 123456 Fistula 2012Q2 3 0 97 0 0.48 0.6271 25 123456 Graft 2012Q2 3 0 63 0 0.88 0.5750 50 123456 Other Access 2012Q2 3 0 3 0 . . . 123456 Tunneled 2012Q2 3 1 45 2.222 3.24 0.0572 46 123456 Nontunneled 2012Q2 3 1 3 33.333 2.78 0.0799 100
123456 Any CVC 2012Q2 3 2 48 4.167 3.21 0.4551 69
Example: Bloodstream Infection Data Rate Table
Numerator
Denominator
Facility Rate
=1
45
x 100Rate = 2.222 BSI/100 patient-months
Location Access Type SummaryYr/Qtr Months
Number Bloodstream
Infections
Patient-Months
Bloodstream Infection Rate/100 patient-months
NHSN Bloodstream
Infection Pooled Mean
Rate/100 patient-months
Incidence Densityp-value
Incidence Density
Percentile
123456 All 2012Q2 3 2 211 0.948 1.27 0.4998 . 123456 Fistula 2012Q2 3 0 97 0 0.48 0.6271 25 123456 Graft 2012Q2 3 0 63 0 0.88 0.5750 50 123456 Other Access 2012Q2 3 0 3 0 . . . 123456 Tunneled 2012Q2 3 1 45 2.222 3.24 0.0572 46 123456 Nontunneled 2012Q2 3 1 3 33.333 2.78 0.0799 100
123456 Any CVC 2012Q2 3 2 48 4.167 3.21 0.4551 69
Example: Bloodstream Infection Data Rate Table
This column shows the mean or average RATE (per 100 patient-months) for all dialysis facilities
reporting to NHSN
Location Access Type SummaryYr/Qtr Months
Number Bloodstream
Infections
Patient-Months
Bloodstream Infection Rate/100 patient-months
NHSN Bloodstream
Infection Pooled Mean
Rate/100 patient-months
Incidence Densityp-value
Incidence Density
Percentile
123456 All 2012Q2 3 2 211 0.948 1.27 0.4998 . 123456 Fistula 2012Q2 3 0 97 0 0.48 0.6271 25 123456 Graft 2012Q2 3 0 63 0 0.88 0.5750 50 123456 Other Access 2012Q2 3 0 3 0 . . . 123456 Tunneled 2012Q2 3 1 45 2.222 3.24 0.0572 46 123456 Nontunneled 2012Q2 3 1 3 33.333 2.78 0.0799 100
123456 Any CVC 2012Q2 3 2 48 4.167 3.21 0.4551 69
Example: Bloodstream Infection Data Rate Table
NHSN Aggregate Rate
Facility Rate
Location Access Type SummaryYr/Qtr Months
Number Bloodstream
Infections
Patient-Months
Bloodstream Infection Rate/100 patient-months
NHSN Bloodstream
Infection Pooled Mean
Rate/100 patient-months
Incidence Densityp-value
Incidence Density
Percentile
123456 All 2012Q2 3 2 211 0.948 1.27 0.4998 . 123456 Fistula 2012Q2 3 0 97 0 0.48 0.6271 25 123456 Graft 2012Q2 3 0 63 0 0.88 0.5750 50 123456 Other Access 2012Q2 3 0 3 0 . . . 123456 Tunneled 2012Q2 3 1 45 2.222 3.24 0.0572 46 123456 Nontunneled 2012Q2 3 1 3 33.333 2.78 0.0799 100
123456 Any CVC 2012Q2 3 2 48 4.167 3.21 0.4551 69
Example: Bloodstream Infection Data Rate Table
P-value and Percentile are provided to assist with interpretation of rate comparison Typically, a p-value of <0.05 is considered a statistically significant
difference between rates The lower the percentile, the better the facility is performing
relative to the others in NHSN
Comparing Rates Using Percentiles
The percentile indicates how a facility ranks for the event among all NHSN facilities A lower the percentile indicates a lower rate of infection.
46% of facilities reported lower BSI rates among patients with tunneled central lines than facility 123456.
Analysis: Rate Table Interpretation Examples
Among patients with tunneled central lines in each quarter, how would you interpret this facility’s rates?
Access Type
Summary Yr/Qtr Months
Number Bloodstrea
m InfectionsPatient-months
BSI Rate/100 patient-months
NHSN BSI Pooled Mean
Rate/100 patient-months
Incidence Density p-value
Incidence Density
Percentile
Tunneled 2014Q1 3 1 8 12.50 3.24
0.2567 96
Tunneled 2014Q2 3 1 30 3.33 3.24
0.8755 58
Tunneled 2014Q3 3 0 100 0.00 3.24
0.0393 10
Quarter
Number Bloodstrea
m Infections
Patient-months
BSI Rate/100 patient-months
NHSN BSI Pooled Mean Rate/100 patient-months
Incidence Density p-value
Incidence Density Percentil
e
1 1 8 12.50 3.240.256
7 96
2 1 30 3.33 3.240.875
5 58
3 0 100 0.00 3.240.039
3 10
1. Quarter 1, facility rate is 12.50, NHSN rate is 3.24 Percentile (96) is high Conclusion: facility has a higher than average BSI rate
2. Quarter 2, facility rate is 3.33, NHSN rate is 3.24 Percentile (58) is medium Conclusion: facility has an average BSI rate
3. Quarter 3, facility rate is zero, NHSN rate is 3.24 Percentile is (10) low Conclusion: facility has a lower than average BSI rate
BSI Resources
http://www.cdc.gov/nhsn/PDFs/dialysis/BSI-cheatsheet.pdf
Guidance for other reports is also available on the NHSN Dialysis homepage.
Interpreting Data Please keep in mind that data quality is
essential for meaningful rates, comparisons, and conclusions Verify: Is the Protocol being followed correctly? Verify: Are all Dialysis Events being captured? Verify: Has all event information been reported to
NHSN? Use all the information available to you,
including percentile rank, to interpret your rates Combine data interpretation with investigative work in
the unit and common sense For evaluation, examining data over longer
timeframes is more informative e.g., draw conclusions based on ≥ 1 data quarter, versus
a single month of data
Data Quality and Quantity
When reviewing your facility’s rates, remember the importance of data quality: High rates may = high event occurrence OR over-
reporting Low rates may = low event occurrence OR under-
reporting NHSN rates could increase if facilities improve the
accuracy and completeness of reporting
And data quantity: Rates may fluctuate over short periods of time Assessing rates over greater time intervals can increase
confidence in the values
Review Your Data
Monthly to: Ensure all data have been accurately reported
Quarterly to: Detect problems in your facility Provide feedback to your staff Get staff engaged in quality improvement Prepare for CMS quarterly reporting deadlines
Better understand your facility’s performance by comparing your facility’s rates against NHSN aggregate rates
Resources for Reviewing the Data
The 3 Steps to Review DE Surveillance is a great tool for ensuring that your data are accurate and complete!
http://www.cdc.gov/nhsn/PDFs/dialysis/3-Steps-to-Review-DE-Data-2014.pdf
WHAT LIES AHEAD FOR NHSNLooking to the future…
NHSN Analysis: Goals for the Future
Update NHSN aggregate data Important to have improved data quality
Continue streamlining Analysis interface Updating the Analysis tree view to reflect new options in an organized
fashion Introduce new reports to track surveillance and facility
participation Healthcare Personnel Flu Vaccination 5 Prevention Process Measures
Increase the use of Analysis tools by all NHSN users!
Summary—Use NHSN Analysis to Your Advantage
The launch of the Dialysis Component separated Dialysis analytical tools from all other tools The component is streamlined Analysis is easier to navigate
Creating and Running Reports 3 step process
• Generate data sets• Modify the report if necessary• Run the report
Suggested Report Modifications1. Filter by date2. Choose variables and organize them to suit your reporting
needs
Summary—Use NHSN Analysis to Your Advantage
Understand reports to see your facility’s performance The CMS ESRD QIP report is a great tool to help users
ensure that they have met minimum CMS reporting requirements• Did the facility report in-plan?• Was a complete numerator reported?• Was a complete denominator reported?
The BSI Data Rate Table (and other rate tables) can inform facility performance and improvement• How does the facility’s BSI rate compare to the NHSN rate?
Summary—Use NHSN Analysis to Your Advantage
Review and interpret your data often Reviewing the data can serve as a learning opportunity By reviewing the data regularly, facilities can
demonstrate progress or need for improvement to frontline staff
Data quality is of utmost importance
For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: [email protected] Web: www.cdc.gov
Thank you!