infection prevention and nhsn webinar series nhsn ...oct 23, 2018  · • surgical site infections...

An Initiative of the Florida Hospital AssociationHospital Improvement Innovation Network

Infection Prevention and NHSN Webinar SeriesNHSN: Surgical Site Infection (SSI) Surveillance Identification and AnalysisOctober 23, 2018

• Welcome & FHA Mission to Care HIIN Overview– Cheryl Love, RN, BSN, BS-HCA, MBA, LHRM, CPHRM, Director of

Quality and Patient Safety and Improvement Advisor, FHA

• NHSN: Surgical Site Infection (SSI) Surveillance Identification and Analysis– Linda R. Greene, RN, MPS, CIC, FAPIC, Manager of Infection

Prevention, UR Highland Hospital, Rochester, NY

• Q&A• Upcoming HIIN Events and Opportunities• Evaluation Survey & Continuing Nursing Education

Agenda

• Adverse Drug Events (ADE)• Catheter-associated Urinary Tract Infections (CAUTI)• Clostridium Difficile Infection (CDI)• Central line-associated Blood Stream Infections (CLABSI)• Hospital-onset MRSA Bacteremia• Injuries from Falls and Immobility• Pressure Ulcers (PrU)• Sepsis• Surgical Site Infections (SSI)• Venous Thromboembolisms (VTE)• Ventilator Associated Events (VAE/IVAC/PVAP)• Readmissions (12% reduction)• Worker Safety

HIIN Core Topics – Aim is 20% reduction

SSI Change Package

SSI Top 10 Checklist

SOAP UP Resources

Watch Past Webinars

HRET HIIN Resource Library

Guides

Case Studies

SSI Resources, Trainings and Toolshttp://www.fha.org/health-care-issues/quality-and-safety/mtc-hiin.aspx

http://www.hret-hiin.org

Simplify safe care and streamline interventions

Reduce multiple forms of harm with simple, easy-to-accomplish activities

Consolidate basic interventions that cut across several topics to decrease harm

UP Campaign

http://www.fha.org/up

FHA Mission to Care Update: SSI - Colon

Source: HRET Comprehensive Data System, October 22, 2018

BL 10/16 11/16 12/16 1/17 2/17 3/17 4/17 5/17 6/17 7/17 8/17 9/17 10/17 11/17 12/17 1/18 2/18 3/18 4/18 5/18 6/18 7/18

FL Rate 4.26 5.35 4.02 5.81 5.38 4.85 4.36 3.46 3.76 3.84 4.64 5.33 4.94 3.79 3.70 5.36 4.52 5.00 4.97 4.62 3.98 4.47 4.34

HRET HIIN Rate 5.15 4.71 4.67 4.81 4.89 4.54 4.55 4.18 4.73 4.61 4.56 5.06 5.13 4.70 4.58 4.96 4.91 5.39 4.79 4.75 4.69 5.05 4.70

# FL Reporting 82 81 81 80 79 79 79 79 79 79 79 79 79 79 79 79 79 79 79 79 79 76 65

#HRET HIIN Reporting 1,109 1,125 1,125 1,124 1,125 1,122 1,121 1,119 1,118 1,115 1,113 1,112 1,115 1,116 1,111 1,111 1,105 1,092 1,091 1,059 1,031 970 785

0.00

1.00

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3.00

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5.00

6.00

7.00

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100

FHA Mission to Care Update: SSI - Hysterectomy

Source: HRET Comprehensive Data System, October 22, 2018

BL 10/16 11/16 12/16 1/17 2/17 3/17 4/17 5/17 6/17 7/17 8/17 9/17 10/17 11/17 12/17 1/18 2/18 3/18 4/18 5/18 6/18 7/18

FL Rate 1.47 1.29 2.08 0.62 0.74 0.92 0.78 0.99 1.34 1.42 1.49 1.06 1.15 1.10 0.96 1.15 0.45 0.69 1.07 1.04 1.17 0.40 1.51

HRET HIIN Rate 1.47 1.14 1.36 1.02 1.18 1.31 1.21 1.34 1.36 1.34 1.22 1.16 1.40 1.14 1.25 1.10 1.17 1.00 1.25 1.28 1.19 1.08 1.29

# FL Reporting 81 80 79 80 78 78 78 78 78 78 78 78 78 78 78 77 78 78 78 78 78 73 65

#HRET HIIN Reporting 1,066 1,081 1,082 1,083 1,077 1,077 1,081 1,073 1,076 1,073 1,070 1,068 1,071 1,072 1,068 1,064 1,062 1,034 1,034 1,015 987 930 757

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FHA Mission to Care Update: SSI - Knee

Source: HRET Comprehensive Data System, October 22, 2018

BL 10/16 11/16 12/16 1/17 2/17 3/17 4/17 5/17 6/17 7/17 8/17 9/17 10/17 11/17 12/17 1/18 2/18 3/18 4/18 5/18 6/18 7/18

FL Rate 0.77 0.87 0.56 0.67 0.50 0.72 0.46 0.60 0.49 0.47 0.81 0.41 0.46 0.59 0.85 0.31 0.50 0.47 0.51 0.69 0.60 0.29 0.24

HRET HIIN Rate 0.74 0.57 0.58 0.74 0.50 0.50 1.00 0.82 0.98 0.63 0.81 0.63 0.88 1.08 0.99 0.49 0.55 0.42 0.57 0.79 0.84 0.72 0.47

# FL Reporting 68 65 66 65 64 64 64 63 61 60 60 61 62 61 61 61 61 60 58 57 57 56 52

#HRET HIIN Reporting 828 834 834 833 867 863 866 863 863 861 856 849 856 856 853 851 845 836 824 791 754 710 576

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0.75

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FHA Mission to Care Update: SSI - Hip

Source: HRET Comprehensive Data System, October 22, 2018

BL 10/16 11/16 12/16 1/17 2/17 3/17 4/17 5/17 6/17 7/17 8/17 9/17 10/17 11/17 12/17 1/18 2/18 3/18 4/18 5/18 6/18 7/18

FL Rate 1.44 0.90 1.15 0.80 1.18 0.90 1.16 0.42 1.07 1.25 1.51 1.13 0.87 0.97 1.00 1.03 1.07 0.63 0.99 1.37 1.50 0.87 0.30

HRET HIIN Rate 1.21 1.00 1.18 0.99 1.04 1.17 1.13 1.18 1.31 1.01 1.26 1.06 1.26 1.26 0.98 1.14 1.22 1.00 1.20 1.12 0.97 1.27 0.70

# FL Reporting 67 64 65 65 64 64 64 63 61 60 60 61 61 61 61 61 61 60 59 57 57 57 52

#HRET HIIN Reporting 810 819 816 813 852 848 847 843 842 841 836 828 829 834 831 831 824 824 811 777 754 703 564

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FHA Mission to Care Update:Florida | SSI Rates

Date Topic Register Online

Oct. 23 NHSN: SSI Surveillance Identification and Analysis (Virtual Event)

Today’s event archive will be posted online

Nov. 20 SSI-Colon: How to Assess Root Cause and Prevention Strategies (Virtual Event)

https://cc.readytalk.com/r/x6cg3sako1xq&eom

Dec. 4 Infection Prevention NHSN Workshop III –Orlando, FL (In-Person Event)

http://www.cvent.com/d/8bqwm5/2K

Dec. 18 NHSN topic to be announced (Virtual Event) https://cc.readytalk.com/r/ag8n7ef9vryt&eom

Infection Prevention and NHSN Webinar Series: 2018-2019

Access Event Archives (Recordings | Slides) on the Mission to Care HIIN Website

NHSN SSI Definitionsand Analysis

Linda R Greene, RN, MPS,CIC, FAPICManager Infection Prevention

University of Rochester, Highland HospitalLinda_greene@urmc.rochester.edu

RemindersNHSN Infection Window Period (Does NOT apply to SSI, VAE, or LabID Event surveillance) Date of Event (Event Date) (Does NOT apply to VAE or LabID Event surveillance) Repeat Infection Timeframe (RIT) (Does NOT apply to SSI, VAE, or LabID Event surveillance)

Polling Question #1Can the culture be used to meet SSI criteria?

Yes

No

Polling Question #2Does this case meet criteria for PATOS?

Yes

No

When in doubt – e-mail NHSN

Polling Question #3Does this case meet criteria for a superficial SSI?

No. The culture shows no growth

Yes. Meets SIP criteria

No. Meets DIP infection

No. Intact fascia

Analysis of Surgical Site Infections

What Information do I need today?

Helpful to run a line list

Variables

Other Variables

Recently Published Data 2016 Analysis

SIR = Observed infections

Expected infections

SIR0 1 2

SameBetter Worse

Standardized Infection RatiosRefresh our memory

https://www.cdc.gov/hai/data/portal/progress-report.html

Colon SSI Percentile Distribution

0.000 0.000 0.000 0.085 0.343 0.444 0.558 0.627 0.710 0.801

0.880 0.959 1.082 1.207 1.336 1.504 1.683 1.919 2.33755% 60% 65% 70% 75% 80% 85% 90% 95%

https://www.cdc.gov/hai/data/portal/progress-report.html

Looking Down the Road

Looking Down the Road

Check Procedures

Exclusions

Tips - Review

Tips Review your data.

Standardized review forms will help with consistency

Review Sheet

Opportunities for Improvement Use available data to drive improvement

NHSN provides a rich variety of information

Virtual Events:• Oct. 25 - HRET HIIN & CMS | Mapping Medicare Disparities• Nov. 1 - HRET HIIN | Multi-Drug Resistant Organism (MDRO) Discovery and

Direction Series: Organizational Risk Assessment• Nov. 7 - FHA HIIN | Hot Topics Monthly Virtual Event• Nov. 9 - HRET HIIN | Readmissions Multi Visit Patient (MVP) Webinar #2• Nov. 14 - HRET HIIN | Culture of Safety Virtual Event - Workplace Violence: Up Close• Nov. 15 - HRET HIIN | Falls Fishbowl #2• Nov. 15 - HRET HIIN | MDRO Discovery and Direction Series: Horizontal Practices• Nov. 20 - FHA HIIN | Infection Prevention & NHSN Series - SSI-Colon: How to

Assess Root Cause and Prevention Strategies• Nov. 29 - HRET HIIN | MDRO Discovery and Direction Series: Special Approaches

and Essential QuestionsIn-Person Event:• Dec. 4 (Orlando, FL) - FHA HIIN | Infection Prevention NHSN Workshop III

Upcoming HIIN Events

Check the weekly MTC HIIN Upcoming Events for details and registration

• Eligibility for Nursing CEU requires submission of an evaluation survey for each participant requesting continuing education:https://www.surveymonkey.com/r/IP-NHSN-102318

• Share this link with all of your participants if viewing today’s webinar as a group (Survey closes Nov. 2)

• Be sure to include your contact information and Florida nursing license number

• FHA will report 1.0 credit hour to CE Broker and a certificate will be sent via e-mail (Please allow at least 2 weeks after the survey closes)

Evaluation Survey & Continuing Nursing Education

Cheryl D. Love, RN, BSN, BS-HCA, MBA, LHRM, CPHRMFlorida Hospital Associationcheryll@fha.org | 407-841-6230

Linda R. Greene, RN, MPS, CICManager of Infection PreventionUR Highland Hospital, Rochester, NYlinda_greene@urmc.rochester.edu

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