National Healthcare Safety Network (NHSN) Update: Influenza Vaccination Reporting

Presentation to: Georgia Hospital AssociationPresented by: Jeanne Negley, MBA,Healthcare Associated Infection CoordinatorDate: September 27, 2012

Agenda1. Background regarding Healthcare Personnel

(HCP) and Influenza Vaccination• Georgia Code• CMS Requirements

2. Reporting Definitions• CDC Documentation• General Reporting Rules• Denominator: Count of Healthcare Personnel• Numerator: HCP Vaccination Status

3. Reporting in NHSN• Preparation to Report• Sample Forms• Sample Reports

Georgia Code• A hospital shall annually offer its healthcare

workers and other employees who have direct contact with patients, at no cost, vaccinations for the influenza virus in accordance to the recommendations of the CDC and contingent on availability of the vaccine.

• O.C.G.A. § 31-7-18 (2012).

CMS Requirements for Reporting HCW Influenza Vaccination

• Requirement: start for all healthcare workers (HCP) vaccinated as of January 2013• http://www.ofr.gov/OFRUpload/OFRData/2012-19079_PI.pdf (p. 1029)

• http://www.cdc.gov/nhsn/PDFs/HPS-manual/Operational-Guidance-HPS-Flu-Vaccination-Sum-Acute-Care.pdf

• Problem: most workers will be vaccinated for the influenza season before January

• Suggestion: start reporting October 2012

Why Start in October?• You will have one season to practice data

collection and improve rate• CMS will not publish first season (2012-13)

on Hospital Compare

• Oregon Hospitals:• Season 1: 22% report all 3 categories• Season 2: 100% report all 3 categories

• Obtain new benchmark: for all categories (not just employees)

CDC Documentation• Main Web Page:

http://www.cdc.gov/nhsn/hps_Vacc.html

• Protocol and Instructions• Forms• Frequently Asked Questions

• CDC FAQ: http://www.cdc.gov/nhsn/faqs/FAQ-Influenza-Vaccination-Summary-Reporting.html

• Optional Survey: distributed with this presentation

General Reporting Rules (1 of 3)• Three required HCP categories:

• Employees• Licensed Independent Contractors• Adult students, trainees, and volunteers

• One optional category:• Contract workers

• All categories mutually exclusive per facility• All categories are for HCP regardless of clinical

responsibility or patient contact.

General Reporting Rules (2 of 3)• For each category, count individuals, not FTEs.• Need to be “physically present” at the facility at

least 30 days between:• Numerator (HCP vaccination status): when you

get vaccine (Aug/Sep/Oct) – March 31• Denominator (HCP count): Oct. 1 – March 31.

• If HCP works at two facilities 30+ days, then count for both facilities.

• Day any portion of day HCP is physically present = 1 day.

General Reporting Rules (3 of 3)• For each category of HCP, you have:

• 5 types of vaccination status (numerator)

• 1 denominator of HCP counts (denominator)

• When all dates are entered (by May 15, 2013), sum of numerators = denominator for each category

Denominator: Counts of Healthcare Personnel

• Three categories of workers: • Employees: staff on facility payroll • Licensed independent practitioners: physicians,

advance practice nurses, and physician assistants• Adult students/trainees & volunteers

• Time period: present in healthcare facility for at least 30 days between October 1 and March 31

REQUIRED

Denominator: Counts of Healthcare Workers

•Employees: staff on facility payroll

• On the “facility payroll” means payment from the facility; do not include health system employees that receive payments from foundations, universities, or other non-facility payroll accounts.

• When trying to determine if you need to include HCP in your reporting, ask two main questions: (1) how is person paid/or is not paid; and (2) is person physically in the facility for at least 30 days during the reporting period.

REQUIRED

Denominator: Counts of Healthcare Personnel

• Licensed independent practitioners (LIPs): physicians, advance practice nurses, and physician assistants

• LIPs limited to the physicians, advanced practice nurses, and physician assistants.

• Advance practice nurses = nurse practitioners, nurse midwives, clinical nurse specialists, and nurse anesthetists.

• Other types of LIPs reported as “other contract personnel” optional category.

• If LIP receives paycheck from facility or is an owner, count as employee.

• Includes post-residency fellow if not on facility payroll.

REQUIRED

Denominator: Counts of Healthcare Personnel

• Adult students/trainees & volunteers

• Age 18+• Includes medical, nursing, or other health professional

students, interns, medical residents, or volunteers.• Can include clergy, board members, auxiliary member,

“shadower” if present at facility at least 30 days during the reporting period.

REQUIRED

Denominator: Counts of Healthcare Personnel

• Other Contract Personnel

• Persons providing care, treatment, or services at the facility through a contract that do not fall into other HCP categories.

• Appendix A provides a list of potential contracted HCP.• Can include both direct care and non-direct care

providers:• Chaplains, dieticians, occupational therapists, admitting

staff/ registrars, and IT staff.• Personnel in this category may be required reporting in

the future.

OPTIONAL

Numerator: HCP Vaccination Status

• For each category: • number who received vaccination at facility• number who provided written

report/documentation of outside vaccination• number who has a medical contraindication• number that declined• number of unknowns

Numerator: HCP Vaccination Status• number who received vaccination at facility

REQUIRED

• Documentation for vaccination received elsewhere: signed statement/form or email from HCW; note, receipt, vaccination card

• Verbal statements not acceptable

• Influenza vaccination administered at facility

• number who provided written report/documentation of outside vaccination

Numerator: HCP Vaccination Status• number with a medical contraindication

REQUIRED

• Medical contraindication: (1) severe allergic reaction to eggs or other components of the vaccine; or (2) history of Guillain-Barré Syndrome (GBS) within 6 weeks after previous influenza vaccination.

• To make reporting comparable, even if live attenuated influenza vaccine (LAIV) is administered, count only these two conditions as medical contraindication. If refused due to additional contraindication conditions for LAIV, count as “declined.”

• Verbal information acceptable; written documentation is not required.

Numerator: HCP Vaccination Status• number who decline

REQUIRED

• For those with medical contraindication other than (1) severe allergic reaction to eggs or other components of the vaccine or (2) history of Guillain-Barré Syndrome (GBS) within 6 weeks after previous influenza vaccination.

• Declined and did not provide reason.• Declined due to religious exemptions.• Deferred vaccination all season.• number of “unknown”s

• Unknown/unconfirmed vaccination status or did not meet any definition of other numerator categories.

Preparation to Report HCW Influenza Vaccination

1. Initialize Healthcare Personnel Component of NHSN

2. Make sure your Users have access to Healthcare Personnel Section of NHSN

3. Identify how you can collect data

Healthcare Personnel Component

If you do not have this component, follow directions on next slide.

Adding Healthcare Personnel Component

1. Facility Add/Edit Component.

Current User Access to Component

1. Users Find. Leave form blank. Select “Find.”

2. Select name of User.3. Scroll to bottom of page, select

“Edit.”4. Scroll to bottom of page, select

“Edit Rights.”

Depending on the role of the User, make sure these boxes are checked.

Add Employee Health Staff

1. Enter Healthcare Personnel Safety module.

2. Users Add.3. Input all fields with an

asterisk.4. Scroll to bottom and select

Save.

Add Reporting Plan

1. Under Healthcare Personnel Safety Module.2. Only need to enter once (not monthly).

Evaluating Methods to Collect Data• Some health systems have employee training

programs with declination forms (e.g., Providence Health Oregon)

• Use employee record/payroll systems

• Use state vaccine registry (Georgia Registry of Immunization and Services (GRITS))

• May need separate system to collect data for volunteers, LIPs, and contract workers

Healthcare Worker Influenza Vaccination

Den

Num

REQUIRED

Sample Data Form

• Each time updated, will overwrite entry.• Enter cumulative data.• First three categories required.• It will accept sum of numerators < denominator.• Final data due: May 15, 2013.

REQUIRED

Sample Report

Sample Vaccination Compliance Calculation

# Employees vaccinated on site + # Employees vaccinated elsewhere

# Employees working in the required time period

x 100

Employee Vaccination Compliance Percentage =

Line Listing:Percentage of Vaccination Compliance

Org ID summarySeason

Type of summary record

Flu Vacc Subtype

Type of Vaccination

% HCP (excluding other contract pers) vaccinated

% HCP (including other contract pers) vaccinated

% of employees vaccinated

% LIPs vaccinated

% adult students/trainees & volunteers vaccinated

%of other contract personnel vaccinated

% non-employees (excluding other contract personnel) vaccinated

% all non-employees (including other contract personnel) vaccinated

15165 2012/2013 VACCSUMANN

SEASONAL FLU 67% 62% 67% 54% 89% 0.0% 68% 38%

GROUP 1 GROUP 2 GROUP 3

Group 1 = overall vaccination rates (with and without “other contractor”

category)

Group 2 = rates for each category

Group 3 = vaccination rates for non-employees (with and without “other

contractor” category)

Another Thought About Data

Hospital EmployeeNon-Employee,

Credentialed Non-Employee, Other

  Vaccinated Declined Unknown Vaccinated Declined Unknown Vaccinated Declined Unknown

Hospital A 69.7 17.6 13.4 100.0 0.0 0.0 22.0 0.0 78.0

Hospital B 63.8 21.4 14.8 64.6 20.8 16.7 48.1 25.9 25.9

Hospital C 80.9 7.3 11.8 18.9 0.0 81.1 42.4 1.3 56.3

Hospital D 75.0 21.2 3.8 88.9 0.0 11.1 50.0 0.0 50.0

Hospital E 82.0 11.0 7.0 66.7 8.3 25.0 40.3 2.3 57.4

• Optional survey

Survey OPTIONAL

The Immunization Action Coalition (IAC). Site includes the IAC Honor Roll for Patient Safety, which lists facilities that have implemented mandatory healthcare worker influenza vaccination. Resources include clinical resources for administering vaccines, screening for contraindications, and vaccine storage and handling. Includes “Declination of Influenza Vaccination” form.  The Centers for Disease Control and Prevention, Influenza Vaccination Information for Healthcare Workers. Includes influenza vaccination facts, myths and frequently asked questions.NHSN HCP Influenza Vaccination Reporting http://www.cdc.gov/nhsn/hps_Vacc.html

Association for Professionals in Infection Control, Protect Your Patients, Protect Yourself. Materials designed to help facilities promote in-house influenza immunization programs, including Influenza Immunization Program Checklists, sample employee education materials, sample newsletter communication materials, staff e-mail messages, and sample declination forms.

New York State Department of Health, Health Care Personnel/Hospital Influenza Immunization Toolkit. Resources to help healthcare facilities implement effective influenza immunization programs for their staff, including research studies, information on ordering, storing, and handling the vaccines, vaccine administration guidelines, and educational materials.

Selected Resources

Questions?

Jeanne Negley, MBAHAI CoordinatorGeorgia Department of Public Health2 Peachtree Street NW, #14-225Atlanta, GA 30303

Phone: 404-657-2593Fax: 404-657-7517

Email: jenegley@dhr.state.ga.us