overview of the nhsn healthcare worker influenza vaccination module and reporting requirements...
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OVERVIEW OF THE NHSN HEALTHCARE WORKER INFLUENZA VACCINATION MODULE AND REPORTING REQUIREMENTS
September 26, 2012
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Why is influenza vaccination being measured among healthcare personnel?
Influenza can be spread by an ill person one day before to 7 days after onset of symptoms.
Healthcare personnel (HCP) care for, or are in frequent contact with, patients with influenza or at high risk for complications of influenza.
Vaccination can help prevent illness, outbreaks, and death, decrease severity of illness, and avoid losses in productivity.
HCP flu vaccination rates are part of the U.S.’s national health goals: Healthy People 2010: 60% Healthy People 2020: 90%
Data systems can capture facility, state, and regional trends on the yearly uptake of the vaccine.
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Benefits for the facility
Provide a record for flu vaccination and adverse reactions for HCP in the facility
Monitor trends in vaccination and declination rates
Assess efficacy of facility influenza vaccination programs
Meet requirement for record-keeping for adult vaccine administration
Comply with federal reporting requirements
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What are the expectations for reporting?
Mandate of participation in the Centers for Medicare and Medicaid Services (CMS) Hospital Inpatient Quality Reporting (IQR) Program Applies to acute care hospitals Data entered into the National Healthcare
Safety Network (NHSN) http://www.cdc.gov/nhsn/PDFs/HPS-manu
al/Operational-Guidance-HPS-Flu-Vaccination-Sum-Acute-Care.pdf
No state mandate for reporting at this time
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What is expected this year vs. subsequent years?
This flu season (2012-2013) Reporting begins January 1, 2013 (voluntary to report
beginning Oct 1, 2012) and ends March 31, 2013 Data due to NHSN by May 15, 2013 CDC will share all in-plan HCP influenza vaccination summary
data with CMS. A hospital-specific HCP flu vaccination percentage will be provided for each reporting hospital.
Facility can edit data after May 15 but changes will not be sent to CMS. Changes after June 30th of an influenza season may not be used for national reporting by CDC for that season.
Subsequent flu seasons (2013-2014 and on) Reporting mandatory from Oct 1 – Mar 31 (entire reporting
period) Mandatory reporting for long-term acute care hospitals
begins with 2013-2014 season
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What’s new about the current forms and module?
Vaccination Module of the Healthcare Personnel Safety Component in NHSN – revised Sept 2012
Captures summary data, not individual-level data
New protocol, forms, and surveys Healthcare Personnel Safety Monthly Reporting
Plan Form Healthcare Personnel Influenza Vaccination
Summary Form Seasonal Survey on Influenza Vaccination Programs
for Healthcare Personnel (coming soon – Jan 2013)
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Getting started
Enroll facility in NHSN Activate Healthcare Personnel Safety
Component Facility Administrator responsible
On left toolbar, click Facility Add/Edit Components
Check box indicating that the facility will be following the Healthcare Personnel Safety Component
Define the primary contact for this component in “Contact Data” section of the page
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Getting started (cont’d)
Make sure primary contact has administrative rights
To create an NHSN user account: On left toolbar of NHSN, click Users Add Add name, e-mail address and save information “Edit User Rights” screen will pop up next. Check
appropriate boxes to grant rights and click “Save”. If already an NHSN user
On left toolbar of NHSN, click on Users Find Search for person or click “Find” to see all users Click on person’s name and “Edit” to be able to
change his/her rights. Check appropriate boxes and save the changes.
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Getting started (cont’d)
Primary contact for HPS Component ensures staff who will be entering the vaccination data have user rights Primary contact (who has admin rights) can
grant the rights New user will have to agree to NHSN rules
of behavior, then apply for and install a digital certificate before being able to use the system
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Monthly reporting plan form
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Notes about the reporting plan Data must be “in-plan” in order to be
shared with CMS. Once the “Influenza Vaccination Survey”
box is checked on a monthly reporting plan, the NHSN system will auto-check that box on every monthly reporting plan throughout the NHSN-defined influenza season (July 1 – June 30)
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Who are “healthcare personnel”?
All employees on payroll Licensed independent practitioners (who are
physicians, advanced practice nurses, and physician assistants affiliated with the hospital but not on payroll)
Students, trainees, and volunteers Other contract personnel (not mandatory that you
report on vaccination status of these staff) See Appendix A of HCP Vaccination Module: Influenza
Vaccination Summary Protocol Must be aged 18 or older Must physically work in the facility for at least 30 days
between October 1 and March 31 to be counted
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Other notes about classification of HCP
Include all HCP who have worked at the facility for at least 30 working days regardless of clinical responsibility or patient contact.
Working for any number of hours a day counts as one working day.
Include both full-time and part-time persons. Count individuals not full-time equivalents. If someone works in two or more facilities,
each facility should include that person in its denominator.
HCP categories are mutually exclusive – count each HCP only once.
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Denominator: number of HCP
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Vaccination status categories
Vaccinated at healthcare facility Vaccinated outside healthcare facility (need
written report or documentation) A signed statement or form, or an
electronic form or e-mail from a healthcare worker (HCW) indicating when and where he/she received the influenza vaccine
A note, receipt, vaccination card, etc. from the outside vaccinating entity stating that the HCW received the influenza vaccine at that location
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Vaccination status categories (cont’d)
Medical contraindication Severe allergic reaction to eggs or other vaccine
components History of Guillain-Barré Syndrome within 6 weeks after a
previous flu vaccination HCP can provide written or verbal documentation of
medical contraindications Declined vaccine (includes religious exemptions,
other medical conditions) HCP can provide verbal or written declination of the
vaccine Unknown vaccination status (or criteria not met for
categories above)
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Numerator: vaccination status
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Reporting
HCP influenza summary reporting consists of a single data entry screen per influenza season.
NHSN defines a flu season as July 1 – June 30. Data covering the entire reporting period (Oct 1 – Mar 31)
must be entered once into NHSN for each reporting year. The data can be entered on a monthly and/or quarterly basis, but
only cumulative data should be entered. Note: any new data will overwrite the previous data. The
system will auto-fill “date last modified”. Message confirming that data were saved will appear at the
top of the screen. Remember, these are summary data and reflect the overall
vaccination status of HCP in your facility for the entire flu season to date.
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Analysis
Not covered in-depth during this webinar CDC training materials do have some
screenshots and sample reports From left toolbar: Analysis Output Options
HCW Vaccination Module Influenza CDC Defined Output Examples of analyses: Number of HCP
Vaccinated, Number of HCP Working During the Required Time Period, Percentage of Vaccination Compliance, Percentage of Vaccination Non-Compliance
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How will these data be publicly reported?
HCP influenza vaccination rates will not be publicly reported for the 2012-2013 season.
Beginning with 2013-2014 season, facility-specific HCP influenza vaccination rates are projected to be posted on the Hospital Compare website.
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Where can I get more information? NHSN Vaccination Module page:
http://www.cdc.gov/nhsn/hps_vacc.html Protocol:
http://www.cdc.gov/nhsn/PDFs/HPS-manual/HPS-protocol-Vaccination-Mod-Influenza-Vaccination-Summary.pdf
FAQs: http://www.cdc.gov/nhsn/faqs/FAQ-Influenza-Vaccination-Summary-Reporting.html
Operational guidance for complying with CMS reporting requirements: http://www.cdc.gov/nhsn/PDFs/HPS-manual/Operational-Guidance-HPS-Flu-Vaccination-Sum-Acute-Care.pdf
[email protected] include “HPS Flu Summary” in the subject line of the e-mail
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NHSN training
http://www.cdc.gov/nhsn/Training/healthcare-personnel-safety/index.html Two slidesets – one on overview of HPS
Component, one on overview of vaccination module
CDC webinars offered 10/3 (12-1PM), 10/11 (2-3PM). Registration is full; however, will be
archived and available soon afterward: http://www2.cdc.gov/vaccines/ed/nhsn
Covers data entry and analysis
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Andrea AlvarezVirginia Department of HealthHealthcare-Associated Infections Program [email protected]
Questions?