NHSN Reporting for Laboratory-identified Clostridium difficile Infection (CDI) and

Methicillin-resistant Staphylococcus aureus (MRSA) (Bacteremia)

Presentation to: Georgia Hospital AssociationPresented by: Jeanne Negley, MBA,Healthcare Associated Infection Coordinator Date: November 15, 2012

AGENDABackground: Purpose, Requirements, & ReferencesStarting with Reporting Plans and DenominatorsMRSA Bacteremia Lab ID Event (Numerator)CDI Lab ID Event (Numerator)Using Electronic Reporting SystemsLab ID Event Reporting Categories(includes risk adjustment)Frequently Asked QuestionsAnnouncements!

Purpose of MDRO and CDI Lab ID Event Reporting

• To calculate proxy measures of MDRO and CDI events, exposures, and healthcare acquisition.

• Provide a monitoring method that enables a facility to rely almost exclusively on data obtained from the laboratory.

• Also provide a mechanism for facilities to report and analyze MDRO and CDI data to inform infection control staff of impact of targeted prevention efforts.

CMS Reporting RequirementsLaboratory-Identified (Lab-ID) MRSA

(bacteremia) and CDI in NHSN

Begins January 2013 for Inpatient Quality Reporting Program for hospitals

Overall Facility-Wide Inpatient (LabID, Method C)

Laboratory-Identified (Lab-ID) module Not an infection event surveillance module Lab-ID is a laboratory driven surveillance

process

We are not following CDI infection event surveillance module

LAB ID MDRO/CDI Reporting References

NHSN MDRO/CDI Module: http://www.cdc.gov/nhsn/mdro_cdad.html

MDRO/CDI NHSN Protocol: http://www.cdc.gov/nhsn/PDFs/pscManual/12pscMDRO_CDADcurrent.pdfCDC Location Labels and Location Descriptions: http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdfTable of Instructions: (Make sure you review instructions for Lab ID for MRSA and CDI.) http://www.cdc.gov/nhsn/PDFs/pscManual/14pscForm_Instructions_current.pdf

NHSN definitions can change; consult on-line references.

Reporting FormsEnter Online. Hardcopy Paper Forms Available.

(http://www.cdc.gov/nhsn/mdro_cdad.html)

1. Monthly Reporting Plan

2. Laboratory-Identified MDRO/CDAD Event Form

• This is the numerator: one form per LabID event

3. MDRO and CDAD Prevention Process and Outcome Measures Monthly Monitoring Form

• This is the denominator: Inpatient – total patient days, admissions

Starting with Reporting Plans and Denominators

• Input Monthly Reporting PlansRecommend input for entire yearIncorrect /incomplete reporting plans affect

reporting to CMS

• Map all inpatient locationsBoth Lab ID MRSA (blood only) and CDI

(stool) are for entire facility (all locations)

Patient Safety Monthly Reporting PlanReporting PlanAdd. Input Month and Year.

Scroll down page.

Reporting Plan (Cont.)1

2

3

4

5

6

1. Input “FacWideIn” for MRSA. 2. Check Lab ID Event Blood Specimen Only3. Add Row to input CDI plan4. Input “FacWideIn” for CDI5. Check Lab ID Event All Specimens for CDI6. Select “Copy from Previous Month” to input multiple reporting plans.

Summary Data RequirementsMRSA Blood Cultures:FacWideIn = Total inpatient admissions and total inpatient days for the month.

CDI:FacWideIn = Total inpatient admissions and total inpatient days minus admission/pt days accrued in a NICU or well baby nursery.

MRSA Overall Facility-Wide InpatientPatient Days = 2950, Admissions = 300

SICU

MICU Wards

Pediatric ICU and Wards

Reference: CDC location list

Well Baby Nurseries & NICUs

CDI Overall Facility-Wide Inpatient

ExcludeWell Baby

Nursery& NICU

Exclude well baby nurseries & NICUs. Include maternity patients and newborn readmitted to pediatricunit.

Patient Days = 2600, Admissions = 250

SICU

MICU Wards

Pediatric ICU and Wards

Reference: CDC location list

Locations not included in Facility-Wide Inpatient

Do NOT include:

• Emergency Department• Observation Units (<24 hour stay)• Outpatient Surgery• Outpatient Radiology• Outpatient Chemotherapy/Infusion

Service

ADDITIONAL RULES:

Emergency Department: If ED pt is admitted as inpatient and lab collected same day as admit, you can report result. Applies to any outpatient location.

Observation Bed Patients in Inpatient Setting: These patients are counted as inpatients.

• Outpatient Dialysis • Operating Rooms• Clinics• Outpatient lab results

Inputting Denominator Data (1 of 2)Summary DataAdd. Select “MDRO and CDI Prevention Process and Outcome Measure Monthly Monitoring.

Input denominator data every month; even if you do not have infection events.

Inputting Denominator Data (2 of 2)

For MRSA

For CDI

MRSA Bacteremia Events(Numerator)

MRSA DefinitionsMRSA: S. aureus testing oxacillin-resistant, cefoxitin resistant, or methicillin-resistant by standardsusceptibility testing methods, or by a laboratory testthat is FDA-approved for MRSA detection from isolatedcolonies

MRSA Isolate: Specimen obtained for clinicaldecision making that tests positive for MRSA Active surveillance testing specimens (e.g., nasal

screen) do not count as clinical specimensMUST have a method to differentiate clinical vs.

surveillance cultures (speak with lab)

MRSA Definitions—Blood Culture OnlyMRSA Blood Isolate LabID Event: All non-duplicate MRSA blood isolates

Duplicate MRSA Blood Isolate: MRSA+ blood culture from the same patient and location, following a previous positive MRSA-positive blood culture within the past 2 weeks (14 days) There should be a full 14 days with no MRSA-

positive blood culture for the patient and location before another blood isolate LabID event is entered into NHSN for that patient

Identifying a Lab ID MRSA Event

(+) MRSA blood culture test result (taken for

clinical purposes)

Prior (+) in< 2

weeks?

Lab ID Event Duplicate MRSA Test

Not a Lab ID Event

No Yes

MRSA Event Example (1 of 3)

As part of the data review, Betty Brown (infection preventionist) identifies new MRSA Lab Events (blood cultures only). For example, Ms. Doe has 5 blood samples reported (+) for MRSA. Applying the 14-day rule, only 3 of the 5 samples will be reported.

MRNLast

NameFirst

Name DOB

Date Admitted to Facility

Date admitted

to unit UnitSpecimen

Type

Date of Specimen Collection

Organ-ism

987654 Doe Jane 11/3/1967 1/20/2009 1/20/2009 1MICU BLOOD 2/7/2009 MRSA987655 Doe Jane 11/3/1967 1/20/2009 1/20/2009 1MICU BLOOD 2/9/2009 MRSA987656 Doe Jane 11/3/1967 1/20/2009 1/20/2009 1MICU BLOOD 2/27/2009 MRSA987657 Doe Jane 11/3/1967 1/20/2009 1/20/2009 1MICU BLOOD 3/5/2009 MRSA987658 Doe Jane 11/3/1967 1/20/2009 1/20/2009 1MICU BLOOD 3/24/2009 MRSA

MRSA Event Example (2 of 3)Betty proceeds to complete a Lab ID MDRO or CDI event for each of the three unique events.

EventAdd.

MRSA Event Example (3 of 3)

Save.

Auto-fill

Location = where specimen collected

Always the same

Always the same

If pt. d/c in past 3 months, input yes and d/c date.

Lab ID Event CDI(Numerator)

DefinitionsLaboratory-Identified (Lab-ID) CDI event: Any

non-duplicate CDI-positive assay on unformed stool.

CDI-positive Lab Assay: Positive lab assay for C. difficile toxin A and/or B, or toxin-producing organism detected from stool culture or other lab means.

Duplicate C. difficile-positive test: CDI-positive assay from same patient within 2 weeks of previous positive assay.

Identifying a Lab ID CDI Event(+) C. difficile test result

(on unformed stool)

Prior (+) in< 2

weeks?

Lab ID Event Duplicate C. difficile Test

Not a Lab ID Event

No Yes

CDI Event Example (1 of 3)

As part of the data review, Betty Brown identifies new cases of C. diff. Applying the 14-day rule, only the first of the 2 (+) stool specimens will be reported as a LabID event.

MRNLast

NameFirst

Name DOB

Date Admitted to Facility

Date admitted

to unit UnitSpecimen

Type

Date of Specimen Collection

Organ-ism

754321Pan Peter 5/6/1975 2/2/2009 2/2/20091 MICU STOOL 2/2/2009C. Difficile

754321Pan Peter 5/6/1975 2/2/2009 2/2/20091 MICU STOOL 2/7/2009C. Difficile

CDI Event Example (2 of 3)

Auto-fill

EventAdd

CDI Event Example (3 of 3)

Auto-fill

Auto-fill

Always the same

Always the same

Always the same

Auto-fill

Save.

Location = where specimen collected

If pt. d/c in past 3 months, input yes and d/c date.

Lab ID Event Categories

You do not

have to

calculate

these rates.

NHSN will do

this for you!

LabID Events Categorized through NHSN Calculations as

• Incident CDI Assay: new cases (specimen obtained >8 weeks after the most recent LabID Event).

• Recurrent CDI Assay: CDI LabID Event from specimen obtained > 2 weeks and < 8 weeks after the most recent LabID Event.

CDI Only

LabID Events Categorized through NHSN Calculations as

1) Healthcare Facility-Onset (HO): LabID Event from specimen collected >3 days after admission to the facility (= on or after day 4)

CO*

Discharge

IndeterminateCO-HCFA

< 4 weeks 4-12 weeks >12 weeks

CO

Admission

2 d

Day 1 Day 4HO

* Depending upon whether patient was discharged within previous 4 weeks, CO-HCFA vs. CO (CDI only)

LabID Events Categorized through NHSN Calculations as

2) Community-Onset (CO): LabID Event from specimen collected from an outpatient or inpatient ≤ 3 days after admission to the facility (Day 1, 2 or 3 with date of admission as Day 1)

CO*

Discharge

IndeterminateCO-HCFA

< 4 weeks 4-12 weeks >12 weeks

CO

Admission

2 d

Day 1 Day 4HO

* Depending upon whether patient was discharged within previous 4 weeks, CO-HCFA vs. CO (CDI Only)

LabID Events Categorized through NHSN Calculations as

3) CO Healthcare Facility-Associated (CO-HCFA): CO LabID Event collected from a patient who was discharged from this facility ≤ 4 weeks prior to stool collection

CO*

* Depending upon whether patient was discharged within previous 4 weeks, CO-HCFA vs. CO

Discharge

IndeterminateCO-HCFA

< 4 weeks 4-12 weeks >12 weeks

CO

Admission

2 d

Day 1 Day 4HO

CDI Only

Facility Healthcare Facility-Onset Incidence for Lab ID Event

# of all Incident HO LabID Events per month in the facility

# of patient days for the facility X 10,000 for CDI

Note: There are several prevalence and other incident metrics not included in this presentation.

X 1,000 for MRSAor

MRSA Blood Lab ID FacWideIn Risk Adjustment Variables

Factor DescriptionFacility Bed Size < 400, >400

Teaching Type Major Teaching vs. All Other

Prevalence Rate Continuous

CDI Lab ID FacWideIn Risk Adjustment Variables

Factor DescriptionCDI Test Type NAAT (PCR), EIA, Non-

NAAT(PCR)/EIA Others

Prevalence Rate Continuous (No CO-HCFA)

Facility Bed Size < 100, 101-245, >245Teaching Type Major, Graduate,

Limited/Non-Teaching

Using Electronic Surveillance Systems (1 of 3)

• Use a positive culture listing; not HAI listing.• Emergency Department: may need to designate as

“Inpatient & Outpatient” location.• Watch for duplicates (within the same month or month to

month).• Once you retrieve data, you can manually enter into NHSN

or prepare to upload electronically.

• Includes data mining software (MedMined, Safety Surveiller, Theradoc, etc.).

Validating Electronic Data (2 of 3)

VALIDATE your Electronic Reporting System• Compare your electronic IC system totals for patient days and

admissions against alternate source, like a financial report, using NHSN definitions.

• Does your system count each transfer between units during same admission as a new admission?

• Does your system count only the Mom or both Mom & Baby (for CDI)? • Does your system count a patient as discharged from your facility

within the last 3 months if they were in for outpatient Lab work last week, but had no inpatient admission/discharge for over a year?

Validating Electronic Data (3 of 3)

Before submitting your data:

Confirm your Positive Culture List against selected patients for download.• If they don’t match, you may need to manually

add or delete cases.

Verify report is complete and fix any issues found during validation • For example, discharged from facility within

last 3 months

FAQ (1)1) What is the most important action to prepare to

report Lab-ID MRSA and CDI?

Obtain a listing of MRSA (bacteremia) and CDI from your laboratory. Smaller hospitals that have fewer events can request a list of organisms. This is the best method to know that your data are correct; it is not recommended that you rely on reports to the Infection Prevention team.

Sample Spreadsheet for Lab Line ListDirections to Use Lab Line List

FAQ (2)2) What if a smaller hospital admits a pt to a

larger hospital in the same health system, and this pt has a positive CDI assay from the smaller hospital?

You can report the positive lab if the admission to the new location is on the same day the specimen was collected. This applies to transfers from any other facility or outpatient location.

FAQ (3)3) If we have a number of admits for each unit, would

you count a transfer from one unit to another as an admit?

No. Facility-Wide Inpatient Admission Count: Include any new patients that are assigned to a bed in any inpatient location within the facility at the time of the facility-wide admission count. Qualification as a new patient means that the patient was not present on the previous calendar day at the time of the patient day count. The daily admission counts are summed at the end of the calendar month for a monthly facility-wide inpatient admission count.http://www.cdc.gov/nhsn/PDFs/PatientDay_SumData_Guide.pdf

FAQ (4)4) What if I have a patient that completed his stay at my hospital and then a week later as an outpatient had a specimen drawn that was positive for CDI?

We are reporting Lab ID CDI or MRSA for facility-wide inpatient (FacWideIn). Inpatient and outpatient reporting for Lab ID CDI cannot be mixed. Therefore, you do not include outpatient specimens in your reporting for FacWideIn. (You may include this data in your internal reporting system, but do not input into NHSN.)

FAQ (5)5) When counting patient days and admissions, do we include “observation” patients?

As long as a patient is on an outpatientobservation unit, you would not count theobservation days as patient days. The date ofadmission will be the date of admission to aninpatient unit. However, if an observation patient islocated on an inpatient unit (like a medical ward),you would count the observation days as patientdays, with the date of admission being the date ofadmission to the inpatient unit.

FAQ (6)6) A patient had a MRSA-positive blood cultureobtained in the ED and was admitted to an inpatientunit on the same day. How do I report this LabIDevent?

If the date of specimen collection in the ED and the date of admission to the inpatient unit are the same calendar date, report the LabID event for the ED and the inpatient unit. If the patient was admitted to the inpatient unit on a later date, you report the event for the ED only.

FAQ (7)7) My facility has a rehab unit with a different CMSCertification Number than the rest of the facility.Should this unit be included in LabID surveillance?

If a unit is considered a part of the facility (not just sharing walls) and there is potential for patient and staff contact across units, the unit should be included in FacWideIN LabID surveillance.

FAQ (8)8) As a follow-up to the previous question, my facility discharges patients before counting them as new admissions to the rehab unit. If I include rehabadmissions in my monthly FacWideIN summarydata, patients who went from the hospital to therehab unit will be counted twice. What should I do? We don’t want to double-count admissions. If it’s not possible to distinguish between patients who arrived from the facility and those who arrived from elsewhere, exclude rehab admissions in your FacWideIN counts. Continue to include rehab patients in patient-day counts.

Announcement 1CDC expects to release version 7.1 of NHSN on February 16, 2013.

New release will include updated protocol (e.g., present on admission, etc.)

We suggest you wait until new release before entering 2013 data.

Announcement 2

Get Smart About Antibiotics Week (November 12-18, 2012).

Tools for your antibiotic stewardship program: http://www.cdc.gov/getsmart/healthcare/

Get CME/CE on antibiotic stewardship: http://www.cdc.gov/getsmart/healthcare/learn-from-others/CME/antimicrobial-resistance.html#Stewardship

AcknowledgementsMatthew Crist, MD, MPHGeorgia Department of Public Health

Brynn Berger, MPH, CICTennessee Department of Public Health

Dawn Sievert, PhD, MSCenters for Disease Control and PreventionDivision of Healthcare Quality Promotion

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