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Kentucky Hospital Improvement Innovation Network

Data Webinar

Agenda 1. HIIN Core and Additional Topics 2. Baseline Data 3. Monitoring Data 4. NHSN 5. Upcoming Data Webinars

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HIIN Core and Additional Topics

1. Adverse Drug Events (ADE) 2. Catheter Associated Urinary

Tract Infection (CAUTI) 3. Central Line Associated Blood

Stream Infection (CLABSI) 4. Clostridium difficile (c-diff) 5. Falls 6. Pressure Ulcer (HAPU) 7. Readmissions

8. Sepsis 9. Surgical Site Infection (SSI) 10. Venous Thromboembolism

(VTE) 11. Ventilator-Associated Events

(VAE) Additional Required Topics 1. Methicillin-resistant

Staphylococcus aureus (MRSA)

2. Culture of Safety – Worker Safety

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Core Measures By Topic

• ADE – three measures –Excessive Anticoagulation –Hypoglycemia in Inpatients Receiving

Insulin –Adverse Drug Events due to Opioids

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Excessive Anticoagulation due to Warfarin

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Hypoglycemia ADE

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ADE due to Opioids

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www.k-hen.com

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Emily C Henderson, PharmD, LDE ehenderson@kyha.com

502-426-6220

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CAUTI and CLABSI

• CAUTI and CLABSI –six measures each as applicable –SIR – ICU Only and All Tracked Units

–Rate – ICU Only and All Tracked Units

–Utilization Ratio – ICU Only and All Tracked Units

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CAUTI/CLABSI Applicability

• SIR – ICU Only and All Tracked Units—Applicable ONLY to facilities that report to NHSN and confer rights to KHA Quality Group

• CAUTI Rate/Utilization Ratio—Applicable to ALL facilities

• CLABSI Rate/Utilization Ratio—Applicable to all facilities that place and/or manage Central Lines

• ICU Rate/Utilization Ratio—Applicable to facilities that have one or more Intensive Care Units

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CAUTI/CLABSI Rate – All Tracked Units

• All Tracked Units—ICUs (excluding NICUs) + Other Inpatient Unit –Numerator— Total number of observed

healthcare-associated CAUTI or CLABSI among patients in bedded inpatient care locations

–Denominator—Total number of device (indwelling urinary catheter or central line) days for bedded inpatient care locations under surveillance

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CAUTI/CLABSI Rate ICUs

• ICUs Only –excluding NICUs –Numerator—Total number of observed

healthcare-associated CAUTI or CLABSI among patients in ICU care locations

–Denominator— Total number of device (indwelling urinary catheter or Central Line) days for ICU units under surveillance for the period

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• All Tracked Units—ICUs (excluding NICUs) + Other Inpatient Unit –Numerator—Total number of device

(indwelling urinary catheter or central line) days for bedded inpatient care locations under surveillance (equals the Rate denominator)

–Denominator— Total number of patient days for bedded inpatient care locations under surveillance

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CAUTI/CLABSI Utilization Ratio - All Tracked Units

• ICUs Only –excluding NICUs –Numerator—Total number of device

(indwelling urinary catheter or Central Line) days for ICU units under surveillance for the period (equals the Rate denominator)

–Denominator— Total number of patient days for ICU units under surveillance for the period

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CAUTI/CLABSI Utilization Ratio – ICU Units

CAUTI/ CLABSI Data Sources

• NHSN • Lab-Microbiology • Direct care givers • Electronic Health Records

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Clostridium difficile

• Two measures –SIR – applicable ONLY to facilities reporting to

NHSN that have conferred rights –Rate – applicable to ALL facilities

• Numerator – Total number of observed hospital onset C. difficile lab identified events among all inpatients in the facility, excluding well-baby nurseries and NICUs

• Denominator – Patient days (facility-wide)

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CDC NHSN Guidelines

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NHSN Resources

• CAUTI CDC NHSN • CLABSI CDC NHSN • C. difficile and MRSA CDC NHSN • Surgical Site Infection CDC NHSN

–Link on page 1 to a spreadsheet that lists ICD 10 codes for each procedure

• VAE CDC NHSN (VAC and IVAC)

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Falls With Injury (Minor or Greater)

• Numerator - Total number of patient falls of injury level minor or greater (whether or not assisted by a staff member) by eligible hospital unit during the measurement period

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Classification Description

None Patient had no injuries (no signs or symptoms) resulting from the fall

Minor Resulted in application of a dressing, ice, cleaning of a wound, limb elevation, topical medication, pain, bruise, or abrasion

Moderate Resulted in suturing, application of steri-strips/skin glue, splinting or muscle/joint strain

Major Resulted in surgery, casting, traction, required consultation for neurological or internal injury or patients with coagulopathy who receive blood products as a result of the fall

Death Patient died as a result of injuries sustained from the fall (not from the physiologic events causing the fall)

NQF# 0202

Falls with Injury (Minor or Greater)

• Denominator - Patient days in eligible units during the measurement period – Included populations – Inpatients, short stay patients,

observation patients and same day surgery patients who receive care on eligible inpatient units for all or part of a day • Adult critical care, step-down, medical, surgical, medical-

surgical combined, critical access and adult rehabilitation inpatient units.

• Patients of any age on an eligible reporting unit are included in the patient day count

– Excluded populations – Other unit types (e.g. pediatric, psychiatric, obstetrical etc.)

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NQF# 0202

Falls With Injury Data Sources

• Surveillance systems • Medical records • Billing systems

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Hospital Acquired Pressure Ulcer/Injury

• Two Measures –Prevalence – Stage II and greater

• Applies to ALL facilities • Must be reported monthly

–Rate – Stage III and greater (AHRQ PSI 2) • May not apply to Critical Access Hospitals because

of length of stay exclusions • KHA uses claims based facility data AHRQ

specifications to obtain this data

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HAPU Prevalence

• Numerator – Patients that have at least one category/stage II or greater hospital-acquired pressure ulcer on the day of the prevalence measurement episode

• Denominator – All patients surveyed for the measurement period – Excluded populations – Patients who

• Refuse to be assessed • Are off the unit at the time of the prevalence measurement • Are medically unstable at the time of the measurement for whom

assessment would be contraindicated at the time of the measures (i.e. unstable blood pressure, uncontrolled pain, or fracture waiting repair)

• Are actively dying and pressure ulcer prevention is no longer a treatment goal

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NQF# 0201

HAPU Prevalence Data Sources

• Ideal (Best) – physical point prevalence surveillance • Acceptable**

– Incident reporting – Medical records – Hospital discharge or administrative data

**Denominator – hospital admissions or discharges for the review period

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Readmissions Hospital Wide/All Payor

• Hospital-wide 30-day all cause readmissions • Numerator – Unplanned inpatient admissions

returning as an acute care inpatient to the same facility within 30 days of date of discharge of the index admission –NOTE: you count the number of patients who are

readmitted within 30 days—not the number of readmissions

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Readmissions Hospital Wide/All Payor

• Denominator – Inpatient discharges – Included populations – patients equal to or greater than

18 years old – Excluded populations – Patient discharge status codes

or primary admitting diagnosis as follows: • Expired (UB04 Code: 20) • Transferred to another acute care facility (UB04 Codes: 02, 05,

43, 66) • Transferred to a rehab facility (UB04 Code: 62) • Patients discharged AMA (UB04 Code: 07) • Patients with medical treatment of cancer • Patients for primary psychiatric disease • Rehabilitation care; fitting of prosthesis and adjustment devices

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Readmissions Hospital Wide/Medicare

• Measure is a subset of the All Payor measure

• Specifications are the same except it applies only to Medicare patients

• Collect your data for All Payors first, then filter on only Medicare patients

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Sepsis

Three Measures 1. Postoperative Sepsis (AHRQ PSI-13)

–Not applicable to facilities that do not perform inpatient surgery

–KHA uses claims based facility data AHRQ specifications to obtain this data

–Post operative sepsis cases (secondary diagnosis) per 1,000 elective surgical discharges for patients 18 years and older

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Sepsis

2. Hospital-Onset Sepsis Mortality Rate –KHA uses claims based facility data –Numerator – Number of in-hospital deaths due to

severe sepsis and septic shock (Diagnosis codes defined in AHRQ PSI-13)

–Denominator – Number of patients with hospital-onset severe sepsis/septic shock. Hospital onset is an infection that is not present on admission

–Rate/1,000 discharges

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Sepsis

3. Overall Sepsis Mortality Rate –KHA uses claims based facility data –Numerator – Number of in-hospital deaths

due to severe sepsis and septic shock (Diagnosis codes defined in AHRQ PSI-13)

–Denominator – Number of patients with severe sepsis/septic shock

–Rate/1,000 discharges

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Surgical Site Infection

• Surgical Site infection SIR and Rate • Four Inpatient Procedures (if performed at your

facility) – Colon surgery – Abdominal Hysterectomy – Total Hip Replacement (voluntary NHSN reporting) – Total Knee Replacement (voluntary NHSN reporting)

• SIR – Applicable if reporting to NHSN and conferred rights

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SSI Data Sources

• Surveillance period is 30 days post procedure • Lab • Emergency Department encounters • Surgeons office • NHSN

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Venous ThromboEmbolism

• Post-Operative pulmonary embolism (PE) or Deep Vein Thrombosis (DVT) rate AHRQ PSI-12 – Specific to surgical discharges – Not applicable for facilities that do not do inpatient

surgery

– KHA uses claims based facility data AHRQ specifications to obtain this data

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Ventilator Associated Events (VAE)

• Applicable to facilities that manage care for mechanically ventilated inpatients meeting ALL of the following criteria 1. Provide care to at least one patient per month that is 2. In an inpatient unit and is 3. Patient is mechanically ventilated for at least 2 or

more consecutive days (48 hours)

• Not required NHSN reportable – Must indicate to KHA how facility will report – NHSN

vs. KQC 39

VAE VAC

• Ventilator Associated Condition (VAC) – Numerator - Number of events that meet the criteria

of VAC; including those that meet the criteria for infection-related ventilator-associated complication (IVAC) and possible/probable ventilator-associated pneumonia (VAP)

– Denominator – number of ventilator days

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VAE IVAC

• Infection-Related Ventilator-Associated Complication (IVAC) – Numerator - Number of events that meet the criteria

of infection-related ventilator-associated condition (IVAC); including those that meet the criteria for Possible/Probable VAP

– Denominator – number of ventilator days

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VAE Sources

• Direct care givers – nurses, respiratory therapists • NHSN

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Data Sources

Core Topic Site NHSN AHRQ ADE CAUTI CLABSI C. diff Falls Pressure Ulcer (Prevalence) (Rate) Readmissions Sepsis SSI * VTE VAE *

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Data Sources

Additional Topics Site NHSN AHRQ

MRSA Culture of Safety – Worker Safety*

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*Worker Safety measures are already collected on the OSHA Log

MRSA

• Hospital onset MRSA bacteremia events – Numerator – MRSA bacteremia events – Denominator – Patient days

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Culture of Safety - Worker Safety

• Harm events related to patient handling – Numerator – Number of worker harm events related

to patient handling for the time period – Denominator – Number of full-time equivalents (FTEs)

for the time period

• Harm events related to workplace violence – Numerator – Number of worker harm events related

to workplace violence for the time period – Denominator – Number of full-time equivalents (FTEs)

for the time period

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Worker Safety Data Sources

• Numerators – obtain from the OSHA 300 log – Recordable injuries include

• Death • Loss of consciousness • Days away from work • Restricted work activity or job transfer or • Medical treatment beyond first aid

• Denominator – obtain from Human Resources

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OSHA 300 Log

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Baseline Periods

Preferred Baseline Periods • Calendar year 2014 except:

– SIRs – Calendar year 2015 – to be collected after the NHSN rebaseline is completed in Dec 2016

– CAUTI & CLABSI – Calendar year 2015

Alternate Baseline Periods • Oldest 12, 9, 6, or 3 month consecutive period prior to

Oct 2016

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Baseline Periods

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Data Submission

• MONTHLY – Beginning Oct 2016 – Site collected data will be entered into the KQC system

by the hospital – Site collected measures specific to your hospital will

show up on your KQC data entry page

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KY Quality Counts Data Collection System

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https://khaqualitydata.org

KY Quality Counts Data Collection System

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• NHSN Website • Updated January 2017 • Changes in reporting go into effect with the entry of January 2017

data • NHSN Annual Training – March 20 – 24, 2017

– In-Person (limited attendees) – Live Webinar

• K-HIIN NHSN Training Session – April 2017 Webinar

– New to NHSN to address HIIN specific data entry issues/questions

Questions regarding NHSN Deb Campbell, RN-BC, MSN, CPHQ Infection Prevention Improvement Advisor 502-992-4383 dcampbell@kyha.com

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• Upcoming Data Webinars: – NHSN Training Session

• April 2017 – Improvement Calculator

• Harm Across the Board Reports –May 2017

– Data Webinar –June 2017

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Questions

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