NHSN Data Submission Requirements 2013Health Care Excel

Cathie Pritchard LPN, RHITQuality Data Reporting Technologist

October 12, 2012

Important Dates

Data must be submitted monthly (within 30 days of the end of the month which is collected).

For data to be shared with Centers for Medicare & Medicaid Services (CMS), each quarter’s data must be entered into NHSN no later than 4 ½ months after the end of the quarter.• e.g. Q1 ( January-March) data must be entered into

NHSN by August 15; Q2 by November 15; Q 3 by February 15 and Q4 by May 15.

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Reminder!

Hospital Inpatient Quality Reporting Program HAI Requirements

January 2011• CLABSI data from adult, pediatric, and neonatal intensive care

units January 2012

• CAUTI from adult and pediatric intensive care units• SSI from inpatient colon and abdominal hysterectomy

procedures January 2013

• Methicillin Resistant Staphylococcus Aureus(MRSA) Bacteremia• Clostridium Difficile (C.Diff)• Healthcare Personnel Influenza Vaccination

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Health Care Facility HAI Reporting to CMS via NHSN—Current and Proposed RequirementsDRAFT (11/23/2011)

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CMS Reporting RequirementsLabID Event for FacWideIN

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Facility-wide InpatientFacWideIN

Includes all inpatient locations,including observation patientshoused in an inpatient location

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CMS 2013What Data Will NHSN Report to CMS?

MRSA Blood and C. difficile HealthcareFacility-Onset (HO) LabID Events

CDI: All non-duplicate, non-recurrent LabID Event specimens collected > 3 days after admission to the facility

MRSA Blood: All non-duplicate, LabID Event specimens collected >3 days afteradmission to the facility

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CMS 2013MRSA Bacteremia LabID Event

Organism: Methicillin-Resistant Staphylococcus aureus (MRSA)

Data Collection: CDC NHSN - MDRO/CDI Module Required Locations

• All inpatient locations (=FacWideIN) for LabID Events

Required Data• Community-Onset (CO) and Healthcare-Onset (HO) Event• MRSA blood specimens at the facility-wide inpatient level

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CMS 2013C. difficile LabID Event

Organism: Clostridium difficile (C. diff ) Data Collection: CDC NHSN - MDRO/CDI Module (LabID Event) Required Locations: All inpatient locations at Facility-wide Inpatient

level (FacWideIN) minus NICU, SCN, or other Well Baby locations (e.g. Nurseries, babies in LDRP)

Required Data• Community-Onset (CO) and Healthcare-Onset (HO) Events• All C. difficile LabID Events on unformed stool specimens at the

facility-wide Inpatient level

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Validation Process

Combines random and targeted sampling approach

• Abstract CLABSI data for candidate CLABSI medical records

• Abstract CLABSI data for all currently requested quarterly medical records being validated for other topics:- Acute Myocardial Infarction (AMI), Heart Failure (HF),

Pneumonia (PN), Surgical Care Improvement Project (SCIP), Emergency Departments (ED) / Immunization (IMM)

• If your hospital is being validated for core measures, you also are being validated for CLABSI

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Validation Process (Continued)

Basics• ICU patients• Positive blood culture results

Complete the positive blood culture template Selection is a two-step process

• Step one—Identify candidate CLABSI patients• Step two—Randomly sample up to three candidate

CLABSI patients from the template

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Validation Process (Continued)

Positive blood culture templates are due quarterly, 15 days prior to clinical submission deadlines• November 15, 2012• February 15, 2013• May 15, 2013

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Training on how to complete the blood culture temple .

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Validation Process (Continued)

Validation process will continue as additional HAI measures are added

CAUTI and SSI data will be validated next (final rule page 1138)

New measures will be added starting with 1st quarter 2013 (final rule page 1114)

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Submitting the Blood Culture Template

Submitted using My QualityNet Secure File Exchange

Infection Preventionists should work with Quality staff who have a QualityNet Account

Validation for hospitals selected for FY 2014 continues through 3rd Quarter 2012

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Questions?

Cathie Pritchard, LPN, RHIT

cpritchard@inqio.sdps.org

812-234-1499, extension 229

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This material was prepared by Health Care Excel, the Medicare Quality Improvement Organization for Indiana, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-IN-INDPAT-12-017 08/30/2012