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Whats New?
2016 NHSN Surveillance Definition Updates
Health Services Advisory Group, Inc.
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Whats New?A Review of National Healthcare Safety
Network (NHSN) Surveillance Definitions
Renee Rush, RN, BSN, Infection Prevention Quality Improvement
Specialist
May 11, 2016
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Whats New?
2016 NHSN Surveillance Definition Updates
Health Services Advisory Group, Inc.
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Todays Presenters
Christine Martini-BaileyRN, BSN, CSSGB
Associate Director, California/Ohio
[email protected]
614.307.2936
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Charlie ChapinMS, CHCA
Director, Arizona
[email protected]
602.801.6940
Renee RushRN, BSN
Infection Prevention Quality Improvement Specialist
[email protected]
NHSN Surveillance Definitions
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Whats New?
2016 NHSN Surveillance Definition Updates
Health Services Advisory Group, Inc.
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Objectives
Relate the changes in the NHSN surveillancedefinitions for
2016.
Utilize the definitions to accurately measureand report select
healthcare-associatedinfections (HAIs).
Discuss impacts of changes.
Quality improvement initiatives
Pay-for-performance programs
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General Surveillance Review
Key Concepts Seven-day infection window period (IWP): Time frame
in
which all infection criteria must be met.
Date of event (DOE): Date on which the first element ofinfection
criterion occurs during IWP.
Present on admission (POA): Date of event two days
beforeadmission until one day after admission. HAI and POA work
sheet generator
HAI DOE: On or after the third calendar day of admission.
Secondary bloodstream infection (BSI) attribution
period:Time-limited (1417 days)
Repeat Infection Timeframe (RIT): 14 days beginning at DOE.
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Whats New?
2016 NHSN Surveillance Definition Updates
Health Services Advisory Group, Inc.
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General Surveillance Review (cont.)
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http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf#page=2*SSI
= surgical site infection
General Surveillance
HAI and POA worksheet generator just released!
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http://nhsn.cdc.gov/nhsntraining/calculator/workgen.html
http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf#page=2http://nhsn.cdc.gov/nhsntraining/calculator/workgen.html
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Whats New?
2016 NHSN Surveillance Definition Updates
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General SurveillancePathogen Assignment
Additional pathogens identifiedadded tooriginal event, if within
an RIT and not anexcluded organism. Example
Meets catheter-associated urinary tract infection
(CAUTI)definition with urine culture and symptoms: E. coli
Two days later, positive urine culture with Enterococcus,
spp.
Organism may be added to more than one event. Example
Meets CAUTI definition with urine culture/symptoms: S. aureus.
Meets pneumonia (PNU2) definition. Two days later, positive blood
culture for S. aureus.
Secondary BSI for CAUTI and pneumonia
9http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf#page=6http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf#page=11
New NHSN Guidance CDC Locations
For inaccurate Center for Disease Control andPrevention (CDC)
location descriptions: NHSN provides instructions to change
locations and
connect data from an older location to a newlymapped location.
CDC Locations and Descriptions Manual, Page 15-8
Added four new outpatient locations for ambulatorysurgery
centers (ASCs).
1. Outpatient Ambulatory Surgery Center
2. Ambulatory Surgery Recovery Room
3. Outpatient Ambulatory Pediatric Surgery Center
4. Outpatient Ambulatory Plastic Surgery Center
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http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf#page=8http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf#page=37
http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf#page=6http://www.cdc.gov/nhsn/PDFs/pscManual/2PSC_IdentifyingHAIs_NHSNcurrent.pdf#page=11http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf#page=8http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf#page=37
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Whats New?
2016 NHSN Surveillance Definition Updates
Health Services Advisory Group, Inc.
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Changes: Multiple Modules
Nonculture diagnostic testing included. Allow use of nonculture
diagnostic laboratory tests in addition to
specimen cultures (PCR, ELISA). Not used in SUTI or ABUTI
(requires quantified urine culture result).
Specimens from brain-dead organ donors excluded. Maintained
patients awaiting organ harvest do not meet criteria
for HAI surveillance.
Specified fungal pathogens excluded from HAIsurveillance.
Commonly community-acquired. Rarely HAI, but may meet NHSN
surveillance criteria due to long
incubation periods. Pathogens are limited to: Blastomyces,
Histoplasma,
Coccidioides, Paracoccidioides, Cryptococcus,
andPneumocystis.
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http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=6
Central Line-Associated Bloodstream Infection (CLABSI) Event
Following devices are NOT considered central lines
Extracorporeal membrane oxygenation (ECMO)
Femoral artery catheters
Intra-aortic balloon pump (IABP) devices
Hemodialysis Reliable Outflow (HeRO) dialysis catheters
Impella heart devices
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http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=26http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=34
http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=6http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=26http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=34
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Whats New?
2016 NHSN Surveillance Definition Updates
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CLABSIAccession of Central Lines
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Documentation of observed or suspected patient accession into
vascular access lines, within the BSI IWP, will be considered a
laboratory-confirmed bloodstream infection (LCBI) but NOT a
CLABSI.
BSI RIT will be created.
Documentation must occur during the BSI IWP.
If reporting the BSI to NHSN, answer NO tothe risk factor event
field Central line
http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=38
CLABSIMucosal Barrier Injury (MBI)-LCBIs
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Absolute neutrophil count/white blood celllevels should not be
used to set IWP oridentify DOE.
Only a subset of LCBI.
Date the patient first meets the LCBI criteria is thedate of the
MBI-LCBI.
http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=38
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Whats New?
2016 NHSN Surveillance Definition Updates
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CLABSIMBI-LCBI (cont.)
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Remember: To meet any criterion, blood culturesmust only have
the organisms specified for each of thethree criteriawith no other
organisms isolated.
No other isolated pathogen or two matching commoncommensals
collected on separate occasions thatwould otherwise meet LCBI
criteria.
A single common commensal does not exclude frommeeting MBI-LCBI
criteria.
CLABSIMBI-LCBI (cont.)
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Organisms that meet criteria:
MBI-LCBI 1: Bacteroides spp., Candida spp.,Clostridium spp.,
Enterococcus spp.,Fusobacterium spp., Peptostreptococcus
spp.,Prevotella spp., Veillonella spp., orEnterobacteriaceae
(intestinal organisms)
MBI-LCBI 2: Viridans group streptococci
Patient of any age
MBI-LCBI 3: Viridans group streptococci
Patient 1 year of age
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Whats New?
2016 NHSN Surveillance Definition Updates
Health Services Advisory Group, Inc.
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Determination of Secondary BSI to Another Site
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Exception: Assigning a BSI secondary to Necrotizing
Enterocolitis.Excluded: Salmonella spp. as pathogen for LCBI; these
organisms may be
secondary BSIs, but not reported as sole pathogens in a primary
BSI.
CLABSISecondary BSI
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Whats New?
2016 NHSN Surveillance Definition Updates
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CLABSISecondary BSI: VASC
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Criteria must be met for LCBI.
Once LCBI has been confirmed, clear evidenceof vascular site is
needed. This must include: Pus AND
A culture of that pus (must be collected during thatLCBI IWP)
AND
At least one organism that matches the bloodspecimen
LCBI will not be considered associated with thecentral line.
CLABSISecondary BSI: VASC (cont.)
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Reporting to NHSN
Report as LCBI
Enter NO for the field Central Line
Enter the patients central line days in the summary denominator
count
Vascular access devices included Peripheral IV
Arteriovenous fistula
Arteriovenous graft
Non-accessed central line (not accessed/inserted during
hospitalization [e.g., non-accessed port])
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Whats New?
2016 NHSN Surveillance Definition Updates
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CLABSISecondary BSI: PNEU
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PNEU definition Site-specific infection for secondary BSI
attribution
when conducting CLABSI surveillance, even foradult patients
Secondary BSIs Only reported for specific events related to
PNU2
and PNU3 (for immunocompromised patients)
CLABSISecondary BSI: IAB
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Intraabdominal infections (IABs) must meet at least one of the
following criteria:1.Patient has organisms identified from an
abscess or from purulent material from intraabdominal space by a
culture or non-culture based microbiologic testing method which is
performed for purposes of clinical diagnosis or treatment (e.g.,
not Active Surveillance Culture/Testing [ASC/AST]).
2. Patient has:
a. abscessor other evidence of intraabdominal infection on gross
anatomic or histopathologic exam
b. abscess or other evidence of intraabdominal infection on
gross anatomic or histopathologic exam and organism(s) identified
from blood by a culture or non-culture-based microbiologic testing
method, which is performed for purposes of clinical diagnosis or
treatment (e.g., not Active Surveillance Culture/Testing
[[ASC/AST]). The organism(s) identified in the blood must contain
at least one of the following organisms: Bacteroides spp., Candida
spp., Clostridium spp., Enterococcus spp., Fusobacterium spp.,
Peptostreptococcus spp., Prevotella spp., Veillonella spp., or
Enterobacteriaceae
3. Patient has at least two of the following signs or symptoms:
fever (>38.0C), nausea*, vomiting*, abdominal pain*, or
jaundice*
and at least one of the following:
a. organisms seen on Gram stain or identified from drainage or
tissue obtained during invasive procedure or from an
aseptically-placed drain (e.g., closed suction drainage system,
open drain, T-tube drain, CT guided drainage)by a culture or
non-culture-based microbiologic testing method which is performed
for purposes of clinical diagnosis or treatment (e.g., not Active
Surveillance Culture/Testing [ASC/AST]).
b. organisms identified from blood by a culture or
non-culture-based microbiologic testing method which is performed
for purposes of clinical diagnosis or treatment (e.g., not Active
Surveillance Culture/Testing [ASC/AST]) and imaging test evidence
suggestive of infection (e.g., ultrasound, CT scan, MRI, radiolabel
scans [gallium,
technetium, etc.] or on abdominal x-ray) which, if equivocal is
supported by clinical correlation (i.e., physician documentation
ofantimicrobial treatment for intraabdominal infection. The
organism(s) identified in the blood must contain at least one of
thefollowing organisms: Bacteroides spp., Candida spp., Clostridium
spp., Enterococcusspp., Fusobacterium spp., Peptostreptococcus
spp., Prevotella spp., Veillonella spp., orEnterobacteriaceae.*
* With no other recognized cause
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Whats New?
2016 NHSN Surveillance Definition Updates
Health Services Advisory Group, Inc.
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CLABSISecondary BSI
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Central Line Insertion Practices (CLIP)
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The only skin prep allowed to meet CLIPbundle adherence is
chlorhexidine gluconate(CHG) for patients 60 days old.
Documented contraindications to use CHGrecorded in NHSN upon
CLIP event entry
Patient less than two months of age.
Patient has a documented/known allergy/reaction toCHG-based
products that would preclude its use.
Facility restrictions or safety concerns for CHG use inpremature
infants preclude its use.
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Whats New?
2016 NHSN Surveillance Definition Updates
Health Services Advisory Group, Inc.
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CAUTI
Indwelling urinary catheter in place could cause patient
complaints of frequency, urgency, or dysuria.
Symptoms cannot be used to meet HAI criteria when catheter is in
place.
Fever is a nonspecific symptom of infection and cannot be
excluded from UTI determination because it is clinically deemed due
to another recognized cause.
http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=84http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=87
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Pathogen Exclusion: CAUTI
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Excluded as organisms in the UTI definition: Candida species or
yeast not otherwise
specified, mold, dimorphic fungi, parasites
Acceptable urine specimen may include these organisms as long as
one bacterium of100,000 colony-forming units (CFUs)/ml isalso
present.
http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=84http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=87
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Whats New?
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Pathogen Exclusion: VAE/VAP
Apply to both Ventilator-Associated Event
(VAE)/Ventilator-Associated Pneumonia (VAP) Candida species or
yeast not otherwise specified;
coagulase negative Staphylococcus and Enterococcusspecies,
unless isolated from lung tissue or pleural flare Indication of
isolation of commensal flora (e.g., normal
respiratory/oral flora or mixed respiratory/oral flora) of the
oral cavity or upper respiratory tract.
Candida species will continue to be included as a pathogen for
meeting PNU3 (immunocompromised patients).
Cryptococcus, Histoplasma, Coccidioides, Paracoccidioides,
Blastomyces, Pneumocystis Community-associated fungal
pathogens.
Rarely cause or are not known to cause
HAIs.http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=142http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=148http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=15227
VAE: Antimicrobials
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Six new antimicrobial agents have been addedto the List of
Antimicrobials Agents Eligible forIVAC, Possible and Probable
VAP
1. Ceftazidime-avibactam
2. Ceftolozane/tazobactam
3. Dalbavancin
4. Isavuconazonium
5. Oritavancin
6. Peramivir
http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=142http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=148http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=152
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Whats New?
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VAE With Secondary BSI
May only be reported for probable ventilator-associated
pneumonia (PVAP) including both of: At least one eligible organism
from the blood
culture specimen matches an eligible organism from an
appropriate respiratory tract specimen collected during the VAE
window period.
Blood culture collected within the 14-day event period.
Are not reported for ventilator-associated condition (VAC) or
infection-related VAC (IVAC).
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VAE With Secondary BSI (cont.)
May not be reported for PVAP when a respiratory culture was not
performed. PVAP met with histopathology criterion.
Positive diagnostic test on respiratory secretions for influenza
virus, respiratory syncytial virus, adenovirus, parainfluenza
virus, human metapneumovirus, rhinovirus, or coronavirus.
No PVAP definition can be met to determine a secondary BSI.
Determine if the BSI is secondary to another site-
specific infection including the PNEU definitions.
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Whats New?
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VAE/VAP
Identification of matching Candida spp. from blood and
respiratory specimen now includes BAL (bronchoalveolar lavage) and
protected specimen brushings in addition to sputum and endotracheal
aspirate (Page 6-9).
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http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=84#page=71
Surgical Site Infection (SSI)
NHSN uses ICD-10-PCS and CPT codes. Transition complete
from ICD-9.
ICD-10-PCS Guidance was provided for spinal level and approach
for FUSN procedures.
Updated supporting materials.
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http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=84#page=71
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Whats New?
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SSI (cont.)
Superficial SSI criterion c Updated to reflect a
symptomatic patient whose incision opened but for whom no
culture was obtained. Note: (+) culture is obtained if
the patient meets SSI criterion b.
Addition of Appendix 1 Contains a list of all NHSN
operative procedure groups.
Site-specific SSIs are available as events for each group.
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http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=102http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=118
Multi-drug Resistant Organism (MDRO)/ Clostridium difficile
Infection (CDI) Module
Two conditionally required questions will move to required
status in 2016: "Last physical overnight location of patient
immediately prior
to arrival into facility"
"Has the patient been discharged from another facility in the
past four weeks? Questions are not intended to be excessively
burdensome to
facilities.
Provide the most accurate information available.
Use Unknown if identifying the required information is an undue
burden.
Continue building processes that support the most information
(recorded and extracted) from the patient record.
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http://www.cdc.gov/nhsn/forms/instr/57_128.pdf#page=4
http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=102http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf#page=118http://www.cdc.gov/nhsn/forms/instr/57_128.pdf#page=4
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Whats New?
2016 NHSN Surveillance Definition Updates
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New Reporting Instructions for CDI DOE
Location is attributedto where thespecimen wascollected.
For specimenscollected in anoutpatient locationother
thanemergencydepartment or 24-hour observation unit Report to
the
inpatient admittinglocation if collectedon the same day.*
MDRO Reporting Plan
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*Must add data for all locations in your plan.
http://www.cdc.gov/nhsn/pdfs/training/2016/labid-event-reporting-leaptrot.pdf#page=21http://www.cdc.gov/nhsn/pdfs/training/2016/labid-event-reporting-leaptrot.pdf#page=37
Key Points: CDC and CMS Joint Reminder on NHSN Reporting
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http://www.cdc.gov/nhsn/pdfs/cms/nhsn-reporting-signed.pdf
http://www.cdc.gov/nhsn/pdfs/training/2016/labid-event-reporting-leaptrot.pdf#page=21http://www.cdc.gov/nhsn/pdfs/training/2016/labid-event-reporting-leaptrot.pdf#page=37http://www.cdc.gov/nhsn/pdfs/cms/nhsn-reporting-signed.pdf
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Whats New?
2016 NHSN Surveillance Definition Updates
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Key Points: Summary Data Examples
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Summary Data:Device-Associated Module
Summary Data:MDRO
Key Points: No Events/No Procedures Examples
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Device-Associated ModuleNo Events
MDRONo Events
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Whats New?
2016 NHSN Surveillance Definition Updates
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Key Points: Every Journey Begins With a Good Map!
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Avoids incorrect reporting to CMS
x
Accurate mapping is critical
http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf*standardized
infection ratio
Find NHSN Reporting Resources!
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http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf
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Whats New?
2016 NHSN Surveillance Definition Updates
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Thank you!Renee L. Rush, RN, BSN
Infection Prevention Quality Improvement Specialist614.653.5445
| [email protected]
Question and Answer Session
mailto:[email protected]
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How to Use Chat Function
1. To submit a question,click on the Chat optionat the top
right.
2. The Chat panel will open.
3. Indicate that you want to send aquestion to the Host &
Presenter.
4. Type your question in thebox at the bottom of the panel.
5. Click Send.
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More Questions? Contact an HSAG Team Member
State Project Lead
Arizona Charlie Chapin 602.801.6940 [email protected]
California Laurie Hensley 818.265.4643 [email protected]
Florida/U.S. Virgin Islands
Rick Welsh 813.549.9920 [email protected]
Ohio Renee Rush 614.653.5445 [email protected]
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mailto:[email protected]:[email protected]:[email protected]:[email protected]
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Thank you!
For More NHSN Resources and a Recording of Todays Webinar
www.hsag.com/NHSN
This material was prepared by Health Services Advisory Group,
the Medicare Quality Improvement Organization for Arizona,
California, Florida, Ohio, and the U.S. Virgin Islands, 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. Publication No. QN-11SOW-C.1-05112016-01.
http://www.hsag.com/NHSN
Structure BookmarksWhats New?A Review of National Healthcare
SafetyNetwork (NHSN) Surveillance Definitions HousekeepingTodays
Presenters NHSN Surveillance DefinitionsObjectivesGeneral
Surveillance Review General Surveillance Review (cont.) General
SurveillanceGeneral SurveillancePathogen AssignmentNew NHSN
Guidance CDC LocationsChanges: Multiple ModulesCentral
Line-AssociatedBloodstream Infection (CLABSI) EventCLABSIAccession
of Central LinesCLABSIMucosal Barrier
Injury(MBI)-LCBIsCLABSIMBI-LCBI (cont.)CLABSIMBI-LCBI
(cont.)Determination of Secondary BSI to Another
SiteCLABSISecondary BSICLABSISecondary BSI: VASCCLABSISecondary
BSI: VASC(cont.)CLABSISecondary BSI: PNEUCLABSISecondary BSI:
IABCLABSISecondary BSICentral Line Insertion Practices
(CLIP)CAUTIPathogen Exclusion: CAUTI Pathogen Exclusion:
VAE/VAPVAE: AntimicrobialsVAE With Secondary BSIVAE With Secondary
BSI(cont.)VAE/VAP Surgical Site Infection (SSI)SSI
(cont.)Multi-drug Resistant Organism (MDRO)/ Clostridium difficile
Infection (CDI) Module New Reporting Instructions for CDI DOEKey
Points: CDC and CMS Joint Reminder on NHSN ReportingKey Points:
Summary Data ExamplesKey Points: No Events/No Procedures
ExamplesKey Points: Every Journey Begins With a Good Map! Find NHSN
Reporting Resources!How to Use Chat FunctionMore Questions? Contact
an HSAG Team Member