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Mandatory Reporting of Mandatory Reporting of Healthcare Associated Healthcare Associated
Infections in Texas Infections in Texas
Jennifer Steinhausen, MPH, CICHealthcare Associated Infections
Disclosure of PHIwww.dshs.state.tx.us/hipaa/webmessage.shtm
Legislation Background
78th legislative Session (2005) passed study bill• Advisory Panel, White Paper
79th legislative Session (2007) passed SB 288• Reporting provisions but no appropriation
80th legislative Session (2009) passed SB 203: Amended SB 288 (Chapter 98)• Added two members to AP• 28 PAE• Included appropriation• BUT does not allow data sharing with CDC
Chapter 98 Requirements
Establish 18 member Advisory Panel Establish Healthcare Associated Infections (HAI) reporting system Compile and make available to the public a data summary, by
health care facility, at least annually Allow health care facilities to submit concise written comments Provide education and training Ensure confidentiality & legal protections Verify the accuracy and completeness of the data reported Receiving reports from the public Enforcement
Link to Legislation: www.HAITexas.org
Caveats to Reporting
Proposed changes to the legislation
Staffing/Funding issues
Composition of the Advisory Panel will and is changing
Please bear with us. This is still a work in progress…
So, what does this really mean?
Reporting Requirements
Who is required to report?• Ambulatory Surgical Centers
o Licensed under Chapter 243• General Hospitals
o Licensed under Chapter 241 o Hospital that provides surgical or obstetrical services
that is maintained or operated by the state.o INCLUDES LTACs and CAHs with ICU/CCU/NICU
• DOES NOT INCLUDE COMPREHENSIVE MEDICAL REHABILITATION HOSPTIAL
Reporting Requirements
Reportable healthcare-associated infections• Central line-associated bloodstream infections in the
following special care settings: adult, pediatric and/or adolescent ICUs & CCUs, NICUs (Level II/III & Level III Nurseries)
• Surgical site infectionso PEDS/ADOLESCENT HOSPITALS: Cardiac procedures, spinal
surgery with instrumentation, and ventriculoperitoneal shunt procedures
o ALL OTHER HOSPITALS: Colon surgeries, hip & knee arthroplasties, abdominal & vaginal hysterectomies, vascular procedures, and coronary artery bypass grafts
SSI Reporting Requirements
Facilities shall report HAI data on patients who are admitted to the facility for inpatient treatment of a surgical site infections associated with a reportable procedure within 30 calendar days of the procedure or within 1 year of the procedure if the procedure involved an implant.
Facilities will be required to report surgical site infections back to the originating facility, if identified.
Originating facility will be required to report the SSI, using NHSN.
Reporting Requirements
Alternative for surgical site infections• A facility that does not perform a least a monthly
average of 50 of any combination of the listed reportable procedures, shall report the surgical site infections relating to the three (3) most frequently performed NHSN procedures.
What to Report?
Report Ventriculoperitoneal shunts including revision and removal of shunt in 2011
Alternative Reporting Selection of surgical procedures to report (example)
Beginning January 2013*• Surgical centers and general hospitals report
abdominal & vaginal hysterectomies, colon surgeries, and vascular procedures
• Pediatric hospitals report spinal surgeries with instrumentation
* Tentative date.
Proposed Reporting Time Line
Reporting Quarter Jan 1 – Mar 31
April 1 – June 1
July 1 – Sept 30
Oct 1 – Dec 31
Facility data submission deadline
31-May 31-Aug 30-Nov 28-Feb
DSHS data reconciliation performed
15-Jun 15-Sep 15-Dec 15-Mar
Facility corrections due 30-Jun 30-Sep 31-Dec 31-Mar
DSHS data summary to facilities
NA 15-Oct NA 15-Apr
Facility comment period NA 30-Oct NA 30-Apr
DSHS review of comments
NA 15-Nov NA 15-May
Public posting of summary
NA 1-Dec NA 1-Jun
HAI Reporting
National Healthcare Safety Network (NHSN) developed and sustained by the Centers for Disease Control & Prevention is the anticipated designated reporting system.
CMS
Texas vs. CMS Reporting: 2011
Texas CMS
Who?
–General hospitals (adult, pediatric, adolescent) with ICU and/or that perform NHSN surgeries. Includes LTACs & CAHs
–ASCs that perform NHSN surgical procedures
Hospitals that receive Medicare reimbursement through (IPPS).
Excludes?Comprehensive medical rehabilitation hospitals
Department of Veterans Affairs/ Department of Defense hospitals.
Q2 or Q3 2011: CLABSIs in ICUs and knee arthroplasties, VP shunts or 3 highest volume NHSN procedures (not due until Aug/Nov 2011)
Q1 2011: CLABSI in ICUs & high-risk nurseries (not due until Aug 2011)
HAI Reporting: NHSNhttp://www.cdc.gov/nhsn/
NHSN 5 Steps to Get Startedhttp://www.cdc.gov/nhsn/cms-ipps-rule_training.html
Advantages of NHSN Training is very thorough and explains, in detail, the
“rules” for complying with NHSN surveillance protocols.
National comparative data is available when reporting infection rates
Surgical denominator data can be uploaded all at once rather than individually entered (IF the user has an electronic surgical record & all required data elements are present)
Vendors have developed compatible software for uploading facility data
Challenges using NHSN
Enrollment & Training process may take 10 – 15 hours
Digital certificate installation can be cumbersome • Will be replaced by SAMS in 2011
Many data elements are required for input into NHSN
NHSN page is extensive
NHSN Data Entry – Summary Data
Establish processes to gather necessary data• Summary Data
o Collection of line days in ICUs– NICU: separate by birth weight, umbilical vs CVC
• Event Datao CLABSIo SSI
• Procedure Datao For each reportable surgery performed
Collecting Summary Data
Collecting Event Data
Preparation for NHSN Data Entry
Establish processes to gather data• Collection of surgical denominator data –
includes patient specific details about EACH procedure preformed for risk stratification.
o http://www.cdc.gov/nhsn/PDFs/ImportingProcedureData_current.pdf
o http://www.cdc.gov/nhsn/forms/57.121_DenomProc_BLANK.pdf
• THIS IS NOT AN AGGREGATE NUMBER OF SURGICAL PROCEDURES!
Collecting Procedure Data
Required for inpatients
Required for Knee
Arthroplasties
Data Mining Vendors
The following vendors completed a HL7 CDA pilot project with NHSN
Enroll your facility in NHSN, using CMS #• May need to request Registration ID from NHSN
Establish facility contact for TEXAS: Primary and secondary contacts who coordinate communications related to data submissions, verifications and approval of data summary to NHSN and DSHS. • Encourage use several contacts and a general facility