Transcript Infection Reporting in Hospitals

Hospital Performance Data
Reporting/Ohio Hospital Compare
(HB 197)
Ohio Department of Health Mandatory Reporting
Requirements for HAIs
3/3/2010
What is Required of Hospitals for HAI
Reporting
 April 1st and October 1st of each year
 Twelve-months of data
 Currently collecting Quarter 3 2008 – Quarter 2 2009 data
 Use the specifications created by the entity that developed or
endorsed the measure
 CDC – NHSN Manuals http://www.cdc.gov/nhsn/library.html
 CMS – Specifications
http://www.qualitynet.org/dcs/ContentServer?cid=114166275
6099&pagename=QnetPublic%
 All data Reported is presented to the public on Ohio
Hospital Compare http://ohiohospitalcompare.ohio.gov/
CMS Infection Measures
Surgical Care Improvement Project (SCIP)
 All hospitals are required to report to ODH regardless of
reporting to CMS
 Hospitals must follow the specifications created by CMS for
each reporting time period
 SCIP procedural measures are intended to improve the safety of
surgical care through the reduction of postoperative
complications
CMS Infection Measures
Surgical Care Improvement Project (SCIP) – cont.
 Appropriateness of care measure ( SCIP‐Inf 1a, 2a, 3a)
 SCIP‐Inf 1a‐ h: Prophylactic Antibiotic Received Within One
Hour Prior to Surgical Incision
 SCIP‐Inf‐2a‐ h: Prophylactic Antibiotic Selection for Surgical
Patients
 SCIP‐Inf‐3a‐ h: Prophylactic Antibiotics Discontinued within 24
Hours after Surgery End Time
 These measures are stratified into 8 surgical categories
 Overall Rate, CABG, Other Cardiac Surgery, Hip and knee
Arthroplasty, Colon Surgery, Hysterectomy, Vascular Surgery
CMS Infection Measures
Surgical Care Improvement Project (SCIP) – cont.
 SCIP‐Card‐2: Surgery Patients on Beta Blocker Therapy Prior
to Admission who Received a Beta Blocker during the
 SCIP‐VTE‐1: Surgery Patients with Recommended Venous
Thromboembolism Prophylaxis Ordered
 SCIP‐VTE‐2: Surgery Patients who Received Appropriate
Venous Thromboembolism Prophylaxis Within 24 Hours Prior
to Surgery to 24 Hours after Surgery
CDC Infection Measures
Surgical Site Infections
 Setting: surgical patients in any inpatient setting
 Coronary artery bypass graft (CABG)
 For CABG surgeries report: Deep incisional and organ space
sternal site infections
 Denominator should include both chest incision only and chest
incision/graft site surgeries
 Infections should only be counted for chest incisions
 C‐Section (CSEC)
 Knee Prosthesis (KPRO)
 For Knee surgeries report: Deep incisional and organ space (knee
joint) infections
CDC Infection Measures
C. diff, MRSA and MSSA
 Follow the NHSN Multidrug-resistant Organism (MDRO) and
Clostridium difficile-Associated Disease (CDAD) Module Protocol
 Laboratory Identified events
 Hospital-Acquired Clostridium difficile (C. Diff.)
 Hospital-Acquired Methicillin Resistant and Methicillin Susceptible
Staphylococcus aureus Bacteremia (MRSA/MSSA Bacteremia) (SAB)
 Healthcare facility onset
 On or after day 4 with the day of admission indicated as day 1
 Lab confirmed positives
 Not duplicate positives
 Do not include readmission prior to 8 weeks
ODH Infection Measures
 Health Care Provider Influenza Vaccination
 First collection: Sept 1, 2009 - Mar 31, 2010
 First reporting: October 1, 2010
 Only Seasonal flu
 Count only paid employees as of March 31st each year
ODH Infection Measures
Hand-washing Program
 Does your hospital have a program to improve hand hygiene practices?
 Yes , No, Under development
 2. Does your hospital teach principles of hand hygiene and proper use of
gloves to all clinical staff upon hire?
 Yes , No
 3. Does your hospital monitor and provide feedback to clinical staff
regarding their hand hygiene practices?
 Yes, both, Partial (monitor only), No
 4. In your hospital’s clinical settings, are alcohol-based hand-rubs available
for use at the point of care?
 Yes , No
 5. In your hospital’s clinical settings, are gloves available for use at the point
of care?
 Yes , No
 6. Does your hospital prohibit the wearing of artificial nails by direct-care
providers?
 Yes , No
ODH Infection Measures
Infection Control Staffing
 1. Does your hospital employ a qualified Infection Control
Professional (ICP)?
 Yes, No
 2. Does your hospital employ an Infection Control
Professional (ICP) who is board certified in infection
control (CIC)?
 Yes, No
 3. Does your hospital have a board-certified Infectious
Disease Physician either on staff or available for consult?
 Yes, No
Process for Reporting
• Currently use an ODH electronic data entry system
• Must coordinate internally with you quality assurance staff
• Refer to the “Hospital Perforamnce Measures Instruction
Manual for guidance http://www.odh.ohio.gov/healthStats/hlthserv/hospitaldata
/hospperf.aspx
NHSN – Purpose
• Provide facilities with risk-adjusted data that can be used for
inter-facility comparisons and local quality improvement
activities.
• Assist facilities in developing surveillance and analysis methods
that permit timely recognition of patient and healthcare
personnel safety problems and prompt intervention with
appropriate measures.
• NHSN participants will not have to do duplicative entry into
the ODH Hospital Reporting collection system
What offers the best transition to
hospitals
• Use data that is already being collected
• Use a standardized data collection system
• Provide reporting to meet the statute’s requirement
• Provide reports that are easily understood by healthcare
professionals
• Provide reports that are easily understood by the general
public
Please contact Kaliyah Shaheen at 614-995-4982 or
[email protected] with questions