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NHSN Reporting: A Q&A with Linda R. Greene, RN, MPS, CIC


By Kelly M. Pyrek

Editor's note: This article originally appeared as part of the 2012 Regulatory Update in the January 2012 print issue of ICT. To access a slide show presenting the highlights of the 2012 Regulatory Update, CLICK HERE.

For the purposes of monitoring and improving patient safety and quality of care, the Centers for Medicare and Medicaid Services (CMS) utilize a system of payment for the operating costs of healthcare facilities based on prospectively set rates. This payment system overall is referred to as the Prospective Payment System (PPS), specifically IPPS for inpatient acute care facilities and OPPS for outpatient facilities. The most recent rulings put forth by CMS have included specifications for use of the CDC's National Healthcare Safety Network (NHSN) for reporting certain healthcare-associated infections (HAIs) and other quality indicators. Initially, reimbursement adjustments will be made to facilities that meet the reporting requirements specified in the rules, and in following years to those who demonstrate reductions in HAI and other quality indicator metrics. The purpose is to incentivize healthcare facilities to decrease and prevent the occurrence of HAIs and improve quality of care.

Acute-care facilities have been reporting central line-associated bloodstream infections (CLABSIs) from all adult, pediatric and neonatal intensive care units (ICUs) into NHSN since January 2011 to meet the requirements of the CMS IPPS FY2011 final rule. Beginning in January 2012, as part of the CMS IPPS FY2012 final rule, the same acute-care facilities will also have to report catheter-associated urinary tract infections (CAUTIs) from adult and pediatric ICUs (no NICUs required). And at the same time, acute-care facilities that perform colon surgery and/or abdominal hysterectomy will also have to report all of these operative procedures and any surgical site infections (SSIs) related to them to NHSN, according to NHSN protocols.

To gain perspective on what continued reporting means to infection preventionists (IPs), ICT consulted Linda R. Greene, RN, MPS, CIC, the director of infection prevention for Rochester General Health System in Rochester, N.Y. Greene currently serves as a member of the Association for Professionals in Infection Control and Epidemiology (APIC) board of directors and sits on several advisory panels including the New York State technical advisory panel for public reporting of HAIs.

Q: Infection preventionists now have several years of reporting to NHSN under their belts; what are the continued challenges they face with this task?

A: The added responsibility of this reporting is always a challenge, and how well infection preventionists meet this challenge varies by state and by healthcare organization. I think that infection preventionists, taking the 30,000-foot view, embrace public reporting in general because they understand its role in addressing HAIs. We have seen some declines in HAI rates and from a patient safety perspective, it's been very encouraging. For example, the CDC recently reported about a 35 percent decline in central line infections. On that level, infection preventionists remain encouraged; however, from a resource perspective I think many IPs are struggling because they have not gotten the added resources in tandem with the requirements for reporting. There is also a lack of technology; when APIC conducted its resource survey in 2009 it was revealed that just one-quarter of APIC members had the technology and resources to help them with surveillance. On the one hand we are encouraged that public reporting is beginning to move the dial, but on the other hand we are challenged without the appropriate resources to help meet all of these requirements. It's difficult to generalize because we do know there are organizations that have the necessary resources and are able to cope, while others are very under-resourced. At the heart of all of this is the desire to prevent patient harm and we're encouraged by the use of the NHSN data as opposed to billing and administrative data, so that's all very positive.

Q: What are the implications of "meaningful use" that infection preventionists should know?

From the CDC perspective, one of the goals is to develop algorithms that can be captured electronically from the electronic health record (EHR), but that's not going to happen right away. Initially, organizations are given dollars to launch their EHRs, in particular being able to capture certain information necessary for CMS. So in a nutshell, stage one is very basic in terms of getting the EHR established and meeting certain criteria to target CMS indicators. Down the road, hospitals will be expected to demonstrate their implementation of EHRs. But for now,  it's about getting that EHR online and being able to capture some of the necessary data in an electronic format. Initial phases of meaningful use criteria are data capture, and then to submit quality measures. What it means for IPs is that there are two strategies that facilities can use when it comes to EHRs. The first is if you are going to capture infection prevention data electronically is to buy a commercial software package. And what that package does is build an interface between the EHR and the surveillance software so that one can send alerts or do some data mining. The second approach with the EHR is that one can do data mining and capture data from the EHR, but the EHR in and of itself doesn't do that -- one needs a number of IT hours to build that capacity. So organizations have chosen to do an either/or method -- some have the software packages, many of them have a hybrid system, and some have not looked at either option yet, and that's where some of the frustration occurs -- from the IP's perspective, they are wondering where they are we going with all of this.

Q: To NHSN novices, the process can be daunting. How can infection preventionists build confidence in performing this task?

A: One has to be able to use the NHSN system and practice with it over time. For example, I am in New York state and we have been using NHSN as part of our state reporting since 2007. Most IPs in New York state have become fairly comfortable with that task. Nonetheless, there are a lot of requirements in the NHSN system that take a great deal of time if one doesn't have an electronic system. It's not rocket science, but it can be time-consuming. For example. CMS added reporting requirements for SSI associated with colon surgery and abdominal hysterectomy and what's required is not just a database that captures infections, but a database that captures all of the denominator data. If you have 300 colon procedures in your organization in a year, all of the patient demographics associated with those procedures must be entered into the NHSN database because that forms the basis for your risk adjustment. If you don't have someone to help retrieve that data from the record or to enter it, IPs are spending a lot of time on data entry and that is not the best use of their valuable time. There are some wonderful capabilities in the NHSN system but one must be able to get that information electronically and that's not the case in a number of facilities. The other challenge is denominator data -- for example if you are looking at your rate of central line infections, your denominator is not patient days, it's line days, so capturing that information electronically and validating it is helpful but only a handful of organizations have been able to do that yet. That information is so important because the end result is a very robust system that when you analyze the information, you have real-time, risk adjusted data that can drive improvement. So, on the input end, it's a bit challenging; on the output end, it's very encouraging because there is very good data to access. You can examine that data on a real-time basis, which is so critical to driving improvement.


CMS reporting requirements by facility type:

General acute care hospitals/inpatient

Reporting beginning in:

January 2011:           

- Central line-associated bloodstream infection (CLABSI) in ICUs

 January 2012:          

- Catheter-associated urinary tract infection (CAUTI)

- Surgical site infections (SSIs)  for colon surgeries and abdominal hysterectomies

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