4 BackgroundFY 2015 Annual Payment Update (APU) Determination (FY 2015 Reference Checklist)Submit Healthcare Associated Infections (HAI) data (http://www.cdc.gov/nhsn/cms/)Hospitals collect and submit data to Centers for Disease Control and Prevention (CDC) through the National Healthcare Safety Network (NHSN).Central Line-Associated Bloodstream Infection (CLABSI) data (ICU)Catheter-Associated Urinary Tract Infection (CAUTI) data (ICU)Surgical Site Infection (SSI) abdominal hysterectomy and colon surgery data (all)Methicillin-resistant Staphylococcus aureus (MRSA) data (all)Clostridium Difficile (C. Diff) data (all)Healthcare Personnel Influenza Vaccination (all)Hospitals with no ICU location and/or that performed 9 or fewer of any of the specified colon and abdominal hysterectomy procedures in the calendar year prior to the reporting year, can request an HAI exception for submission of CAUTI, CLABSI and SSI measures to fulfill the CMS Hospital IQR Program NHSN reporting requirement.
5 Background, cont.400 Hospitals at random, with additional hospitals targeted15 records selected per quarter for chart-abstracted clinical process of care measures (SCIP, HF, AMI, PN, ED/IMM)12 records selected per quarter for HAI measuresPass validation requirementsReceive a Confidence Interval of 75 percent or greater based on the combined chart audit validations for 4Q12 - 3Q13 discharges.Submit HAI Validation Templates via QNet each quarter:Validation Blood Culture TemplateValidation Urine Culture TemplateSSI COLO/HYSTQ4 2012, Q1 2013, Q2 2013, Q3 2013400 hospitals with a supplemental selection of 200 hospitals based on targeting criteria. In addition, validation results for chart-abstracted clinical process of care and HAI measures will be separated.Selected hospitals pass Validation requirements by receiving a Confidence Interval of 75 percent or greater based on the combined chart audit validations for 4Q12 through 3Q13 discharges.New for FY Submit HAI Validation Templates: Hospitals submit a Validation Blood Culture Template and a Validation Urine Culture Template each quarter to facilitate the validation of the CLABSI and CAUTI measures.FY2015 Validation – SSI – Colon and SSI – Abdominal Hysterectomy Validation:• Identified through claims process -SSIs are reported more consistently in claims data than CLABSI and CAUTI.• Candidate SSIs identification is different from the process for identifying candidate CLABSI and CAUTI.• Claims data provide a resource for selecting candidate events for SSI using a methodology which limits burden to hospitals.– SSI validation starts with 4Q12. These cases will be selected from claims data so there is nothing that the hospital needs to submit.
6 Validation Methodology Basics for Candidate CLABSIs:Final results for positive blood cultures for patients who were in the ICU when the blood culture was drawnPresence of a central venous catheter (CVC) any time during the stay (including on admission)Basics for CAUTIs:Final results for all positive urine cultures with greater than or equal to 103 colony-forming units (CFUs)/mlICU admission during the hospital stay
7 Sample CLABSI Validation Steps - LEGEND Hospital Iowa QIO (CMS Support Contractor) QIO Clinical Warehouse Centers for Disease Control and Prevention (CDC) Clinical Data Abstraction Center (CDAC)
8 Sample CLABSI Validation Steps Identify candidate CLABSI eventsPopulate Blood Culture templateSubmit Blood Culture template to CMS Contractor (Iowa QIO) via QNet by quarterly deadlineQNet Security AdministratorIowa QIO loads all data from the Blood Culture template into large databasePositive blood cultures without the presence of a central venous catheter are removed from the database(example – submit 60 +BCs on spreadsheet but only 10 have CVC answered Yes, then other 50 are removed)
9 Sample CLABSI Validation Steps, cont. Iowa QIO randomly selects up to 4 candidate CLABSIs from the list remaining(example – select 4 from the remaining 10)Iowa QIO sends list of 4 candidate CLABSIs from each hospital to the QIO Clinical Warehouse and the CDCCDC looks to see if hospital reported any of the 4 candidate CLABSIs via NHSNQIO Clinical Warehouse adds the 4 candidate CLABSIs to the other 15 charts (HF, PN, AMI, SCIP, ED/IMM)
10 CLABSI Validation Steps, cont. CDAC sends chart request for all medical records to hospitalHospital produces copies of all requested medical records and submits to CDAC within 30-day timeframeCDAC abstracts candidate CLABSI charts for each hospital to determine if the patient had infection related to a central line and sends results to Iowa QIOCDC sends results of whether any of 4 CLABSI candidates were submitted via NHSN to Iowa QIO
11 CLABSI Validation Steps, cont. Individual validation score is computed for each of the 4 candidate CLABSIsCDC & CDAC report case CLABSI is 1/1CDC & CDAC report different results causes case to return to Iowa QIO for review with CDACCDC & CDAC final determinations do not match, then case is 0/1Individual validation scores will be combined with scores of other validation chartsOverall Validation Score <75% due to a CLABSI validation chart, hospital can appeal normally
12 HAI Validation TIPS Start Now! First Deadline is May 1st! Hospital must continue to submit CLABSI/CAUTI/SSI data to NHSNNHSN entry data submission deadline vs. CLABSI/CAUTI validation spreadsheets deadlineIf hospital has a waiver in place, they are not required to submit the CLABSI/CAUTI templateIf hospital has no positive blood cultures for a particular quarter, they are required to submit the CLABSI and CAUTI templates by the quarterly deadline
13 Deadlines Discharge Quarter HAI Template Due HAI Data Due Q4 2012 May 1, 2013May 15, 2013Includes Healthcare Personnel VaccineQ1 2013August 1, 2013August 15, 2013Q2 2013November 1, 2013November 15, 2013Q3 2013February 1, 2013February 15, 2013