1. Introduction to the National Healthcare Safety Network (NHSN) Richard Rodriguez, MPH Connecticut Department of Public Health 4/9/2014 Thank you to CDC for allowing CT-DPH to utilize NHSN training material in the current presentation

2. Objectives Why use the National Healthcare Safety Network (NHSN) to monitor C.difficile infection (CDI) in long-term care facilities? What is NHSN? How can NHSN help you monitor and track CDI trends over time in your facility?

3. How NHSN is Being Used in CT Ct healthcare facilities currently use NHSN to fulfill CMS and state reporting mandates Type of facilities currently using NHSN to fulfill mandates  Acute Care Facilities  Long-term Acute Care Facilities  Inpatient Rehabilitation Facilities  Outpatient Dialysis Facilities

4. Why use NHSN to Monitor CDI? Residents in long term care facilities are at risk of carrying or acquiring C. difficile Infections from C. difficile can be severe, hard to treat, and are associated with increased risk of hospitalization, debility, and death Focused monitoring of C. difficile helps to evaluate trends and changes in its occurrence and related infections in the facility over time Tracking these events can help infection control staff identify problems, and help evaluate the impact of targeted prevention efforts Familiarize yourselves with NHSN before LTC facilities are mandated to use it

5. NHSN: What is it? Internet-based surveillance system that monitors patient, resident and healthcare personnel safety NHSN maintains data security, integrity, and confidentiality (all data is viewable to CDC) Has capacity for users to share data in a timely manner between facilities or with other entities No fee for participation in NHSN

6. NHSN: Its Purpose Collects data from a sample of U.S. healthcare facilities to permit valid estimation of :  the magnitude of adverse events (i.e. HAIs)  healthcare process measures such as healthcare personnel influenza vaccine status and infection control adherence rates Data is analyzed and reported to permit recognition of trends

7. NHSN: Its Purpose Provides facilities with data that can be used for  Local quality improvement activities  Inter-facility comparisons Assists facilities in developing surveillance and analysis methods that permit  Timely recognition of problems  Prompt intervention with appropriate measures Conduct collaborative research studies with members

8. Authority and Confidentiality for NHSN Public Health Service Act (42 USC 242b, 242k, and 242m(d)) Confidentiality protection  Sections 304, 306, 308(d) of the PHS Act “The information contained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306, and 308(d) of the Public Health Services Act (42 USC 242b, 242k, and 242m(d)).”

9. NHSN Structure Patient Safety Healthcare Personnel Safety Biovigilance Long-term Care Facility Components of NHSN

10. NHSN Components for Long-term Care Facilities Currently, LTCF can enroll in two NHSN Components  Long-term Care Facility Component  Healthcare Personnel Safety Component

11. Long-term Care Facility Healthcare associated infection Laboratory identified (Lab ID) event Prevention process measures Modules of the LTCF Component

12. Long-term Care Facility Component Modules Healthcare Associated Infection Module  Urinary tract infection events (both catheter- and non catheter-associated) Laboratory Identified (Lab-ID) Event Module  C. difficile infections (CDI)  Multidrug-resistance Organisms (MDRO) Preventions Process Measures Module  Hand hygiene  Gown and glove use

13. Purpose of Lab-ID Event Reporting for CDI To calculate proxy measures for CDI events, exposures, and healthcare acquisition This method is based solely on laboratory data and limited resident admissions/transfer data  This includes results of testing performed on residents while at the facility Clinical evaluation of resident is not required, and therefore this surveillance option is less labor intensive

14. Reporting Requirements Facility survey  Completed once a year  Collects information on facility characteristics Facilities must indicate Lab-ID event surveillance in the Monthly Reporting Plan for LTCF Surveillance must be reported for at least 6 consecutive months to provide meaningful measures CDI surveillance should be performed facility-wide

15. Reporting Requirements (continued) Numerator data  Collect and report each CDI event that meets the Lab-ID Event definition Denominator data  Resident-days each month  Resident admissions each month

16. Form for Data Collection One form per MDRO or CDI Event “

17. Data Entry in NHSN Data entered into NHSN are available to the facility and CDC as soon as they are saved  No “transmission” lag Data can be edited after they are saved Records can be deleted

18. CDI Definitions for Lab-ID Event C. difficile positive laboratory assay: A positive result for a laboratory test detecting presence of either of the following:  C. difficile toxin A or B (e.g., enzyme immunoassay or EIA test), OR  toxin-producing C. difficile organism detected in the stool specimen by culture or other laboratory means (e.g., nucleic acid amplification testing by polymerase-chain reaction, or PCR). Duplicate C. difficile positive assay: Any C. difficile positive laboratory test from the same resident following a previous C. difficile positive test within the past 2 weeks

19. CDI Definitions (continued) CDI Lab-ID Event: All non-duplicate C. difficile positive laboratory assays obtained while a resident is receiving care in the LTCF  Lab results from outside facilities, before a resident’s admission, should not be included in Lab-ID event reporting  It is helpful to keep a log of all the positive C. difficile tests sent from your facility so you can track duplicate results to ensure they are not incorrectly entered as CDI Lab-ID Events

20. CDI Definitions (continued) Once CDI Lab-ID Events are entered into NHSN, they are further categorized by the NHSN system:  Incident CDI Lab-ID Event: The first Lab-ID Event ever entered or a subsequent Lab-ID Event entered > 8 weeks after the most recent Lab-ID Event reported for an individual resident  First or new infections that are unrelated to previous infections  Recurrent CDI Lab-ID Event: Any Lab-ID Event entered > 2 weeks and ≤ 8 weeks after the most recent Lab-ID Event reported for an individual resident  Infections that recur after having been thought resolved

21. Lab-ID Event Categorization Based on data provided for the Lab-ID Event, each event is categorized by NHSN as  Community-onset (CO) Lab-ID Event: Date specimen collected ≤ 3 calendar days after current admission to the facility (i.e., days 1, 2, or 3 of admission)  Long-term Care Facility-onset (LO) Lab-ID Event : Date specimen collected > 3 calendar days after current admission to the facility (i.e., on or after day 4)

22. Lab-ID Event Categorization (continued) LO Events are further sub-classified  Acute Care Transfer-Long-term Care Facility-onset (ACT-LO): LTCF-onset (LO) Lab-ID event with specimen collection date ≤ 4 weeks following date of last transfer from an Acute Care Facility (Hospital, Long-term acute care hospital, or Acute inpatient rehabilitation facility only) Categories are based on the date of current admission to facility and the date specimen collected

23. What Information Can you Get from NHSN? Total CDI Rate (per 10,000 resident-days) Long-term Care Facility-onset (LO) Incidence Rate (per) 10,000 resident-days Percent that is Community-onset (CO) Percent that is Long-term Care Facility-onset (LO) and CDI LO that is Acute Care Transfer (ACT LO) Percent that is Recurrent CDI

24. Using Your Data Data can be used to characterize CDI in your facility Data can be looked at over time for trends Data can be used to evaluate interventions

26. NHSN Website http://www.cdc.gov/nhsn/

27. NHSN Website (continued)

29. NHSN Website

30. Contact Information Richard Rodriguez, MPH Epidemiologist Healthcare Associated Infections Program Infectious Disease Section Connecticut Department of Public Health Tel: (860) 509-7995 Fax: (860) 509-7910 Email: Richard.rodriguez@ct.govRichard.rodriguez@ct.gov