1. CLABSI K-HEN Data Collection & Submission
Dolores Hagan, RN BSN
K-HEN Education and Data Manager
August 2012

2. Objectives Review reporting requirements
Review K-HEN recommended measures
Review the specifications for monitoring data (Inclusion and exclusion criteria)
Discuss requirements for baseline data
Define data entry and submission timeline
Identify measures that may be pulled from other systems where data is currently being entered

3. Reporting Requirements
For each topic area chosen, hospitals are required to submit data for at least
One process measure AND
One outcome measure
Hospitals are strongly encouraged to report on the K-HEN recommended measures
Additional outcome and/or process measures may be selected and reported as desired

4. K-HEN Recommended Measures
Purpose—standardize reporting on the same measures across the state for robust benchmarking capability
Measures selected based on polling data from the KHA Quality Conference in March 2012
Have continued to evolve with your feedback (Keep it coming! )

5. HRET HEN Encyclopedia of Measures
Lists all measures available in the CDS
Defines the numerator and denominator for each measure
Provides a link to the source of the measure

6. CLABSI: Outcome Measure
Preferred measure: #24, 25 or 26 All units, ICU or NICU CLABSI rate (device days denominator)
Alternate measure: #27, 28 or 29 All units, ICU or NICU CLABSI rate (patient days denominator)
**To capture unit specific measure, must build a custom measure.

7. # 24, 25, 26 CLABSI Criteria Follow the CDC NHSN specifications
Numerator—The primary bloodstream infection (BSI) form (CDC ) is used to collect and report each CLABSI that is identified during the month selected for surveillance
Denominator—Number of device days
#24—All units
#25—ICU device days
#26—NICU device days
Equation—(Number of CLABSI/Number of central line days) * 1000
Source: CDC NHSN

8. # 27, 28, or 29 CLABSI Criteria Follow the CDC NHSN criteria
Numerator—The Primary Bloodstream Infection (BSI) form (CDC ) is used to collect and report each CLABSI that is identified during the month
Denominator—Number of patient days
#27—All units patient days
#28—ICU patient days
#29—NICU patient days
Source: CDC NHSN CLABSI

9. CLABSI: Process Measure
Preferred Measure: #22 Central Line Insertion Bundle Adherence Rate
Alternate Measure: #23 Hand hygiene adherence rate (CLABSI)
Source: CDC NHSN & Joint Commission Hand Hygiene Reference

10. #22 Central Line Insertion Bundle Criteria
Numerator—Adherence to the bundle requires a “Yes” to all of the following:
Hand hygiene performed
Appropriate skin prep
Skin prep agent completely dried before insertion
All five maximal sterile barriers used (gloves, gown, cap, mask, full body drape)
Denominator—Total number of central line insertions
Source: CDC NHSN CLIP

11. #23 CLABSI Hand Hygiene Compliance
Numerator—Hand hygiene performed consistent with guidelines
Denominator—Total number of hand hygiene observation opportunities
Equation—(Total number of acts of hand hygiene consistent with guidelines/total number of observed hand hygiene opportunities) X 100
Source: Joint Commission Hand Hygiene Reference

12. Baseline Data Only submitted one time
For all topic areas except Readmissions:
Baseline data is from 2011 prior to January 1, 2012
May be the entire calendar year of 2011 or any other period within the year (a month, a quarter, etc)
Enter your specific period beginning and ending dates
Readmission Baseline Data
Preferably CY 2011
May use Jan – Jun 2012 if 2011 data is not available
If no baseline data is available, do not enter anything for baseline—begin with monitoring data

13. Complete baseline data entry by August 15!
CLABSI Baseline Data
Complete baseline data entry by August 15!
NHSN data will be extracted once rights are conferred
Data should be entered on a monthly basis as much as possible

14. 2012 CLABSI Monthly Data Entry Schedule
Monitoring Month
Data Entry Available
Data Entry Complete
January
Immediately
As soon as possible*
February
March
April
May
June
July
August 1, 2012
August 31, 2012
August
September 1, 2012
September 30, 2012
September
October 1, 2012
October 31, 2012
October
November 1, 2012
November 30, 2012
November
December 1, 2012
December 31, 2012
December
January 1, 2013
January 31, 2013
*If data is available

15. Comprehensive Data System (CDS)
Link to HRET training webinar for CDS located on K-HEN website under Data Page
Data coordinator receives initial login and creates hospital’s users
At least two data administrators
As many data entry users as needed

16. Measure Selection
Review the K-HEN Recommended Measures and the HRET Encyclopedia of Measures
Determine which measures you will report
Remember you MUST report on at least one
process and one outcome measure
per topic area selected

17. Measure Enrollment Enroll in the measures that you are reporting
Select Admin  Measure Enrollment
Select the topic area
Select/deselect and save the measures that you will be reporting on
This will narrow your choices for data entry to only those selected
You may reselect those measures at a later time if desired

18. Data Collection & Entry
Review the numerator and denominator criteria for the measures selected
Collect and compile the data
Sign on to the CDS
Select Data Entry tab
Select the topic from the drop  Select Next
Find the appropriate measure  Select Enter Data

19. Baseline Data Entry Defaults to the Baseline tab
Enter the Measurement start and end dates  Select ‘Add’
Under ‘Data Entry’ column, Select ‘Go’
Was data collected for this measurement period?  Select Yes or No
If No, enter reason (e.g. data not available)
If Yes, enter the numerator and denominator
Select Save or Submit
Save holds data in ‘temporary’ area and is not available for reporting within the CDS
Data may be edited by the hospital until it is submitted

20. Monitoring Data Entry Select the Monitoring tab
Under the Data Entry column, Select ‘Go’ for the appropriate month
Was data collected for this measurement period?  Select Yes or No
If No, enter reason (e.g. data not available)
If Yes, enter the numerator and denominator
Select Save or Submit
‘Save’ holds data in ‘temporary’ area and is available for reporting within the CDS
Data may be edited by the hospital until it is submitted

21. Data Tidbits
Each month should have data entered or a reason it was not collected
Additional training will be provided after data has been entered and reporting is available

22. Monthly Progress Report
Due to K-HEN by the 10th of each month
Use template provided
One report per topic area
Report template and sample complete report located on K-HEN website ( under Tools and Resources

23. Project Title: ______________________________ Date: _____________
Hospital Name: ____________________________ State: _____________
Self Assessment Score, 1-5 (see AHA/HRET Assessment Scale document) = <enter score here>
Aim Statement
Run Charts
Lessons Learned
Aim?: (Including your How Good and By When statement)
(Make fonts large, title, labels, dates
and notes very simple on graphs prior
to shrinking graphs. Should be able to
fit 6-8 readable graphs here.
If no data are available for a particular measures either create “empty” run list
the name of the measure(s) to be collected.)
(Enter summary here)
Why is this project important?:
Recommendations and Next Steps
Enter summary here (what do you need from Executive Project Champion, Sponsor at this time to move project?)
Recommendations
Next steps for testing
Changes being Tested, Implemented or Spread
(For each listed change, indicate whether it is being tested (T), Implemented (I) or Spread (S))
Team Members
(Name of Project Champion, Senior Leader Sponsor & all other names & roles)
© 2012 Institute for Healthcare Improvement

25. Project Assessment Scale

26. Homework Set up CDS users for your site
Collect and enter baseline data by Aug 15
Enter monitoring data for Jan - Jun 2012 as available and time permits
Enter monitoring data for Jul 2012 by Aug 31
Complete July progress report by Aug 10 and to

27. Questions