1. National Healthcare Safety Network (NHSN) in 2015
Ashlie Dowdell
HAI Surveillance Coordinator
SEW APIC, February 5, 2015
Wisconsin Department of Health Services

2. Agenda Review the 2015 definition change highlights.
Recap state and federal NHSN reporting requirements.
What’s coming in 2015 for:
Ambulatory surgery centers (ASC).
Long-term care (LTC) facilities.
ICD-10.

3. When Do I Need To Incorporate These Changes?
All definition/surveillance protocol changes took effect January 1, 2015.
Changes to fields/reporting rules will be part of the database after the first 2015 version update (January 31).
Wait until after the version update to enter 2015 reporting plans, data and the annual facility survey for CY 2014.

4. Patient Safety Component
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5. General NHSN Changes NHSN Infection Window Event Date
Repeat Infection Timeframe
Secondary Bloodstream Infection (BSI) Attribution Period
CDC/NHSN Surveillance Definitions for Specific Types of Infections (aka Chapter 17)
Note: These general changes do not apply to Long-Term Care Component users.

6. NHSN Infection Window Replaces “gap day” methodology from 2014.
All elements of the criteria must be part of this window.
For criteria that include diagnostic testing:
Day the first positive diagnostic test included in the infection criteria was obtained.
Three calendar days before the test.
Three calendar days after the test.
Day -3
Day -2
Day -1
Day of first positive test
Day 1
Day 2
Day 3

7. Event Date 2014: Date the last element of the criteria was met.
2015: Date the first element of the criteria occurs for the first time within the seven-day infection window.
Event date still determines whether an infection is present on admission (POA) or healthcare-associated.
Event dates on the date of admission, two days before and the day after are POA.
Events dates on or after hospital day 3 (hospital admission day is day 1) are HAIs for NHSN surveillance.

8. Repeat Infection Timeframe (RIT)
14-day period during which repeat infections of the same type cannot be reported.
Any additional pathogens collected during this timeframe should be added to the original infection report.
Event date for the first infection is day 1 of the RIT.

9. Secondary BSI Attribution Period
Must meet the Secondary BSI Guideline criteria and fall during this time period.
14-17-day period (depending on where the event date falls within the Infection Window):
7-day Infection Window of the primary infection.
14-day Repeat Infection Timeframe of the primary infection.

10. Sun
Mon
Tue
Wed
Thu
Fri
Sat
Nov 23
Nov 24
Nov 25
Nov 26
Nov 27
Nov 28
Day -3 before culture =
Beginning of Infection Window
Nov 29
Day -2 before culture
Nov 30
Day -1 before culture
Dec 1
Fever, + culture = CAUTI
Date of Event
Day 1 of RIT
Dec 2
Day 1 after culture
Day 2 RIT
Dec 3
Day 2 after culture
Day 3 RIT
Dec 4
Day 3 after culture (End of IW)
Day 4 RIT
Dec 5
Day 5 RIT
Dec 6
Day 6 RIT
Dec 7
Day 7 RIT
Dec 8
Day 8 RIT
Dec 9
Day 9 RIT
Dec 10
Day 10 RIT
Dec 11
Day 11 RIT
Dec 12
Day 12 RIT
Dec 13
Day 13 RIT
Dec 14
Day 14 RIT (End of RIT)
Dec 15
Dec 16
Dec 17
Dec 18
Dec 19
Dec 20
Infection Window
Repeat Infection Timeframe
Secondary BSI Attribution Window

11. Excluded Modules for Certain General HAI Rules
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12. Specific HAI Definitions/ Chapter 17
HAI definitions for anything without a devoted module.
First significant update since the 1990s.
Bring them up to date and make them consistent with other NHSN changes over the years.
Available at:

13. BSI Protocol Secondary BSI Guide
Will no longer ask whether blood culture organism is a logical pathogen for the primary site of infection.
Introduction of the Secondary BSI Attribution Period (Infection Window + Repeat Infection Timeframe for the primary infection).
Core temperatures no longer required for infant fevers. Use the documented temperature and do not convert.

14. UTI Protocol No longer included:
Colony counts less than 100,000 CFU/ml.
Urinalysis results.
Cultures positive only for yeast, mold, dimorphic fungi, or parasites.
Uropathogen list for asymptomatic bacteremic UTI (ABUTI) (will use the same list as for symptomatic UTI).
Protecting and promoting the health and safety of the people of Wisconsin

15. New Denominator Sampling Option
Alternate method for collecting CLABSI and CAUTI denominator data.
Can only be used in ICUs and wards with 75 or more device-days per month.
Collect patient days and device days one day per week (e.g., every Tuesday) at the same time and provide the total number of patient days for the month.
NHSN will estimate the device days based on the collected data for use as the denominator.

16. Ventilator-Associated Events (VAE) Protocol
Combine possible VAP and probable VAP into one event: PVAP.
Exclude typically environmental pathogens (i.e., community-associated fungal pathogens) not known/rarely acquired in healthcare for PVAP.
New optional denominator: Episodes of Mechanical Ventilation. Vent days and APRV days continue to be required.
Daily minimum PEEP/FiO2 when there is no value documented as maintained for 1 hour during the calendar day: Use the lowest value documented in that calendar day.

17. Pneumonia/Ventilator- Associated Pneumonia Changes
Bringing testing, pathogens in line with VAE definitions.
Cannot report pathogens or attribute secondary BSIs for PNU1 definition. If blood cultures are collected and pathogens identified within the required period, modify the designation to PNU2.
Protecting and promoting the health and safety of the people of Wisconsin

18. SSI Protocol Inpatient/outpatient procedures.
**Changed 2/3/15**: Back to the 2014 definitions.
Inpatient procedure – different dates of admission and discharge.
Outpatient procedure – same date of admission and discharge.
Infection present at the time of surgery (PATOS). SSIs with PATOS excluded from SSI SIRs beginning in 2016 with the new baseline.

19. SSI Protocol, cont.
Prior infection at the index joint for HPRO/KPRO revisions.
Primary closure: Any portion closed at the skin level rather than all tissue levels.
Diabetes: Medication-based definition of diabetes or ICD-9 discharge codes.
Scope field: Y if the procedure was coded as a lap procedure performed using a laparoscope/robotic assist.

20. MDRO/CDI Protocol: Denominator
Be prepared to exclude unit-based inpatient rehab facilities (IRF), inpatient psychiatric facilities (IPF) and skilled nursing facilities (SNF) with a different CMS Certification Number (CCN) than the acute care hospital.
New denominator screen will walk through that removal:
Total patient days/admissions = all locations.
MDRO patient days/admissions = exclude IPF/IRF/SNF.
CDI patient days/admissions (if reporting CDI) = exclude IPF/IRF/SNF and NICU/well baby counts.

22. MDRO/CDI Protocol: New Locations
Map ERs and dedicated 24-hour observation locations.
Any time you use FACWIDEIN as a location, you also need to report the same organism for the ER and observation.
Attribute cultures taken in the ER to the ER (not the admitting inpatient unit as was done in 2014).

23. CRE Changes
CRE = E. coli, Klebsiella pneumoniae/oxytoca, and Enterobacter.
Definition changes:
Ertapenem has been added.
Only includes pathogens testing resistant to a carbapenem (intermediates will no longer count).
CRE-Klebsiella will be limited to Klebsiella oxytoca and Klebsiella pneumoniae.

24. New CRE Definition
Any Escherichia coli, Klebsiella oxytoca, Klebsiella pneumoniae, or Enterobacter testing resistant to imipenem, meropenem, doripenem, or ertapenem by standard susceptibility testing methods (i.e., minimum inhibitory concentrations of ≥ 4 mcg/mL for doripenem, imipenem, and meropenem or ≥ 2 mcg/mL for ertapenem) or by production of a carbapenemase (i.e., KPC, NDM, VIM, IMP, OXA-48) demonstrated using a recognized test (e.g., PCR, metallo-β-lactamase test, modified-Hodge test, Carba-NP).
Protecting and promoting the health and safety of the people of Wisconsin

25. MDRO/CDI Protocol Optional questions to be added to LabID Event form:
Last physical location of patient immediately prior to arrival to facility (if specimen is community-onset).
Has patient been discharged from another facility in the past four weeks? (this includes NH, rehab, other hospitals, LTACs, etc.).
Protecting and promoting the health and safety of the people of Wisconsin

26. Dialysis Component
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27. 2015 Changes (All Optional – Not Part of CMS Reporting)
5 new process measures:
Hemodialysis catheter connection/disconnection.
Hemodialysis catheter exit site care.
Arteriovenous fistula and graft cannulation/decannulation.
Dialysis station routine disinfection.
Injection safety.
Influenza vaccination for dialysis patients.
Analysis – data quality reports.

28. Dialysis Events Form
New question: “Where was this positive blood culture collected?”
Responses include dialysis clinic, hospital (day of or day following hospital admission) or ER, and other location.
Loss of vascular access field under the outcomes section will now be required.

29. LONG-TERM CARE Facility Component
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30. New Required Denominator Fields
Enter the monthly total for each new field when entering the monthly total resident days:
If reporting UTI: Number of new antibiotic starts for UTI indication.
If reporting CDI: Number of admissions on CDI treatment.
Protecting and promoting the health and safety of the people of Wisconsin

31. General HAI Surveillance Definitions
New terms used in the Patient Safety Component (infection window, repeat infection timeframe, etc.) do not apply to the LTC Component and should not be used at this time.
Refer back to the LTC module protocols instead.
Updated LTC Component protocols and training slides available now at

32. NHSN Reporting Requirements
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33. CMS Healthcare Facility NHSN HAI Reporting Requirements
Reporting Specifications
Existing Requirement
New Requirement for 2015
Acute Care Hospitals (Prospective Payment
System – PPS)
CLABSI (ICUs, PICUs, NICUs)
CAUTI (ICUs, PICUs)
SSI (COLO and HYST)
MRSA Bacteremia LabID Event
C. difficile LabID Event
HCP Influenza Vaccination
CLABSI and CAUTI Expansion (Medical, Surgical and Medical/Surgical Wards)
Outpatient Dialysis
IV antimicrobial start
Positive blood culture
Signs of vascular access infection
Long-Term Acute Care (LTAC) Hospitals
CLABSI
CAUTI
Ventilator-Associated Events (2016)
Inpatient Rehabilitation Facilities (IRF)
Ambulatory Surgery Centers (ASC)
None
Inpatient Psychiatric Facilities (IPF)
Long-Term Care (LTC) Facilities

34. State Reporting Requirements
Medicaid P4P Program.
CAUTI.
PPS and CAH.
April 2014 – March 2015 due September 30, 2015.
HCP Influenza Vaccination.
PPS, CAH, psych and children’s.
season due May 15, 2015.
CRE.
PPS, CAH, children’s and LTAC hospitals.
Data reported monthly even if no positive cultures have been identified.

35. Reminder: NHSN 2015 Changes Training
10-minute videos available now at
February via live webstream, includes overview of each module and case studies.
DPH January 7 webcast recording available at

36. What’s coming in 2015 for ambulatory surgery, long-term care and ICD-10?
Protecting and promoting the health and safety of the people of Wisconsin

37. ASCs in 2015 All should be enrolled or enrolling.
Finishing up the first season of flu reporting ( ). Due May 15.
Outpatient Component due to launch in the summer.
Protecting and promoting the health and safety of the people of Wisconsin

38. Outpatient Component - ASCs
Focus on SSIs, same day adverse events, and IV antibiotic prophylaxis timing initially.
Start with ASCs, open up to hospital outpatient departments later.
Start with 10 procedures (breast, colon, hernia, abdominal hyst, laminectomy, gallbladder, fractures, hip and knee replacements, vaginal hyst).
Denominators will be aggregate numbers of procedures, admissions, etc.
Risk adjustment/analysis still TBD.

39. LTC Participation in NHSN
13 Wisconsin facilities live (206 across the country).
3 have conferred rights to DPH so far.
Per the surveillance workshops last fall:
64 facilities plan to use the protocols outside NHSN.
57 facilities plan to enroll in the near future.
Protecting and promoting the health and safety of the people of Wisconsin

40. Current LTC Reporting Options
MDRO/C. difficile – laboratory-identified events
Urinary tract infections
Prevention process measures
Hand hygiene
Gown and glove use
Staff flu vaccination
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41. LTC in 2015 Pilot for interested facilities in 2015.
Enroll (see checklist
Start reporting at least CRE.
Determine the LTC-specific questions, road blocks, tools, etc. for enrolling and participating.
Protecting and promoting the health and safety of the people of Wisconsin

42. Why NHSN for LTC? Standardized definitions. NHSN = McGeer’s criteria.
National standard - try to use protocols, even if you’re not ready to enroll.
Start to build data for comparison, both locally and nationally.
Helps with the survey/QAPI process.
2013 National HAI Goal to enroll 5% of nursing homes by 2017.

43. Transitioning to ICD-10
NHSN ICD-10 code mapping is expected to be available by March 2015.
ICD-10 coding starts October 2015.
ICD-10 codes will be accepted into NHSN starting January 2016 after the version update. Between October and January, omit the ICD code in the procedure record to avoid error messages.
Protecting and promoting the health and safety of the people of Wisconsin

44. Questions?
Ashlie Dowdell HAI Surveillance Coordinator Wisconsin Division of Public Health
Protecting and promoting the health and safety of the people of Wisconsin