1. March 27 th & 31 th, 2015 I NFECTION W ATCH 2015

2.  Introduction to Network 14 HAI Team  Share goals of InfectionWatch2015  Discuss focus facility selection  Explain project components  Provide project and training material:  Hand Hygiene observation audits  Catheter Connection and Disconnection observation audits  AVF/G Cannulation observation audits  Facility NHSN data entry and reporting  Best practices for reporting OBJECTIVES *Please utilize the chat function for questions* 2

3. Jason Simmington, QI Specialist*  jsimmington@nw14.esrd.net jsimmington@nw14.esrd.net Kelly Shipley, QI Director  kshipley@nw14.esrd.net MRB Workgroup Advisors kshipley@nw14.esrd.net Nathan Muzos, IM Director PAC Advisors  muzos@nw14.esrd.net muzos@nw14.esrd.net Aparna Biradar, QI Analyst  abiradar@nw14.esrd.net abiradar@nw14.esrd.net Dany Anchia, QI Coordinator  danchia@nw14.esrd.net danchia@nw14.esrd.net *Project Lead for InfectionWatch2015’s CDC Audits reporting in NHSN NETWORK 14 HAI TEAM 3

4. NETWORK 14 MISSION STATEMENT We support equitable patient- and family- centered quality dialysis and kidney transplant health care through the provision of patient services, education, quality improvement, and information management. 4

5.  Reduce blood stream infections (BSI) in dialysis facilities by correctly implementing/performing infection control. Network 14 facilities will do this by:  Encouraging/promoting CDC established BSI prevention practices and resources  Identify areas for improvements  Engage staff with regular feedback  Increase familiarity with CDC-recommended practices  Encourage habitual attention to and assessment of infection control and prevention practices  Identify and address barriers to recommended practices  Engage patients in HAI awareness/reduction/elimination activities  Share and spread best practices by participating in the HAI LAN GOALS 5

6. 6

7. STRATEGY ALIGNED WITH METRICS

8. BLOODSTREAM INFECTIONS AND THE QIP 6 8

9. INFECTIONWATCH2015 COMPONENTS Patient Engagement Regional HAI LAN CDC Monthly Audits 9

10. NHSN Eligible facilities for 2015, n= 542 Network analysis of Blood Stream Infection (BSI) rate per 100 patient months, Q2-Q3 2014 New facilities eligible to report in 2015 n=33 Remaining Facilities, n=509 Facilities with 0 BSI rates by “Any CVC” Group 2 Group 1 Facilities with BSI rates in the range of 3.21(±1) by “Any CVC” 2015 HAI Focus Facility Selection NHSN data cross reference with corporate facility selection Corporate selection: -High BSI -Low BSI -Suspected NHSN data accuracy issues SOW requirement: 20% Network facilities 132 facilities chosen (25% over sampled) combination of Group 1 and 2 after facilities with no catheter patients and no NHSN access were removed 23 new facilities 100 corporate selected facilities - some from Network NHSN analysis 9 non-batch submitting facilities from Network NHSN analysis

11. HAND HYGIENE AUDIT TOOL: PAGE 1 Numerator Denominator 11

12. HH AUDIT TOOL: PAGE 2 12

13. WHO 5 MOMENTS FOR HH 13

14. CATH CONNECT/DISCONNECT AUDIT TOOL Numerator Denominator 14

15. AUDIT TOOL CORRESPONDS TO CDC CHECKLIST http://www.cdc.gov/dialysis/PDFs/collaborative/CL_Hemodialysis-Catheter-Connection-508.pdf http://www.cdc.gov/dialysis/PDFs/collaborative/CL-Hemodialysis-Catheter-Disconnection-508.pdf 15

16. AVF/G CANNULATION AUDIT TOOL Numerator Denominator 16

17. AUDIT TOOL CORRESPONDS TO THE CDC AVF/G CANNULATION CHECKLIST http://www.cdc.gov/dialysis/PDFs/collaborative/AV-Fistula-Graft-Cannulation-Observations.pdf 17

18. TRAINING INFORMATION FOR QIA FACILITIES CDC can assist with PPM facility training! 18

19. The Value of Auditing CDC Recommended Infection Prevention Practices  Increased adherence to CDC recommended practices can prevent infections:  Outpatient hemodialysis facilities that implemented the package of CDC recommended practices saw a 32% reduction in BSIs and a 54% reduction in access-related BSIs. 1  Auditing adherence to recommended practices:  Promotes and reinforces recommended practices among staff.  Ensures complete and correct implementation. 1. Am J Kidney Dis. August 2013, 62(2): 322–330 19

20. CDC Infection Prevention Audit Tools  Facilities begin by learning recommended practices:  CDC Recommended Interventions to Prevent Bloodstream Infections in Dialysis Settings: http://www.cdc.gov/dialysis/prevention-tools/core-interventions.html  CDC recommended checklists: http://www.cdc.gov/dialysis/prevention-tools/index.html Simple reference tools useful for training staff.  Then use the audit tools as part of a planned series of observations within their hemodialysis facility. Learn CDC Recommended Practices Implement CDC Recommended Practices Audit CDC Recommended Practices Provide Feedback on Adherence 20

21. Tips for Facilities to Successfully Implement New Practices  Facilities should review current practices to identify discrepancies between current practices and CDC recommended practices.  Facilities should develop an implementation strategy, they may consider:  Input from patient care staff  Training needs  How to inform patients of changes  Whether necessary supplies (e.g., chlorhexidine) are available Learn CDC Recommended Practices Implement CDC Recommended Practices Audit CDC Recommended Practices Provide Feedback on Adherence 21

22. Available CDC Dialysis Infection Prevention Audit Tools: http://www.cdc.gov/dialysis/prevention-tools/index.html HD Catheter Connection/ Disconnection Hand Hygiene Learn CDC Recommended Practices Implement CDC Recommended Practices Audit CDC Recommended Practices Provide Feedback on Adherence AV Fistula/ Graft Cannulation/ Decannulation Although the audit tool includes both cannulation and decannulation, only cannulation is included in the QIA 22

23. Data Collection  All audits – observer(s) should try to ensure that observations are as representative as possible of normal practice at the facility:  Observe different staff members on different days and shifts.  Consider observing during particularly busy times (e.g., shift change), when staff may be less attentive to proper practices. 23

24. How to Use the Audit Tool: Opportunities  Each audit includes multiple observations.  An observation is an opportunity to perform hand hygiene (when warranted)  If an opportunity is observed and hand hygiene is performed, the observation is marked a success: The third observation was not successful because the warranted opportunity for hand hygiene was missed. The first two observations were successful because hand hygiene was warranted and was performed. 24

25. Tallying Opportunity Audit Results  Number of Successful Opportunities: Sum of observed instances during which staff hand hygiene was warranted and was successfully performed.  Total Number Opportunities: Total number of observed instances during which staff hand hygiene was warranted. 1 2 3 4 5 25

26. Audit Results Reported to NHSN  Number of Successful Opportunities: Sum of observed instances during which staff hand hygiene was warranted and was successfully performed.  Total Number Opportunities: Total number of observed instances during which staff hand hygiene was warranted. 1234512345 These are the numbers reported to NHSN 26

27. How to Use the Audit Tools: Procedures  Each audit includes multiple observations.  An observation is the review of a procedure to indicate which steps were performed correctly or incorrectly.  If each step of a procedure is observed and correctly performed, the observation is marked a success: The first observation (catheter connection) was not successful because hub antiseptic was not allowed to dry. The second observation (catheter disconnection) was successful because all steps were observed and completed. 1. 2. 27

28. Tallying Procedure Audit Results  Once all observations have been completed, add the successful observations and note the total number of observations performed: 1 2 3 4 5 6 7 28

29.  Once all observations have been completed, add the successful observations and note the total number of observations performed: Audit Results Reported to NHSN 12345671234567 These are the numbers reported to NHSN 29

30. NHSN PREVENTION PROCESS MEASURES (PPM) MODULE – INFORMATION FOR FACILITIES 30

31. Prevention Process Measures (PPM) Module  How facilities add PPM to Monthly Reporting Plans  How facilities report PPM data to NHSN  How to interpret NHSN missing/incomplete data alerts  How facilities Confer Rights to share data with Groups  Differences for QIA vs. non-QIA facilities  Analysis: available reports and percent adherence 31

32. Facilities Report Audit Results to NHSN  Audit results can be reported to NHSN either “in- plan” or “off-plan.”  In-plan refers to the selections made on the NHSN Monthly Reporting Plan:  By making a selection on the Monthly Reporting Plan, facilities agree to follow the NHSN Protocol for monitoring and reporting of that prevention process measure. NHSN Dialysis Prevention Process Measures Protocol  In-plan reporting requires a minimum number of observations for each audit each month and will generate alerts to remind facility users to report additional data  In-plan reporting is suggested for QIA facilities. 32

33. Monthly Reporting Plan: Prevention Process Measures  Facilities indicate which audits will be performed during the month by checking the corresponding box(es):  By checking the box, the facility agrees to follow the NHSN protocol for monitoring and reporting of that prevention process measure.  There are a minimum number of observations for in-plan reporting, specified below each checkbox. Tip – “Copy from the Previous Month” to make the same selections as before. 33

34. How Facilities Report Audit Results to NHSN  From the navigation bar, select “Summary Data,” then “Add.”  Select “Prevention Process Measures” from the menu.  Click the “Continue” button. 34

35. Numerators and Denominators  Facilities report the sum of successful observations and the total number of observations that month on the Prevention Process Measures form in NHSN NumeratorsDenominators 35

36. Example of Reporting Audit Results to NHSN 5 7 36

37. Combine Multiple Audits of the Same Type, from the Same Month 12 17 Successful Obs. = 5 + 2 + 5 = 12 Total Obs. = 7 + 4 + 6 = 17 37

38. NHSN Action Items and Alerts  If facilities make a Prevention Process Measure (PPM) selection on the Monthly Reporting Plan, but do not:  Report data for it, NHSN will show a Missing Summary Data alert  Report the minimum number of total observations required by the Protocol, NHSN will show an Incomplete Summary Data alert 38

39. Prevention Process Measure Alerts  Missing Summary Data alerts can be removed by:  Reporting the additional data required by the Protocol  Un-checking the surveillance option from that Monthly Reporting Plan (i.e., making the data “off-plan”) 39

40. Prevention Process Measure Alerts  Incomplete summary data alerts can be removed by:  Reporting the additional data required by the Protocol  Un-checking the surveillance option from that Monthly Reporting Plan (i.e., making the data “off-plan”)  Selecting “Dismiss Alert” after the month has ended Alerts for 02/2015 40

41. Prevention Process Measure Alerts  Incomplete summary data alerts can be removed by:  Reporting the additional data required by the Protocol  Un-checking the surveillance option from that Monthly Reporting Plan (i.e., making the data “off-plan”)  Selecting “Dismiss Alert” after the month has ended If too few observations were collected and the month has passed, incomplete alerts can be dismissed. Alerts for 02/2015 41

42. “Confer Rights” Alert for Facility Users with Administrator Rights When Groups request these new data, a Confer Rights alert will display on the facilities’ homepage. 42

43. “Confer Rights” Alert for Facility Users with Administrator Rights  Facility users should click “not accepted” to see all Groups that have modified their data sharing requests 43

44. “Confer Rights” Not Accepted List  Facility administrative users should click on the Group’s name to view the new request 44

45. Facilities “Confer Rights” to Share PPM Data with Group(s)  Facility users should review their Confer Rights screen to see which data the Group is requesting.  All changes are marked: 45

46. Facilities “Confer Rights” to Share PPM Data with Groups  If the facility agrees to share all data specified on the Confer Rights page, they should scroll to the bottom and click the “Accept” button. 46

47. New PPM Reports  Scheduled for April 2015 – Line Listings that calculate percent adherence by month:  Hand Hygiene Percent Adherence  HD Catheter Connection/Disconnection Percent Adherence  AV Fistula/Graft Cannulation/Decannulation Percent Adherence  HD Catheter Exit Site Care Percent Adherence  Dialysis Station Routine Disinfection Percent Adherence  Injection Safety Percent Adherence  Scheduled for July 2015 – Line Listing to review what’s been reported:  All Prevention Process Measures For QIA 47

48. Interpreting NHSN PPM Reports  Percent adherence is calculated by dividing the number of successful observations by the total number of observations and multiplying by 100. Facility Org ID Summary Year/ Month HD Catheter Connection/ Disconnection # of Successful Observations HD Catheter Connection/ Disconnection Total # of Observations HD Catheter Connection/ Disconnection Percent Adherence 123452015M01 61060.0 123452015M02 71070.0 123452015M03 81080.0 Example NHSN Report for HD Catheter Connection/Disconnection 48

49. Online Reporting Resources  Resources for PPM reporting are being updated  E.g., Protocol, training, etc. http://www.cdc.gov/nhsn/dialysis/prevention-process-measures.html 49

50.  Barriers  Performing 50 audits is time consuming  Many patients do not want to wash their access prior to treatment  Staff issues  Lessons learned  Schedule your time  Bad habits in facilities happen over time and auditing is a way to catch and correct  Raised awareness in doctors of their own practices  Assisted facilities stay survey ready  The most successful facilities were those that embraced the project and had fun with it. WHAT WE LEARNED 50

51.  ≥ 30 hand hygiene observations  Collect data using CDC audit tool  Report data to Network via entering results into NHSN  ≥ 10 catheter connection/disconnection observations  Collect data using CDC audit tool  Report data to Network via entering results into NHSN  ≥ 10 fistula/graft cannulation observations  Collect data using CDC audit tool  Report data to Network via entering results into NHSN MONTHLY FACILITY ACTIONS 51

52. PROJECT TIMELINE INFECTIONWATCH2015 FOCUS FACILITY (FF) TIMELINE DESCRIPTIONMARAPRMAYJUNJULAUGSEPOCTNOVDEC Introductory Project Webinar 3/27 or 3/31 FF deadline to accept Network 14 NHSN confer rights template 4/3 FF designate auditors 4/3 FF auditors review CDC audit protocols/guidelines 4/3 Focus Facility InfectionWatch2015 CDC audits begin 4/1 Hand Hygiene audit tallies due in NHSN Cath Connection audit tallies due in NHSN AVF/G audit tallies due in NHSN Patient Engagement HAI Activity Webinar and Selection X Patient Engagement HAI Activity SubmissionX Regional HAI LAN Webinars – 1 X 3Q15, 1X 4Q15 TBD Wrap-Up Project Webinar TBD SEE MONTHLY DUE DATES FOR ENTERING AUDIT TALLIES INTO NHSN

53. Monthly Reporting Due Dates of Audit Tallies in NHSN >= 30 Hand Hygiene observations per month >= 10 Catheter Connection observations per month > = 10 AVF/AVG Cannulation observations per month Audit MonthMayJunJulAugSepOctNovDec April1-May May 1-Jun June 1-Jul July 31-Jul August 1-Sep September 1-Oct October 30-Oct November 1-Dec MONTHLY DUE DATES FOR ENTERING AUDITS INTO NHSN 53

54.  http://esrdnetwork.org/patients-families/patient- representatives/ PATIENT ENGAGEMENT ASPECT 54

55. GEORGIA NORTH CAROLINA SOUTH CAROLINA MISSISSIPPI ALABAMA TENNESSEE TEXAS REGIONAL HAI LEARNING AND ACTION NETWORK (LAN) https://youtu.be/zUnEzRijSBk 55

56. PROJECT LOCATION ON WEBSITE HTTP://ESRDNETWORK.ORG/PROFESSIONALS/QUALITY-IMPROVEMENT/HAI-LAN/ HTTP://ESRDNETWORK.ORG/PROFESSIONALS/QUALITY-IMPROVEMENT/HAI-LAN/ 56

57.  Best Practices Video  Covers hand hygiene, catheter connection/disconnection, and fistula/graft cannulation  Procedure steps mirror the checklists  http://www.cdc.gov/dialysis/prevention-tools/training-video.html http://www.cdc.gov/dialysis/prevention-tools/training-video.html  Catheter Scrub-the-hub Protocol  Key step in catheter connection/disconnection  http://www.cdc.gov/dialysis/PDFs/collaborative/Hemodialysis- Central-Venous-Catheter-STH-Protocol.pdf http://www.cdc.gov/dialysis/PDFs/collaborative/Hemodialysis- Central-Venous-Catheter-STH-Protocol.pdf  Checklist tools  http://www.cdc.gov/dialysis/prevention-tools/index.html http://www.cdc.gov/dialysis/prevention-tools/index.html  Hand Hygiene Observation Protocol  http://www.cdc.gov/dialysis/prevention-tools/Protocol-hand-hygiene- glove-observations.html http://www.cdc.gov/dialysis/prevention-tools/Protocol-hand-hygiene- glove-observations.html ADDITIONAL RESOURCES FOR FACILITIES 57

58.  Introduction to Network 14 HAI Team  Share goals of InfectionWatch2015  Discuss how focus facilities were selected  Explain project components  Provide training material for  Hand Hygiene  Catheter Connection & Disconnection  AVF/G Cannulation  Facility NHSN data entry  Best practices for reporting OBJECTIVES 58

59. Thank you for participating! POLLING QUESTIONS Kelly Shipley, RHIA Quality Improvement Director 469-916-3803 kshipley@nw14.esrd.net Jason Simmington, MHS Quality Improvement Specialist 469-916-3806 jsimmington@nw14.esrd.net 59