INFECTIONWATCH2015
March 27 th &
31 th , 2015
OBJECTIVES
 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
2
*Please utilize the chat function for questions*
NETWORK 14 HAI TEAM
Jason Simmington, QI Specialist*
 jsimmington@nw14.esrd.net
Kelly Shipley, QI Director
 kshipley@nw14.esrd.net
Nathan Muzos, IM Director
MRB Workgroup Advisors
PAC Advisors
 muzos@nw14.esrd.net
Aparna Biradar, QI Analyst
 abiradar@nw14.esrd.net
Dany Anchia, QI Coordinator
 danchia@nw14.esrd.net
*Project Lead for InfectionWatch2015’s CDC Audits reporting in NHSN
3
NETWORK 14 MISSION STATEMENT
We support equitable patient- and familycentered quality dialysis and kidney
transplant health care through the
provision of patient services, education,
quality improvement, and information
management.
4
GOALS
 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
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STRATEGY ALIGNED WITH METRICS
BLOODSTREAM INFECTIONS AND THE QIP
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INFECTIONWATCH2015 COMPONENTS
CDC
Monthly
Audits
Patient
Engagement
Regional HAI LAN
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2015 HAI Focus Facility Selection
NHSN data cross reference with corporate facility selection
NHSN Eligible facilities for 2015, n= 542
New facilities eligible to report in 2015
n=33
Group
1
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
Remaining Facilities, n=509
Corporate
selection:
-High BSI
-Low BSI
-Suspected
NHSN data
accuracy
issues
Network analysis of Blood
Stream Infection (BSI) rate
per 100 patient months,
Q2-Q3 2014
Group
2
Facilities
with 0
BSI rates
by “Any
CVC”
Facilities with
BSI rates in the
range of
3.21(±1) by
“Any CVC”
HAND HYGIENE AUDIT TOOL: PAGE 1
Numerator
Denominator
11
HH AUDIT TOOL: PAGE 2
12
WHO 5 MOMENTS FOR HH
13
CATH CONNECT/DISCONNECT AUDIT TOOL
Numerator
Denominator
14
AUDIT TOOL CORRESPONDS TO CDC
CHECKLIST
15
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
AVF/G CANNULATION AUDIT TOOL
Numerator
Denominator
16
AUDIT TOOL CORRESPONDS TO THE CDC
AVF/G CANNULATION CHECKLIST
17 http://www.cdc.gov/dialysis/PDFs/collaborative/AV-Fistula-Graft-Cannulation-Observations.pdf
TRAINING INFORMATION
FOR QIA FACILITIES
CDC can assist
with PPM facility
training!
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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
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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
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Implement
CDC
Recommended
Practices
Audit CDC
Recommended
Practices
Provide
Feedback on
Adherence
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
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Implement
CDC
Recommended
Practices
Audit CDC
Recommended
Practices
Provide
Feedback on
Adherence
Available CDC Dialysis Infection Prevention Audit Tools:
http://www.cdc.gov/dialysis/prevention-tools/index.html
Hand
Hygiene
HD Catheter
Connection/
Disconnection
AV Fistula/
Graft
Cannulation/
Decannulation
Although the audit tool includes both
cannulation and decannulation, only
cannulation is included in the QIA
Learn CDC
Recommended
Practices
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Implement
CDC
Recommended
Practices
Audit CDC
Recommended
Practices
Provide
Feedback on
Adherence
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.
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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 first two observations were successful
because hand hygiene was warranted and
was performed.
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The third observation was not successful
because the warranted opportunity for
hand hygiene was missed.
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
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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
instancesare
during
These
the
which staff hand hygiene was warranted.
numbers
reported to
NHSN
1
2
3
4
5
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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:
1.
2.
The first observation (catheter connection)
was not successful because hub antiseptic
was not allowed to dry.
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The second observation (catheter
disconnection) was successful because all
steps were observed and completed.
Tallying Procedure Audit Results

1
2
3
4
5
6
7
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Once all observations have been completed, add the
successful observations and note the total number
of observations performed:
Audit Results Reported to NHSN

Once all observations have been completed, add the
successful observations and note the total number
These are the
of observations performed:
numbers
reported to
NHSN
1
2
3
4
5
6
7
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NHSN PREVENTION PROCESS
MEASURES (PPM) MODULE –
INFORMATION FOR FACILITIES
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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

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Analysis: available reports and percent adherence
Facilities Report Audit Results to NHSN


Audit results can be reported to NHSN either “inplan” 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

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In-plan reporting is suggested for QIA facilities.
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.
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How Facilities Report Audit Results to NHSN



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From the navigation bar, select “Summary Data,” then
“Add.”
Select “Prevention Process Measures” from the menu.
Click the “Continue” button.
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
Numerators
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Denominators
Example of Reporting Audit Results to NHSN
5
36
7
Combine Multiple Audits of the Same Type, from the
Same Month
Successful Obs. = 5 + 2 + 5 = 12
12
Total Obs. = 7 + 4 + 6 = 17
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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
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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”)
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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
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Alerts for 02/2015
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 fromIfthat
Reporting
too Monthly
few
Plan (i.e., making the data “off-plan”)
observations were
 Selecting “Dismiss Alert” after the month
has ended
collected
and the
month has passed,
incomplete alerts
can be dismissed.
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Alerts for 02/2015
“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.
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“Confer Rights” Alert for Facility Users with
Administrator Rights

43
Facility users should click “not accepted” to see all
Groups that have modified their data sharing requests
“Confer Rights” Not Accepted List

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Facility administrative users should click on the
Group’s name to view the new request
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:
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Facilities “Confer Rights” to Share PPM Data
with Groups

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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.
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
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For QIA
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.
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑆𝑢𝑐𝑐𝑒𝑠𝑠𝑓𝑢𝑙 𝑂𝑏𝑠𝑒𝑟𝑣𝑎𝑡𝑖𝑜𝑛𝑠
𝑥 100
𝑃𝑒𝑟𝑐𝑒𝑛𝑡 𝐴𝑑ℎ𝑒𝑟𝑒𝑛𝑐𝑒 =
𝑇𝑜𝑡𝑎𝑙 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑂𝑏𝑠𝑒𝑟𝑣𝑎𝑡𝑖𝑜𝑛𝑠
Example NHSN Report for HD Catheter Connection/Disconnection
Facility
Org ID
12345
48
HD Catheter
Connection/
Disconnection # of
Summary
Successful
Year/ Month
Observations
2015M01
6
12345
2015M02
12345
2015M03
7
8
HD Catheter
Connection/
Disconnection
Total # of
Observations
10
10
10
HD Catheter
Connection/
Disconnection
Percent Adherence
60.0
70.0
80.0
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
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WHAT WE LEARNED
 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.
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MONTHLY FACILIT Y ACTIONS
 ≥ 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
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PROJECT TIMELINE
INFECTIONWATCH2015 FOCUS FACILITY (FF) TIMELINE
DESCRIPTION
Introductory Project Webinar
FF deadline to accept Network 14 NHSN confer
rights template
FF designate auditors
MAR
APR
MAY
JUN
JUL
AUG
SEP
OCT NOV DEC
3/27 or
3/31
4/3
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
SEE MONTHLY DUE DATES FOR ENTERING
AUDIT TALLIES INTO NHSN
Cath Connection audit tallies due in NHSN
AVF/G audit tallies due in NHSN
Patient Engagement HAI Activity Webinar and
Selection
Patient Engagement HAI Activity Submission
Regional HAI LAN Webinars – 1 X 3Q15, 1X 4Q15
Wrap-Up Project Webinar
X
X
TBD
TBD
MONTHLY DUE DATES FOR ENTERING
AUDITS INTO NHSN
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 Month
May
April
1-May
May
Jul
Aug
Sep
Oct
1-Jul
July
31-Jul
Dec
1-Sep
September
1-Oct
October
30-Oct
November
Nov
1-Jun
June
August
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Jun
1-Dec
PATIENT ENGAGEMENT ASPECT
 http://esrdnetwork.org/patients -families/patientrepresentatives/
54
GEORGIA
REGIONAL HAI
NORTH CAROLINA
LEARNING AND
SOUTH CAROLINA
MISSISSIPPI
ACTION NETWORK (LAN)
ALABAMA
TENNESSEE
TEXAS
https://youtu.be/zUnEzRijSBk
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PROJECT LOCATION ON WEBSITE
HTTP://ESRDNET WORK.ORG/PROFESSIONALS/QUALIT Y -IMPROVEMENT/HAI-LAN/
56
ADDITIONAL RESOURCES FOR FACILITIES
 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
 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
 Checklist tools
 http://www.cdc.gov/dialysis/prevention-tools/index.html
 Hand Hygiene Observation Protocol
 http://www.cdc.gov/dialysis/prevention-tools/Protocol-hand-hygieneglove-observations.html
57
OBJECTIVES
 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
58
POLLING QUESTIONS
Thank you for participating!
Kelly Shipley, RHIA
Quality Improvement Director
469-916-3803
kshipley@nw14.esrd.net
59
Jason Simmington, MHS
Quality Improvement Specialist
469-916-3806
jsimmington@nw14.esrd.net