NHSN Reporting for Laboratory-identified
Clostridium difficile Infection (CDI) and
Methicillin-resistant Staphylococcus aureus (MRSA)
(Bacteremia)
Presentation to: Georgia Hospital Association
Presented by: Jeanne Negley, MBA,
Healthcare Associated Infection Coordinator
Date: November 15, 2012
AGENDA
Background: Purpose, Requirements, &
References
Starting with Reporting Plans and
Denominators
MRSA Bacteremia Lab ID Event (Numerator)
CDI Lab ID Event (Numerator)
Using Electronic Reporting Systems
Lab ID Event Reporting Categories
(includes risk adjustment)
Frequently Asked Questions
Announcements!
Purpose of MDRO and CDI Lab ID
Event Reporting
•To calculate proxy measures of MDRO and CDI
events, exposures, and healthcare acquisition.
• Provide a monitoring method that enables a facility
to rely almost exclusively on data obtained from the
laboratory.
•Also provide a mechanism for facilities to report and
analyze MDRO and CDI data to inform infection
control staff of impact of targeted prevention efforts.
CMS Reporting Requirements
Laboratory-Identified (Lab-ID) MRSA
(bacteremia) and CDI in NHSN


Begins January 2013 for Inpatient Quality
Reporting Program for hospitals
Overall Facility-Wide Inpatient (LabID, Method C)
Laboratory-Identified (Lab-ID) module


Not an infection event surveillance module
Lab-ID is a laboratory driven surveillance
process
We are not following CDI infection
event surveillance module
LAB ID MDRO/CDI Reporting
References
NHSN MDRO/CDI Module:
http://www.cdc.gov/nhsn/mdro_cdad.html
MDRO/CDI NHSN Protocol:
http://www.cdc.gov/nhsn/PDFs/pscManual/12pscMDRO_CDADcurrent.pdf
CDC Location Labels and Location
Descriptions:
http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_curre
nt.pdf
Table of Instructions: (Make sure you review instructions for
Lab ID for MRSA and CDI.)
http://www.cdc.gov/nhsn/PDFs/pscManual/14pscForm_Instructions_curre
nt.pdf
NHSN definitions can change; consult on-line references.
Reporting Forms
Enter Online. Hardcopy Paper Forms Available.
(http://www.cdc.gov/nhsn/mdro_cdad.html)
1. Monthly Reporting Plan
2. Laboratory-Identified MDRO/CDAD Event
Form
•
This is the numerator: one form per LabID event
3. MDRO and CDAD Prevention Process and
Outcome Measures Monthly Monitoring Form
•
This is the denominator: Inpatient – total patient
days, admissions
Starting with Reporting Plans and
Denominators
•Input Monthly Reporting Plans
Recommend input for entire year
Incorrect /incomplete reporting plans
affect reporting to CMS
•Map all inpatient locations
Both Lab ID MRSA (blood only) and CDI
(stool) are for entire facility (all locations)
Patient Safety Monthly Reporting Plan
Reporting PlanAdd. Input Month and Year.
Scroll down page.
Reporting Plan (Cont.)
1
2
4
5
3
1.
2.
3.
4.
5.
6.
6
Input “FacWideIn” for MRSA.
Check Lab ID Event Blood Specimen Only
Add Row to input CDI plan
Input “FacWideIn” for CDI
Check Lab ID Event All Specimens for CDI
Select “Copy from Previous Month” to input multiple reporting plans.
Summary Data Requirements
MRSA Blood Cultures:
FacWideIn = Total inpatient
admissions and total inpatient days for
the month.
CDI:
FacWideIn = Total inpatient
admissions and total inpatient days
minus admission/pt days accrued in a
NICU or well baby nursery.
MRSA Overall Facility-Wide Inpatient
Patient Days = 2950, Admissions = 300
MICU
Wards
SICU
Well Baby
Nurseries & NICUs
Reference: CDC location list
Pediatric ICU
and Wards
CDI Overall Facility-Wide Inpatient
Patient Days = 2600, Admissions = 250
MICU
Wards
SICU
Pediatric ICU
and Wards
Reference: CDC location list
Exclude
Well Baby
Nursery& NICU
Exclude well baby nurseries
& NICUs. Include maternity
patients and newborn
readmitted to pediatric
unit.
Locations not included in FacilityWide Inpatient
Do NOT include:
• Emergency Department
•Observation Units (<24 hour stay)
• Outpatient Surgery
•Outpatient Radiology
•Outpatient Chemotherapy/Infusion
Service
•Outpatient Dialysis
•Operating Rooms
•Clinics
•Outpatient lab results
ADDITIONAL RULES:
Emergency Department: If ED pt is admitted as inpatient and lab
collected same day as admit, you can report result. Applies to any
outpatient location.
Observation Bed Patients in Inpatient Setting: These patients are
counted as inpatients.
Inputting Denominator Data (1 of 2)
Summary DataAdd. Select “MDRO and CDI
Prevention Process and Outcome Measure Monthly
Monitoring.
Input denominator data every month; even if you do
not have infection events.
Inputting Denominator Data (2 of 2)
For MRSA
For CDI
MRSA Bacteremia Events
(Numerator)
MRSA Definitions
MRSA: S. aureus testing oxacillin-resistant, cefoxitin
resistant, or methicillin-resistant by standard
susceptibility testing methods, or by a laboratory test
that is FDA-approved for MRSA detection from isolated
colonies
MRSA Isolate: Specimen obtained for clinical
decision making that tests positive for MRSA
 Active surveillance testing specimens (e.g., nasal
screen) do not count as clinical specimens
 MUST have a method to differentiate clinical vs.
surveillance cultures (speak with lab)
MRSA Definitions—Blood Culture Only
MRSA Blood Isolate LabID Event: All non-duplicate
MRSA blood isolates
Duplicate MRSA Blood Isolate: MRSA+ blood
culture from the same patient and location,
following a previous positive MRSA-positive blood
culture within the past 2 weeks (14 days)
 There should be a full 14 days with no MRSApositive blood culture for the patient and
location before another blood isolate LabID
event is entered into NHSN for that patient
Identifying a Lab ID MRSA Event
(+) MRSA blood culture test
result (taken for clinical
purposes)
Prior (+) in
< 2 weeks?
No
Lab ID Event
Yes
Duplicate MRSA
Test
Not a Lab ID
Event
MRSA Event Example (1 of 3)
As part of the data review, Betty Brown (infection
preventionist) identifies new MRSA Lab Events (blood
cultures only). For example, Ms. Doe has 5 blood
samples reported (+) for MRSA. Applying the 14-day
rule, only 3 of the 5 samples will be reported.
Last
MRN
Name
987654 Doe
987655 Doe
987656 Doe
987657 Doe
987658 Doe
First
Name
Jane
Jane
Jane
Jane
Jane
DOB
11/3/1967
11/3/1967
11/3/1967
11/3/1967
11/3/1967
Date
Date
Admitted admitted
to Facility
to unit
Unit
1/20/2009 1/20/2009 1MICU
1/20/2009 1/20/2009 1MICU
1/20/2009 1/20/2009 1MICU
1/20/2009 1/20/2009 1MICU
1/20/2009 1/20/2009 1MICU
Date of
Specimen Specimen OrganType
Collection
ism
BLOOD
2/7/2009 MRSA
BLOOD
2/9/2009 MRSA
BLOOD
2/27/2009 MRSA
BLOOD
3/5/2009 MRSA
BLOOD
3/24/2009 MRSA
MRSA Event Example (2 of 3)
Betty proceeds to complete a Lab ID MDRO or CDI event for
each of the three unique events.
EventAdd.
MRSA Event Example (3 of 3)
Always the same
Always the same
Location = where
specimen collected
Auto-fill
Save.
If pt. d/c in past 3 months,
input yes and d/c date.
Lab ID Event CDI
(Numerator)
Definitions
Laboratory-Identified (Lab-ID) CDI event: Any
non-duplicate CDI-positive assay on
unformed stool.
CDI-positive Lab Assay: Positive lab assay
for C. difficile toxin A and/or B, or toxinproducing organism detected from stool
culture or other lab means.
Duplicate C. difficile-positive test: CDIpositive assay from same patient within 2
weeks of previous positive assay.
Identifying a Lab ID CDI Event
(+) C. difficile test result
(on unformed stool)
Prior (+) in
< 2 weeks?
No
Lab ID Event
Yes
Duplicate C.
difficile Test
Not a Lab ID
Event
CDI Event Example (1 of 3)
As part of the data review, Betty Brown identifies new
cases of C. diff. Applying the 14-day rule, only the first of
the 2 (+) stool specimens will be reported as a LabID
event.
MRN
Last
Name
First
Name
754321Pan
Peter
754321Pan
Peter
Date
Date
Admitted admitted
to Facility to unit
Date of
Specimen Specimen OrganDOB
Unit
Type
Collection
ism
C.
5/6/1975 2/2/2009 2/2/20091 MICU STOOL
2/2/2009 Difficile
C.
5/6/1975 2/2/2009 2/2/20091 MICU STOOL
2/7/2009 Difficile
CDI Event Example (2 of 3)
EventAdd
Auto-fill
CDI Event Example (3 of 3)
Always the same
Always the same
Always the same
Auto-fill
Auto-fill
Location = where
specimen collected
Auto-fill
Save.
If pt. d/c in
past 3 months,
input yes and
d/c date.
Lab ID Event Categories
CDI Only
LabID Events Categorized through
NHSN Calculations as
•
Incident CDI Assay: new cases (specimen
obtained >8 weeks after the most recent
LabID Event).
•
Recurrent CDI Assay: CDI LabID Event
from specimen obtained > 2 weeks and
< 8 weeks after the most recent LabID
Event.
LabID Events Categorized through
NHSN Calculations as
1) Healthcare Facility-Onset (HO): LabID Event from
specimen collected >3 days after admission to the
facility (= on or after day 4)
Admission
Discharge
2d
< 4 weeks
CO*
Day 1
HO
CO-HCFA
4-12 weeks
>12 weeks
Indeterminate
CO
Day 4
* Depending upon whether patient was discharged within previous 4 weeks,
CO-HCFA vs. CO (CDI only)
LabID Events Categorized through
NHSN Calculations as
2) Community-Onset (CO): LabID Event from
specimen collected from an outpatient or inpatient ≤ 3
days after admission to the facility (Day 1, 2 or 3 with
date of admission as Day 1)
Admission
Discharge
2d
< 4 weeks
CO*
Day 1
HO
CO-HCFA
4-12 weeks
>12 weeks
Indeterminate
CO
Day 4
* Depending upon whether patient was discharged within previous 4 weeks,
CO-HCFA vs. CO (CDI Only)
CDI Only
LabID Events Categorized through
NHSN Calculations as
3) CO Healthcare Facility-Associated (CO-HCFA):
CO LabID Event collected from a patient who was
discharged from this facility ≤ 4 weeks prior to stool
collection
Admission
Discharge
2d
< 4 weeks
CO*
Day 1
HO
CO-HCFA
4-12 weeks
>12 weeks
Indeterminate
CO
Day 4
* Depending upon whether patient was discharged within previous 4 weeks,
CO-HCFA vs. CO
Facility Healthcare Facility-Onset
Incidence for Lab ID Event
# of all Incident HO LabID
Events per month in the facility
# of patient days for the facility
X 1,000 for MRSA
or
X 10,000 for CDI
Note: There are several prevalence and other incident metrics not
included in this presentation.
MRSA Blood Lab ID FacWideIn
Risk Adjustment Variables
Factor
Description
Facility Bed Size
< 400, >400
Teaching Type
Major Teaching vs. All
Other
Prevalence Rate
Continuous
CDI Lab ID FacWideIn
Risk Adjustment Variables
Factor
Description
CDI Test Type
NAAT (PCR), EIA, NonNAAT(PCR)/EIA Others
Prevalence Rate
Continuous (No COHCFA)
< 100, 101-245, >245
Facility Bed Size
Teaching Type
Major, Graduate,
Limited/Non-Teaching
Using Electronic Surveillance Systems
(1 of 3)
• Includes data mining software (MedMined, Safety Surveiller,
Theradoc, etc.).
•Use a positive culture listing; not HAI listing.
•Emergency Department: may need to designate as
“Inpatient & Outpatient” location.
•Watch for duplicates (within the same month or month to
month).
•Once you retrieve data, you can manually enter into NHSN
or prepare to upload electronically.
Validating Electronic Data (2 of 3)
VALIDATE your Electronic Reporting System
• Compare your electronic IC system totals for patient days and
admissions against alternate source, like a financial report, using NHSN
definitions.
• Does your system count each transfer between units during same
admission as a new admission?
• Does your system count only the Mom or both Mom & Baby (for CDI)?
• Does your system count a patient as discharged from your facility within
the last 3 months if they were in for outpatient Lab work last week, but had
no inpatient admission/discharge for over a year?
Validating Electronic Data (3 of 3)
Before submitting your data:
Confirm your Positive Culture List against
selected patients for download.
• If they don’t match, you may need to manually
add or delete cases.
Verify report is complete and fix any issues
found during validation
• For example, discharged from facility within last
3 months
FAQ (1)
1) What is the most important action to prepare to
report Lab-ID MRSA and CDI?
Obtain a listing of MRSA (bacteremia) and CDI from
your laboratory. Smaller hospitals that have fewer
events can request a list of organisms. This is the
best method to know that your data are correct; it is
not recommended that you rely on reports to the
Infection Prevention team.
Sample Spreadsheet for Lab Line List
Directions to Use Lab Line List
FAQ (2)
2) What if a smaller hospital admits a pt to a
larger hospital in the same health system, and
this pt has a positive CDI assay from the
smaller hospital?
You can report the positive lab if the admission to
the new location is on the same day the specimen
was collected. This applies to transfers from any
other facility or outpatient location.
FAQ (3)
3) If we have a number of admits for each unit, would
you count a transfer from one unit to another as an
admit?
No. Facility-Wide Inpatient Admission Count: Include any
new patients that are assigned to a bed in any inpatient
location within the facility at the time of the facility-wide
admission count. Qualification as a new patient means that
the patient was not present on the previous calendar day at
the time of the patient day count. The daily admission
counts are summed at the end of the calendar month for a
monthly facility-wide inpatient admission count.
http://www.cdc.gov/nhsn/PDFs/PatientDay_SumData_Guid
e.pdf
FAQ (4)
4) What if I have a patient that completed his stay at
my hospital and then a week later as an outpatient
had a specimen drawn that was positive for CDI?
We are reporting Lab ID CDI or MRSA for facility-wide
inpatient (FacWideIn). Inpatient and outpatient reporting
for Lab ID CDI cannot be mixed. Therefore, you do not
include outpatient specimens in your reporting for
FacWideIn. (You may include this data in your internal
reporting system, but do not input into NHSN.)
FAQ (5)
5) When counting patient days and admissions, do
we include “observation” patients?
As long as a patient is on an outpatient
observation unit, you would not count the
observation days as patient days. The date of
admission will be the date of admission to an
inpatient unit. However, if an observation patient is
located on an inpatient unit (like a medical ward),
you would count the observation days as patient
days, with the date of admission being the date of
admission to the inpatient unit.
FAQ (6)
6) A patient had a MRSA-positive blood culture
obtained in the ED and was admitted to an inpatient
unit on the same day. How do I report this LabID
event?
If the date of specimen collection in the ED and the date
of admission to the inpatient unit are the same calendar
date, report the LabID event for the ED and the inpatient
unit. If the patient was admitted to the inpatient unit on a
later date, you report the event for the ED only.
FAQ (7)
7) My facility has a rehab unit with a different CMS
Certification Number than the rest of the facility.
Should this unit be included in LabID surveillance?
If a unit is considered a part of the facility (not just
sharing walls) and there is potential for patient and staff
contact across units, the unit should be included in
FacWideIN LabID surveillance.
FAQ (8)
8) As a follow-up to the previous question, my
facility discharges patients before counting them as
new admissions to the rehab unit. If I include rehab
admissions in my monthly FacWideIN summary
data, patients who went from the hospital to the
rehab unit will be counted twice. What should I do?
We don’t want to double-count admissions. If it’s not
possible to distinguish between patients who arrived
from the facility and those who arrived from elsewhere,
exclude rehab admissions in your FacWideIN counts.
Continue to include rehab patients in patient-day counts.
Announcement 1
CDC expects to release version 7.1 of
NHSN on February 16, 2013.
New release will include updated
protocol (e.g., present on admission,
etc.)
We suggest you wait until new release
before entering 2013 data.
Announcement 2
Get Smart About Antibiotics Week (November 12-18,
2012).
Tools for your antibiotic stewardship program:
http://www.cdc.gov/getsmart/healthcare/
Get CME/CE on antibiotic stewardship:
http://www.cdc.gov/getsmart/healthcare/learn-fromothers/CME/antimicrobial-resistance.html#Stewardship
Acknowledgements
Matthew Crist, MD, MPH
Georgia Department of Public Health
Brynn Berger, MPH, CIC
Tennessee Department of Public Health
Dawn Sievert, PhD, MS
Centers for Disease Control and Prevention
Division of Healthcare Quality Promotion
Questions?
Jeanne Negley, MBA
HAI Coordinator
Georgia Department of Public Health
2 Peachtree Street NW, #14-225
Atlanta, GA 30303
Phone: 404-657-2593
Fax: 404-657-7517
Email: jenegley@dhr.state.ga.us