Data Quality Guidance Manual –This manual outlines the ... You can review vendors that have Passed the AU SDS Validation website.
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Volume 16, Issue 1 Inside this Issue: March 2021 New Publication of Hospital COVID-19 Data 2 Patient Safety Component Updated Patient Safety Analysis Guides 2 2021 NHSN Training Videos Now Available! 3 Antimicrobial Use and Resistance Module Updates 4 Reminder! Data for CMS Quality Reporting Programs due Soon! 8 Outpatient Procedure Component (OPC) No updates at this time -- Long Term Care Facility (LTCF) Component LTCF Updates 9 Healthcare Personnel Safety Component Training Presentation for the New Healthcare Personnel Influenza Vaccination Data Submission Requirement Now Available 10 Dialysis Component Weekly Dialysis Patient COVID-19 Vaccination Module Just Launched 10 NHSN Dialysis COVID-19 Module Update 11 Mark Your Calendars - Q4 2020 QIP Deadline 11 Biovigilance Component Hemovigilance Module Updates 12 General NHSN Information CDA Corner 12 NHSN Help Desk: Activity Update 16 Enrollment Update 16 Page 1 New Publication of Hospital COVID-19 Data CDC recently published an analysis of data collected from the NHSN COVID-19 module. The analysis utilized weighted national and state time series estimates with the aim of creating near-real-time indicators of COVID-19 hospital capacity, which allowed for direct state-to-state comparisons and an accurate picture of the national burden of COVID-19. The paper, titled "Impact of coronavirus disease 2019 (COVID-19) on US Hospitals and Patients, April-July2020", was published in Infection Control and Hospital Epidemiology, and is available at this link: http://dx.doi.org/10.1017/ice.2021.69. PATIENT SAFETY COMPONENT Updated Patient Safety Analysis Guides We are excited to announce the release of updated training resources for NHSN users who are analyzing data in the Patient Safety Component. Please see below for a list of new/updated analysis guides: NEW! How to Add and Analyze Surgeon Codes in NHSN - Surgeon codes are optional data fields that may be entered into NHSN and used in surgical site infection (SSI) data analysis reports. This Quick Reference Guide (QRG) provides instructions for the process of entering and analyzing SSI data by surgeon code. NEW! Data Quality Guidance Manual This manual outlines the recommended data quality verification steps users can perform in the NHSN application to ensure accurate data entry. This manual applies to all HAI types. SIR Guide - The Standardized Infection Ratio (SIR) Guide has been updated to include model details for the Total VAE and IVAC+ SIRs for acute care hospitals. Reporting Procedure Duration Guide - Procedure duration outliers are defined by the universal exclusion criteria in SIR Guide as either a procedure duration that is less than 5 minutes or greater than five times the interquartile range (IQR5). This guide will provide instructions on how to identify procedure duration outlier data using NHSN Analysis reports. Using the Statistics Calculator - The NHSN Statistics Calculator has a new "look and feel" inside the NHSN application. Additional instructions are now available on the data entry screens, and a user-friendly display allows for easy navigation within the Calculator. This guide provides updated instructions for utilizing the six options available in the NHSN Statistic Calculator. Guides for analyzing HAI antimicrobial resistance data These guides have been updated to reflect new phenotype definitions due to the incorporation of additional drugs on the HAI event form in 2021. Updated guides are available for the phenotype definitions, line list, frequency table, and rate table. Page 2 2021 NHSN Training Videos Now Available! The 2021 NHSN Training videos are now available on the NHSN website! Due to the travel concerns related to the COVID-19 pandemic, NHSN will not hold in-person annual training for 2021. As an alternative, the NHSN subject matter experts have created training videos for updates. Recorded presentations cover the following topics: · LabID Analysis in Acute Care Hospitals FAQs and Troubleshooting · MRSA Bacteremia and CDI LabID Event Reporting Refresher · Clarifications to 2021 Bloodstream Infection Definitions · 2021 Secondary BSI and Chapter 17 Updates · Catheter-associated Urinary Tract Infection (CAUTI) Update · Ventilator-associated Event (VAE) and Pediatric Ventilator-associated Event (PedVAE) Analysis · Surgical Site Infection (SSI) Updates and Refresher · Optimizing the Group User Analysis Experience · NHSN Antimicrobial Resistance (AR) Option: Facility-Wide Antibiogram Report · Internal Data Validation · Healthcare Personnel Vaccination Module: Influenza Vaccination Summary Reporting for IRF Units in LTACHs and IPFs Continuing Education CE credits are available after viewing all the 2021 NHSN Training videos. The 2021 NHSN Training videos, Q&A session registration, question form, and continuing education information can be accessed here: https://www.cdc.gov/nhsn/training/annualtraining/index.html Please contact NHSNTrain@cdc.gov with any questions regarding NHSN training activities. Page 3 Antimicrobial Use and Resistance Module Updates NHSN Facility Administrators, De-clutter your Inbox by Assigning AU and AR Option Contacts for your NHSN Facility! NHSN updated the User profile screen to include the ability to designate new and existing NHSN users as Antimicrobial Use (AU) and Antimicrobial Resistance (AR) Option contacts. NHSN Facility Administrators, if your facility submits data into the AU and/or AR Options, please edit the user profile for users that you'd consider to be the correct contact person for these two Options. You can assign more than one facility user as a contact for each Option and a single user can be the contact for both Options. The NHSN AUR Team will use this information to target notifications for AUR related content like AU and AR quarterly users calls, updates regarding AUR resources, and data quality related outreach. You can find the instructions for updating the AUR user profiles in the User Rights in NHSN AUR Module guide in the "Supporting Materials" section of the Antimicrobial Use and Antimicrobial Resistance Options page. New feature will save time updating historical reporting plans Within the December 2020 NHSN update, we updated the application to allow monthly reporting plans containing inactive locations to be edited and saved. Prior to this update, facilities wishing to submit historical AUR data often needed to re-activate old locations to save an updated reporting plan then set the old locations back to inactive again. This change means you'll no longer have to update your locations prior to updating a historical reporting plan hopefully making it easier and faster to submit historical AUR data! Antimicrobial Use and Resistance Module Updates continued on page 5 Page 4 Antimicrobial Use and Resistance Module Updates (continued) Admissions definition clarification The AUR Team conducted facility outreach surrounding discrepancies in FacWideIN admissions counts between the AU Option, AR Option and MDRO/CDI Module. After receiving informative feedback from both facilities and vendors about admission counting, we added clarification to our AUR Module admissions definition. The AUR Module will still define admissions as the aggregate number of patients admitted to an inpatient location within the facility (facility-wide inpatient) starting on the first day of each calendar month through the last day of the calendar month. The following statements were added to the 2021 AUR Module Protocol & FAQs to further clarify the definition: · A patient is counted as an admission when they arrive in an NHSN designated inpatient location regardless of patient status (for example, inpatient, observation). · A patient is counted as an admission even if they are discharged that same calendar day. · The AUR Module definition is different than the MDRO/CDI Module admissions definition. 2020 NHSN Annual Hospital Survey Responses and Potential SAAR Value Changes The 2020 NHSN Annual Hospital Survey is now available and being completed by all NHSN facilities. As a reminder, variables on the annual survey are used in SAAR risk adjustment. Prior to the completion of the 2020 survey, your 2020 and 2021 SAARs were being risk adjusted based on your 2019 survey. Once the 2020 survey has been completed and you've generated new data sets within NHSN, those survey responses will be used to risk adjust your 2020 (and 2021) SAARs. It's possible for the 2020 survey responses to move your facility to a different risk adjustment category for a given SAAR. If this happens, you will notice a change in your 2020 and 2021 SAAR values from what they were when the 2019 survey was being used for risk adjustment. Refer to page 22 of the SAAR Guide for more information: https://www.cdc.gov/nhsn/pdfs/ps-analysis-resources/aur/au-saar-guide-508.pdf. New AUR Resources Posted! AR Option: Facility-Wide Antibiogram Report Training See the NHSN Training article about where to find our new 23-minute training video on the updates to the AR Option Antibiogram Report. AUR Protocol - https://www.cdc.gov/nhsn/pdfs/pscmanual/11pscaurcurrent.pdf The AUR Protocol was recently updated with the clarifications for the admissions definition as listed above. As a reminder, we'd recommend bookmarking the protocol link, instead of downloading a copy, so you're always referring to the most up-to-date version. Antimicrobial Use and Resistance Module Updates continued on page 6 Page 5 Antimicrobial Use and Resistance Module Updates (continued) AU Validation Protocols - https://www.cdc.gov/nhsn/psc/aur/index.html The Implementation and Annual AU Data Validation protocols were reviewed and updated. We encourage facilities to validate their data not only during initial implementation of AU submissions but also on an annual basis. You can find the updated protocols in the Data Validation section of our webpage: AU & AR FAQs - https://www.cdc.gov/nhsn/faqs/faq-au.html & https://www.cdc.gov/nhsn/faqs/faq-ar.html The AU and AR FAQs underwent their yearly update and are now posted. You can find answers to questions we commonly receive through the NHSN Helpdesk. Check them out today! Training Timestamps - https://www.cdc.gov/nhsn/training/patient-safety-component/aur.html PDFs containing the timestamps for our AU and AR Option training videos were added to assist users in navigating to specific parts of the training video. The timestamps are located with their associated videos on the AUR Training page. Antimicrobial Use and Resistance Module Updates continued on page 7 Page 6 Antimicrobial Use and Resistance Module Updates (continued) List of Eligible AUR Antimicrobial Agents - https://www.cdc.gov/nhsn/psc/aur/index.html The 2021 list of eligible antimicrobial agents for the AUR Module has been posted. The Excel workbook lists the drug categories and classes along with the specific code used in the AU and AR CDA files. You can find this list in the Supporting Materials section of our AUR webpage. AU Option Synthetic Data Set Initiative As a reminder, we have a webpage for Antimicrobial Use Synthetic Data Set (AU SDS) Validation here: https://www.cdc.gov/nhsn/cdaportal/au-sds/index.html. It's important for AU reporting facilities to be aware of this new requirement and the validation status of their vendor. However, for facilities using an AU CDA vendor, there is no direct action needed from the facility. You can review vendors that have Passed the AU SDS Validation website. Facilities that create their own AU CDA files in-house using their own "homegrown" IT or informatics resources need to go through the AU SDS Validation process. Please refer to the General NHSN Information CDA Corner section of the NHSN Newsletter below for additional information related to AU SDS Validation. Page 7 Reminder! Data for CMS Quality Reporting Programs due Soon! The following data must be entered NHSN by May 17, 2021, for facilities that participate in certain CMS quality reporting programs. Acute Care Hospitals that participate in the Hospital Value-Based Purchasing and Hospital-Acquired Condition Reduction Program: 2020 Quarter 4 (October 1 December 31) CLABSI and CAUTI data · All ICU locations · Adult and pediatric medical, surgical, and medical/surgical wards 2020 Quarter 4 (October 1 December 31) Inpatient COLO and HYST SSI data 2020 Quarter 4 (October 1 December 31) MRSA Bacteremia and C. difficile LabID Events (all healthcare-onset and community-onset) · FacWideIN · ED and 24-hour observation locations 2020 Quarter 4 & 2021 Quarter 1 (October 1 March 31) Healthcare Personnel Influenza Vaccination Summary data Cancer Hospitals that participate in the PPS-Exempt Cancer Hospital Quality Reporting Program: 2020 Quarter 4 (October 1 December 31) CLABSI and CAUTI data (all bedded inpatient care locations) 2020 Quarter 4 (October 1 December 31) Inpatient COLO and HYST SSI data 2020 Quarter 4 (October 1 December 31) MRSA Bacteremia and C. difficile LabID Events (all healthcare-onset and community-onset) 2020 Quarter 4 & 2021 Quarter 1 (October 1 March 31) Healthcare Personnel Influenza Vaccination Summary data Inpatient Rehabilitation Facilities (IRFs) that participate in the Inpatient Rehabilitation Facility Quality Reporting Program: 2020 Quarter 4 (October 1 December 31) CAUTI data (all bedded inpatient locations) 2020 Quarter 4 (October 1 December 31) C. difficile LabID Events (all healthcare-onset and community-onset) · Freestanding IRFs: Reporting by FacWideIN · IRF units within other hospital types: Reporting by each CMS IRF unit 2020 Quarter 4 & 2021 Quarter 1 (October 1 March 31) Healthcare Personnel Influenza Vaccination Summary data · IRF units within other hospital types must submit a separate summary record specifically for the IRF unit: http://www.cdc.gov/nhsn/pdfs/training/vaccination/hcp-flu-vaccination-summary-reporting-irf-trainingslides.pdf. Long-Term Acute Care Facilities (LTACs/LTCHs) that participate in the Long-Term Care Hospital Quality Reporting Program: 2020 Quarter 4 (October 1 December 31) CLABSI and CAUTI data (all bedded inpatient locations) 2020 Quarter 4 (October 1 December 31) C. difficile LabID Events (FacWideIN, all healthcare-onset, and community-onset) 2020 Quarter 4 & 2021 Quarter 1 (October 1 March 31) Healthcare Personnel Influenza Vaccination Summary data Reminder! Data for CMS Quality Reporting Programs due Soon continued on page 9 Page 8 Reminder! Data for CMS Quality Reporting Programs due Soon! (continued) Please ensure that at least one individual at your facility can access NHSN via their Secure Access Management Services (SAMS) account and has been assigned appropriate user rights in NHSN to enter and view your facility's data. To guarantee that your data is accurately entered into NHSN, verify that; 1) your monthly reporting plans are complete; 2) you've entered appropriate summary and event data or checked the appropriate no events boxes; and 3) you've cleared all alerts from your NHSN facility homepage. For additional guidance on ensuring your data are accurately sent to CMS for Quality Reporting purposes, please visit our website and navigate to the appropriate section(s) for your facility type: https://www.cdc.gov/nhsn/cms/index.html If you have any questions, please contact the NHSN Helpdesk: NHSN@cdc.gov. The NHSN Helpdesk is staffed Mondays thru Fridays, 7 am ET 5 pm ET, excluding Federal Holidays. LONG-TERM CARE FACILITY COMPONENT LTCF Updates Updates can be found in the LTCF newsletters, available here: https://www.cdc.gov/nhsn/ltc/newsletters/index.html Page 9 HEALTHCARE PERSONNEL SAFETY COMPONENT Training Presentation for the New Healthcare Personnel Influenza Vaccination Data Submission Requirement Now Available The following units with these facilities are now required to report healthcare personnel (HCP) influenza vaccination data to NHSN beginning with the 2020-2021 influenza season: · Inpatient psychiatric facility units and inpatient rehabilitation facility units located within long-term acute care facilities · Inpatient psychiatric facility units located within inpatient rehabilitation facilities · Inpatient rehabilitation facility units located within inpatient psychiatric facilities A video presentation on the new healthcare personnel influenza vaccination data submission requirement is available and posted on the NHSN website: https://www.cdc.gov/nhsn/training/annualtraining/index.html. The presentation reviews the NHSN HCP Vaccination Module, how to get started in the HCP Safety (HPS) Component and describes reporting requirements for the HCP Influenza Vaccination Summary. Facilities are required to report these data to CDC by May 17, 2021. Training materials should be posted on the NHSN website by April 2021. CDC apologizes for the delay in providing these materials. If you have any questions about this new requirement, please send an e-mail to: NHSN@cdc.gov with `HPS Flu Summary' in the subject line. DIALYSIS COMPONENT Weekly Dialysis Patient COVID-19 Vaccination Module Just Launched CDC released a new weekly COVID-19 vaccination data reporting module for dialysis patients in March 2021. This module allows dialysis facilities to track and report COVID-19 vaccination patient data using the NHSN Dialysis Component. Facilities will report COVID-19 vaccination status for patients receiving dialysis care from the facility during the current reporting week, including in-center dialysis patients and home dialysis patients. The weekly Dialysis Patient COVID-19 Vaccination Module is designed to allow reporting of vaccination percentages and to ensure consistent reporting over time within a single dialysis facility. The data will help to identify dialysis patients with lower vaccination rates, improve vaccination tracking, and monitor vaccination trends over time. Training materials (such as data collection forms, tables of instructions, .CSV data file instructions, and a data tracking worksheet) can be accessed using this link: https://www.cdc.gov/nhsn/dialysis/pt-covid-vac/index.html. Weekly Dialysis Patient COVID-19 Vaccination Module Just Launched continued on page 11 Page 10 Weekly Dialysis Patient COVID-19 Vaccination Module Just Launched (continued) Dialysis facilities can also track weekly COVID-19 vaccination data for healthcare personnel (HCP). These data are reported through the NHSN Healthcare Personnel Safety (HPS) Component. Training materials can be accessed using this link: https://www.cdc.gov/nhsn/hps/weekly-covid-vac/index.html. Please send all questions and concerns to user support at: nhsn@cdc.gov and include `Weekly COVID-19 Vaccination' in the subject line of the e-mail. NHSN Dialysis COVID-19 Module Update In March 2021, several updates were made to the COVID-19 Dialysis Module. The calendar feature used for COVID-19 data entry is now in a weekly format to more accurately represent the surveillance or reporting week. Users can click on the week they are entering data to be directed to the COVID-19 data entry form. The COVID-19 data entry form now has an additional data field where a value for "total number of staff (physicians, nurses, technicians, etc.) who work at least one day during the current reporting week" can be entered. This will be a required field that must be completed weekly. The updated COVID-19 Module Table of Instructions (TOI) and forms can be found on the NHSN website at https://www.cdc.gov/nhsn/dialysis/covid19/index.html . There are also updated resources for facility and group users who use csv files to upload data. Mark Your Calendars Q4 2020 QIP Deadline The Quarter 4 deadline for the Centers for Medicare and Medicaid (CMS) End Stage Renal Disease (ESRD) Quality Incentive Program (QIP) rule for calendar year 2020 (payment year 2022) is right around the corner! Quarter 4 2020 data deadline for reporting is Wednesday, March 31, 2021. Facilities reporting to NHSN should report all three months (October, November, and December 2020) of data no later than March 31, 2021 to receive full credit for Quarter 4 reporting and meet requirements for the CMS ESRD QIP. Page 11 BIOVIGILANCE COMPONENT Hemovigilance Module Updates The NHSN-Biovigilance Component's training Introduction to Hemovigilance Module Reporting is currently being updated. We are in the process of renewing our continuing education credits so that our users may receive appropriate credit. Access to the training will remain on the NHSN website. Continuing education credit will be available again after March 22, 2021. Questions Regarding Hemovigilance Module For additional information please send all questions regarding the Hemovigilance Module (i.e., technical issues, support questions) to nhsn@cdc.gov and include `Hemovigilance' in the subject line for a quicker response. GENERAL NHSN INFORMATION CDA Corner Notes on the NHSN Release Schedule · Release 9.5.2 was deployed to NHSN on 03/04/2021. This release largely included updates to the LTC COVID- 19 Module. o Additionally, CEFTAR was missing `N' as an accepted susceptibility, this was corrected in v9.5.2. · Release 9.5.2 will be added in NPPT. o The NPPT site is currently on v9.5.1 Please send any issues found to NHSNCDA@CDC.GOV. COVID-19 Data Uploads · Please visit the NHSN COVID-19 Information webpage for more details: https://www.cdc.gov/nhsn/covid19/index.html o The new forms are on the website and will be valid from 03/08/2021, with the v9.5.2 update. · Currently, COVID-19 Module is available for LTC and Dialysis facilities. COVID-19 Addition to HAI CDAs · The following CDAs will have a new COVID-19 question added: BSI, SSI, VAE, and UTI. o The companion guide (R3-N1) to start development of these new CDAs can be found in "CDA 9.5 Guides" zip file within the Release 9.5 toolkit: https://www.cdc.gov/nhsn/cdaportal/toolkits.html. o This question is currently being updated, more information will be shared once the question is finalized. CDA Corner continued on page 13 Page 12 CDA Corner (continued) · The COVID-19 question is currently optionally available for manual entry within the NHSN User Interface. · POC Data can be uploaded via CSV through Direct Automation. Send an email to NHSNCDA@CDC.GOV to request more information. The accepted format is either CSV or HL7 2.5.1. o POC CSV manual import will be developed for use in the near future. CDA Vendor Webinar · Scheduled for April 27, 2021 from 12:00pm 1:30pm ET. Registration information will be sent soon. Antimicrobial Use Synthetic Data Set (AU SDS) version 4.3 Please use release 4.3 as the version for AU SDS Validation if you have not already passed AU SDS Validation as documented on the Vendors that have Passed the AU SDS Validation website. The AU SDS release 4.3 can be downloaded from the main AU SDS Validation website. Antimicrobial Use Option Synthetic Data Set Initiative 2021 Requirement Antimicrobial Use Synthetic Data Set (AU SDS) Validation is required prior to submitting 2021 AU CDA files. This means that all production 2021 AU Summary CDA files must contain the SDS Validation ID - provided by the NHSN Team after confirmation of successful validation - and must contain a Vendor (Application) OID. NHSN will reject 2021 AU Summary CDA files that do not contain this information. NHSN will continue to accept 2020 AU Summary CDA files without the SDS information. It is the vendor's responsibility to obtain the Vendor (Application) OID. Please see the following website for instructions: https://www.cdc.gov/nhsn/cdaportal/au-sds/oid.html. Note that PHINTECH, the issuing authority of the Vendor OID, cannot answer questions about next steps about AU SDS Validation. If vendors still have questions after reviewing the AU SDS material including instructions and FAQs available on the CDA Submission Support Portal at the following link, https://www.cdc.gov/nhsn/cdaportal/au-sds/index.html, then please email nhsncda@cdc.gov. AU SDS FAQ We encourage vendors to review all the AU SDS FAQs at the beginning and throughout working through AU SDS Validation as many of the questions that we receive are already answered here. AU SDS FAQs are available at the following link: https://www.cdc.gov/nhsn/cdaportal/au-sds/sds-faq.html Antimicrobial Resistance Synthetic Data Set We are still working on creating an Antimicrobial Resistance Synthetic Data Set (AR SDS). We hope to begin piloting in 2021. If you would like to be a pilot participant, please send an email to nhsncda@cdc.gov indicating your interest. If you have any AU or AR SDS questions, please email nhsncda@cdc.gov. CDA Corner continued on page 14 Page 13 CDA Corner (continued) CDA and CSV Import Metrics Update Guide to CDA Versions · The Guide to CDA versions on the NHSN CDA Submission Support Portal is always available to verify valid CDA imports based on the correct Implementation Guide. · We've now included guidance for 2021: http://www.cdc.gov/nhsn/cdaportal/toolkits/guidetocdaversions.html Page 14 CDA Corner continued on page 15 CDA Corner (continued) As an Important Reminder... Not all NHSN changes are documented in the IDM so be sure to reference the updated protocols. Other helpful links are the following: · Archived Newsletters: https://www.cdc.gov/nhsn/newsletters/index.html · Archived NHSN email communication: https://www.cdc.gov/nhsn/commup/index.html · CDA vendor webinars & training videos: https://www.cdc.gov/nhsn/cdaportal/webinars.html Update for CDA Direct Automation At this time, over 7,000 facilities from 20 separate vendors have signed up for DIRECT CDA Automation. If your facility is sending data via CDA and you are interested in learning more about DIRECT CDA Automation, ask your CDA vendor or check out the information on the CSSP site: http://www.cdc.gov/nhsn/cdaportal/importingdata.html#DIRECTProtocol. Page 15 NHSN Help Desk Activity Update Quarter 1, 2021 (Averages) 2, 081 Email Inquiries per Week 184 Facilities Enrolled NHSN Enrollment Update NHSN Enrollment Update (as of March 22, 2021): 6,935 Hospitals (this includes 459 Long-term Acute Care Hospitals and 397 Free-standing Inpatient Rehabilitation Facilities) 7,900 Outpatient Hemodialysis Facilities 4,675 Ambulatory Surgery Centers (ASCs) 17,843 Long-term Care Facilities 37,353 Total Healthcare Facilities Enrolled The National Healthcare Safety Network (NHSN) is a voluntary, secure, Internet-based surveillance system that integrates patient and healthcare personnel safety surveillance systems managed by the Division of Healthcare Quality Promotion (DHQP) at CDC. During 2008, enrollment in NHSN was opened to all types of healthcare facilities in the United States, including acute care hospitals, long-term acute care hospitals, psychiatric hospitals, rehabilitation hospitals, outpatient dialysis centers, ambulatory surgery centers, and long term care facilities. The Centers for Disease Control and Prevention (CDC) MS-A24, 1600 Clifton Road, Atlanta, GA 30333 E-mail: NHSN@cdc.gov; CDC's NHSN Website: www.cdc.gov/nhsn Page 16Microsoft Word for Microsoft 365