Infection Reporting in Hospitals - PowerPoint

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					   Hospital Performance Data
Reporting/Ohio Hospital Compare
            (HB 197)
Ohio Department of Health Mandatory Reporting
           Requirements for HAIs
 What is Required of Hospitals for HAI
 April 1st and October 1st of each year
 Twelve-months of data
   Currently collecting Quarter 3 2008 – Quarter 2 2009 data
 Use the specifications created by the entity that developed or
  endorsed the measure
   CDC – NHSN Manuals
   CMS – Specifications
 All data Reported is presented to the public on Ohio
  Hospital Compare
  CMS Infection Measures
Surgical Care Improvement Project (SCIP)
 All hospitals are required to report to ODH regardless of
  reporting to CMS
 Hospitals must follow the specifications created by CMS for
  each reporting time period
 SCIP procedural measures are intended to improve the safety of
  surgical care through the reduction of postoperative
  CMS Infection Measures
Surgical Care Improvement Project (SCIP) – cont.
 Appropriateness of care measure ( SCIP‐Inf 1a, 2a, 3a)
 SCIP‐Inf 1a‐ h: Prophylactic Antibiotic Received Within One
  Hour Prior to Surgical Incision
 SCIP‐Inf‐2a‐ h: Prophylactic Antibiotic Selection for Surgical
 SCIP‐Inf‐3a‐ h: Prophylactic Antibiotics Discontinued within 24
  Hours after Surgery End Time
 These measures are stratified into 8 surgical categories
   Overall Rate, CABG, Other Cardiac Surgery, Hip and knee
    Arthroplasty, Colon Surgery, Hysterectomy, Vascular Surgery
  CMS Infection Measures
Surgical Care Improvement Project (SCIP) – cont.
 SCIP‐Card‐2: Surgery Patients on Beta Blocker Therapy Prior
  to Admission who Received a Beta Blocker during the
 SCIP‐VTE‐1: Surgery Patients with Recommended Venous
  Thromboembolism Prophylaxis Ordered
 SCIP‐VTE‐2: Surgery Patients who Received Appropriate
  Venous Thromboembolism Prophylaxis Within 24 Hours Prior
  to Surgery to 24 Hours after Surgery
  CDC Infection Measures
Surgical Site Infections
 Setting: surgical patients in any inpatient setting
 Coronary artery bypass graft (CABG)
   For CABG surgeries report: Deep incisional and organ space
    sternal site infections
   Denominator should include both chest incision only and chest
    incision/graft site surgeries
   Infections should only be counted for chest incisions
 C‐Section (CSEC)
 Knee Prosthesis (KPRO)
   For Knee surgeries report: Deep incisional and organ space (knee
    joint) infections
  CDC Infection Measures
C. diff, MRSA and MSSA
 Follow the NHSN Multidrug-resistant Organism (MDRO) and
  Clostridium difficile-Associated Disease (CDAD) Module Protocol
   Laboratory Identified events
 Hospital-Acquired Clostridium difficile (C. Diff.)
 Hospital-Acquired Methicillin Resistant and Methicillin Susceptible
  Staphylococcus aureus Bacteremia (MRSA/MSSA Bacteremia) (SAB)
 Healthcare facility onset
   On or after day 4 with the day of admission indicated as day 1
 Lab confirmed positives
 Not duplicate positives
 Do not include readmission prior to 8 weeks
  ODH Infection Measures
 Health Care Provider Influenza Vaccination
   First collection: Sept 1, 2009 - Mar 31, 2010
   First reporting: October 1, 2010
 Only Seasonal flu
 Count only paid employees as of March 31st each year
    ODH Infection Measures
Hand-washing Program
 Does your hospital have a program to improve hand hygiene practices?
   Yes , No, Under development
 2. Does your hospital teach principles of hand hygiene and proper use of
  gloves to all clinical staff upon hire?
    Yes , No
 3. Does your hospital monitor and provide feedback to clinical staff
  regarding their hand hygiene practices?
    Yes, both, Partial (monitor only), No
 4. In your hospital’s clinical settings, are alcohol-based hand-rubs available
  for use at the point of care?
    Yes , No
 5. In your hospital’s clinical settings, are gloves available for use at the point
  of care?
    Yes , No
 6. Does your hospital prohibit the wearing of artificial nails by direct-care
   Yes , No
  ODH Infection Measures
Infection Control Staffing
 1. Does your hospital employ a qualified Infection Control
  Professional (ICP)?
   Yes, No
 2. Does your hospital employ an Infection Control
  Professional (ICP) who is board certified in infection
  control (CIC)?
   Yes, No
 3. Does your hospital have a board-certified Infectious
  Disease Physician either on staff or available for consult?
   Yes, No
   Process for Reporting
• Currently use an ODH electronic data entry system
• Must coordinate internally with you quality assurance staff
• Refer to the “Hospital Perforamnce Measures Instruction
 Manual for guidance -
   NHSN – Purpose
• Provide facilities with risk-adjusted data that can be used for
  inter-facility comparisons and local quality improvement
• Assist facilities in developing surveillance and analysis methods
  that permit timely recognition of patient and healthcare
  personnel safety problems and prompt intervention with
  appropriate measures.
• NHSN participants will not have to do duplicative entry into
  the ODH Hospital Reporting collection system
   What offers the best transition to
• Use data that is already being collected
• Use a standardized data collection system
• Provide reporting to meet the statute’s requirement
• Provide reports that are easily understood by healthcare
• Provide reports that are easily understood by the general
Please contact Kaliyah Shaheen at 614-995-4982 or with questions

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