Latest / The SHEA Podcast / Basics of NHSN, Public Reporting, Payment reduction and Regulatory Agencies

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Basics of NHSN, Public Reporting, Payment reduction and Regulatory Agencies · The SHEA Podcast

• 0:08
  SPEAKER_01: Welcome to the podcast series, Infection Control Basics, brought to you by the Society for Healthcare Epidemiology of America, SH, which promotes the prevention of healthcare associated infections and antibiotic resistance and seeks to advance the field of healthcare epidemiology and epic.
• 0:35
  SPEAKER_01: Our two categories are Dr.
• 0:36
  SPEAKER_01: Sarah Hexer and Dr.
• 0:38
  SPEAKER_01: Archives.
• 0:40
  SPEAKER_01: Dr.
• 0:40
  SPEAKER_01: Sarah Hecker ID.
• 0:42
  SPEAKER_01: And is the hospital academic for Base Data and Dr.
• 0:46
  SPEAKER_01: Massachusetts.
• 0:48
  SPEAKER_01: He's an associate professor at CNAC Medical School Base Data.
• 0:51
  SPEAKER_01: And is the Vice Chair for Clinical Operations in the Department of Medicine.
• 0:56
  SPEAKER_01: Dr.
• 0:56
  SPEAKER_01: Surveys is the Associate Director for Healthcare Associated Infection Prevention Programs in the Division of Healthcare Quality Promotion Effects for Disease Control and Prevention.
• 1:06
  SPEAKER_01: His primary responsibilities include oversight and coordination of efforts to eliminate health care associated infections and reduce antibiotic resistance.
• 1:14
  SPEAKER_02: Great.
• 1:15
  SPEAKER_02: Thanks for the introductions.
• 1:16
  SPEAKER_02: So this is Sarah Hessler, and I just wanted to thank you, Arjun, for joining me today to talk about all of the topics that Jay just introduced.
• 1:26
  SPEAKER_02: So, you know, from a hospital epidemiologist standpoint, I feel like there is a lot of sort of mystery around NHSN and CMS, and a lot of people don't really understand it.
• 1:37
  SPEAKER_02: And it feels a little bit like a black box to people.
• 1:40
  SPEAKER_02: So the goal of today is to sort of demystify these areas for people that practice hospital epidemiology and really open it up and just make sure that we have a good basic understanding of the terminology and what NHSN can do for you.
• 1:56
  SPEAKER_02: Why do we use it?
• 1:57
  SPEAKER_02: And talk about HAI program and sort of basic definitions around surveillance and why we might want to even perform surveillance.
• 2:06
  SPEAKER_02: What does it get for us?
• 2:07
  SPEAKER_00: Yeah, absolutely.
• 2:09
  SPEAKER_00: So it's a real pleasure to get to talk to you, Sarah.
• 2:12
  SPEAKER_00: And this will be fun because I think I'll be able to provide kind of in theory what we think happens with all of this stuff.
• 2:18
  SPEAKER_00: And you can tell folks how that translates into reality.
• 2:21
  SPEAKER_00: You can tell us how close we are to achieving the big aims that we set for ourselves.
• 2:25
  SPEAKER_00: So I can start with, I think it's useful to just start with a little bit, a very brief history of the national healthcare safety network, you know, how all of this came to be.
• 2:34
  SPEAKER_00: So many years ago, back in the 70s, there was a surveillance system that was started at CDC, called the National Nosocomial Infection Surveillance System or the NIST system.
• 2:44
  SPEAKER_00: And the system was started because the healthcare epidemiology community, which was pretty small at that point, but a growing community, was beginning to realize that benchmarking was so important for them to try and figure out how to best reduce infections, right?
• 3:00
  SPEAKER_00: They said, like, look, we're monitoring these things because we know that these are events that we're trying to prevent central line associated bloodstream infections, catheter-associated urinary tract infections, surgical site infections, right?
• 3:12
  SPEAKER_00: There's a little bit of research that suggests to us that these things are preventable.
• 3:16
  SPEAKER_00: We're trying to prevent them.
• 3:18
  SPEAKER_00: But if we don't know where we stand compared to other hospitals, it's very hard for us to know if we're doing a good job at preventing them or a bad job at preventing them.
• 3:27
  SPEAKER_00: So that's where NIST arose.
• 3:29
  SPEAKER_00: It was a system with 300 or so hospitals from around the country who would do surveillance.
• 3:36
  SPEAKER_00: And CDC worked with experts to create these surveillance definitions for what is an infection.
• 3:42
  SPEAKER_00: And then infection preventionists would do the surveillance and they would send that data into CDC.
• 3:48
  SPEAKER_00: Back in the day, I'm told I wasn't here then, but I'm told that it used to be literally would come in on floppy disks.
• 3:54
  SPEAKER_00: So it was a DOS-based system that people would enter data onto these floppy disks and send it into CDC.
• 4:01
  SPEAKER_00: And then CDC would publish these reports on rates of infections for all different location types in the hospitals, focused primarily on intensive care unit locations.
• 4:11
  SPEAKER_00: And then, you know, as things progressed, that system was in place for a very long time.
• 4:16
  SPEAKER_00: It was in place for, I think, 30 or so years.
• 4:19
  SPEAKER_00: The definitions evolved.
• 4:21
  SPEAKER_00: You know, there was more understanding of how to define them.
• 4:23
  SPEAKER_00: So the definitions got more and more sophisticated, accounting for new changes in practice and all those kinds of things.
• 4:29
  SPEAKER_00: And then in the early 2000s, there was really the sense that, gosh, you know, it's a closed system, right?
• 4:35
  SPEAKER_00: Only 300 hospitals can participate.
• 4:37
  SPEAKER_00: And with the advent of the internet, there was this movement to say, well, we should really have a bigger system, right?
• 4:44
  SPEAKER_00: We should have a web-based system so that anybody who wants to submit data could participate.
• 4:51
  SPEAKER_00: So many hospitals are doing this type of surveillance.
• 4:53
  SPEAKER_00: Let's open it up.
• 4:54
  SPEAKER_00: And so that was the genesis of the national healthcare safety network, which launched, I think, in 2006.
• 5:01
  SPEAKER_00: And it was this system that was open.
• 5:03
  SPEAKER_00: It was an internet-based system and everybody could report.
• 5:06
  SPEAKER_00: So that infrastructure came into being at about the time when CMS became really interested in the issue of preventable adverse events in hospitals.
• 5:19
  SPEAKER_00: And one of the events that they, you know, as they read the literature and came to an understanding, some of the events that they understood that were potentially preventable were healthcare-associated infections.
• 5:30
  SPEAKER_00: And so, you know, as this began to move forward, especially with the advent of the Affordable Care Act and the real push towards paying for higher quality health care.
• 5:42
  SPEAKER_00: So let's not pay for things that are preventable.
• 5:44
  SPEAKER_00: We shouldn't reward people for preventable adverse events.
• 5:49
  SPEAKER_00: There was a move towards let's begin doing this in a way we need to begin monitoring these infections in a way that would facilitate payment incentives and penalties for people who were either doing really well with preventing adverse events or doing really poorly.
• 6:05
  SPEAKER_00: And so CMS approached CDC and said, we want your help in identifying like what are pre- what are conditions that are potentially preventable and where could we be targeting these prevention efforts?
• 6:17
  SPEAKER_00: And we'll need to come up with a way to monitor them, obviously.
• 6:21
  SPEAKER_00: And so we engaged in these discussions with CMS.
• 6:24
  SPEAKER_00: And you know, as this began moving forward, there's the real sticking point became, well, if we're gonna do this, CMS was saying, well, we we're gonna have to come up with a monitoring system.
• 6:34
  SPEAKER_00: So the initial discussion was, well, CMS is gonna have to create an entire monitoring system for healthcare associated infections if we want to make this part of the payment program.
• 6:45
  SPEAKER_00: And so when we began discussing with them, we're like, gosh, we've got this new infrastructure, we've got the National Healthcare Safety Network, we've got 30 years of experience with definitions, with how to do them, how to change them.
• 6:57
  SPEAKER_00: What if you, CMS, used the CDC system, NHSN, for the payment program?
• 7:05
  SPEAKER_00: And this was a big transition.
• 7:07
  SPEAKER_00: This was, you know, CMS had never used a non-CMS system for their payment programs, but to them it made a lot of sense.
• 7:15
  SPEAKER_00: And so this was a complete kind of reimagination of the role of NHSN.
• 7:21
  SPEAKER_00: And what happened was NHSN went from being a kind of small voluntary system that people used to report data and to get benchmarks to being the foundation system that CMS was going to use for their payment programs.
• 7:37
  SPEAKER_00: So, you know, in the matter in a span of a few years, enrollment in NHSN went from a few hundred voluntary facilities to thousands of facilities who were reporting because of mandates.
• 7:51
  SPEAKER_00: And over time, NHSN has grown to try to accommodate the capacity that CMS wants to have for reporting all of these types of adverse events.
• 8:00
  SPEAKER_00: And you know, we have really worked very hard with CMS to be that one-stop shop for them.
• 8:07
  SPEAKER_00: When they began moving forward on dialysis reporting, we said, you know, let us try to build that capacity in NHSN to do dialysis reporting with ambulatory surgical centers, with inpatient rehabilitation facilities.
• 8:20
  SPEAKER_00: So over time, NHSN has become huge.
• 8:24
  SPEAKER_00: There are now more than 20,000 healthcare facilities that report data into NHSN.
• 8:30
  SPEAKER_00: So we've come from a 300 hospital system to a 20,000 facility reporting system that includes acute care hospitals, several thousand nursing homes, several thousand dialysis facilities, several thousand ambulatory surgical centers, long-term acute care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities.
• 8:51
  SPEAKER_00: So it's grown tremendously.
• 8:54
  SPEAKER_00: But I think that synergy has been really good.
• 8:57
  SPEAKER_00: And it was a great model of collaboration where CMS kind of rather than creating their own system, NHSN used the system that was already in place.
• 9:06
  SPEAKER_00: And of course, the advantage there is that CDC continues to be the subject matter experts there.
• 9:13
  SPEAKER_00: So we continue to work with the field, work with healthcare epidemiology experts to really define like how do we use the definitions, what's preventable, where should we be targeting efforts, how do we make the system usable for healthcare epidemiologists?
• 9:30
  SPEAKER_00: So NHSN is a system that we view as being kind of dual functional.
• 9:35
  SPEAKER_00: Obviously, it serves CMS's needs for reporting and payment determinations, but we also view it as being a service system to the healthcare epidemiologist.
• 9:46
  SPEAKER_00: So the tools that are built in there, the analyses that you can run, are intended to allow you to look at your rates of infections, your standardized infection ratios, to compare that to the nation, to other hospitals, to risk adjust, to understand where you might have opportunities for prevention.
• 10:06
  SPEAKER_00: You know, there are functionalities built in, like a targeted assessment for prevention functionality, which allows you to translate rates into numbers of infections needed to prevent in order to reach target standardized infection ratios.
• 10:20
  SPEAKER_00: So we do view it as a system that hopefully is truly dual functional, where it's useful for CMS, but also useful for prevention.
• 10:30
  SPEAKER_00: So that I think is kind of the maybe not so brief history of how we landed where we did with the National Healthcare Safety Network.
• 10:36
  SPEAKER_00: But I think that's important context for people to understand that this really is a system that, yes, CMS uses that data, but we view the system as serving the needs of the healthcare epidemiology community.
• 10:49
  SPEAKER_00: And we're always open to knowing more about how we can make the system more useful to healthcare epidemiologists.
• 10:57
  SPEAKER_00: And a quick example before I kind of stop talking is the with the definitions, right?
• 11:03
  SPEAKER_00: So there is a panel of folks, there's a whole change control board, it's called at NHSN that is constantly reviewing the definitions.
• 11:13
  SPEAKER_00: And so we get emails, dozens, hundreds of emails from people about definitions, about hey, we had this case, we think the definition would be better for a CLABSE if you excluded this or adjusted for that or accounted for this.
• 11:26
  SPEAKER_00: And we look at all those suggestions all the time, and that's how definitions get changed in NHSN.
• 11:33
  SPEAKER_00: So the changes that we make to the definitions really come from the field, and it's as the science evolves and as people make suggestions, NHSN is then able to make adjustments to try and accommodate for all of that.
• 11:48
  SPEAKER_00: So, you know, that's the system itself and how we conceive of it and how we use it.
• 11:53
  SPEAKER_00: So I would love to hear from you.
• 11:54
  SPEAKER_00: So, you know, you I assume uh probably interact with NHSN, your IPs, I assume, on a nearly a daily basis, but you on a really regular basis.
• 12:03
  SPEAKER_00: So, I mean, how does it work for you?
• 12:05
  SPEAKER_02: So thanks.
• 12:06
  SPEAKER_02: That's a really great overview, Arjun.
• 12:08
  SPEAKER_02: You know, as a as a hospital epidemiologist, I think that NHSN is really very central to the work that we do, but we don't necessarily interact with it on a daily basis the way that the infection preventionists do.
• 12:21
  SPEAKER_02: I mean, they're they're, you know, on a daily basis interacting, entering data and pulling reports.
• 12:27
  SPEAKER_02: And I think it's it's worth noting for people that don't use NHSN that it's a system really where you're doing a lot of entering of data, but the data doesn't get pushed to you.
• 12:38
  SPEAKER_02: You have to pull it out.
• 12:39
  SPEAKER_02: And so, and what you can pull out are reports that tell you, as you referred to previously, what your standardized infection ratio is and your standardized utilization ratio, which can really help you to sort of benchmark yourself on how you're doing.
• 12:55
  SPEAKER_02: I feel like um, and I don't know when this occurred, maybe you can fill us in on this, but we went from just looking at rates and you had to try to guess where you were in terms of your hospital's size and composition and complexity compared to other hospitals in the country.
• 13:11
  SPEAKER_02: And then we switched over to using the standardized infection ratio, which you know really helped us to understand sort of benchmarking against what's expected for us in particular.
• 13:21
  SPEAKER_02: And I think that change has helped us to be more targeted in understanding, okay, you know, I think there's a little bit of a desire sometimes to say, well, you know, our hot our rate may be higher, but it's because we're being compared to organizations that don't have as complex cases as we have.
• 13:38
  SPEAKER_02: So therefore it's okay in a way, whereas this methodology really helps you to understand where you're supposed to be and how can you get there.
• 13:48
  SPEAKER_02: You know, and that's then the job of the hospital epidemiologist and the infection preventionist to look at what are you doing in your organization to help you to address that uh SIR that's higher than where it should be.
• 14:02
  SPEAKER_02: So that's kind of a 10,000-foot overview for healthcare epidemiologists in terms of what we do with NHSN.
• 14:10
  SPEAKER_02: Arjun, I wanted to ask you about the importance of surveillance overall.
• 14:14
  SPEAKER_02: Like, why do we do surveillance and why did we choose historically and why do we continue to choose the measures that we choose?
• 14:21
  SPEAKER_02: So Cloud C, CODI, surgical site infections, DAP, C diff rates, MRSA, why are we focusing on those things and why do we even look at them in the first place?
• 14:32
  SPEAKER_02: What is that from the perspective of NHSN and the CDC, why would we choose to focus on those things in particular?
• 14:39
  SPEAKER_00: Yeah, it's those are all great questions.
• 14:41
  SPEAKER_00: And you know, I think that you know it's it's that old adage that what gets measured gets done, or what gets measured gets addressed, right?
• 14:48
  SPEAKER_00: So if we don't do surveillance, if we don't monitor things, then we really don't know what we're doing in the field.
• 14:53
  SPEAKER_00: And so that is, I think, where really where all of this arose from was the need to say, well, look, if we think that there are things that we should be preventing, we have to measure them so that we know how many are occurring and how many we're preventing and whether or not we're making progress.
• 15:06
  SPEAKER_00: And then the challenge then becomes, well, well, what should we be measuring?
• 15:09
  SPEAKER_00: And that is always, you know, that's always been kind of the central question for really for the entire healthcare epi community.
• 15:17
  SPEAKER_00: And, you know, I think it began way back when with device associated infections, because there was a sense that, you know, well, we could prevent some of those.
• 15:25
  SPEAKER_00: And there was experience from outbreaks, and then there were some guidelines for prevention, and there was a sense that, well, we could probably prevent some of these infections.
• 15:32
  SPEAKER_00: So, you know, initially it really was kind of central line associated bloodstream infections, catheter-associated urinary tract infections that were kind of the focus of the monitoring systems, along with surgical site infections, because again, there was uh some pretty good data suggesting that if you monitor those infection rates, if you fed that data back to surgeons, you could make progress in preventing those outcomes.
• 15:54
  SPEAKER_00: So over time, the preventability piece has always been the focus of what we should be monitoring.
• 16:01
  SPEAKER_00: You know, you're never monitoring for monitoring's sake, you're monitoring as a servant to prevention.
• 16:07
  SPEAKER_00: So certainly, you know, you're looking for things that are important infections that are also preventable ones.
• 16:16
  SPEAKER_00: And so that's really kind of how this has evolved, and it's where the focus is.
• 16:20
  SPEAKER_00: So, you know, certainly we know that there's long-standing prevention recommendations for centraline associated bloodstream infections, catheter-associated urinary fraction infections, surgical site infections.
• 16:32
  SPEAKER_00: And then over time, there's become an increasing sense in more publications on prevention of methicillin-resistant staph aureus bacteremia.
• 16:39
  SPEAKER_00: There was a lot of reports and a lot of push that you'll look, this is an important infection with really bad outcomes in hospitals.
• 16:46
  SPEAKER_00: It's one we should really be working on.
• 16:48
  SPEAKER_00: So that was added, Clostridium difficile, same story.
• 16:51
  SPEAKER_00: Good information on preventing that.
• 16:53
  SPEAKER_00: These are all things that are flagged in the Shea compendium as their prevention strategies in place.
• 16:59
  SPEAKER_00: And so that got added to the monitoring system.
• 17:01
  SPEAKER_00: But you know, sometimes we're faced with things that we don't think are ready to put into a monitoring system to use for payments.
• 17:09
  SPEAKER_00: And so there are things in NHSN that facilities can use, can track and record, but they're not part of the CMS payment program.
• 17:17
  SPEAKER_00: So a couple of good examples there with ventilator-associated pneumonia or now ventilator-associated adverse events.
• 17:24
  SPEAKER_00: And you know, when we began these discussions, that was one where CMS, in conversation with CDC, said, okay, well, is this something that we should make part of the mandatory reporting and payment system?
• 17:35
  SPEAKER_00: And we had been working with experts and we knew that the definition, the old definition of ventilator-associated pneumonia, very subjective and hard to know if what we do actually can move that needle, right?
• 17:48
  SPEAKER_00: Are our prevention recommendations going to reduce rates of ventilator-associated pneumonia as measured by this definition?
• 17:56
  SPEAKER_00: So that was one where we said, you know, no, that shouldn't be part of public reporting and payment determinations.
• 18:02
  SPEAKER_00: Now, there is a module, of course, as you know, for ventilator-associated adverse events in NHSN.
• 18:08
  SPEAKER_00: So any facility that is trying to address ventilator-associated events can report their data into that.
• 18:15
  SPEAKER_00: They can use it for their own quality improvement work, but it's not part of the CMS program.
• 18:21
  SPEAKER_00: And the other one that's you know a big part of NHSN that's not used by CMS right now is of course the antibiotic use and resistance reporting.
• 18:30
  SPEAKER_00: So there is an option in NHSN for you to report data on your antibiotic use, and you can get risk-adjusted benchmarking of your antibiotic use through something called standardized antimicrobial administration ratio.
• 18:44
  SPEAKER_00: And you can get risk-adjusted benchmarks on resistance now through some of the resistance rates that we have.
• 18:49
  SPEAKER_00: But again, that's reporting that's intended for quality improvements.
• 18:53
  SPEAKER_00: It's not part of the CMS program.
• 18:55
  SPEAKER_00: And the question always becomes at what point do those other measures move in or should they ever move into the CMS program?
• 19:03
  SPEAKER_00: And those are the ongoing discussions that we have with the healthcare Epi community and with CMS and with external stakeholders like the consumer groups to try and figure out well, what makes sense in terms of things that should be in NHSN so that people can just use them for quality improvement and what makes sense to move into this kind of payment determination system.
• 19:25
  SPEAKER_02: That's great.
• 19:26
  SPEAKER_02: And you know, as we wrap up here, I just wanted to echo as you use the example of ventilator-associated pneumonia, I think it's really important to point out that surveillance definitions are exactly that.
• 19:39
  SPEAKER_02: They're for surveillance, and I think that every hospital epidemiologist has faced a situation where they give rates to stakeholders in the hospital and they get pushback because they're being told, well, that case wasn't a surgical site infection and/or that case wasn't a VAP.
• 19:57
  SPEAKER_02: And particularly with VAP, there was so much subjectivity in the definitions around that.
• 20:03
  SPEAKER_02: Uh, it really opened a lot of confusion for people within the hospitals who were arguing about the definitions.
• 20:11
  SPEAKER_02: And so I think it's just really important to point out that surveillance definitions, they are intended to be as objective as possible.
• 20:19
  SPEAKER_02: And they are they're measures that everybody can use that are, again, objective.
• 20:23
  SPEAKER_02: So we're we're comparing apples to apples.
• 20:26
  SPEAKER_02: And if as a practicing hospital epidemiologist, you're faced with surgeons or other stakeholders in your hospital, intensivists that are arguing with you that case is or isn't a VAP, or why aren't you including this one?
• 20:40
  SPEAKER_02: You know, the point is to say these are not clinical definitions.
• 20:44
  SPEAKER_02: This is separate from clinical work and clinical practice.
• 20:48
  SPEAKER_02: If you think a patient has pneumonia, treat them for pneumonia.
• 20:52
  SPEAKER_02: It's not about whether or not this is a VAP.
• 20:55
  SPEAKER_02: And I think that we as hospital epidemiologists need to be able to explain to our stakeholders in our hospital that we're doing this again for the purposes of benchmarking ourselves in areas where we can improve, as you noted, potentially preventable hospital-acquired conditions.
• 21:15
  SPEAKER_02: So clinical definitions are, you know, are a lot more gray, and surveillance definitions are intended to be very objective, again, comparing apples to apples and are separate from clinical definitions.
• 21:28
  SPEAKER_00: Yeah, I think that that is such a critical point.
• 21:30
  SPEAKER_00: And it's it's such a struggle, such a source of tension.
• 21:34
  SPEAKER_00: And I know I hear this from so many hospital epidemiologists, that really frustrating discussion with the clinicians when they're like, clearly, this was not an infection.
• 21:43
  SPEAKER_00: And but the IP is like, look, it meets the criteria.
• 21:46
  SPEAKER_00: I have to report this in as one.
• 21:48
  SPEAKER_00: And one of the things that I always tell people is when you look at those cases, try to look at them with the lens of how could the definition be changed in order to take care of that problem.
• 22:01
  SPEAKER_00: And if if you can come up with a way that's a relatively objective way to change the definition, if there's a risk factor that should be included or something like that, those are the types of things that we try to incorporate into the NHSN definitions in order to reflect the constantly evolving practice of medicine.
• 22:22
  SPEAKER_00: And it's tough because, you know, if it's something that's truly subjective and it's an infection because you know it's an infection, that's hard for us because you can't put that in a definition.
• 22:30
  SPEAKER_00: But where there are things where, you know, and a great example are the change that was made with mucosal barrier injury events for patients who are neutropenic, right?
• 22:39
  SPEAKER_00: So this was a whole category of infections where people were saying, gosh, you know, it doesn't really make sense to call these central line associated bloodstream infections because they're related to the mucosal injury that these patients have suffered and not their central line.
• 22:55
  SPEAKER_00: So we did, you know, we were able to come up with a way to modify the definitions to accommodate that.
• 23:01
  SPEAKER_02: That's great.
• 23:02
  SPEAKER_02: Well, I want to thank you so much for joining me this morning.
• 23:05
  SPEAKER_02: It's been really eye-opening and has really helped to clear up some things for me.
• 23:10
  SPEAKER_02: And I hope that other people find our talk enlightening.
• 23:14
  SPEAKER_00: Thank you, Sarah.
• 23:14
  SPEAKER_00: So great to talk with you.
• 23:16
  SPEAKER_01: Thank you to our panelists for sharing their perspectives and experiences.
• 23:20
  SPEAKER_01: Looking to expand your knowledge and infection control.
• 23:23
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• 23:25
  SPEAKER_01: This conference provides the latest science-based education related to healthcare epidemiology and antibiotic stewardship, building on the education of this podcast and providing in person networking opportunities.
• 23:36
  SPEAKER_01: Find out more and register at www.shayspring.org.
• 23:41
  SPEAKER_01: This concludes today's podcast.