The CMS has raised the bar for reporting healthcare-associated infections by tying hospitals’ annual payment update to submission of infection data via the Centers for Disease Control and Prevention’s secure, Web-based surveillance system.
The infection connection
Only a few months remain until voluntary participation in CDC's reporting network begins, and Medicare dollars are on the line
Beginning next year, the agency is requiring that hospitals use the CDC’s National Healthcare Safety Network, or NHSN, to report their incidences of central line-associated bloodstream infections, in order to receive a full Medicare payment update for 2013. In addition, hospitals will need to report on surgical-site infections beginning in January 2012 to receive full reimbursement for 2014.
The NHSN has been widely praised for its use of set definitions and protocols, and the move is expected to introduce much-needed standardization to national reporting of healthcare-associated infections, at least for those two measures.
“We’re very pleased with the announcement,” said Russell Olmsted, president-elect of the Association for Professionals in Infection Control and Epidemiology, and an epidemiologist at St. Joseph Mercy Health System, Ann Arbor, Mich. “Using one single platform with standard definitions helps ensure that the method of evaluating infections in San Diego is the same as it is in Boise. It creates a level playing field.”
The measures were included in the CMS’ final revisions to the inpatient prospective payment system, or IPPS, issued July 30, and are part of the Reporting Hospital Quality Data for Annual Payment Update program. In the final rule, the CMS left the door open to include other types of infections for future NHSN reporting, including ventilator-associated pneumonia and multidrug-resistant organism infections.
Enrollment in the NHSN is free, but it does require time and patience, according to infection preventionists. Facilities must agree to use the network’s tools and interfaces, adhere to set methodologies and report results periodically. They must also fulfill a number of training requirements. The CDC’s NHSN website features instructional webcast sessions covering enrollment, data entry, surveillance, patient safety and healthcare personnel safety. For instance, all NHSN users are required to receive central-line-insertion practices training, which is available as a module on the site. Once training is completed, users receive secure digital certification and can access the network.
Currently, almost 2,650 facilities are reporting data on at least one type of healthcare-associated infection to the CDC’s network, and 21 states mandate such reporting.
Hospitals will likely experience some bumps in the road as they transition to NHSN reporting. “The data is important and it’s an excellent tool, but there is a fairly steep learning curve,” said Baerbel Merrill, vice president of missions and an infection preventionist at 90-bed Campbell County Memorial Hospital, Gillette, Wyo. “It does take some time.”
Campbell County Memorial Hospital has been enrolled in the NHSN for two years, although Wyoming does not require it.
Merrill used the NHSN’s online sessions and manual to get ready, and she also attended training courses during an APIC conference. At first, she said, the surveillance process was time-consuming and frustrating, but with practice it became much easier. “Like anything else, you become more efficient with time,” she said.
She uses the real-time data the NHSN provides as a tool for analysis and benchmarking. For instance, when she noticed that Campbell County’s colonization rates of methicillin-resistant Staphylococcus aureus, or MRSA, were much higher than the CDC’s national 3% estimate, she shared the data with administrators and staff, and then instituted new protocols for identifying colonized patients before surgery.
According to Lynn Reynolds, an infection preventionist at Southeast Georgia Health System in Brunswick, hospitals that are not yet reporting to the NHSN should begin the training process now so they are ready to begin submitting data on central line infections in January and avoid the 2% cut to their Medicare payment update. Reynolds was recently appointed to serve on Georgia’s Healthcare-Associated Infections Advisory Committee and will be charged with developing prevention strategies and boosting statewide enrollment in the NHSN.
“NHSN requires users to be thoroughly trained in their Web-based education before they can submit data,” Reynolds said, adding that her hospital has been enrolled in the network since May 2009. “My advice is to start by dedicating a day to click through the site and look at the program. It is very user-friendly once you get used to it. It’s like detective work.”
The NHSN’s training requirements are customized for facility administrators, who oversee hospitals’ enrollment and participation, and regular users, Reynolds said. The number of trained users will vary based on factors such as hospital size, but many facilities rely on one or two infection-prevention professionals and then use data-entry clerks—who are not required to receive specialized NHSN training—for support.
Michael Rapp, director of the CMS’ quality measurement and health assessment group, said that in spite of training requirements, hospitals have a reasonable amount of time to prepare. In the proposed changes to the IPPS, the CMS had initially included both central line infections and surgical-site infections for reporting in January 2011. But a flood of comments from providers and advocacy groups persuaded them to defer surgical-site infection reporting until 2012. It was too much too soon, he said.
Central line-associated bloodstream infections are a good place to start, Rapp added, because so many states are already mandating some kind of reporting for those infections, and central line infection specifications are not expected to change. According to the CDC, central line infections result in an estimated 30,000 deaths each year and cost the healthcare system billions of dollars.
Successful prevention campaigns have galvanized providers and put central line infection prevention high on their priority lists. For instance, one well-known initiative called the Keystone project lowered the rate of central line-associated bloodstream infections by two-thirds in more than 100 intensive-care units in Michigan, and has since been expanded to a national program called On the CUSP: Stop BSI (CUSP is short for Comprehensive Unit-Based Safety Program).
“It’s just one measure, and although hospitals will have to start reporting on discharges beginning in January, they are given 4½ months after the end of each quarter to submit the data,” Rapp said. In other words, the first quarter reporting deadline is Aug. 15 and the second quarter deadline is Nov. 15.
The NHSN is also a critical component of HHS’ Action Plan to Prevent Healthcare-Associated Infections, a five-year, multipronged program aimed at decreasing rates of HAIs, Rapp said.
Some infection preventionists expressed concern about whether the network will be able to handle the deluge of new users. The CDC is expecting nearly 1,000 new hospitals for a total of about 3,500, said Mike Bell, deputy director of the CDC’s division of healthcare quality promotion, in a blog post.
But Rachel Stricof, an epidemiologist and director of New York State Health Department’s bureau of HAIs, said the NHSN has experienced rapid growth in recent years with little problem. New York was the first state to mandate NHSN enrollment. The bigger worry, Stricof said, is whether hospitals will be validating the data they enter into the network.
“We think validation is critical because we want to ensure everyone is doing things the same way,” Stricof said. In one survey of New York hospitals conducted before the NHSN requirement was instituted, nearly all reported using set definitions for identifying infections. But upon closer inspection, she said, they had made small adjustments that made data comparison very difficult.
“If I’m comparing Hospital A to Hospital B, I need to make sure they use the same case definitions and the same inclusion and exclusion criteria,” Stricof said. “It’s especially critical because better surveillance often means a higher infection rate because you’re able to catch more of them.”
Five states—New York, Maryland, South Carolina, Tennessee and Connecticut—have some sort of formal process for validating, or double-checking, NHSN data. Olmsted said other states are headed in that direction.
Janis Ober, director of epidemiology at Virginia Commonwealth University Health System in Richmond, echoed Stricof’s sentiment and pressed for the need for validation. Ober leads the mandatory reporting task force for APIC’s Virginia chapter and, in late 2007, she led a successful effort to get all of the state’s acute-care hospitals, which number more than 90, to report central line-associated bloodstream infections using the NHSN.
VCU uses the network’s data for benchmarking and performance improvement, Ober said, and with nearly 100% compliance, they are in good shape to meet the CMS’ new requirement. The problem, she said, is that it is extremely difficult in most instances to be sure hospitals are reporting properly.
“You need trained infection preventionists who go to facilities and review records to see if the definitions have been applied appropriately,” Ober said. “It’s a huge concern because people are putting so much store in that number without checking to see if it is correct.”
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