NHSN Healthcare Worker Influenza Vaccination Reporting

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NHSN HealthcareWorker InfluenzaVaccination
Reporting Good Times!!!

• CIP Consulting LLC
• Michele Barr, RN, BSN, CIC
• Jennifer Perry, RN, BSN, CIC

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A bit of NHSN History.
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Characteristics

• Started in 1970 with 62 hospitals
• Peaked at 320 hospitals in 42 states
• Participation voluntary and confidential
• Focused on monitoring infections in critical care
  and surgery patients
• Requirements
• Hospitals with at least 100 occupied beds
• Trained ICPs 1 FTE ICP per first 100 beds plus
  0.5 FTE support staff (median 1 ICP per 115
  beds)
• NNIS hospitals tend to be large, academic
  institutions with higher average daily census
  over-represented in Northeast/Southeast

Richards C, et al. AJIC 200129400-3.
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NNIS System Methods

• Used standard definitions for infections,
  operations, and all data fields
• Used standard protocols to collect data
• Hospitals reported data electronically to CDC
  monthly using CDC-provided software
• CDC published reports of aggregated data
• www.cdc.gov/ncidod/hip/surveill/nnis.htm
• American Journal of Infection Control

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NNIS - 2004
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2005 present
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Healthcare Facility ParticipationAs of December
1, 2012

• 5,227 Hospitals (this includes 504 Long-Term
  Acute Care Hospitals and 249 Free- standing
  Inpatient Rehabilitation Facilities)
• 5,778 Outpatient Hemodialysis
• 251 Ambulatory Surgery Centers (ASCs)
• 63 Long-term Care Facilities
• 11,319 Healthcare Facilities Enrolled

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NHSN Structure
Healthcare Personnel Safety
Biovigilance
Patient Safety
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NHSN provides medical facilities, states,
regions, and the nation with data collection and
reporting capabilities needed to

• Identify infection prevention problems by
  facility, state, or specific quality improvement
  project
• Benchmark progress of infection prevention
  efforts
• Comply with state and federal public reporting
  mandates, and ultimately,
• Drive national progress toward elimination of
  HAIs.

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CMS Reporting Program HAI Event Reporting Specifications Reporting Start Date
Hospital Inpatient Quality Reporting (IQR) Program CLABSI Acute Care Hospitals Adult, Pediatric, and Neonatal ICUs January 2011
Hospital Inpatient Quality Reporting (IQR) Program CAUTI Acute Care Hospitals Adult and Pediatric ICUs January 2012
Hospital Inpatient Quality Reporting (IQR) Program SSI Acute Care Hospitals Inpatient COLO and HYST Procedures Janaury 2012
ESRD Quality Incentive Program (QIP) I.V. antimicrobial start Outpatient Dialysis January 2012
ESRD Quality Incentive Program (QIP) Positive blood culture Outpatient Dialysis January 2012
ESRD Quality Incentive Program (QIP) Signs of vascular access infection Outpatient Dialysis January 2012
Long Term Care Hospital Quality Reporting (LTCHQR) Program CLABSI Long Term Care Hospitals Adult and Pediatric LTAC ICUs and Wards October 2012
Long Term Care Hospital Quality Reporting (LTCHQR) Program CAUTI Long Term Care Hospitals Adult and Pediatric LTAC ICUs and Wards October 2012
Inpatient Rehabilitation Facility Quality Reporting Program CAUTI Inpatient Rehabilitation Facilities Adult and Pedatric IRF Wards October 2012
Hospital Inpatient Quality Reporting (IQR) Program MRSA Bacteremia LabID Event Acute Care Hospitals FacWideIN January 2013
Hospital Inpatient Quality Reporting (IQR) Program C. difficile LabID Event Acute Care Hospitals FacWideIN January 2013
Hospital Inpatient Quality Reporting (IQR) Program HCW Influenza Vaccination Acute Care Hospitals January 2013
PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program CLABSI (proposed) PPS-Exempt Cancer Hospitals all locations TBD
PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program CAUTI (proposed) PPS-Exempt Cancer Hospitals all locations TBD
Long Term Care Hospital Quality Reporting (LTCHQR) Program HCW Influenza Vaccination (proposed) Long Term Care Hospitals TBD
Ambulatory Surgery Centers Quality Reporting Program HCW Influenza Vaccination Ambulatory Surgery Centers October 2014
Ambulatory Surgery Centers Quality Reporting Program TBD (future proposal) Hospital Outpatient Departments and Ambulatory Surgery Centers TBD
Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN
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Influenza Vaccination Reporting

• Reporting required for Acute Care Hospitals
  starting January 2013 and ASCs starting October
  2014.
• Reporting will be done through NHSNs Healthcare
  Personnel Safety Component.
• This component has 2 modules
• Healthcare Personnel Exposure
• Healthcare Personnel Vaccination

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Influenza Vaccination Reporting

• CDC encourages that HCP influenza vaccination
  summary counts be updated on a monthly basis
  within 30 days of the end of each month.
  However, entering a single influenza vaccination
  summary at the conclusion of the measure
  reporting period will meet the minimum data
  requirements for NHSN participation.

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Influenza Vaccine Reporting

• You must complete the monthly plan for this
  module.

Healthcare Personnel Safety Monthly Reporting
Plan
Page 1 of 1 Page 1 of 1
required for saving required for saving
Facility ID ____________________________ Month/Year __________ /________
? No NHSN Healthcare Personnel Safety Modules followed this month ? No NHSN Healthcare Personnel Safety Modules followed this month
Healthcare Personnel Exposure Modules Healthcare Personnel Exposure Modules
? Blood/Body Fluid Exposure Only ? Blood/Body Fluid Exposure Only
? Blood/Body Fluid Exposure with Exposure Management ? Blood/Body Fluid Exposure with Exposure Management
? Influenza Exposure Management ? Influenza Exposure Management
Healthcare Personnel Vaccination Module Healthcare Personnel Vaccination Module
? Influenza Vaccination Summary ? Influenza Vaccination Summary
   
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Healthcare Personnel Influenza Vaccination
Summary
Page 1 of 2 Page 1 of 2 Page 1 of 2 Page 1 of 2 Page 1 of 2 Page 1 of 2
required for saving required for saving required for saving required for saving required for saving required for saving
Record the number of healthcare personnel (HCP) for each category below for the influenza season being tracked. Record the number of healthcare personnel (HCP) for each category below for the influenza season being tracked. Record the number of healthcare personnel (HCP) for each category below for the influenza season being tracked. Record the number of healthcare personnel (HCP) for each category below for the influenza season being tracked. Record the number of healthcare personnel (HCP) for each category below for the influenza season being tracked. Record the number of healthcare personnel (HCP) for each category below for the influenza season being tracked.
Facility ID Facility ID Facility ID Facility ID Facility ID Facility ID
Vaccination type Influenza Influenza subtypea ? Seasonal Influenza Seasonb   Date Last Modified __/__/____
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  Employee HCP Non-Employee HCP Non-Employee HCP Non-Employee HCP
  Employees (staff on facility payroll) Licensed independent practitioners Physicians, advanced practice nurses, physician assistants Adult students/ trainees volunteers Other Contract Personnel
1. Number of HCP who worked at this healthcare facility for at least 30 days between October 1 March 31        
2. Number of HCP who received an influenza vaccination at this healthcare facility since influenza vaccine became available this season        
3. Number of HCP who provided a written report or documentation of influenza vaccination outside this healthcare facility since influenza vaccine became available this season        
4. Number of HCP who have a medical contraindication to the influenza vaccine        
5. Number of HCP who declined to receive the influenza vaccine        
6. Number of HCP with unknown vaccination status (or criteria not met for questions 2-5 above)        
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Question 1 (Denominator) Notes

• Include all HCP who have worked at the facility
  for at least 30 working days during the reporting
  period, regardless of clinical responsibility or
  patient contact. This includes HCP who joined
  after October 1 or left before March 31, or who
  were on extended leave during part of the
  reporting period. Working for any number of
  hours a day counts as one working day.
• Include both full-time and part-time persons. If
  an HCW works in two or more facilities, each
  facility should include the HCW in their
  denominator. Count HCP as individuals rather than
  full-time equivalents.
• Licensed practitioners who receive a direct
  paycheck from the reporting facility, or who are
  owners of the reporting facility, should be
  counted as employees.
• The HCP categories are mutually exclusive. Each
  HCP should be counted only once in the
  denominator (question 1).

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Questions 2-6 (Numerator) Notes

• Questions 2-6 are mutually exclusive. The sum of
  the HCP in questions 2-6 should equal the number
  of HCP in question 1 for each HCP category.
  Questions 2-6 are to be reported separately for
  each of the three HCP categories.
• Only the following HCP should be counted in
  question 4 HCP with (1) a severe allergic
  reaction to eggs or other vaccine component(s) or
  (2) a history of Guillain-Barré Syndrome within 6
  weeks after a previous influenza vaccination.
• The following should be counted in question 5
  (declined to receive influenza vaccine)
• HCP who declined vaccination because of
  conditions other than those included in question
  4.
• HCP who declined vaccination and did not provide
  any other information.
• HCP who did not receive vaccination because of
  religious exemptions.
• HCP who deferred vaccination for the entire
  influenza season (i.e. from October 1 to March
  31).

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FAQ

• http//www.cdc.gov/nhsn/faqs/FAQ-Influenza-Vaccina
  tion-Summary-Reporting.html

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FAQ

• Who do I contact for questions related to NHSN
  reporting?

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FAQ

• My hospital is part of a multi-hospital system
  that has one corporate payroll. Each hospital has
  its own NHSN number, so how should each hospital
  report its total number of HCP?

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FAQ

• Should I count HCP who are not working with
  patients for 30 days or more, but because of
  staff meetings, etc. are physically in the
  facility for 30 days or more?

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FAQ

• If a HCW was vaccinated at his/her doctors
  office in August, should he/she be included?

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FAQ

• What is acceptable documentation for a HCW
  vaccinated outside of the healthcare facility?

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FAQ

• What is acceptable documentation for a HCW
  vaccinated outside of the healthcare facility?

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Hand hygiene MATTERS!

• What are you doing to keep it fresh?

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Hand hygiene campaigns

• Hand hygiene team (meetings, data)
• Communication of the data

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Questions??

• Thank you!!
• Look forward to seeing you in Fargo, ND in
  September 2013 ?
• Email if you have questions
• Cipconsulting_at_live.com