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Administrator
Posts: 578
Registered: ‎02-22-2010
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NHSN Reporting Webinar

[ Edited ]

Thanks for joining Tom Jordan's presentation on "Federally Mandated CLABSI and SSI Reporting to NHSN."

 

View the on-demand recording and download the slides.

 

Is your facility prepared for these new reporting requirements? Have a question for Tom? Post it here and he will answer your questions to the best of his ability.

Administrator
Posts: 578
Registered: ‎02-22-2010
0

Re: NHSN Reporting Webinar

Here are some questions from our live presentation:

 

Q: Will data reported to CMS Hospital Compare or other public format be in SIR format or actual infection numbers?

 

Q: Do you need to have a digital certificate for each computer if two are collecting data from two campuses?

 

Q: Are these mandated reporting due to the Healthcare Law that was passed this year?  How much time will it costs medical facilities to implement these reporting stats? How much costs (per FTEE) do you expect it will result?  

 

Q: Do you know how the "group" function works (for state reporting groups)?

 

Q: I work for an Orthopedic Specialty Hospital without a ICU.  From my understanding we are not required to enroll in NHSN by this January, but must fill out a form.  Is this correct?  Is the form available yet?  By 2012 I would have to enroll in the NHSN for reporting SSIs.

 

Q: My hospital is an LTAC.  I understand we must report CLABSIs for our ICU.  Just to be clear, is it mandated that we begin reporting for our med/surg and our Intermediate unit as well? 

 

Q: Will CMS use a threshold SIR to determine non-payment?

Pharmacy OneSource
Posts: 4
Registered: ‎10-12-2010
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Re: NHSN Reporting Webinar

I am currently working on getting the answers to the other questions from our live webinar. Stay tuned!

 

Q: Will data reported to CMS Hospital Compare or other public format be in SIR format or actual infection numbers?

A: The SIR format will be used.  In May, 2010, Don Wright, MD, Administrator of CMS, stated the following:  “It's through effective partnerships that we can accelerate national progress to achieving the action plan goal of a 50 percent reduction in central line-associated bloodstream infections that is a .50 standardized infection ratio by the end of 2013.

 

Q:  Do you need to have a digital certificate for each computer if two are collecting data from two campuses?
A:  The  following is from the NHSN web site:
3f. Installing your Digital ID Certificate on Another Computer
If you are installing your digital ID certificate onto a computer other than the computer to which you originally downloaded it, or restoring your digital ID certificate on the original computer, make sure you have administrative privileges on the second computer and that the second computer meets the system requirements. See System Requirements on page 6. Go to:  http://www.cdc.gov/nhsn/PDFs/FacilityAdminEnrollmentGuideCurrent.pdf

 

Q: Are these mandated reporting due to the Healthcare Law that was passed this year? 

A: The reporting requirement was included as part of CMS’s annual Inpatient Prospective Payment Schedule (IPPS) rule, and is not part of recent health care legislation.

 

Q: How much time will it cost medical facilities to implement these reporting stats? How much costs (per FTEE) do you expect it will result?  

A: It is difficult to quantify the amount of time it will take to maintain the CMS-required reporting.  However, this is a very labor intensive undertaking.  Sentri7 autopopulates most of the patient information required and eliminates a significant amount of manual entry into NHSN.  You must submit every CDC defined  CLABSI in ICU or NICU.  And you must report the number of patient days and central line days for every ICU or NICU in your facility.  The SSI requirements are much more lab intensive.  In order to submit SSIs to NHSN, you must submit a significant amount of information for EVERY knee replacement, hip replacement, open heart, and abdominial hysterectomy.  This is not limited to those cases where an SSI occurs.  It includes all of the cases delineated above.  For every one of these procedures you must enter the information indicated on the Denominator for Procedures form below.

 

denom_form.jpg

 

In many hospitals in Pennsylvania, where all HAIs must be submitted to NHSN per state law, significant FTE resources are used just for this mandatory data entry into NHSN. 

Pharmacy OneSource
Posts: 4
Registered: ‎10-12-2010
0

Re: NHSN Reporting Webinar

[ Edited ]

Q: Do you know how the "group" function works (for state reporting groups)?

A:  Go to the following website for details in the NHSN Group Administrator Guide:

http://www.cdc.gov/nhsn/PDFs/GroupAdminStartupGuideCurrent.pdf

Q: I work for an Orthopedic Specialty Hospital without a ICU.  From my understanding we are not required to enroll in NHSN by this January, but must fill out a form.  Is this correct?  Is the form available yet?  By 2012 I would have to enroll in the NHSN for reporting SSIs.

A: If your hospital does not have an ICU or NICU, you do not have to report CLABSIs to the NHSN.  The CLABSI and SSI reporting requirement only applies to hospitals that receive Medicare reimbursement through the IPPS. Hospitals and hospital units that are specifically excluded from this rule are: rehabilitation hospitals and units; long-term care hospitals; psychiatric hospitals and units; children’s hospitals; cancer hospitals; religious nonmedical health care institutions; critical access hospitals, and Department of Veterans Affairs/ Department of Defense hospitals.

 

Q: My hospital is an LTAC.  I understand we must report CLABSIs for our ICU.  Just to be clear, is it mandated that we begin reporting for our med/surg and our Intermediate unit as well? 

A:  See the answer above.  Only CLABSIs related to ICUs and NICUs must be reported at this time.

 

Q: Will CMS use a threshold SIR to determine non-payment?

A:  Yes. 

Highlighted
Administrator
Posts: 578
Registered: ‎02-22-2010
0

Re: NHSN Reporting Webinar

Here are some more questions from our live presentation:

 

Q: We are registered with NHSN, we do not have any ICU beds, and we have not reported anything, do we need to log on to the web site even though there is nothing to report?

 

Q: Should we start using the NHSN denominator forms now for NICU?

 

Q: How does CMS get the data from NHSN?

 

Q: If you cannot find the exact name for a specific floor location at your facility from the NHSN list how do you enter it?

 

Q: Is CLIP form required with CLABSI?

 

Q: Are there particular types or ICD-9 codes of surgeries that are required to be reported on or does each facility chose their own? 

 

Q: I report central line data for ICU. For location, the option is MSICU, MS-ICU. Is there a difference?