Background

A recent amendment to the hospital licensure regulations establishes new requirements for acute care hospitals to begin reporting selected healthcare-associated infection (HAI) measures (see MDPH circular letter 08-02-482). Following the recommendations of an Expert Panel, 10 specific outcome and process measures have been selected for reporting to one of two state entities --- the Massachusetts Department of Public Health (MDPH) or the Betsy Lehman Center for Patient Safety and Medical Error Reduction (BLC). Three other outcome measures are to be monitored within the hospital but not reported externally. Most of the required HAI measures will be submitted by hospitals through the National Healthcare Safety Network (NHSN), a secure internet portal operated by the Centers for Disease Control and Prevention for collection and analysis of a range of related data. There is no cost to hospitals for NHSN participation and several other states currently collect HAI data in this way.

The purpose of this document and the supporting materials is to guide hospitals through the steps involved in enrolling in NHSN and provide critical documents and other detailed resources for training and technical assistance. The information below explains the process of compliance with the 3 requirements of the new regulation 130.1701 "HAI Data Collection, Submission and Reporting".

The enclosed packet of resource materials represent the necessary documents provided by CDC for NHSN enrollment and subsequent data reporting. These documents can also be downloaded from http://www.cdc.gov/ncidod/dhqp/nhsn_documents.html.

1. NHSN Enrollment Process

Registration for NHSN is required by April 1, 2008. If your hospital is not already enrolled, follow the instructions provided in Section II and Section III of the enclosed resource material packet. Involvement of both your Infection Control Department and your Information Technology Department will be required.

The CDC Enrollment webcast and accompanying slide set should be viewed as soon as possible and are available at http://www.cdc.gov/ncidod/dhqp/nhsn_training.html. Follow the links for both the Facility Administrator and User trainings to fulfill the NHSN mandatory training requirements. The Group Administrator module is NOT required and will not be helpful for hospitals.

Other states implementing NHSN reporting have found that self-training with the CDC materials is adequate for the enrollment step. If you encounter difficulties at this stage, contact the CDC support line at (800) 893-0485, option 1. You may also send an email to nhsn@cdc.gov that includes your name, NHSN Facility ID number (if applicable), phone number, and email address. Additional resources for help are provided on the last page of this memo.

2. Grant Access to MDPH/BLC

In Section IV-B of the attached materials describes how to "confer group rights". This is the process through which a facility allows outside agencies (such as state health departments and quality organizations) to view specific elements of their data. Hospitals must have completed the enrollment process before they can confer rights and a timeline of approximately 2 weeks may be needed to complete enrollment.

Upcoming Webcast for Massachusetts Hospitals:

JSI Research and Training Institute will conduct a facilitated webcast on Conferring Group Rights to MDPH and BLC on Tuesday March 25 from 10-11am; Infection Control Professionals and Facility Administrator (for NHSN) should plan to participate. Shortly thereafter, the webcast will be posted, for later viewing, on the MDPH Healthcare Quality webpage www.mass.gov/dph/dhcq.

Information on how to access the webcast will be mailed separately and will be posted on the Healthcare Quality website. For more information, please email haihelp@jsi.com or call 617-385-3992.

The CDC webcasts and slide sets for Facility Startup and Conferring Rights to Groups can be viewed now at http://www.cdc.gov/ncidod/dhqp/nhsn_training.html but they do not contain Massachusetts-specific information. The details of the Massachusetts Group instructions will be part of the March 25 webcast.

3. Collect and Submit Specified HAI Data

Submission of data on selected HAIs is not required until July 1, 2008. The immediate priority is to enroll in NHSN, complete certain initial set-up functions and confer rights to MDPH/BLC. After completing these steps, training activities will progress to address the specific infections required for initial reporting --- certain specific bloodstream and surgical site infections.

Section I (attached) contains descriptions of the measures to be reported, as defined by the Massachusetts Expert Panel on HAI. On page 29, Attachment E provides a summary table of the 13 selected measures; these are also part of the Circular Letter (DHCQ 08-02-482, 2/22/08).

A. Measures Reported Through NHSN

Sections V and VI (attached) address the surveillance process, measure specifications and data submission details relative to the following 6 required measures currently reportable via NHSN:

  • Central-venous catheter-associated bloodstream infection (CVC-BSI) in intensive care units (ICUs) - true pathogens (CDC criterion 1)
  • CVC-BSI in ICUs - skin contaminants (CDC criterion 2 and 3)
  • Surgical site infection (SSI) resulting from hip arthroplasty
  • · SSI resulting from knee arthroplasty
  • · SSI resulting from hysterectomy
  • · SSI resulting from coronary artery bypass graft

BSI and SSI Webcasts are available http://www.cdc.gov/ncidod/dhqp/nhsn_training.html

In the coming weeks, more training opportunities will be announced by JSI and posted on the MDPH Healthcare Quality website.

B. Measures in Development (not part of NHSN currently)

The MDPH Technical Advisory Group will be finalizing the specifications of the following measures that are not contained in NHSN:

  • Point prevalence of methicillin-resistant Staphylococcus aureus (MRSA)
  • VAP prevention: Daily application of protocol-driven assessments for readiness to discontinue mechanical ventilation
  • VAP prevention: Elevation of the head of the patient's bed

Also, NHSN expects that their new module for reporting on influenza vaccination of healthcare workers will be launched in the near future. However, hospitals will not be required to report on this measure until the next influenza season starting in fall 2008.

You will receive additional details on these measures when they become available.

C. Measures for Internal Tracking Only

Note that although you can use NHSN to track CVC-BSI outside of ICUs and rates of ventilator associated pneumonia (VAP), access rights to these measures will not be requested by MDPH or BLC. Since there will be no inter-hospital comparison, your hospital may opt to collect these data through other means and not use NHSN if you prefer. Also, Clostridium difficile-associated disease (CDAD) is not captured in NHSN at this time so you will need to devise your own system for monitoring this measure.

Other specific data issues

a) You will notice that NHSN has required data elements and optional fields. Section VI contains data collection forms and required data fields are indicated by a * on the data forms. Patient identifiers are largely optional; however, social security numbers should NOT be entered. The patient safety component protocol ( Section V) includes instructions on how to complete the data forms.

b) In keeping with the Department's goal of eliminating health disparities, a plan to collect data on patient race/ethnicity will be developed as this information is not part of NHSN data elements currently.

Contact Information for Assistance

Centers for Disease Control and Prevention

If you have questions about NHSN, please send an email to nhsn@cdc.gov or call (800) 893-0485, option 1. Please include your name, NHSN Facility ID number (if applicable), phone number, and email address.

JSI Research and Training Institute

If you have questions about Massachusetts requirements for HAI reporting, please send an email to haihelp@jsi.com or call 617-385-3992. Please include your name, hospital name, phone number, and email address.

Massachusetts Department of Public Health

Division of Healthcare Quality

Roberta Bernstein 617-753-8062 ( roberta.bernstein@state.ma.us)

Bureau of Communicable Diseases

Arquimedes Areche 617-983-6820 ( arquimedes.areche@state.ma.us)

Betsy Lehman Center

Eileen McHale 617-624-5723 ( eileen.mchale@state.ma.us)

This information is provided by the Division of Health Care Quality within the Department of Public Health.