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NYS HAI Reporting Program Audit and Validation


Betsy Todd Hudson Valley. Marie Tsivitis Long Island. Kate Gase NYC. Boldt Tserenpuntag Data Manager. Kamal Nan Siag MPH Student ... – PowerPoint PPT presentation

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Title: NYS HAI Reporting Program Audit and Validation

NYS HAI Reporting Program Audit and Validation
  • Rachel L. Stricof
  • rls01_at_health.state.ny.us

Data Validity Checks - Process
  • Central office generates bi-weekly reports
  • By region
  • For each hospital
  • Regional staff review
  • Contact hospitals
  • Data verified
  • If indicated, NHSN data corrected by hospital

Data Validity ChecksColon Surgery Indicators
  • Clean colon procedures
  • Outpatient colon procedures
  • Colon procedures without general anesthesia
  • Colon surgery duration less than 30 minutes or
    more than 15 hours

Data Validity ChecksCABG Surgery (CBGB and CBGC)
  • Outpatient CABG surgery
  • CABG procedures without the use of general
  • American Society of Anesthesiologists (ASA)
    Classification of Physical Status score of 1 or 2
  • CABG surgery duration less than 30 minutes or
    more than 15 hours
  • CABG surgery designated as trauma case

Data Validity Checks Central Line-Associated
Blood Stream Data
  • Monthly summaries in which CL Days Patient Days
  • Recognized pathogens designated as a skin
    contaminant (added recently)

Audit Objectives
  • Determine the reliability and consistency of
    surveillance definitions
  • Evaluate current surveillance methods used to
    detect infections
  • Evaluate current risk adjustment methods and
    determine if additional factors need to be
    considered for public reporting purposes
  • Evaluate intervention strategies designed to
    reduce or eliminate specific infections
  • Provide on-site education on the definitions,
    surveillance mechanisms and use of the NHSN

Hospital Audits
  • 180 hospital site visits between July 2007 and
    January 2008
  • 320 - ICU surveys conducted
  • 1162 - ICU charts reviewed
  • 213 - CABG charts reviewed
  • 664 - Colon charts reviewed

Selection of CLABS Medical Records
  • Evaluation of 1st quarter reporting
  • All reporting ICUs were evaluated
  • Review microbiology lab reports
  • Select 5 10 positive blood cultures from each
  • Review medical record
  • Determine if a central line was in place on date
    of culture
  • If yes, continue audit and collect NHSN data and
    supplemental information
  • A standardized data collection form
  • HAI staff were blind to case status (reported or
    not) until after the chart reviews were completed

Selection of Surgical Patients
  • Central office created list of medical records
  • All SSI cases reported for 1/1/07 3/31/07
  • Two controls per case Internal and External
  • CABG Gender, Age within 10 years, CBGB or CBGC,
    Multiple procedure status
  • Colon Duration above or below 3 hour cut point,
    trauma, emergency, ASA, age / 1 year
  • HAI regional staff blind to case/control status
  • After review, sealed envelope opened
  • Discrepancies reconciled with hospital ICP
  • If indicated, hospital revised data in NHSN

CABG Chart Audits, 35 NYS Hospitals
CABG Chart Audits, 35 NYS Hospitals
CABG Chart Audits, 35 NYS Hospitals
CABG Chart Audits, 35 NYS Hospitals
Colon Chart Audits, 153 Hospitals
Colon Chart Audits, 153 NYS Hospitals
Audit Challenges
  • Age of Transition
  • Information going from paper to electronic
  • Every hospital has a different system(s)
  • Within a hospital, systems not integrated
  • Password protection issues
  • Even with focus on limited variables, factors,
    and infection indicators chart reviews took 30
    minutes 1 hour to review on average

Cardiac Surgery Reporting System (CSRS)
  • Developed to assess hospital and surgeon-specific
    risk-adjusted mortality rates
  • Deep surgical site infections involving bone are
    supposed to be reported
  • HAI data reconciliation with CSRS
  • CRSR had 25 infections not in NHSN under
  • 1 associated with procedure in 2006
  • 1 duplicate in CRSR
  • 5 should have been in NHSN
  • ICP stated she thought she had entered the SSIs

Cardiac Surgery Reporting System
  • The following factors were associated with SSIs

Patient Risk Factors Surgical Risk
Factors Female Gender Emergency
Procedure COPD Bleeding Requiring
Re-operation Diabetes Immunodeficiency Bod
y Mass Index Post-operative Respiratory
Failure Post-operative Renal Failure Post-operativ
e GI Bleeding
Pre-operative risk factors to be evaluated for
potential risk adjustment
Risk Factors Next Steps
  • To determine if individual patient risk factors
    influence hospital rankings
  • If high risk patients are evenly distributed,
    rankings will not change
  • If high risk patients are seen in select
    facilities, we will need to adjust
  • Provide public with better understanding of
    their individual risk factors

Post-Discharge Surveillance Survey
  • PHL revised to require reporting of infections
    between hospitals
  • Readmission facility must notify hospital where
    surgery performed
  • Original surgery hospital to report SSI in NHSN
  • 87 percent of facilities have a mechanism to
    identify readmissions
  • 55 percent of facilities had active
    post-discharge surveillance system for outpatient

CABG Chest Site Infections by Extent and
Detection Time, 40 NYS Hospitals
Colon SSIs by Extent and Detection Time,182 NYS
Hospitals, 2007
CABG Donor Vessel Site Infections by Extent and
Detection Time, 40 NYS hospitals
NYSDOH Decision re PDS
  • Do not require or mandate a universal,
    post-discharge surveillance mechanism
  • Continue to monitor the severity of these events
  • For hospital-specific comparisons, only include
    patients identified post discharge if they were
    readmitted to another hospital
  • Patients readmitted to the same facility already
  • Established custom field in the NHSN reporting
    system to identify SSI events detected following
    readmission to another hospital

Validation is ?
  • Being at once relevant and meaningful
  • Being well grounded provide direction for
  • Conforming to accepted principles of sound
    biological classification
  • Ensuring appropriateness
  • Having legal efficacy or force

It Takes a Village
  • Carole Van Antwerpen, Program Manager
  • Peggy Hazamy Buffalo and Rochester Region
  • Diana Doughty Syracuse Region
  • Betsy Todd Hudson Valley
  • Marie Tsivitis Long Island
  • Kate Gase NYC
  • Boldt Tserenpuntag Data Manager
  • Kamal Nan Siag MPH Student
  • Edgar Manukian MPH Student
  • Andrea Fischer MPH Student
  • Mary Andres and Teresa Horan Always there to
    support and defend us.
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