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Good morning everybody.
Welcome to the September IP call. We are going to report this session today, so those that are not with us can come back and launch it at a later date. Just a reminder to please mute your lines. I am going to try to leave all lines unmuted during the call so people can speak up and ask questions throughout the call. So please be sure to mute on your end, do not place us on hold, otherwise we will hear your hold music from your system. So, again, welcome. Today, we are going to talk about C. diff reporting and antimicrobial stewardship. We are just doing our part one, just community practice, just really getting started with this topic. So, I am going to go ahead right away and hand it off to Nancy Wild and she is going to talk about CDR reporting. Nancy, are you on the call?
I am, can you hear me?
I can.
Great, okay. I am going to try to go through these slides pretty quick. They really will not allow for sometime for certain discussions. So, Jennifer I think it is going to work best if we just use the slides I think, and just let you forward through those.
Yes, call out to me when you are ready.
Okay. So we will go on next. So really what I want to do today, I know that most of you are already reporting on C. diff. and MRSA bacteremia, but just wanted to kind of review what the reporting plans would look like, how you report for both of those, and then really want to start out with the impact of antibiotics stewardship on CDI rates, because that is going to be some place that we are going to go a little bit further with this after further phone calls and webinar. So you can go ahead and go to the next slide. I put this picture in there because this is a huge reason for what we are doing today and this slide reflects where Iowa is at on a national level with antibiotic prescribing and this is for all prescribers, and we see here that 50% of all antibiotics prescribed at the provider level office are either unnecessary or they are inappropriate. That is not new information. So what is concerning to me is that Iowa is in that group that is the second highest user of antibiotics in the country. So, I think this is something we need to be paying attention to. And that leads right into next slide which shows us where we rank as far as hospitals having fully implemented antibiotic stewardship programs. And this is based on 2014 data, so this is old and I think that we have done better that at that point we were at 18.6% of our hospitals had fully implemented antibiotic stewardship, and I know that a lot of you have started and are doing things and even in this, it does not reflect those of you that have already started and had some really good processes in place, but this was those that had fully implemented programs. And I am going to do some additional, we should be getting some additional updates based on 2015 data, so I would expect this number to improve, but you can see that we are in the group of states that really have the least and we are in that 7-28% of our hospitals have stewardship programs. So, that is really not where we want to be. We would really like to see that improved. So going on to the next, just look quick and I am going to slide through these real quick, Jennifer so we can just go. This is you all know by now that you all have to have a monthly reporting plan out at each month. So, next slide, and this is for those of you that are either are not reporting or still in the process of setting this up. Really, one of the first things that you should be looking at for C. diff., you want the facility wide and lab IDs event reporting, your emergency department and if you do happen to have an OBS unit, you would want to be including that too. It is not showing on this slide, but also if you have an inpatient rehab facility, you would want to add that on to this reporting and I have another slide that will talk about that. So, and in the next slide we will show you just the same thing with the MRSA bloodstream infection. As I have known about one of the things that I do see in some facilities is that instead of the blood specimens only, some of you are trying to report all lab IDs done for MRSA and that is okay if that is what you choose to do, but what most places are doing are the blood specimens only, which would alleviate some of the burden in reporting. So, this would require you to report all positive MRSA results regardless of whether or not they were hospital-acquired or community-acquired, it is there in your facility. So the next slide. One of the things that surprisingly still twists people up is how do you actually put the numbers in for the denominators. So if you are doing this the way that you are supposed to be doing it, the facility wide and you are going to have your total patient days, your total admissions and then you would have your MDRO days and your C. diff. days. On the C. diff. days and the MDRO days, they both take our your inpatient rehab facility because you are going to report those separate. And then for the C. diff., you would be taking out your newborn babies because we do not use C. diff. survey in infant newborns. So, going ahead for the next, and I have shown this slide before, but this is just an example of how those numbers would look. So you can see there that your CDI days are different than your total facility days because we subtracted babies out. So the next slide. So this is the slide I told you that I would have but I had in here for the inpatient rehab. I know that some of you do have units in your facility, so those are also required to report MRSA bacteremias and C. diff. lab ID then and that is regardless of whether it is a freestanding facility that you are responsible for or if is a unit in your hospital. So, going on to the next, I am going to switch slides. Thank you. So reporting a lab ID event. This is where you are going to be reporting all positive tests regarding that are located on your inpatient unit and also if you have emergency room and observation units that you would also report those events. So, your facility wide in is going to include all your bedded patients on your med-surg unit. That is going to include observation beds, swing beds, in one of those classifications, they would still be included in your facility wide. If it is collected in the emergency room or in the obs unit, assign to that unit regardless of whether or not they are admitted to the hospital. And one of the things that I have seen on occasion is and I will show you, I actually have a slide that shows you this, but under the event type you are going select lab ID, then GI which is kind of confusing at times, but if you choose GI, then it does not report under your lab ID and you will not be able to find that. So make sure that you choose the lab ID event as your event type. And then the organism would either be your C. diff. or your MRSA. So going to the next slide, we will actually show you how that works. And that is just adding an event, so the next slide, this is where you would choose your MDRO event, your lab ID event, and then your specific organism type would be your C. diff. or your MRSA. Then go to the next slide. Well, that does not help much. I have duplicate slides there, so go ahead and call next. So this is showing the C. diff. there for the digestive systems and then where it needs to be, those, has the patient been discharged from your facility in the past four weeks is a required field, and has the patient been discharged from another facility in four weeks is a required field. And if you say yes, that is going to ask you the level of care that is being provided at that facility whether it is a long-term care facility if they were another hospital or whatever. The documented evidence of previous infection is not a field that you enter if you have entered a person in there and they have got that it has been a positive test based on your medical record number. It searches for that, then that automatically populates into response of that. Going on to the next. So, here again is where it asks you the level of facility, just wanted to show you that there is an option to select a nursing home. I hear an awful lot of times that some of you are getting patients in from nursing home long term care facilities in the unit and that is where you are going to record that. So, lets go on to the next. This slide here is, well, shows whether or not it is an inpatient. So if it is located on your inpatient unit, whether it is an observation or swing, it is going to be a yes for that. Basically, the point there is that if they are in a bedded unit they are considered an inpatient for NHSN. And I do see a question here that is asked if there is a minimum number of recurrences that are required for reporting and the answer to that is no, now for critical accidents it is not required. We are asking and encouraging all hospitals to report on C. diff. because it is not a requirement, but we are encouraging that reporting, so it is not based on the minimum number, but it is something that we are asking all facilities to do. There is another question here for the lab IDs and as I am understanding this question, it has the numbers that are reported. Jennifer, can you go back that slide for the, that shows the denominator information. Yeah, it is in there. Since it is a lab ID, then number for C. diff includes the total number of positive C. diff. If you are asking as far as the, I guess I am not sure of the question. This is a lab ID that number for C. diff. include the total number of positive C. diff. that are hospital onset added to the total number of community onset, and I believe if you are talking about that being for report, then, Jennifer, I will have you go back because I think I can clarify that with the next couple of slides. And if I misinterpreting your question, just go ahead and clarify it for me. Lets go ahead and go again here. And the next one, okay, I did want to stress and I put this in here so before I answer this question, I just wanted to show you real quick for lab ID that reporting if it is, if you get a positive isolate, you can look at these algorithms and give you an idea of whether or not you need to be reporting it, because if it is on the same unit and the same patient within the last two weeks, it is a duplicity and if it is a new then it goes ahead, you would go ahead and answer that and as a unique or some bloodstream infection or C. diff. event. So, go ahead to the next. Just a reminder here that C. diff. testing should only be done on unformed stool specimens; if it is not conforming to the shape of the container, it should not be sent. And there again if it is the first specimen within 14 days for that patient on that same location, it gets reported. So go ahead to the next. And I did want to talk a little bit about how those are categorized and I think this will answer that last question. There are three different categories essentially for NHSN will put to your reported event. So there is a community onset, a healthcare facility onset, or community onset healthcare facility associated. So for the community onset, it is essentially those patients that have a positive specimen within the first three days of an overnight stay. The healthcare facility onset would be collected after those first three days, so day four or after. And then the community onset healthcare facility associated would be if that patient was discharged from your facility within four weeks prior to that, but the testing itself was done in the first three days of that given stay. So if somebody goes home from your hospital, comes back in two weeks and has a positive test, and that would be a community-onset healthcare facility-associated. So, lets go on to the next, because I actually have a couple of pictures of how those reports are written and show up. This is where you are going to find a report that you have run and you can run a serve report or a rateable. For most of you, the best information or the most information that you are going to get is actually for a rateable, although for those of you that are in PPS hospitals, I am going to ask you forgiveness because I am not going to show the stir on this. I think most of you really know how to find and how to run that. So that I did not do this. So what I am showing today is mostly the rateables. So go ahead and go to the next. And this is an example of one of the pieces of information you were in a rateable for your hospital, you get a variety of reports that are all in one report. The first one is your inpatient admission prevalence rate. So this is how many patients come in to your facility over the number of admits and they already have C. diff. or MRSA at the time of the admission to your facility, in this case the slide is for C. diff. So gives you an overall prevalence rate. So the next slide is the how many of those are actually inpatient C. diff. overall prevalence rates. So this is a different facility so the numbers are going to show different, but this will be the total number of patients in your facility, both healthcare-onset and community-onset that were in your facility for each quarter. Then next one. So these are the community-onset admission prevalence rates of, you can see that with this facility those numbers are pretty high, but these are all people that came in with that organism. So the next slide. And these are the facility onset rates. So this is the rate that most of us are looking for and I am going to let Jennifer address the question as to how that is reported out for the HEN and reports that they are sending now, but I want you to be able to see that you can get each one of those reports for your facility just by running one report. It gives you all of those tables for your facility. So I think that is about to the end of my slides. You can see if there is another one in there Jennifer. Just my little INAUDIBLE18:10 is my last slide here. Everytime I go out to a facility to work with people, most of you are really picking up on how much the alerts can help you, but if you were to go in and select that 13 missing summary items, that is going to take you right where you need to be to answer all of that data, and it just makes it so much easier. So, when you go in, I encourage you to go in and look at your alerts and respond to those that are missing. So I think that we will go ahead and wind up with and I will just allow for questions, so I answer your questions and if you do still have, that is all. Go ahead.