NSHN: The gold standard for HAI surveillance
CDC expanding HAI tracking beyond hospital
The Centers for Disease Control and Prevention's rapidly expanding National Healthcare Safety Network (NHSN) has long been the gold standard surveillance system for health care associated infections (HAIs). From its relative humble origins with a few hundred hospitals in the National Nosocomial Infections Surveillance (NNIS) System, the NHSN continues a dramatic expansion driven in large part by the growing requirements for HAI reporting by state and federal agencies. We recently spoke with Daniel Pollock, MD, surveillance branch chief of the CDC's Division of Health Care Quality Promotion, about the expanding role of the NHSN.
Hospital Infection Control & Prevention: How many facilities are now reporting HAI data to the NSHN? Do you have sufficient capacity and budget to meet this demand?
Pollock: "Well, there are 10,000 facilities all together, half of which are hospitals. We are a federally funded program and receive funds through various mechanisms. We are part of the equation but there has to be an investment on the side of the reporting hospital as well. States have been investing — in that they need staff to participate. CMS Medicare has invested in that we are now sending data to Medicare and there is a processing and eventually a posting and use of the data on the CMS side. So it's an investment from many quarters. Clearly, the lion's share is here [at CDC]. We are supporting a large and complex system that requires considerable investment, development and maintenance."
You said in a recent speech at a CDC meeting on the NHSN that "Our assumption is that the advent of public reporting and the adoption of data driven performance incentives are transforming the question of whether HAIs will be included in publically reported metrics and pay for performance to when and how." Can you expand on that?
"Right now we are engaged with the CMS value-based purchasing program around how the central-line associated bloodstream infection (CLABSI) data will be used as part of the program — which is also known as a pay for performance program. This could be described as a payment-driven incentivization to improve quality in response to a quality performance metric — namely a CLABSI metric. That is very much in play. It has begun. We have already delivered data to the [CMS] hospital value-based purchasing [system]. We will deliver more data, and right now those are data to establish a baseline. Data reported the next calendar year will be measured [against the baseline]."
You also mentioned in that talk that we are at something of a crossroads between using discharge data versus other measures that would be more valid for comparison and reporting. Is that going to be a critical part of this?
"The short answer is yes. Because the fork in the road has two different paths from it — one of them is to use coded claims or other administrative data that take the infection preventionists out of the supply chain. The hospital themselves or someone the hospital would hire could analysze the administrative data without an IP ever even looking at it. We know that there are fundamental shortcomings in the use of hospital discharge data alone to ascertain whether or not a case meets criteria for an HAI. There has been study after study that substantiates the concern that claims data alone should not be used as an outcome measure in the HAI domain. That is a road from the fork that we do not support. We do see value in the use of claims data as a tool, rather than as an outcome measure."
Just to clarify, the NHSN does not use claims data for surveillance?
"We do not. What we are saying is that it is fine for IPs to use the discharge data as a safeguard to see whether there may have been a surgical site infection that ultimately was picked up and that has a discharge code that suggests an infection. It should be corroborated with a review of that record. IPs can miss cases so the discharge data can serve potentially as a backstop under those circumstances. And we're fine with that, it's just when you use the discharge data alone as the outcome measure there are many, many cases that are missed."
Is part of the challenge to convince hospitals that it's worth the bang for the buck to invest in collecting good HAI surveillance data?
"Yes, part of the challenge is communicating that to do the type of active surveillance that is necessary for HAI prevention there is an investment. It is the price of doing business in a way that preventing those infections is a top priority. No question, that is part of our communications. We want this to be seen as a standard business practice across the industry. And to that end we work very closely with the American Hospital Association and some of the other national associations on NHSN matters. We communicate with them regularly, we have a monthly call and we communicate between calls. We keep them posted as to what changes are on the horizon for NHSN, what the potential impact is for their member hospitals, and we work with them to educate them to respond to issues that arise. I would say the hospital industry on the national level has an understanding of the level of commitment that is needed. That doesn't necessarily translate down to each and every hospital, but I think we are making good progress."
The old CDC NSIS system began to draw criticism for establishing a kind of benchmark range for hosptials rather than encouraging an aggressive pursuit of HAI eradication. There has been a dramatic culture change on that issue with the idea of pushing HAIs to zero.
"We're strong proponents of wanting to get to zero with HAIs. It's a good thing to be making progress. It's a good thing to have a summary metric that compares favorably to the national aggregate, but the best thing of course is to drive to zero across the board for all of these infections. I think increasingly that is seen as an achievable objective for some infections — not necessarily all. But it is a mindset and it does require a commitment that translates to resources. We see a continuing problem with C. diff and one that seems to be becoming more difficult. We have made significant progress certainly with CLABSIs in intensive care units."
Isn't the NHSN system ultimately limited to the data you receive? There are anecdotal reports of in-house debates on whether an infection should be a reportable HAI.
"We are dependent on hospitals that are reporting to have staff that have committed themselves to understanding the protocols and to engaging in active surveillance and to abiding by our structures for reporting. In some cases, that doesn't happen. We are working closely with states and with CMS on strategies for validation. Validation is tied closely to training, because some of what we learn in the process of validating data is a reflection of a lack of understanding and not so much an intentional omission. That may be something we can address better in training."
But do you think you are seeing the real picture — actual decreases in clinical events?
"I think we are seeing measureable decreases and also persistence of some problems. So yes, we use the data and recognize that there are shortcoming and we want to address those, but even still the data can be very important as an indicator of the direction we are headed across the various infection types.
The NHSN system is expanding into long-term care, health care worker vaccination data and dialysis settings. Does this reflect the necessary move of HAI surveillance beyond the hospital?
"That is what we are after. We recognize that more and more health care is delivered outside the hospital walls and we want to make sure that some of the tried and true methods for detecting and responding to infections can be applied regardless of where care is being rendered, including extending our capacity for surveillance to ambulatory surgery centers, dialysis facilities and long-term care."
What about antibiotic stewardship measures and antimicrobial resistance?
"We are introducing that. Antimicrobial use and resistance reporting is a part of the NHSN that we are developing right now. It will be possible for hospitals to report this data electronically. One of the reasons that it has been so difficult in the past to capture antimicrobial use and resistance data across the board has been the labor intensiveness of manual methods of entering those data. We are moving to a fully electronic means of reporting both antimicrobial use and resistance data so that hospitals will have antibiogram information that is reported electronically from microbiology results and pharmacy [data]."
Yes, infection preventionists have been clearly concerned about the burdens of data collection and the impact it will have on their programs.
"Absolutely. The whole process can be burdensome and labor intensive, particularly if we are dependent on manual [methods] rather than electronic. What we have been talking about these last few minutes is the tail end of the supply chain of actually delivering [the data] to us. But what we also need to work on and focus on are the earlier steps in the supply chain. [Things that] would enable infections to be detected electronically from data entered into electronic health records systems [in order to] enable the denominator data — such as central line days, catheter days, ventilator days — to be ascertained electronically. So we want to move up the supply chain as well in those steps that remain labor intensive for the IPs."
The Centers for Disease Control and Prevention's rapidly expanding National Healthcare Safety Network (NHSN) has long been the gold standard surveillance system for health care associated infections (HAIs).You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content