NHSN has advised that NHSN data for July 1-September 30, 2018 must be submitted and corrected by December 31, 2018 in order to be applied to PY2020 QIP scores. NHSN recommends:
Contact the NHSN Helpdesk at email@example.com with subject line “Dialysis” if you have any questions.
The NHSN software was updated to Version 9.2 on December 8, 2018, with many additions and changes, including analysis updates. Please carefully review pages 1 and 7-8 of the Version 9.2 release notes at https://s3-us-west-2.amazonaws.com/nwrn.org/files/NHSN/NHSN9.2.pdf for important details about these changes. To use any of the new analysis output options you must first Regenerate Datasets. Send any questions to the NHSN Helpdesk at NHSN@cdc.gov.
Reporting to NHSN for the CMS ESRD QIP rule:
Facilities must follow NHSN Dialysis Event Surveillance Protocol and Reporting for calendar year 2018 (payment year 2020) for compliance with the ESRD QIP. The quarterly reporting deadline for April – June 2018 data is on or before September 30, 2018.
Data Quality Checks:
NHSN data should be completely and accurately reported according to the Dialysis Event Protocol. Determining whether or not the data are correct is your facility’s responsibility. Data quality checks should be performed before the data submission deadline for the quarter. For example, for April to June data, quality checks should be performed by September 30. For more information on how to perform data quality checks, please go to https://iproesrdnetwork.freshdesk.com/solution/articles/9000153404-how-to-perform-data-quality-checks- or https://iproesrdnetwork.freshdesk.com/support/solutions/folders/9000169529
NHSN’s stated purposes have been recently updated with new provisions for sharing data with local and territorial health departments and with the Centers for Medicare & Medicaid Services (CMS). As a result all newly enrolled facilities must accept the Agreement to Participate and Consent upon enrollment, and all currently participating facilities must accept or “re-consent” to the Agreement.
- Currently enrolled facilities are required to accept the new Agreement to Participate and Consent electronically by June 15, 2018.
- If a facility fails to re-consent by the deadline, its NHSN functionality will be suspended until the consent form is accepted.
- Newly enrolled facilities must consent within 60 days of enrolling in NHSN.
- After submitting enrollment forms, the person(s) listed as the Dialysis Component Primary Contact and the Healthcare Personnel Primary Contact must log in to the enrolled facility in NHSN.
- On the Dialysis component homepage, the primary contact should review the electronic consent form and then check the ‘Accept’ box and click ‘Submit’.
- For more information contact NHSN@cdc.gov with “consent form” in the subject line or visit https://www.cdc.gov/nhsn/about-nhsn/faq-agreement-to-participate.html.
The Centers for Disease Control and Prevention (CDC) has extended the deadline for completing the online National Healthcare Safety Network (NHSN) Agreement to Participate and Consent form, referred to as the Consent in this announcement. The new deadline for completing the Consent, June 15, 2018, applies to ALL facilities reporting data to NHSN including those for the following Centers for Medicare and Medicaid Services (CMS) programs:
- Hospital Inpatient Quality Reporting Program
- Hospital Outpatient Quality Reporting Program
- Ambulatory Surgical Center Quality Reporting Program
- Inpatient Psychiatric Facility Quality Reporting Program
- End Stage Renal Disease Quality Incentive Program
- Long Term Care Hospital Quality Reporting Program
- Inpatient Rehabilitation Facility Quality Reporting Program
The Consent is accessible to only the NHSN Facility Administrator or Primary Contact user. The new deadline provides additional time for each facility’s NHSN Facility Administrator or Primary Contact to complete the online Consent and avoid any interruptions in access to the NHSN application, including access for purposes of submitting data to meet local, state, or federal reporting requirements. If the Consent is not completed by the new deadline, access to NHSN will be temporarily suspended. Additionally, users will receive an error message when they attempt to log into NHSN, redirecting them to the Facility Administrator or Primary Contact.
CMS quality reporting deadlines for NHSN measure reporting are not affected by this extension.
NHSN provides assistance to address any questions or concerns you may have regarding the Consent process. For more information on how to complete the NHSN Agreement to Participate and Consent process, please visit, https://www.cdc.gov/nhsn/about-nhsn/faq-agreement-to-participate.html. You may also direct questions to NHSN@cdc.gov.
The CDC National Healthcare Safety Network (NHSN) Dialysis Team will provide live webinars in May for new or experienced NHSN users. CDC subject matter experts will be available to answer your questions about NHSN Dialysis Event Surveillance.
Introduction to the NHSN Dialysis Event Surveillance Protocol: NHSN Dialysis Event Surveillance reporting is required for Centers for Medicare and Medicaid Services (CMS) End-Stage Renal Disease (ESRD) Quality Incentive Program (QIP) rule. This session will provide a complete introduction to the NHSN Dialysis Event reporting requirements and the surveillance definitions necessary to complete accurate monthly reporting.
Advanced NHSN Dialysis Event Surveillance Reporting and Introduction to NHSN Reports: Learn how to apply NHSN Dialysis Event Surveillance definitions through case studies that address common reporting questions. The session also will include an introduction to running and interpreting the most popular NHSN reports so you can review your facility’s data, including Dialysis Event bloodstream infection rates.
Information on infections identified in the hospital setting and reported in the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN), is not easily obtained by dialysis providers. Access to these data can improve surveillance of bloodstream infections and patient outcomes. Enrollment in the Health Information Exchange (HIE) can overcome this barrier. A recent article published in Nephrology News & Issues, ” Closing the information gap: Health information exchange in dialysis“, gives an overview of the benefits of HIE and how it provides a vehicle for improving the quality and safety of patient care.
For more information on HIE, go to https://www.healthit.gov/providers-professionals/health-information-exchange/ .
For information on HIE in your state, go to https://www.healthit.gov/policy-researchers-implementers/state-health-information-exchange-cooperative-agreement-program-key
The Centers for Disease Control and Prevention reports infection is the second most common cause of death and hospitalization among dialysis patients. Hemodialysis patients have multiple and frequent exposure to healthcare environments undergoing treatment three times per week with direct access to their bloodstream via venipuncture and catheters. Healthcare expenditures for these infections are staggering. Research has shown that the Implementation of the CDC core interventions reduces infections dramatically, saving lives and reducing healthcare costs. Take a minute to review these interventions, by clicking here, to assure your facility is doing everything possible to be safe and save lives.
The NHSN is an electronic tracking system for healthcare-associated infections (HAIs) that integrates patient and healthcare personnel surveillance systems managed by the CDC. To fulfill the annual NHSN training requirement, at least one NHSN user at each facility must read the Dialysis Event Protocol and subsequently take the online Dialysis Event Surveillance Training before September 30, 2018. By completing the Annual Training and passing the post-training assessment, individuals are eligible to earn continuing education credits (CE), provided they complete this process online.
Beginning January 1, 2018, dialysis facilities should include acute kidney injury (AKI) patients in National Healthcare Safety Network (NHSN) Dialysis Event Surveillance. Reporting AKI patient data to a new, separate NHSN location will enable CDC to exclude AKI patient data from NHSN Bloodstream Infection (BSI) information shared with CMS for purposes of the ESRD Quality Incentive Program (QIP).
The “Acute Kidney Injury (AKI) Location” should be used to report Dialysis Events, and denominator data for patients who have acute kidney injury and do not have an end-stage renal disease (ESRD) diagnosis at the time of the Event, or at time of denominator data collection.
The “Acute Kidney Injury Location” was released as part of the NHSN version 8.8 update on December 2, 2017. Please click here for instructions on using the “Acute Kidney Injury Location”.
Of those included in the NHSN Dialysis Event Surveillance population, the following criteria should be used to identify patients who have acute kidney injury:
1. No diagnosis of “End Stage Renal Disease” or “ESRD” in the patient medical record, or through the ESRD Medical Evidence Form (Form CMS-2728-U3).
2. Physician-diagnosis of “Acute Kidney Injury: or “AKI” listed in the patient medical record (e.g., nephrologist consult or referral form).
3. The event date, or date of denominator data collection, is not more than 6 months after the date the patient initiated outpatient hemodialysis.
For questions, please contact the NHSN helpdesk: firstname.lastname@example.org with “dialysis” in the subject line.
After the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN) system release on December 2, 2017, analysis reports and select alerts were not accessible to some NHSN Dialysis Component group and facility users. This issue has since been resolved, and users are now able to access their reports and receive alerts.
As a result of this issue, outpatient dialysis facilities and groups were unable to review NHSN data for completion and accuracy from December 2, 2017 through December 21, 2017. To provide facilities with ample time to review their NHSN data and make any corrections, CMS has extended the ESRD QIP deadline for facilities to enter third-quarter 2017 NHSN data to January 31, 2018.
For more information on the ESRD QIP, please visit https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ESRDQIP/index.html. For more information about NHSN, please visit https://www.cdc.gov/nhsn/dialysis/.
Thank you for your attention in this matter and for entering your facility’s data promptly. If you have any additional questions or concerns, please contact the NHSN helpdesk at mailto:NHSN@cdc.gov or CMS ESRD QIP team at email@example.com.