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: email@example.com 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 firstname.lastname@example.org.
Have you been to the National Healthcare Safety Network (NHSN) section of the Network web site? You’ll find a shortcut to your most frequently needed NHSN resources that include:
- Required Training
- Enrollment Steps
- NHSH Event Protocol
- NHSN Dialysis Event Surveillance Data
- CMS ESRD QIP Rule Report
- Health Care Personnel Safety Components
- NHSN Contact Information
REMINDER: NHSN Data Reporting Deadline for Quality Incentive Program (QIP) is Quickly Approaching
September 30, 2017 is the deadline for National Healthcare Safety Network (NHSN) second quarter 2017 Dialysis Event reporting.
Tips for Accurate Reporting of NHSN Data:
- Follow the guidelines provided using the 3 step guide:
- Run the “Line Listing – CMS ESRD QIP report” to check for compliance: http://www.cdc.gov/nhsn/pdfs/cms/dialysis/cms-qip-nhsn-report.pdf
- Check CCN and CCN Effective Date in the Facility Info page in NHSN:
- Identify “Acute Kidney Injury” patients in NHSN to be excluded by CDC for QIP measure: https://www.cdc.gov/nhsn/pdfs/dialysis/aki-2017-instructions-enter-patients.pdf
If you have any questions, contact the NHSN helpdesk (email@example.com) and include ‘Dialysis’ in the subject line.
Click here to open the June 2017 NHSN Newsletter, which provides helpful resources for data reporting.
The CDC recently hosted webinars that provided a complete introduction to the National Healthcare Safety Network (NHSN) Dialysis Event reporting requirements and the surveillance definitions necessary to complete accurate monthly reporting. NHSN Dialysis Event Surveillance reporting is required for the CMS ESRD Quality Incentive Program (QIP).
If you missed the live webinar, continuing education (CE) credits are available for the recorded presentation, which can be found at https://www.cdc.gov/nhsn/Training/continuing-edu.html.
The Centers for Medicare & Medicaid Services (CMS) announced an extension of the deadline for 2017 First Quarter NHSN reporting to Monday, July 31, 2017, at 11:59 p.m. PT. The extension will allow facilities the opportunity to ensure data are complete and accurate in accordance with ESRD QIP reporting policy.
To read the full announcement, please click here.
The current ESRD QIP measure set is not designed to measure the quality of care provided to patients with acute kidney injuries (AKI). CMS will use only ESRD patient data to calculate the NHSN Bloodstream Infection (BSI) clinical measure, NHSN Dialysis Event reporting measure, or any other measure in the ESRD QIP for Payment Year (PY) 2019; AKI patient data will not be included in the calculations.
However, facilities are encouraged to consider reporting AKI patients on a voluntary basis for internal quality improvement efforts and Centers for Disease Control and Prevention (CDC) public health surveillance purposes. Please use the following guidelines to ensure AKI patient data are excluded from QIP scoring purposes for Calendar Year (CY) 2017 NHSN BSI data.
- Adding and Editing Dialysis Positive Blood Culture Events to Indicate an Acute Kidney Injury (AKI) Patient: Instructions for Calendar Year 2017
- Editing Denominators for Dialysis Event Surveillance to Remove Acute Kidney Injury (AKI) Patient Counts: Instructions for Calendar Year 2017
If you have any questions or concerns regarding the extension, please contact the CMS ESRD QIP team at firstname.lastname@example.org with “AKI” in the subject line.
If you have questions regarding how to remove patients with AKI from data reported to NHSN, please contact the NHSN helpdesk at NHSN@cdc.gov with “Dialysis” in the subject line.
To meet the Centers for Medicare & Medicaid Services (CMS) ESRD Quality Incentive Program (QIP) National Healthcare Safety Network (NHSN) reporting requirements for Payment Year 2019, outpatient hemodialysis clinics must submit first quarter 2017 Dialysis Event data collected from January 1, 2017 through March 31, 2017, by Friday, June 30, 2017. New or revised first quarter data entered into NHSN after June 30, 2017 will not be received by CMS. Therefore, please be aware that any changes or corrections to first quarter 2017 data should be made prior to the reporting deadline.
The following steps are recommended to review your data before the deadline. Additional resources can be found on the Dialysis Event homepage:
- Review the NHSN Dialysis Event Protocol to ensure all data were correctly reported to NHSN.
- 3 Steps to Review Dialysis Event Surveillance Data
- Use the How to Create and Read an NHSN Report for CMS ESRD QIP guide to verify that your facility has met the minimum CMS reporting requirements.
- Refer to the How to Create and Read an NHSN Report for Bloodstream Infections guide to review your facility’s bloodstream infection rates.
Please contact the NHSN Helpdesk at email@example.com include ‘Dialysis’ in the subject line) with any questions.