NHSN MDRO and CDI Monthly Denominator Form for FacWideIN Surveillance in ACH – 2019


Welcome to the ‘Patient Safety Component:
Multidrug-Resistant Organism and Clostridioides difficile Monthly Denominator form for FacWideIN
Surveillance’ Quick Learn. In this presentation, we will describe how
acute care hospitals should enter data into the monthly FacWideIN denominator record,
and highlight changes users will notice in this form starting in 2019. This Quick Learn is targeted for NHSN users
from acute care or critical access hospitals who enter monthly facility-wide inpatient,
also known as FacWideIN, denominator data into the Patient Safety Component
The purpose of this Quick Learn, is to introduce NHSN users to the 2019 updated MDRO and CDI
monthly denominator form. After viewing this Quick Learn, NHSN users
will be able to accurately complete the updated MDRO and CDI Monthly Denominator form for both
internal and CMS inpatient quality reporting purposes The NHSN team has updated the MDRO and CDI
Monthly Denominator form due to numerous and consistent data entry errors made on the FacWideIN
denominator record. Several cosmetic changes were implemented
to improve the clarity of data entry requirements and to provide additional instructions. These changes also improved the look and feel
of the denominator record. No changes were made to the definitions of
the denominators themselves. Before we begin to detail the updates made
to the MDRO and CDI monthly denominator form, we will provide a brief overview of the purpose
and use of this form. The monthly denominator form is a summary
record in which total counts of patient days and admissions are entered into NHSN. This summary record should contain a count
of all patients who were admitted to an inpatient unit in your healthcare facility throughout
the reporting month. This denominator information is used to help
generate your facility’s rates and SIRs for Lab ID reporting. To access the MDRO and CDI denominator form,
users must log into their facility within the NHSN application. Once logged into NHSN, select the summary
data tab on the left hand side of the page and then click Add to enter a new monthly
form. The next page will provide you options for
the summary data type. To obtain the Lab ID denominator form, select
MDRO and CDI Monthly Denominator Form-All Locations and click “Continue” directly
below your selection. You’ll notice the first change to the 2019
denominator form on this slide, which involves the title of the denominator record. Notice that the title has changed, and is
now a simple and concise title. NHSN uses a single facility-wide inpatient
denominator to encapsulate every active physically mapped inpatient location located within the
hospital for Lab ID reporting. In order to make the reporting process more
efficient, all eligible and active inpatient units are aggregated to a non-physical location
titled FacWideIN. This is the location that should be selected
on your adjacent monthly reporting plan to follow for the Lab ID module and will be selected
on the summary page’s drop-down box for location code. Ensure that you have selected the appropriate
month and year for data entry. If there is no data entered for the month
and year you’ve selected, a blank summary form should remain on the page. To meet the CMS inpatient quality reporting
requirements that stipulate Lab ID reporting must include every mapped active inpatient
unit, facilities need to use the FacWideIN location to comply with the requirement. After selecting the location, month, and year
for the denominator record, you will then see the denominator form as shown on the slide. The picture here highlights the three required
rows of data that need to be entered in order to successfully save the form. You may notice several changes on this form
compared to previous years. First, the description text for rows 2 and
3 have changed, and the terms MDRO patient days or admissions and CDI patient days or
admissions have been removed. In addition, formulas have been added to the
instructions for rows 2 and 3, so that users can see exactly how to calculate the correct
patient days and admissions on these rows. These formulas are highlighted in yellow and
blue on the slide. Next, we will go through the requirements
for data entry on each row. This slide provides instructions on how to
complete each line of the denominator form that was shown on the previous slide. These instructions have not changed from prior
years. The first row is the total number of patient
days and admissions from all active inpatient locations from your facility. Exclude outpatient location totals from these
fields, or any location that is enrolled in NHSN as a separate facility. The second row on the slide is a subset of
Row 1, and represents the total number of patient days and admissions from all active
inpatient units with the exception of CMS-certified rehab units and CMS certified psych units,
also known as IRF and IPF units, respectively. Totals from these two CMS certified Rehab
and Psych units are to be subtracted from the totals found on row 1, and the new totals
entered in row 2. Row 3 is a subset of Row 1, and represents
the total number of patient days and admissions from all active inpatient units with the exception
of the CMS certified rehab and psych units, as well as the NICU and well-baby units. These unit types, just as in row 2, are to
be subtracted from the total patient days and total admissions entered on row 1 of this
form. As shown on the previous slide, the formulas
to help calculate the number of patient days and admissions for rows 2 and 3 are now available
on the denominator form and can be seen on this slide. Please remember that the Lab ID denominator
form only collects the total number of patient days and admissions and is not concerned with
the infection status of any of the patients. All patients housed in the applicable units
should be counted in the denominators. Also remember, CMS certified rehab and psych
units are identified by a unique C-C-N that is different from the main acute care hospital’s
CCN. Let’s walk through an example of how a hospital
should report their FacWideIN denominator record. In our example, the hospital had a total of
1,000 patient days and 500 admissions across all inpatient units during the month of January
2019. The Hospital has an IRF unit, which had 200
patient days and 100 admissions, and an IPF unit, which had 100 patient days and 50 admissions. Finally, the facility has several NICU and
well-baby nurseries, which contributed a combined total of 350 patient days and 75 admissions. What numbers should the facility enter on
Row 1 of the FacWideIN denominator form? Feel free to pause this video to complete
the calculation. The correct answer is 1,000 patient days and
500 admissions. Remember, row 1 is the total number of patient
days and admissions from all active inpatient locations from your facility. The only units that should be excluded from
these counts are outpatient locations or any location that is enrolled in NHSN as a separate
unique facility. Now, using the totals of 1,000 patient days
and 500 admissions across all inpatient locations that were entered in row 1 of the form, what
values of patient days and admissions should be entered on the second row of the FacWideIN
denominator form? The formula for calculating Row 2 denominators
is shown on the screen, highlighted in yellow. Feel free to pause this video to complete
the calculation. The correct answer is 700 patient days and
350 admissions. To reach these figures, the 1,000 total patient
days were subtracted by the combined totals of IRF and IPF patient days of 300 to equal
700 patient days. The 500 total number of admissions was subtracted
by the combined totals of IRF and IPF admissions of 150 to equal 350 admissions. Finally, using the same totals of patient
days and admissions used for Rows 1 and 2, what values should the hospital report on
Row 3 of the denominator form? The formula for calculating Row 3 denominators
is shown on the screen, highlighted in blue. Feel free to pause this video to complete
the calculation. The correct answer is 350 patient days and
275 admissions. To reach these figures, the 1,000 total patient
days were subtracted by the combined totals of IRF, IPF, NICUs, and well-baby units patient
days of 650 to equal 350 patient days. The 500 total number of admissions was subtracted
by the combined totals of IRF, IPF, NICUs, and well-baby unit’s admissions of 225 to
equal 275 admissions. Another element captured on this form is the
C. difficile, or CDI, test type. This is the primary testing method for CDI
used most often by your facility’s laboratory. The CDI test type is collected only on the
third month of each quarter. Without indicating the test type, an S-I-R
for CDI will not be generated for the quarter. A drop down box is available on the appropriate
months and provides the common methods that are used for CDI testing. Please do not select Other if possible. The list of test types are regularly updated
and should cover the majority of tests used by labs all across the country. The final item to complete on the denominator
form is the organism selection box. If you’ve selected the correct organisms
on the corresponding monthly reporting plan, the checkboxes on the table will automatically
be checked by default, as shown here on the slide. Notice that MRSA and C. difficile are now
the first two columns in this table. This is an update from the previous Organism
Selection boxes. Next to each organism there is a checkbox
to select if there were no events for that month. If your facility reported a Lab ID event for
any of the organisms that you’re following within any inpatient location, then you will
not check the Report No Events box. If you add an event after checking the Report
No Events box, the system will automatically uncheck the box for you. After you’ve entered the required data on
this form you will finish the process by selecting Save at the bottom of the page. To edit your Lab ID denominator form you will
use the same navigation tab on the left hand side of the application as you did to add
the denominator form under Summary Data. To edit, select Summary Data and then Find
on this screen. Data can always be edited in NHSN after a
record has been saved. Please remember that any edits made to existing
data in NHSN will not be re-submitted to CMS after a reporting deadline has passed. Data that is submitted to CMS and then changed
after a deadline may result in discrepancies between NHSN analysis reports and public reporting
information published on CMS websites. Once you have selected find, as shown on the
previous slide, you’ll be taken to the page where you will need to specify the appropriate
summary data type, the location code, and month and year you’re interested in reviewing. For users who want to view Lab ID denominator
data that is reported to CMS, please enter the search criteria for Summary Data Type
and Location Code as seen on this slide. To do this, use the drop-down boxes to select
MDRO and CDI monthly denominator-All locations for the summary data type field, and FacWideIN
for the location code field. Finally, using the drop-down boxes, select
the month and year you’re interested in viewing. Select Find when you’ve selected elements
in each of the four fields. If you’d like to view the data entered or
edited in the denominator form in NHSN analysis reports, please remember to generate datasets. These reports will not reflect any changes
you’ve made to your data until after datasets have been generated. We hope viewers of this quick learn have identified
the new changes made to the MDRO and CDI monthly denominator form in NHSN. Viewers of this video should now be aware
of the formulas provided for the three rows of data that need to be entered on this form. They should also know that FacWideIN Lab ID
data that is entered or modified after a particular CMS deadline will not be re-submitted to CMS. The NHSN website offers additional resources
that can help users accurately complete their Lab ID summary reporting forms. The first item listed on the screen is the
table of instructions for the MDRO and CDI monthly denominator form. Next, there is a quick reference guide for
how to run a line list in NHSN. This output can help identify the months in
which Lab ID events were reported in order to accurately select the Report No Events
checkbox on the summary form. Lastly, we have another quick reference guide
to obtain summary data line lists. This output option allows users to view multiple
months of data entered on specific HAI monthly summary reporting forms. Thank you for taking the time to view this
NHSN Quick Learn about completing the MDRO and CDI Monthly Denominator Form for FacWideIN
Surveillance. If you have additional questions about Lab
ID reporting, please e-mail us at [email protected]

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