Welcome to the 2019 National Healthcare Safety Network, or NHSN quick learn series.
These are brief and informative presentations from the Centers for Disease Control and Prevention.
They serve as an educational resource for healthcare facilities working to prevent Healthcare
Associated Infections, or HAI’s.
In this Quick Learn we discuss using the Targeted Assessment for Prevention Strategy, or TAP.
We’ll review the TAP Strategy and how generating reports can assess and guide HAI prevention efforts.
By the end of the lesson you will be able to: Identify the three components of the TAP
strategy, Know the elements used to create a TAP Report, Define and calculate the Standardized
Infection Ratio or SIR or Define and calculate the Cumulative Attributable Difference or
(CAD), Learn how to calculate the CAD using an HAI Reduction Goal, and Learn how to create
a TAP Report in NHSN . Let’s get started with defining the TAP strategy.
What is the TAP Strategy?
The Targeted Assessment for Prevention Strategy, or TAP, is a method developed by the Centers
for Disease Control and Prevention to apply NHSN data toward strategies to eliminate HAI’s.
The TAP Strategy can help target healthcare facilities and specific units within facilities
with a disproportionate burden of HAI’s so that gaps in infection prevention in the
targeted location can be addressed.
Several partners are involved in this strategy, including the Centers for Medicare & Medicaid
Services, or CMS, Quality Innovation Network-Quality Improvement Organizations, State Health Departments,
healthcare systems, and facilities.
TAP uses data for action, by helping facilities identify locations with excessive HAI’s,
prioritizing prevention efforts, and evaluating performance toward reaching prevention goals.
Target, Assess, and Prevent are the 3 main objectives of TAP.
The “T” in the TAP strategy stands for “Target”.
Using TAP Report functions available in NHSN, can help facilities and unit locations with
a higher burden of infection.
Next is “A”, it stands for “Assess” uses the Facility Assessment Tools for the
TAP Strategy to assess gaps in a facility’s infection prevention resources.
And lastly, the “P”, which stands for “Prevent”, aims to prevent HAI’s by
providing facilities with infection prevention strategies to address the identified gaps.
While all three steps are equally important, this Quick Learn will focus on the first step
of the TAP strategy, targeting facilities.
TAP reports have the ability to give facilities more insight into their data and help them
develop a strategy for HAI prevention.
TAP Reports bring together data elements from various places within NHSN, such as the Annual
Survey, Rate Tables, SIRs, and Event-level information for catheter-associated urinary
tract infections or CAUTIs, central line-associated bloodstream infections , or CLABSIs, C. difficile
infections CDIs and MRSA LabID.
Here, we can see the TAP Reports are available for each facility type.
Acute Care Hospitals can run CLABSI, CAUTI, CDI LabID, and MRSA LabID TAP Reports.
For Long Term Acute Care Hospitals, there are CLABSI, CAUTI, and CDI LabID TAP Reports.
Inpatient Rehab Facilities have CAUTI and CDI LabID reports.
Now, let's discuss an overview of the SIR and the CAD.
The Standardized Infection Ratio or SIR is a summary measure used to track HAIs at a
national, state, or local level over time.
The SIR adjusts for various facility and/or patient – level factors that contribute
to HAI risk within each facility.
The Cumulative Attributable Difference or CAD is used to identify facilities and units
with a higher burden of HAIs.
The CAD allows specific gaps in infection prevention to be identified and addressed.
The SIR is a measure that compares the observed number of HAIs to the number of infections
that would be predicted based on national baseline data.
An SIR of 1 indicates that the number of observed infections reported to NHSN is equal to the
number of infections predicted, given the US baseline data to which HAI data are being compared.
While an SIR greater than 1 indicates that a group or facility has more observed infections
than predicted, an SIR less than 1 indicates that a group or facility has fewer observed
infections than predicted.
SIR accounts for differences in incidence and exposure across available factors known
to be associated with the given HAI or event.
The predicted number of infections in the SIR ratio is influenced by many factors including
incidence and exposure across the facility.
For example, the summarized HAI experience at a hospital with a large burn unit, a location
associated with higher HAI incidence, cannot be directly compared to a facility without
a burn unit unless this difference in exposure and incidence is taken into account.
As a result of differences in exposure and incidence, the predicted number of HAIs will
vary among hospitals or facilities.
Factors that are taken into account in the calculation of an SIR, sometimes called “risk
factors,” help to promote comparisons that are more fair and valid.
Cumulative attributable difference, or CAD, is a measure that shows the difference between
the number of observed infections and predicted infections multiplied by an SIR goal in a defined period.
When we incorporate an SIR goal into our calculation for CAD, the value of CAD represents the number
of infections that a healthcare facility or organization needs to prevent to reach that
specific HAI reduction goal.
Therefore, depending on the choice of an SIR goal, the magnitude of CAD will vary.
A positive CAD means, more infections than what would be predicted with regard to an SIR goal.
A Negative CAD means fewer infections than what would be predicted.
It should also be noted that CAD is not a metric to compare performance of units or
facilities like SIR because CAD is not adjusted by risk exposure size, for example, catheter days.
The CAD was developed as a prioritization metric to target the facilities and units
with the highest burden of excess infections to help reach the targeted SIR goal.
Therefore, ranking the facilities and units by CAD value in descending order is the basic
concept of TAP report generation.
An important component of the CAD calculation is the HAI Reduction Goal.
The HAI Reduction Goal can be calculated using the HHS action plan goals for 2020 or a customized
SIR goal the HHS goal for 2020 can be found at the HHS website for National Targets and Metrics.
The link is displayed on this slide.
Here is an example of the influence of the SIR goal on the CAD calculation.
As the goal SIR becomes lower, the CAD, or the number of infections the facility would
need to prevent to reach the SIR goal, increases.
For example, an SIR goal of 0.50 correlates to a CAD of 15.
If the SIR goal is decreased to 0.25, the CAD becomes 22.5
Now let’s talk about creating a TAP report.
Prior to running a TAP report, you should verify facilities are mapped to the appropriate
NHSN locations and that an up-to-date data set was generated.
Guidance on mapping NHSN locations can be found on the NHSN website.
TAP Reports are organized by facility type in the TAP Reports Folder in the analysis
reports section of NHSN.
The TAP Reports for all HAI types utilize 2015 baseline data, thus data analyzed are
from January 2015 to present.
Data from before January 2015, must be analyzed using the original baseline models.
These can be found in the Baseline Set One folder directly below the TAP Reports folder.
There are three options to select when running TAP Reports.
The first option is “Run”, this option will run the default TAP Report.
The second option is “Modify”, this option allows the user to customize the default TAP Report.
The third option is “Export Data Set”, selecting this option exports the data set for the report.
The default time period will provide a report inclusive of all data reported to NHSN that
are in the analysis datasets.
To limit the TAP Report by time period, the user must select a date range for the period
of interest by either year, half-year, quarter or month.
In general, at least one quarter period should be specified in order to have a representative
amount of data.
In this example, the data variable, “summaryYQ” is selected for summary data by quarter.
The Beginning and Ending fields are pre-formatted to help specify dates.
If we want to see data for quarters 1 through 3 of 2019; we enter this period in the provided fields.
For beginning date, enter 2019 then 1 to indicate the year and quarter in the empty field.
For ending date, we enter 2019 and 3.
Under the Display Options tab, users can select to use HHS goals, or a custom SIR goal.
HHS goals are the default goals for TAP Reports.
If a user does not change the Display options, the HHS goal for each specific HAI will automatically be used.
If a custom value is specified as the SIR Goal, this value must be less than 1.
Remember, the lower the SIR Goal the higher the prevention goal.
If a facility has reached the HHS target, they may want to set a more ambitious SIR goal.
The flexibility of this metric is important to keep in mind as you run, interpret, and
communicate information on the TAP reports.
As mentioned earlier each HAI type has a separate HHS 5-year HAI Reduction Target goal and these
are listed by HAI type on this slide.
Let’s look at a sample TAP report.
In this example using the fictitious, DHQP Memorial Hospital, the user has submitted
data for many locations within the hospital.
All locations with data are ranked in descending order according to CAD.
The CAD promotes the use of data for action by helping the user quickly identify units
with excess HAIs.
Together with the SIR, the CAD can be used to identify and target prevention efforts
toward locations with higher CADs.
For the time period represented in the table, DHQP Memorial needed to prevent 26 CLABSIs
to meet the HHS goal for CLABSI of 0.05.
A closer look into our example reveals DHQP Memorial Hospital’s 1 West location has
the highest CAD in the facility.
This location has a CAD of 13.08.
That’s a majority of the facility’s 26 CADs.
This hospital may opt to prioritize CLABSI prevention efforts within this location before
other locations in the hospital.
Targeting assessment resources and intervention methods to the unit with highest CAD is an
efficient way for this hospital to utilize HAI prevention resources.
Here are some helpful hints to keep in mind while running TAP reports.
Because TAP reports are built on the same guidelines that influence SIRs, the same rules
and exclusions will apply.
For example, hospital units that lack baseline data to calculate SIR values are excluded
from TAP reports.
Don’t be alarmed if events on the hospital line listing cannot be found in the TAP report.
It may be an excluded location.
Remember to look at the footnotes.
The footnote provides information about the report including rules for interpreting data,
abbreviation meanings, pathogen names, and the date the report was generated.
Additionally, tables are easier to view in landscape if you choose a format other than
the default HTML.
On the “Title/Format Tab”, users can also choose to create the report using PDF, Microsoft
Excel, or Rich Text Format.
Above the “Title/Format” Tab there is an option to “Show descriptive variable names”.
This will create variable labels with more descriptive column headers.
Not only are they more descriptive, the variable labels also align with the descriptions found
in the footnotes.
There are many resources available for the TAP strategy.
Here are some of those links.
For more information about the Tap Strategy visit www.cdc.gov/nhsn.
And for help with TAP reports email nhsn@cdc.gov. Thank you.