- [Karen] Hello and thank you for joining this presentation.
I will be presenting the use of NHSN annual survey data
and its involvement in the HAI SIR models.
I have no disclosures.
By the end of this training,
viewers will be able to locate the annual survey variables
involved in the HAI SIR calculations
as well as determine which annual survey year
is included in the HAI SIR calculations.
An outline of this presentation will involve
providing an overview of the annual survey and SIR,
discussing the annual survey facility characteristics,
and providing an example showing the relationship
between the annual survey year and the SIR year.
So for the overview.
One and more annual facility surveys
must be completed upon enrollment in NHSN,
activation of an NHSN component,
and/or the identification of select CMS-certified units.
Therefore, at the beginning of each year,
a new facility survey or surveys
must be completed to reflect data
from the prior calendar year.
The deadline to complete the patient safety annual survey
is March 1st of each year.
Within NHSN, there are separate facility,
separate surveys by facility type.
The majority of facilities reporting to NHSN
completes the hospital survey.
Hospital would include, primarily, the acute care hospital,
which is described as general acute care,
critical access, hospital oncology, and so on.
Another survey type would be LTAC,
which will be completed by longterm acute care hospitals
and then the last survey type is the rehab
and those are completed
by free-standing rehabilitation facilities
and CMS-certified inpatient rehabilitation facilities.
So for example, at the beginning of 2022,
an acute care hospital completes
a 2021 annual hospital survey
that will contain data from 2021.
Please reference the link
included at the bottom of the slide
to view additional annual survey details
and find the data collection forms
and table of instructions.
Now the standardized infection ratio or SIR
is a metric used to track HAIs within your facility.
The SIR compares the number of observed infections
to the number of predicted infections.
The SIR may be used by CMS Quality Reporting programs
for select HAIs and facility types,
your state health department
to track and publish HAI prevention work.
SIRs may be used by your organization or corporate entity
or if your facility chooses, the SIRR can be shared
within an (indistinct) group.
The SIR is also included
in CDC's national surveillance reports.
The SIR is risk adjusted for various HAI risk factors
and facility-specific characteristics.
So for the information presented in the overview,
related resources can be found on the resources slide
at the end of this presentation.
Now onto facility characteristics.
The facility characteristics
are collected on each annual survey
and it differs by survey type.
The facility characteristics are required questions
and select facility characteristics are used
as risk adjustment factors for select SIR models.
This slide shows the facility characteristics
captured on the hospital survey.
The variables involved in at least one HAI SIR model
are highlighted within the yellow box.
This includes the number of patient days,
number of admissions, the medical affiliation
and teaching status, and the number of ICU beds
and all other inpatient beds.
For the LTAC survey, what's included is
the number of patient days, number of admissions,
total number of LTAC beds, number of single occupancy beds,
and the number of ventilator dependence
and hemodialysis admissions.
And lastly, for the rehab survey,
the number of admissions due
to select primary diagnosis characteristics,
traumatic and non-traumatic spinal cord dysfunction,
stroke, orthopedic, and all other admissions
as well as the total number of admissions.
The annual survey line listing can be used
to view the facility characteristics involved in the SIR.
This line listing can be found by navigating to the survey
and year of interest as shown on the right.
On this slide, I have listed the variable names
from each of the annual surveys.
These are the variable names
as accessed from the annual survey line listing
as displayed on the previous slide.
The name of the annual survey analysis data set
is listed in parentheses so you will have
the variables associated with the SIR
under the hospital survey, LTAC survey, and rehab survey.
The screenshot on the bottom
of the slide is showing an example
of the LTAC SIR involved facility characteristics
as pulled from the LTAC survey line listing.
Now to discuss the relationship
between the survey year and the SIR year.
When analyzing your data, you may have already observed
a possible difference between the survey year
and the surveillance year depending
on when you are attempting to view your SIR.
When calculating the SIR for a current reporting year
or for this example, 2022, the survey will use
the same survey year, but if not yet completed,
the SIR will use the most recently completed survey.
So for this example, the 2021 annual survey responses
are used currently in the 2022 SIRs.
Therefore, the survey year and the SIR year
may not always be the same.
The relationship between the survey year and the SIR year
often comes into question as it relates to a CMS deadline
if your facility has CMS report and requirements.
To explain this relationship,
I will use the 2021 CMS submission as an example.
The table shows the CMS deadline month,
the CMS submission corresponding to the NHSN data,
and the survey year.
So for this facility, at the time of the CMS submission,
the facility had already completed their 2020 survey
and the facility completed their 2021 survey
in January 2022.
So the 2020 survey was used during the 2021 quarter one
and 2021 quarter two CMS submissions
and again, given that the facility
completed their 2021 survey in January,
they would've been ahead
of the 2021 quarter three submission so the 2021 survey
is used during the 2021 quarter three
and 2021 quarter four submissions.
A common question we receive
about the HAI SIR as it relates to the annual survey is,
"My 2021 SIR report
and the number predicted events has changed.
I ran an SIR report in December 2021
and again at the end of February 2022.
No events with surveillance, excuse me,
no events or summary data were changed,
but my number predicted is different.
Can you explain this?"
To explore this question, let's assume
that there were no reporting changes
and that there were no changes
to the monthly reporting plans, events, or summary data.
If that is the case and given this question,
the most likely cause
is that the number predicted calculation
used a different survey year
at the time the reports were prepared.
To confirm the annual survey as a cause,
I outlined a few steps and we will walk
through each of these steps in a bit more detail
in the approaching slides.
So the first step is to review the SIR guide
for HAI of interest so you can observe
the HAI SIR risk factors.
Then review the variables of interest
using the survey line list and include the completed date
so we can see when the survey was submitted.
If the HAI of interest is MRSA or CDI,
the risk adjustment factors that is included
in the SIR report, can be used to help with the step
and lastly, we would want to review the data
and confirm that there was a change
in the risk adjustment parameter estimate.
So let's look at an example to answer this question
and we are using completely fictitious data
for these slides.
So looking at the SIR for MRSA blood FacwideIN
for LabID data in acute care hospitals.
Again, we are assuming that there were no reporting changes
during 2021 quarter three and we are going to compare
the SIR reports of interest,
so looking at the December 2021 report
compared to the February 2021 report
and we're looking, again,
at the 2021 quarter three number predicted
and we see that there is a difference
between the December 2021 report
and the February 2021 report.
This slide compares the SIR reports
from the December 2021 report and the February 2022 report
and I've just included the variables
that we're gonna be focusing on
and just to highlight the difference
in the number predicted, which is the numberPred variable.
So in December 2021, the numberPred was 0.995,
however, but then on the February 2022 report,
we see that the numPred is 0.828
and we can see that the other variables are stable,
such as the number of observed events,
which for MRSA SIR is represented
by the MRSA_bldIncCount variable
and we see that the number of patient days reported
for the quarter is also the same.
So since we are interested in exploring
the MRSA FacWideIN model, this is a capture
from the SIR guide showing
the annual survey variables of interest.
Again, a link to the SIR guide is provided
on the resources slide at the end of this presentation.
So given these variables, let's look
at what the facility reported for these variables.
So now that we have reviewed the SIR guide
and identified the survey variables involved
in the MRSA FacWideIN SIR calculation,
now let's review the annual survey line list
showing those variables of interest.
Since we are interested in the 2021 SIR difference,
given the relationship between the annual survey variables
and the SIR year, we should focus our review
on the most recently available annual survey.
So for this fictitious facility,
we will focus on the 2020 and 2021 annual survey.
So on this slide,
we have a line list that will be consistent
with the data included in the SIR report
from the earlier slide and that the top will,
in addition that the top rep corresponds to the report
the data from the December to 2021 SIR report
and you can see that at the time, that the 2021 SIR report
was based on the 2020 survey.
However, on the bottom,
we have the February 2022 SIR report
and you can see that that data included in this table
will be consistent with the SIR report.
Now, given that we have
that the facility completed their survey
in January 12th, 2022, we can see that that was
before this February 2022 report was generated.
Now that we've compared these two survey captures,
at first glance, there appears to be
no other notable differences,
but I should have warned you all that-
I chose a pretty hard example for this one.
So let me draw your attention to the difference.
We should take a closer look at the responses
for the number of patient days and number of annual,
excuse me, the number of admissions
between the 2020 and 2021 annual survey.
Those variables are involved in the MRSA model,
but as derived variables,
in this case, the average length of stay.
So if we focus on the average length of stay
between the December 2021 SIR report
and the February 2022 report, we will see the difference
in that the length of stay from the 2020 survey was 5.2
compared to the length of stay of 4.5 using the 2021 survey.
The screenshot of the parameter estimate
just focuses on the average length of stay,
but you can see that the derived value
for the length of stay between the 2020
and 2021 surveys are different.
With that, the parameter estimate changed between the report
which will explain the change in the number of predicted.
If you are investigating the MRSA or CDI SIR,
you can also use the risk adjustment factors table
included in the SIR report
to view the risk factors involved in the SIR
as well as those involved in the annual survey.
So here, I've highlighted the variables involved,
the variables from the annual survey
that are highlighted in red,
where you will see that the LOS variable was length of stay
and the SIR report risk adjustment factors report
that that risk adjustment is automatically calculated,
whereas if we were looking, as we saw in the previous slide,
when we looked just at the annual survey line listing,
we had to manually calculate it
in order of for us to confirm
that the annual survey was indeed
the cause of our difference and answered our question.
I will like to point out that on this particular slide,
the numpatdays variables, number of patient days,
here on this slide is actually
from the MDRO CDI summary form which is collected monthly
and on this table, it's presented here quarterly
and that it is not the variable that corresponds
to the number of patient days
as collected on the annual survey.
So thank you for coming with me through that example.
So we advise facilities to save their SIR reports
for each HAI ahead of a deadline
to capture the data that was sent to CMS
or data that might have been used
for any facility-specific deadline.
This will ensure that there is documentation
of what HAI data were submitted at the time of a deadline.
This tracking will allow your facility
to maintain a copy of data
that is either submitted or to be published
despite any possible reporting changes
such as for this example, we saw the addition
of a new survey year.
Given the relationship between the survey year
and the SIR year, we also recommend saving a copy
of the survey line list ahead of those deadlines
and as promised, the resources that were referenced
during this presentation are included here.
Thank you for your time
and if you have any questions or concerns,
please contact the NHSN help desk nhsn@cdc.gov.
Thank you.