>> Alright, we're going to do our group exercise.
If you're in the room, open your resource manual to page 62
and you will find the case study that we'll be using.
I'm going to give you about five minutes to work
through the protocol portion of the group exercise.
We're going to try to find the slide deck
to put the case study up.
But I'm going to read through it real quickly
and there will be eight questions that I want you to answer.
And then I'm going to have a couple
of tables help us out in groups of two.
So the case scenario is that Tim is discharged from Three East
at Memorial Medical Center, MMC on 2/24/18
after a long hospitalization.
On this date, a C. difficile LabID event is identified.
On 1/9/19, he feels ill with fever and is transported
to the ER at MMC for assessment.
In the ER, he's noted to be dehydrated and hypotensive
with concern for sepsis.
Blood cultures are collected, diarrhea is noted,
antibiotics are initiated, and Tim is admitted
to observation status on 1/9.
Due to bed availability, he remains in the ER until 1/10
when he transfers to an inpatient medical unit
where again, diarrhea is noted.
On 1/12, blood cultures return MRSA positive,
so orders are written for inpatient admission.
Tim is hypoxic with spike in temperature
and continued loose stools.
He's transferred to ICU later this day
where a stool specimen is collected and submitted
for C. difficile testing.
The facility standardly tests
for CDI using a multistep algorithm of GDH/EIA with PCR
for discrepant results.
The C. diff test is reported as GDH positive,
toxin negative, PCR positive.
Tim stabilizes and transfers to the medical floor on 1/16
where a single loose stool is noted
and submitted for CDI testing.
This CDI test is finalized as GDH negative, toxin positive
with no additional testing or results noted
on the final lab report.
MMC follows FacWideIN MRSA bacteremia
and C. difficile LabID event reporting.
So there are eight questions, two are bonus questions.
And I would like for you to just take a few minutes and work
through those and then we will review for correct responses.
So it's a group exercise,
which means you can work amongst the tables.
You can work across tables.
And get help from all your neighbors.
[ Background Conversations ]
Okay, so we are going go forward with this case.
Everybody has been working hard on it.
So here's the case and we are going to start
with the protocol questions.
And the first question.
Is there a MRSA bacteremia LabID event identified?
Go to the microphone.
This table over here volunteered.
>> Yes.
>> Yes. And that is because.
>> There is an MRSA positive blood culture.
>> Alright.
So what location gets the event attribution?
>> We attribute it to ER.
>> Correct.
Nicely done.
Thank you.
Alright, moving on to question three.
Is the MRSA LabID event considered recurrent due
to the prior admission?
>> No.
>> Why is that?
Recurrent is not an eligible categorization
for MRSA bacteremic events.
Alright. So the bonus.
Memorial conducts active surveillance screening for MRSA
and Tim screens positive.
Does it change the event determination?
>> No.
>> No. Because active surveillance screens are
ineligible for LabID event reporting.
Alright, moving on to question five.
How many CDI events are identified at MMC?
>> Three.
>> Alright.
Correct, three.
Whew, y'all are listening good.
Woo hoo. What is the dates of events?
So we have number one occurring on what day?
>> 12/24.
>> 12/24. Yeah don't forget this is all the same hospital
so this is -- the first event is 12/24.
The second event is?
>> 1/12.
>> 1/12. And the third event is?
>> 1/16.
>> 1/16. Excellent work.
Excellent work.
Alright, number seven.
Should the 1/16 CDI finding be disregarded since the algorithm
of testing wasn't complete?
>> No.
>> Correct.
You have to go with whatever the report identifies.
And so here's our bonus.
How should the facility answer the quarterly primary testing
methodology question?
And I did provide the dropdown menu from NHSN.
So what do you think about that?
>> [ Inaudible Answer ]
>> So this one is kind of an unusual case.
In the narrative, we see the facility states
that they standardly test using GDH/EIA with PCR
for discrepant results.
So if that is their standard testing you could say
that is their primary testing
and you would answer the question with GDH/EIA with PCR
for discrepant results.
However, I would question whether
or not this truly is their standard testing algorithm
since we have a test here that simply is GDH and toxin
and there is no PCR follow up.
So in this situation, what I would normally recommend
to the facility is you're going to have to look at the volume
of the test that has been done over the course of the quarter
and see how many tests you have that did go
to a discrepant result step of PCR
versus how many stopped with just the toxin.
And determine which of those accounts for greater
than 50 percent of testing performed which would equate
to your primary testing method.
And it's unfortunate that some facilities do have to look
at this to really get the most appropriate answer
for testing method question answers.
But y'all did a great job.
Thank you.
Give yourselves a hand.
[Applause] I'm going to turn it over to Lindsey now
and she's going to -- oh no Karen.
Karen is going to do the analysis.
[ Background Conversations ]
>> Okay. So I hope you guys are ready
for the LabID event analysis exercises.
So for these exercises,
anyone viewing the presentation via web streaming,
you can access the handouts at this link.
So in this exercise, you're going
to find eight analysis questions.
So take about seven to ten minutes to work
on this at your table.
And of course raise your hands if you get stuck.
We'll be walking around assisting whenever needed.
And so we'll be going through the answers in the end.
Feel free, again, work together as a group.
Feel free to identify a team spokesperson.
And so in our review questions we will hopefully get a
few volunteers.
So Exercise A, we love Denise's Tim so much, we had him focused
on for our Exercise A.
And Exercise B, you will find information
that will help prepare as if you're preparing data
for CMS data submission as well
as reviewing risk adjustment factors.
So some helpful definitions as you're completing the exercises,
you will find on the screen the categorizations
for onset and cdiAssay.
And again, let us know if you need any help.
[ Background Conversations ]
>> Alright.
How are we doing?
Ready for some answers?
Okay, so we're going to start
with Exercise A, question number one.
The line list has a data entry error
on Tim's second and third event.
Was anyone able to identify the data entry error?
>> [ Inaudible Answer ]
>> Perfect.
Yes. Date of admission was incorrect.
So the facility admission date should actually be 1/10 not 1/9.
The rationale is because January 10 is
when the patient was first placed on that inpatient unit.
It doesn't matter when the facility might put them
in admission status or observation status.
What counts is when the patient physically moves
to that inpatient unit.
Okay. So question number two, after we fix
that data entry error
and we correct the facility admission date,
how does the CDI Line List change?
So does anyone want to come to the mic
and tell us what their table felt for this question?
No takers, okay.
So the main thing here that changes is your onset column.
So for event number two, when we change the facility admission
date to the 10th and we see the specimen date is on the 12th,
so that occurs on day two.
I'm sorry, day three.
However, this patient was previously discharged
from the facility and therefore onset is CO-HCFA.
Okay, everything else on the line will stay the same.
Okay why is cdiAssay blank for event number three?
>> [ Inaudible Answer ]
>> Yes. Yes, correct.
I heard that from a few people.
So cdiAssay is blank when there is a prior positive specimen
in the previous 14 days.
So remember we don't use the term recurrent
until at least 15 days have passed between that specimen
and the prior specimen.
Okay, Exercise B. We have the answers up here on the slide
for onset and for that SIR indicator variable.
So event number four is CO-HCFA.
Five is community onset.
Six, healthcare onset.
Seven, healthcare onset.
Eight, community onset.
Nine, healthcare onset.
Ten, community onset.
And 11, CO-HCFA.
And for the SIR indicator, all of the events are zero except
for event number seven.
That should have a one.
Oh, I'm sorry, okay, okay.
And we will have the answers posted
and available for you as well.
>> Is number six definitely hospital onset?
>> Number six.
So the facility admission date was 2/27
and the specimen date was 3/2.
Yes. So that is more than day four later.
So that is healthcare onset.
Any other questions about any of these?
Okay. So I have the rationales here again just repeating the
definitions for those three categories of onset.
We're only looking at the facility admission date
and the specimen date.
Any prior events for the patient are not considered
when we define onset, but they are considered when we talk
about the SIR numerator.
Okay, questions number three and four for Exercise B is
which events will be counted in the SIR numerator?
>> [ Inaudible Answer ]
>> Correct.
So event number seven.
This is the only one that had a one in that indicator column.
So that is the event that is counted in the SIR.
Okay, question five.
So we showed you an example table with the risk factors used
for the SIR calculation.
And we asked you to identify
where there is a potential data quality issue.
And what additional steps you could do
in NHSN to investigate this.
Do we have any volunteers?
Okay, I'll go ahead and give you the answer.
So what jumped out at us is that the big change
in the CDI community onset prevalence rate in 2019 quarter one.
And because that's so much higher
than the previous two quarters, that should be a trigger for you
to future investigate what's going on here.
So to confirm the prevalence rate is accurate we would check
our community onset events from the line list,
and we would check our number of admissions
from the FacWideIn denominator form.
Okay, and then the bonus question.
How would this data quality issue impact the SIR?
So if we assume that this prevalence rate is incorrect,
that something happened when the facility,
when they entered their admissions,
maybe they entered the wrong number
of admissions and it was too low.
Okay? So this prevalence rate is high
and high prevalence rate will lead
to a higher number of predicted events.
And if we assume that nothing else changed in the SIR,
when the number of predicted events increases,
it can lead to a decrease in the SIR.
Okay. Karen and myself as well Denise will be up at the front
if anyone wants to ask us some questions.
[ Applause ]