- Hello, my name is Melissa Otis
and I am one of the SSI subject matter experts
on the protocol and training team.
I'm excited to talk to you today
about navigating SSI reporting and NHSN.
Please note, my colleague Victoria Russo
will be covering SSI surveillance
in a separate live training.
Our objectives include identifying surveillance methods,
demonstrating how to locate SSI resources
from the NHSN website,
we'll review reporting requirements
for the monthly reporting plans,
numerator and denominator data,
and learn to recognize alerts for resolution,
and the process for generating data sets.
First, let's review SSI event surveillance methods.
As a reminder, surveillance should be active, patient based,
and prospective,
and it may occur concurrent with the admission
or post discharge.
A few examples of SSI surveillance
include medical record review,
consultation with primary care staff,
this may be on wards or ICUs, for example.
There also may be surgeon surveys
via mail or telephone,
as well as patient surveys via mail or telephone.
Next, we will look at some SSI resources
that are available for use.
Here, we have the SSI landing page
where you can find many resources.
First, is one that you are all probably very familiar with.
The SSI protocol found
in chapter nine of the NHSN patient safety manual.
This is reviewed and updated on an annual basis
and it is key that you are using the appropriate protocol
for the event that you are investigating.
Another important section is the data collection forms
and instructions.
We have forms for both event and denominator data
as well as table of instructions for each of these forms.
Here, we have the SSI event form
followed by the SSI event table of instructions.
This table of instructions will provide each data field,
both a required as well as optional fields,
on the SSI event form with detailed instructions
on how to complete each of these fields.
Here, we have the denominator for procedure form
followed by the denominator
for procedure table of instructions.
Just as the SSI event table of instructions
covered each data field on the SSI event form,
this table of instructions will provide each data field,
again, both the required,
as well as optional on the denominator for procedure form,
as well as detailed instructions
on how to complete each of these fields.
The FAQ section has a wealth of information
and I would highly suggest reviewing this.
There are over 25 FAQs on the SSI event FAQ section alone.
These FAQs cover topics such as what is acceptable evidence
of infection found on gross anatomic exam
to petos as well as invasive manipulation.
In addition, you can find guidance
on determining the level of an SSI
after a breast or cardiac procedure.
Please note, there are also FAQ sections
on surgical site procedure codes, analysis, survey,
locations, CDA,
as well as miscellaneous NHSN patient safety guidance.
In addition to the resources we've covered so far,
there are also operative procedure code documents
included for mapping for both ICD-10 PCs
as well as CPT on the SSI landing page.
You'll also find additional guidance
for HPRO, KPRO, and fusion operative procedures
as well as diabetes codes to use
when answering the diabetes question
on the operative procedure denominator form.
There are also a great deal of training resources available.
The SSI training link will take you to self-paced
as well as video-based training.
There's an educational roadmap
that will take you step by step through training.
There's a link to CMS requirements,
as well as HAI checklists,
which does include the SSI checklist.
Now, let's move on to cover reporting requirements
and the monthly reporting plan.
NHSN is a mechanism for collecting
and analyzing surveillance data.
NHSN does not have mandates for reporting,
but does expect specific data
based on the facility selections
on the monthly reporting plan.
The decision to use NHSN may include
the CMS inpatient quality reporting program,
your facility internal risk assessment,
as well as required reporting by your state
or other organizations.
You must have a monthly reporting plan filed
for each month to inform NHSN
which modules will be included for reporting.
If a module is included in the monthly reporting plan,
this is an agreement to follow the details
of the module in its entirety.
The data will be included in NHSN annual reports
or other NHSN publications,
and it will be submitted to CMS
in accordance with CMS's quality reporting program.
To add a monthly reporting plan,
you'll select reporting plan and add
from the left navigation bar in the NHSN application.
Next, you will add the month and the year
that you will be adding a monthly reporting plan for,
and in the procedure associated module section,
you can add rows for as many procedure categories
as you will be following for that particular month.
You can select from each
of the 39 operative procedure categories
available in the NHSN patient safety module.
You will also need to note
for each operative procedure category
if you will be performing surveillance
for inpatient procedures, outpatient procedures, or both,
and you will do so by simply selecting the check box
next to in or out for each procedure category.
You can also choose to copy from previous month
which can be a time saver
if you will be reporting on the same procedures
as you did for the prior month.
You can also select the check box
next to no NHSN patient safety modules followed this month.
Please note, you should only do this
if absolutely no modules will be reported for the month.
Now that we have reviewed adding a monthly reporting plan,
let's talk about completing the SSI event form.
To add an event you'll select event and add
from the left navigation bar
in the NHSN application.
The required fields are noted here
with the purple boxes.
They include patient ID, gender, and date of birth.
The fields marked with an asterisk, in this field,
in the screen, I apologize,
or a greater than sign
are required in order to add an event.
Next, you will select the tissue level
for the event that you are to report.
As a reminder, only one SSI event will be reported
for the deepest tissue level
in which SSI criteria are met
during the surveillance period.
You'll only select the applicable signs or symptoms
and, as a side note,
for organ space SSI events,
you will select criteria used
to meet both general organ space definitions
found in chapter nine,
as well as the criteria used
to meet the site specific definition found in chapter 17.
Next, you will enter the following event details.
The detected field has four options.
You'll select A if that was identified
before the patient was discharged from the facility
following the procedure,
P if the event was identified
in the patient after discharge from the index procedure,
but the patient was not readmitted to any facility,
RF if the SSI was identified
in a patient readmitted to the facility
where the procedure was performed,
and RO if the SSI was identified
in a patient admitted to a facility
other than that in which the index procedure was performed.
If there is a bloodstream infection
secondary to the SSI event,
you will select yes
next to the secondary bloodstream infection field
and no if there was not a secondary bloodstream infection.
After that, you will identify
if the patient died during the hospitalization
and if the SSI contributed to the patient's death.
Next, you will note if there were any pathogens identified.
And, finally, if the patient had COVID 19
on the date of event.
Now that we reviewed adding an SSI event,
let's talk about completing the SSI denominator form.
To add a procedure you'll select procedure and add
from the left navigation bar in the NHSN application.
All fields identified with an asterisk are required fields.
We do have forms for reference.
In addition to the required fields,
they also note the conditional fields
that are required
for the following operative procedure categories,
c-section, fusion, and HPRO/KPRO.
Please note, these are available for manual entry
although many facilities choose
to use the CVA or CSV upload,
and we'll discuss this more later.
Let's cover some other data sources
that the application will use to generate reports.
A survey must be completed
by each facility on an annual basis.
In order to complete the survey,
you will select survey and add from the left navigation bar
in the NHSN application.
The application will use
all of the data that we have entered
up to this point to generate reports.
Desired reports may include the rate,
standardized infection ratio, or other custom reports.
Now, we'll move on to review how the data may be uploaded
into the application.
NHSN does offer a sample procedure import file
found under supporting materials on the SSI landing page.
It is crucial to make sure
that the most current template is being used to upload data.
Please note, you will receive error codes
if the data is not entered and or uploaded correctly,
or if the incorrect template is used.
If error codes do occur,
this is an opportunity to look at your data
and make corrections.
Let's move on to discuss linking a procedure and an event.
The index procedure should have been entered
as per the instructions we've discussed.
Then, you will want to be sure
that all the event details are entered accurately.
As a reminder,
you will want to select all criteria used
to meet the specific SSI event when entering the SSI event,
and only select the applicable signs or symptoms.
For organ space SSI events,
you will select criteria used to meet both
general organ space definition found in chapter nine
and the criteria used
to meet the site specific definition found in chapter 17.
Then, you'll want to select link to procedure,
as I have highlighted it here in the purple box.
When you do so,
a box similar to the one that's up on the screen,
highlighted with the purple,
will appear on your screen,
and you will want to simply check the box
next to the procedure that you wish to link to,
and then select the link button.
After selecting the link button,
you have now successfully linked a procedure to an event.
Finally, I would like to cover resolving alerts
and generating data sets.
It is key that any alerts in the application be resolved
before data sets are generated.
You can find alerts by selecting alerts
from the left navigation bar and the NHSN application.
Any alerts will then be displayed for you to resolve.
After data entry is complete,
and all results are resolved,
all alerts are resolved,
generate data sets so that all crosses...
All data crosses over for use in the NHSN analysis reports.
To do this, you will select analysis
from the left navigation bar in the NHSN application
and then select generate data sets.
Next, you will select the time frame
that you will want to generate data sets for.
And, then, select the generate reporting data sets button.
You will receive a reporting, a warning,
that looks like the one on the screen
that I have shown here.
It will state the current data sets will be updated.
Are you sure you want to continue?
You will want to ensure
that your dates are correct
and then select, okay.
Once all data sets are generated,
you will receive this message.
This will ensure
that all data we have entered will be available for use
in NHSN generated analysis reports.
This completes a training
on navigating SSI reporting and NHSN.
Thank you for your time today.
And, if you have any questions,
please email us at NHSN@cdc.gov