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What to Expect for Infection Prevention Reporting in 2015

Posted on 09/12/14

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In 2015, new requirements under the Centers for Medicare and Medicaid Services (CMS) Hospital-Acquired Condition (HAC) Reduction Program established by the Affordable Care Act (ACA) will expand reporting of healthcare-associated infections (HAIs) from acute care hospitals to patient populations outside of the intensive care unit and increase reporting from long-term acute care facilities to include laboratory-based surveillance for multi-drug resistant organisms. The findings could have financial and reputational implications for hospitals, making timely and accurate reports essential.

Acute care hospitals will be required to report central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) in adult and pediatric medical, surgical and medical/surgical wards to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) through the Hospital Inpatient Quality Reporting (IQR) Program starting January 1, 2015. Currently, reporting is required only from intensive care units, so this represents a substantial increase in scope for infection preventionists.

These new reporting requirements extend to hospitals in all 50 states, not just the 31 that currently require reporting to NHSN.

Low-performing hospitals penalized

In October, CMS will release  the final hospital scores for the HAC Reduction Program which were calculated using a 10-point scale based on three measures, including CLABSI and CAUTI rates of ICU patient populations. In a preliminary assessment, hospitals with a score of 7 or higher would be penalized as the higher scores indicate more adverse patient outcomes. Each of the measures count a third toward the score with infection rates adjusted by type of hospital and patient characteristics. Data for 2012 and 2013 were used for the final scoring. Penalized hospitals will lose 1 percent of each Medicare payment from Oct. 1 through Sept. 30, 2015.

Infection prevention programs need to ensure the reliable and complete detection of CLABSI and CAUTI events are required by CMS to avoid higher scoring and subsequent reimbursement penalties.  

New requirements also are required for long term acute care hospitals (LTACHs). These facilities will need to report blood cultures positive for methicillin resistant Staphylococcus aureus (MRSA) and positive Clostridium difficile toxin assays identified by lab testing (LabID). The use of lab tests as proxy measures for MRSA and C. difficile infections is currently required for acute care hospitals and it is expected that additional LabID events will be part of future CMS mandates.

New reports start on October 1, 2014

Two other changes go into effect even sooner--As of October 1, 2014, hospital outpatient departments, long term acute care hospitals, rehabilitation centers, and ambulatory surgery centers will need to submit data on the number of employees who have received an influenza vaccination by category of employment in their quality reporting programs. A reason must be provided for why any employee has not been vaccinated. Acute care hospitals have been reporting inpatient healthcare personnel influenza vaccination rates since January 2013. The reports must include both hospital paid employees and non-hospital employees.

Is your hospital ready for the expansion of infection prevention reporting in 2015? Let us know what you think about these new requirements for infection prevention reporting in hospitals, long term care facilities, rehabilitation centers and outpatient departments.

 

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Topics: Infection Prevention

About the Author

Joan N. Hebden, RN, MS, CIC served as the Director of Infection Prevention and Control for 28 years at the University of Maryland Medical Center, Baltimore, MD. Her clinical background includes general medicine, oncology, and cardiothoracic intensive care. She has presented at national epidemiology conferences, participated in research regarding the transmission of multi-drug resistant bacteria, contributed chapters on infection control to nursing resource textbooks, and published in medical and infection control journals. Joan received her Bachelor of Science degree in nursing and a Master of Science degree in nursing education and trauma/critical care from the University of Maryland School of Nursing. She is certified in Infection Control & Epidemiology (CIC). Joan is an active member of SHEA and APIC and is currently on the Editorial Board of the American Journal of Infection Control (AJIC).