MDCH - National Healthcare Safety Network (NHSN) Information

National Healthcare Safety Network (NHSN) Information

NHSN is a voluntary, secure, internet-based surveillance system that integrates patient and healthcare personnel safety surveillance systems. It is managed by the Division of Healthcare Quality Promotion (DHQP) at the Centers for Disease Control and Prevention (CDC) in Atlanta. NHSN enables healthcare facilities to collect and use data about healthcare-associated infections, multi-drug resistant organisms, and other adverse events. The Michigan Department of Community Health is using NHSN to collect information from hospitals about healthcare-associated infections (HAIs) in order to monitor and characterize the burden of HAIs in Michigan. This page provides a listing of commonly used NHSN links and explanation about the MDCH SHARP Unit's use of NHSN data. If you would like to suggest a link be added to this page or if you find problems with the existing links, please let us know. See the About the SHARP Unit page for contact information.

CDC NHSN Information

Enrollment in NHSN

Enrollment in the NHSN is through the CDC; however, the MDCH SHARP Unit can assist with questions about the NHSN. Healthcare facilities wishing to enroll in NHSN should go to the CDC website for NHSN enrollment requirements. Enrollment forms can be found at the CDC NHSN Data Collection Forms website.

Enrollment Requirements for Inpatient Hospital Inpatient Quality Reporting Program
Provides a step-by-step guide on training and enrollment requirements for the Centers for Medicare and Medicaid Services (CMS) Hospital Inpatient Quality Reporting Program, formerly known as Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU).

Training on NHSN

Multiple webcast lectures are available online for those who need to fulfill the training requirements of the NHSN, or for those who need a refresher on a particular topic. Training is also available on the various modules of the NHSN.

See also:
NHSN Training Website

CDC Help Desk

CDC staff in the Division of Healthcare Quality Promotion (DHQP) are available to assist with questions regarding NHSN. CDC staff may be contacted at: nhsn@cdc.gov

Helpful Tips for CLABSI Reporting for the Centers for Medicare and Medicaid Services' Hospital Inpatient Quality Reporting Program (CMS Reporting Program)

CDC has released a tip sheet to help facilities ensure that they are releasing accurate CLABSI data beginning with the August 15, 2011 CDC release of NHSN data to CMS. To view the tip sheet, click here.

NHSN Data Analysis

Infection control staff may be interested in comparing their HAI rates to the national average or benchmark. The latest national benchmarks for device associated and procedure associated modules can be found here:

CDC 2010 NHSN Device Associated National Benchmarks
CDC 2006-2008 NHSN Procedure Associated National Benchmarks
MPRO NHSN Analysis Training October 31, 2012

The Standardized Infection Ratio (SIR) is also a useful tool in analyzing risk-stratified NHSN HAI data. Info on how to use and interpret SIRs can be found here: CDC NHSN Guide to SIR Data Analysis

NHSN Summary Data Reports

First State-Specific Healthcare-Associated Infections Summary Data Report, CDC's National Healthcare Safety Network (NHSN)
Composite statistics summarizing CLABSI HAI data available from NHSN at the national and state levels. The Standardized Infection Ratio (SIR) is used to compare the actual number of HAIs in a facility or state with the baseline U.S. experience, adjusting for several risk factors that have been found to be most associated with differences in infection rates.

The MDCH SHARP Unit and NHSN

The MDCH SHARP Unit Surveillance Project

At the end of August 2009, the Michigan Department of Community Health (MDCH) Surveillance for Healthcare-Associated and Resistant Pathogens (SHARP) Unit received funding from the American Recovery and Reinvestment Act (ARRA) to expand its efforts in the surveillance and prevention of healthcare-associated infections. With this funding, SHARP has hired additional staff to focus on the surveillance of MRSA and Clostridium difficile infections. Surveillance data is being collected by hospitals who voluntarily participate in the Lab ID Event option of the Multidrug Resistant Organism / Clostridium difficile-Associated Disease (MDRO/CDAD) module of NHSN and who have conferred viewing rights to the SHARP Unit. The goal of the SHARP Unit is to have 30 hospitals participate in this surveillance project by October 2010, and 50 hospitals by October 2011.

Data Use Agreement

Hospitals who wish to participate in HAI surveillance with the MDCH SHARP Unit using NHSN will first need to enroll in NHSN (see links above), then sign an MDCH SHARP Data Use Agreement. The Agreement describes the purposes of the surveillance and provides assurances of confidentiality of the data. Click here to view a sample copy of the Data Use Agreement. To obtain an official copy of the Data Use Agreement, please contact Judy Weber, SHARP Unit Hospital Liaison. Two original signed copies of the Agreement should be returned to the SHARP Unit. See the About the SHARP Unit page for contact information.

MDCH SHARP NHSN Trainings

Previous NHSN and MDCH SHARP Unit Surveillance Project trainings are archived here.

MDCH SHARP NHSN Training Webinars

Session 1 -- NHSN Intro & Enrollment
Session 1 -- Adding Users & Locations
Session 2 -- Monthly Reporting Plan
Session 2 -- Conferring Rights (this webinar is undergoing revision)
Session 2 -- Entering Data in General
Session 3 -- CLABSI Event Numerators
Session 3 -- CLABSI & other Device-Associated Denominators
Session 4 -- MDRO-CDAD LabID Numerators
Session 4 -- MDRO-CDAD Denominator Data

MDCH SHARP Archived Monthly Michigan NHSN User Group Calls
Audio Call-in Number: 877-336-1831
Audio Passcode: 9103755
Webinar: http://breeze.mdch.train.org/mdchsharp/

Helpful Tips for Reporting CAUTI, CLABSI and SSI

Hands-On NHSN Training, October 13, 2010. Lexington Hotel, Lansing, MI

NHSN Training Webinars held May 18th and 19th, 2010

More Information about the trainings.
May 18th webinar: Monthly Reporting Plans, the Group Feature, and Conferring Rights to MDCH SHARP within NHSN.
- May 18th Webinar Slides
- Due to technical difficulties, no recording of this presentation is available. Please contact the SHARP Unit if you have any questions about the content. You may also find more information about the NHSN training at www.cdc.gov/nhsn, or contact the CDC with your questions at nhsn@cdc.gov.
May 19th webinar: MDRO/CDAD Module.
- May 19 Webinar Slides
- The webinar recording is in two parts. First hour of the webinar: Final 30 minutes

"Infection Prevention: A Community Effort" Symposium, September 9, 2011

AGENDA: To view the full program agenda and speaker list, click here.

PRESENTATIONS:
Dr. Marcus Zervos (Keynote):   Epidemiology of Antimicrobial Resistance in the Community: Implications for Control
Jennifer Beggs:  Who You Gonna Call? The Professionals!
Eric Zaban:  Occupational Health Hazards in the Healthcare Industry
Jaclyn Bates:  Weapons of Mass Disinfection
Dr. Jennie Finks:  When Sharing ISN'T Caring: Preventing HAI/MDRO Transmission
SHARP Unit:  What Would You Do?
Jane L. Finn:  Community and Provider Education: Preserving Our Antibiotic Lifeline
Nancy Vecchioni:  The ABCs of Coalition Building

PRESENTED BY: The Michigan Department of Community Health (MDCH) Surveillance for Healthcare-Associated and Resistant Pathogens (SHARP) Unit, The Michigan Antibiotic Resistance Reduction (MARR) Coalition, The Michigan Health & Hospital Association (MHA) Keystone Center for Patient Safety & Quality, and MPRO.

Conferring Data Rights to the MDCH SHARP Unit

With the release of NHSN version 6.4 on June 6, 2011 the process for conferring rights to Groups within NHSN has changed. The SHARP Unit now has a template of conferred rights, i.e. data that we would like to receive from healthcare facilities who have joined our Group and are sharing data with us. This template of conferred rights will appear on NHSN when any new facilities join the MDCH-SHARP Group. For those facilities that have joined the MDCH-SHARP Group prior to June 6th , they are now required to re-confer their rights to MDCH SHARP using the new template.

The MDCH-SHARP Group template can be accessed by going to "Group" on the navigation bar of the Home Page within NHSN. Under "Group", click on "Confer Rights" and highlight the "MDCH-SHARP" Group on the screen that appears. Following this, the Conferring Rights template should appear.

We request that you share all of your facility's NHSN data by accepting the template in its original form. As Michigan has no HAI mandates and because it is important that you feel comfortable with the amount of data your facility shares with MDCH SHARP, there are two ways to modify the template.

Option 1 : Your facility is able to "opt out" an entire device-associated or surgical site infection module. By choosing "NA" (not applicable), you may continue to collect data for that infection on NHSN but this data will not be shared with the MDCH SHARP Group.

Option 2 : If you would like to share particular device-associated or surgical site infection module data from some (but not all) locations, you may uncheck the location(s) from the drop down menu. Leave location(s) you would like to share with MDCH SHARP checked.

If you are not participating in a listed module, please disregard that section on the template. There is no penalty for not providing requested data, and this will not affect your reporting plan or data output. The SHARP Unit does request that facilities accept the template as is so that it covers all modules used in the future as well. If there are questions regarding the conferring rights process, please contact Judy Weber, SHARP Unit Hospital Liaison. See the About the SHARP Unit page for contact information.

Adding New Locations & Editing Old Locations

Facilities often need to create/add new locations in NHSN because of mapping issues, new construction, etc. Facilities may also need to change the name of a location because the location's use has changed, or it may have been designated incorrectly when the facility locations were initially set up withing NHSN.

To change a code/label/CDC description for a locationin NHSN, click on "Facility" in the left navigation bar of the NHSN Home Page. Under "Facility", click on "Locations" and a screen will appear with a heading of "Locations". Note the "Find" button at the bottom of the page which will generate a list of your facility locations. From this list, you can edit any previously entered locations. Follow the instructions listed for "Adding", "Finding", "Editing", or "Deleting" a record. If you need assistance with this, please contact Judy Weber, SHARP Unit Hospital Liaison. See the About the SHARP Unit page for contact information.

Remember that editing or adding a location will neccesitate re-confering rights to any NHSN Groups with which you share data. NHSN will prompt the user to do this. Click on "Group" on the left navigation bar, and click on "Confer Rights". Highlight the Group to which you would like to re-confer rights and click on "Confer Rights". If updating MDCH-SHARP Group rights, the confer rights template will appear. Under "Your Locations", the user should activate the checkbox next to the new/edited location and then click "Accept" to give the Group access to data from this new/edited location.