Ventilator-Associated Pneumonia

K-HEN Data Collection & Submission

Dolores Hagan, RN BSNK-HEN Education and Data Manager

August 2012

Objectives• Review reporting requirements• Review K-HEN recommended measures• Review the specifications for monitoring

data (Inclusion and exclusion criteria)• Discuss requirements for baseline data• Define data entry and submission timeline• Identify measures that may be pulled

from other systems where data is currently being entered

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Reporting Requirements• For each topic area chosen, hospitals are

required to submit data for at least– One process measure AND– One outcome measure

• Hospitals are strongly encouraged to report on the K-HEN recommended measures

• Additional outcome and/or process measures may be selected and reported as desired 3

K-HEN Recommended Measures

• Purpose—standardize reporting on the same measures across the state for robust benchmarking capability

• Measures selected based on polling data from the KHA Quality Conference in March 2012

• Have continued to evolve with your feedback (Keep it coming! )

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HRET HEN Encyclopedia of Measures

• Lists all measures available in the CDS• Defines the numerator and denominator for

each measure• Provides a link to the source of the measure• http://www.k-hen.com/Portals/16/Documen

ts/HRET_HEN_Encyclopedia_of_Measures_v3.pdf

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VAP: Outcome Measure

• Preferred measure: #92 or 95 ICU or High Risk Nursery (HRN) Ventilator-associated pneumonia rate (ventilator days denominator)

• Alternate measure: #93 or 94 All non-ICU units or all units, ventilator-associated pneumonia rate (ventilator days denominator)

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# 92 or # 95 VAP Criteria

• Numerator—The number of ventilator-associated pneumonia in ICU or HRN

• Denominator—Number of ventilator days (collected daily)– #92—ICU ventilator days– #95—HRN ventilator days

• Equation—(Number of VAP/Number of ventilator days in specified unit) * 1000

7Source: CDC NHSN

# 93 or # 94 VAP Criteria• Numerator—The number of ventilator-

associated pneumonia within the specified unit or units

• Denominator—Number of ventilator days within the specified unit– #93—All non-ICU units patient days– #94—All units

• Equation—(number of VAPs in specified units/number of ventilator days in same specified units)*1000

8Source: CDC NHSN VAP

VAP: Process Measure

• Preferred Measure: #90 Ventilator Bundle Adherence Rate

• Alternate Measure: #91 Hand hygiene adherence rate (VAP)

9Source: CDC NHSN & Joint Commission Hand Hygiene Reference

#90 Ventilator Bundle Use Criteria

Numerator—Number of patients on mechanical ventilation at the time of survey for whom all four elements of the bundle are documented in place.

• HOB elevation ≥ 30 degrees or contraindication; noted on 2 different shifts within a 24-hour period

• Daily sedation interruption and assessment of readiness to extubate; complete documentation required

• Peptic ulcer disease prophylaxis• DVT prophylaxis

Denominator—Total number of patients on ventilators at the time of observation

10Source: NQF Ventilator Bundle Use

#91 VAP Hand Hygiene Compliance

• Numerator—Hand hygiene performed consistent with guidelines

• Denominator—Total number of hand hygiene observation opportunities

• Equation—(Total number of acts of hand hygiene consistent with guidelines/total number of observed hand hygiene opportunities) X 100

11Source: Joint Commission Hand Hygiene Reference

Baseline Data• Only submitted one time• For all topic areas except Readmissions:

– Baseline data is from 2011 prior to January 1, 2012– May be the entire calendar year of 2011 or any other

period within the year (a month, a quarter, etc)– Enter your specific period beginning and ending dates

• Readmission Baseline Data– Preferably CY 2011– May use Jan – Jun 2012 if 2011 data is not available

• If no baseline data is available, do not enter anything for baseline—begin with monitoring data

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VAP Baseline Data

Complete baseline data entry by August 15!

• NHSN data will be extracted once rights are conferred

• Data should be entered on a monthly basis as much as possible

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2012 VAP Monthly Data Entry Schedule

Monitoring Month Data Entry Available Data Entry Complete

January Immediately As soon as possible*

February Immediately As soon as possible*

March Immediately As soon as possible*

April Immediately As soon as possible*

May Immediately As soon as possible*

June Immediately As soon as possible*

July August 1, 2012 August 31, 2012

August September 1, 2012 September 30, 2012

September October 1, 2012 October 31, 2012

October November 1, 2012 November 30, 2012

November December 1, 2012 December 31, 2012

December January 1, 2013 January 31, 201314

*If data is available

Comprehensive Data System (CDS)

• Link to HRET training webinar for CDS located on K-HEN website under Data Page

• https://www.hretcds.org/Login.aspx• Data coordinator receives initial login and

creates hospital’s users– At least two data administrators– As many data entry users as needed

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Measure Selection

• Review the K-HEN Recommended Measures and the HRET Encyclopedia of Measures

• Determine which measures you will report

Remember you MUST report on at least one process and one outcome measure

per topic area selected16

Measure Enrollment

• Enroll in the measures that you are reporting

• Select Admin Measure Enrollment– Select the topic area– Select/deselect and save the measures that

you will be reporting on– This will narrow your choices for data entry to

only those selected– You may reselect those measures at a later

time if desired17

Data Collection & Entry

• Review the numerator and denominator criteria for the measures selected

• Collect and compile the data• Sign on to the CDS

– Select Data Entry tab– Select the topic from the drop Select Next– Find the appropriate measure Select Enter

Data

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Baseline Data Entry• Defaults to the Baseline tab• Enter the Measurement start and end dates

Select ‘Add’• Under ‘Data Entry’ column, Select ‘Go’• Was data collected for this measurement period?

Select Yes or No– If No, enter reason (e.g. data not available)– If Yes, enter the numerator and denominator– Select Save or Submit

• Save holds data in ‘temporary’ area and is not available for reporting within the CDS

• Data may be edited by the hospital until it is submitted 19

Monitoring Data Entry

• Select the Monitoring tab• Under the Data Entry column, Select ‘Go’ for

the appropriate month• Was data collected for this measurement

period? Select Yes or No• If No, enter reason (e.g. data not available)• If Yes, enter the numerator and denominator• Select Save or Submit

– ‘Save’ holds data in ‘temporary’ area and is available for reporting within the CDS

– Data may be edited by the hospital until it is submitted 20

Data Tidbits

• Each month should have data entered or a reason it was not collected

• Additional training will be provided after data has been entered and reporting is available

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Monthly Progress Report

• Due to K-HEN by the 10th of each month• Use template provided• One report per topic area• Report template and sample complete

report located on K-HEN website (www.k-hen.com) under Tools and Resources

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Aim?: (Including your How Good and By When statement)

Why is this project important?:

Aim StatementAim Statement

Changes being Tested, Changes being Tested, Implemented or Implemented or

SpreadSpread

Recommendations and Recommendations and Next StepsNext Steps

Lessons LearnedLessons LearnedRun ChartsRun Charts

(For each listed change, indicate whether it is being tested (T), Implemented (I) or Spread (S))

(Enter summary here)

• Enter summary here (what do you need from Executive Project Champion, Sponsor at this time to move project?)

• Recommendations

• Next steps for testing

Project Title: ______________________________ Date: _____________Hospital Name: ____________________________ State: _____________

© 2012 Institute for Healthcare Improvement

Team MembersTeam Members

(Name of Project Champion, Senior Leader Sponsor & all other names & roles)

(Make fonts large, title, labels, datesand notes very simple on graphs prior to shrinking graphs. Should be able to

fit 6-8 readable graphs here. If no data are available for a particular

measures either create “empty” run list

the name of the measure(s) to be collected.)

Self Assessment Score, 1-5 (see AHA/HRET Assessment Scale document) = Self Assessment Score, 1-5 (see AHA/HRET Assessment Scale document) = <enter score here><enter score here>

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Project Assessment Scale

• http://www.k-hen.com/Portals/16/Documents/HRETHENProjectAssessmentScale.pdf

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Homework

• Set up CDS users for your site • Collect and enter baseline data by Aug 15• Enter monitoring data for Jan - Jun 2012 as

available and time permits• Enter monitoring data for Jul 2012 by Aug

31• Complete July progress report by Aug 10

and email to info@k-hen.com

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Questions

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