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>> Good morning, everybody.
Glad you all came back for a second day and you're ready
to hit analysis again.
We're not going to be any demonstration type things today,
but we will focus a lot on some interpretation,
and then we'll talk about some advanced analyses.
So specifically we'll look at frequency tables,
that's one of the output options I mentioned yesterday.
But we're going to spend quite a bit of time on frequency tables
because I think they're going to be extremely helpful to you,
and we're going to kind of learn how to read and interpret those.
We'll also describe and interpret the SIR
for surgical site infections using a real-world scenario.
And then, finally, we're going to outline steps
for investigating inaccuracies or unexpected results
in the SSI SSR, specifically that is going to be focused
on the CMS SIR output option that we have
because we get a lot of questions about it.
So even though it will be focused on that CMS SSI SIR,
you could apply the same sort of methods to other SIRs as well.
Okay. So here's our first example.
For everybody here in the room, again,
you have a results handout right behind the slides
for this presentation.
I think it's only like four pages or so, and, again,
you'll see a page with the modifications.
We're not going to demonstrate the modifications
but it's just more informative so you know what we did,
and then we have the results.
And the results are going to be really helpful to you today
because it's going to be very easy to see it in front
of you probably better than it will be on the screen again.
So that's pages 2 and 3 of your results handout.
So for this example, you need to obtain a count
of specific SSI events --
and when I say "specific SSI events,"
I mean how many are deep, how many are superficial,
how many are within each of the organ space categories --
that were identified following COLO, abdominal hysterectomy,
hip, and knee procedures that were performed in 2011.
And so that's inclusive of the entire year of 2011.
So I'm just going to highlight some of the things --
or actually the output option
that we used instead of doing this live.
So on our output options treeview, because we're looking
at SSI data, we wanted to look at procedure associated module,
and when we open that up, we have a folder for SSI
and then CDC to find out output; very similar
to what we had yesterday.
But this time we're using the second option called
"frequency table, all SSI events."
"frequency table, all SSI events." We modified this example.
I'm not going to run through all of the modifications,
but I will highlight just a couple.
The first one is the time period.
Now, we're interested in SSIs that are attributed
to procedures that were performed in 2011.
So for our date variable we limited it to procedure date,
the year of the procedure date of 2011.
We did not look at event date.
And so if we were to look at event date,
we could get different numbers, right, because there could be
up to a one-year follow-up period for our SSIs,
and so if we were to look at event date 2011,
we could be looking at SSIs that are actually attributed
to procedures performed in 2010.
So it's very important to make this distinction,
because if you don't make this distinction
and then you're looking later on at your SIRs,
you could notice a mismatch.
So just to reiterate: We are looking at the procedure date;
how many SSIs attributed to procedures
that were performed during this year.
The other option I wanted to highlight --
or the other changes -- are in this other options section --
remember, it's the bottom of that modification screen, right,
and it's the only section that really differs depending
on which report you're running.
So we have a lot of options here.
We can select our row and our column and our page by variable.
So the row and the column is really what sets up your table;
what values do you want across the top columns
and what do you want in the rows.
The page by variable is the same as we saw for line listing.
If you want one page or one table per, let's say, month,
we could do that here, but we're not going
to be using it in this example.
So we've used proc code, which is the NHSN procedure code,
as our row, so we'll see all the procedures going down;
and then our column is specific event.
So across the top we should see every value
of the specific event types, like superficial, incisional,
deep incisional, and so on.
There are additional frequency table options.
We are selecting all of the percentages
for this example, so a table percent.
So it will tell us the percentage in each cell
of the entire table; of everything
that we have included,
what's the percentage for this one cell.
We are using a row percent and column percent.
That's what we're going to spend time interpreting
for the first part of this presentation.
You could look at missing, and that will give you a count
of how many records you have
where a certain value was not recorded.
That should be rare.
And then, of course, if you wanted to get
into some statistics, you could look at expected
and chi-square analyses if you're looking
to get more into those data.
So I'm going to explain this.
This is hard to see, but I'm just pointing out --
this is our whole table, okay.
This is the table that we generated based
on those modifications.
So this is going to represent all of the SSIs
in those four procedure categories
that were performed in 2011.
Now, there's a lot of numbers on here, so for today we're going
to be focusing on the cells that are outlined in red.
So we're going to be looking specific at colon procedures
and deep incisional primary infections attributed
to those procedures during that year.
And you've -- for those in the room, you have your handout
where the table is much bigger, but we're going
to pull out just that cell.
Okay. So what we're going to do is we're going to kind of talk
about each of these numbers in the cell, and we're going
to interpret it just because it's a lot
and it can take a minute to really get oriented
to where you are in this table.
In the upper left of your frequency table, you have a key
where it says frequency, pressure,
row percent, and column percent.
All right?
The first one we're going to talk about it frequency.
The frequency is the first -- the first row in each section.
The one I have highlighted now is 82 under total.
So we could say, 82 total SSIs attributed
to these procedures performed in 2011.
So these are not 82 ever reported
in our facility for 2011.
This is 82 out of the four procedure categories
that we included in this table.
Does that make sense?
So we have 82 SSIs identified and attributed
to those four procedure categories.
Whoops, sorry.
When we go to the top row and look at COLO
and then the total column, we see 49.
So we could say that there are 49 total SSIs following COLO
procedures in that year.
All right?
So that 49 is the total of that row; so the total number
of infections following colon procedures.
We jump back down to the total line, we have 33 total SSIs
that were deep incisional primary.
So now we're in the deep incisional primary column.
We're in that total line at the bottom, and we see 33.
So out of all the procedures --
out of all four procedure categories,
we had 33 that were deep incisional primary.
And finally, when we look back up to the COLO row
and the deep incisional primary column, we have 18.
All right?
So we can interpret that as there were 18 SSIs
that were deep incisional primary following
colon procedures.
So that helps you narrow it down.
This is how many we had in this specific grouping.
Now we can look at percent.
So this percent, this first percentage that we're going
to encounter, is the total percentage of the data
in this specific table, okay.
So the first number we want to look at --
again, let's look at that total column
and we have a percentage of 59.76.
So we could interpret that as 59.76 percent of all SSIs
in this example were attributed to COLO procedures,
and we get that by taking 49 divided by 82, okay;
49 of 82 is 59.76 percent.
If we go into the deep incisional primary column and go
to that bottom -- that total
at the bottom, we get 40.24 percent.
So we could say that 40.24 percent of all SSIs
in this example were identified as deep incisional primary,
and we get that by taking the 33 over 82.
And then, finally, we have a total percentage
within our little strata of COLOs
and deep incisional primary, okay.
So our 18 deep incisional primaries following COLOs,
that represents almost 22 percent
of the total SSIs identified following all four procedures.
So we could say 21.95 percent of all SSIs
in this example were identified
as deep incisional primary following COLO procedures.
All right?
So that's how we move through the total percentages.
Now we're going to move down to a row percent, okay.
Now, this row percent -- the row percent
and the column percent is what can cause a little bit confusion
trying to figure out where the percentage is coming from.
The row percent is the percent of the total within that row.
So when we're looking at COLO procedures
and deep incisional primary SSIs, those 18,
those represent 36.73 percent of the SSIs
that were attributed to COLOs.
So out of all 49 of our SSIs that that are attributed
to COLOs, almost 37 percent were deep incisional primary.
So that's how you would read that row percentage number,
you want to look across the row.
So out of the 18 I have in this cell, how many --
what percentage is that of the total for my row,
for these colon procedures.
For column percent, it's very similar except we're looking
down the column.
So now we want to see, out of these 18, what percentage
of the total from my deep incisional primaries are
attributed to colon procedures, okay.
So we're looking down that column.
So our 18 deep incisional primaries attributed
to COLO represent 54.55 percent of all SSIs that were identified
as deep incisional primary, okay.
Does that kind of make sense?
So we've got 33 deep incisional primary procedures, 18 --
or I'm sorry -- deep incisional primary SSIs,
and 18 of those were attributed to COLOs,
and that represents 54 percent of my --
of all of my deep incisional primaries, okay.
So it can be a little tricky trying
to find your way through these tables.
So what we're going to do now is we're going
to take a different example.
We're going to look at hip procedures
and superficial incisional primaries.
This is in your big table.
If you can't see -- and we're going to go ahead
and have you vote and just see how you do
at reading these numbers.
So what we want to know is, what percentage
of our HPRO SSIs are identified
as superficial incisional primary?
Do we think it's 20?
6.1 percent?
31.25 percent?
or 19.51 percent?
So you can go ahead and vote.
I think you should all have the remotes on your tables.
The clicker.
[ Background voices ]
Okay. I'll give you a few more seconds.
[ Background voices ]
And there's no shame in bringing out a calculator if you need it.
I do it.
[ Background voices ]
Give you ten more seconds.
[ Background voices ]
Okay. Let's see how you guys did.
All right.
53 percent of you said that three was the correct answer,
31.25 percent; and then we have about 35 percent who thought
that the correct answer was about six percent.
The correct answer is No.
3, 31.25 percent.
And let's look at why that is.
Where are we looking?
So we're looking again at the percentage
of our HPRO procedures that were identified as SIP.
So what we see here is we have 16 SSIs total
that were identified following our hip procedures,
five of those are superficial incisional primary,
and that five represents 31 --
about 31 percent of the total identified after hips, okay.
So that's how we got that number.
We took that five across -- that five out of the 16.
All right?
Let's move on to our second one.
So what percentage of all SSIs were identified
as superficial incisional primary?
Do we think it's 19 and a half percent?
Do we think it's 30.49?
Do we think it's 20 percent?
Or do we think it's about 6 percent?
[ Background voices ]
Ten more seconds
[ Background voices ]
All right.
Let's see how you guys did on this one.
All right, 79 percent of you felt
that the correct answer was 2,
30.49 percent, and you are correct.
So good job.
So why is that?
Where are we looking?
We're looking -- again, we want to know of all the SSIs
that we identified, what percentage
of them were superficial incisional primary.
So what we're looking at, we're looking at that column for SIP,
we see we've got 25 infections out of 82 total infections
that were identified for our four procedures.
So 25 of 82 is 30.49 percent.
Okay.
[ Pause ]
All right.
Now, we got one more question on frequency tables.
What percentage of all SSIs were identified
as superficial incisional primary following our
hip procedures?
Okay. So you can see our options here: We have 30.49 percent,
19.51, 20 percent, or 6 percent.
And the voting is open.
[ Background voices ]
All right, ten seconds.
[ Background voices ]
Okay. Let's see how everybody did on this one.
All right, 72 percent of you felt
that 4 was the correct answer, that there were six percent,
and you would be correct.
So, again, what are we looking at here?
Well, again, we want to know what percentage of all
of the SSIs that were reported --
so remember, we have 82 total SSIs identified following these
four procedures --
what percentage of those were actually the superficial
infections following hips.
So we're looking at that five out of 82,
which comes out to be six --
about six percent of the total, okay.
All right.
So now that we've talked about frequency tables,
I've warmed you up a little bit,
let's get into the really fun stuff and we're going
to talk about SSI SIRs, okay.
We're going to spend a good portion
of this morning's presentation talking about this
because it's really, really important to hit
on some of these points.
So our example is that,
let's say you've been following four select procedures
in your facility for SSIs, and you report these data to NHSN.
So these are the same procedures we just talked about;
we have colons, we have abdominal hysterectomies,
we have hips, and we have knees.
And you've been asked to report a measurement
of your facility's SSI experience for these procedures
for the first half of 2011 at your next committee meeting,
and you decide to use the SIR.
I know you all would, right.
You're like that -- you're like, you know what?
My go-to is SIR.
That's what I'm going for.
But why not use a rate?
I know you wouldn't ask that either, but why not use a rate?
Well, I'm sure many of you who have been doing SSI surveillance
for a while you're familiar with the way we used
to calculate SSI rates, and we used to have it stratified
by risk index, which they --
the procedures were given a score of 0, 1, 2, or 3.
And that risk index was based on three factors --
procedure duration, ASA score, wound class -- and there were --
there were limitations to using that risk index.
First of all, we know it only relied
on those three risk factors, and there was a bunch
of other data reported for procedures
that could be potential risk factors
and it was not accounting for any of that.
Also, those same three risk factors had
to differentiate risk for all types of procedures.
So regardless of what type procedure was performed,
those three risk factors were weighted the same
for each patient, for each procedure, and --
and so they were -- they were considered
to be equals regardless of what it was.
So my colleagues did a lot of work looking at the SSI data
that had been reported in NHSN and decided
to move towards a method that would ultimately result
in the use of SSI SIRs.
So we have, therefore, replaced SSI rates
at a national level with SIRs.
If you're reporting data to NHSN,
you can still get an SSI rate based on the older risk index;
however, we moved those to an advanced folder.
We don't provide any comparison to national data,
we're not updating national SSI rates based on that risk index,
so if you wish to look at any comparison, you have to pull
out the paper copy of that report from --
that was published in 2009 and look at the rates
that were published at that point.
So what we're going to get into now with the SS --
SIRs is that these SIRs now can use several risk factors,
not just the basic three, and we build what's called
"logistic regression models" that --
that ends up resulting in improved risk adjustment
for each of our procedures.
So the basic calculation of an SIR remains the same
from what we saw yesterday.
Right? This is a review.
We're still looking at the observed number of HAIs,
in this case SSIs, and dividing
that by the expected number of SSIs.
But the expected number in the calculation
of that is what changes, and that's what we have
to spend our time on today.
Regardless, with an SSI SIR, if you had an SIR of 1.21,
you could interpret that as 21 percent more infections
than expected.
So your interpretation would still be the same,
the calculation, this basic observed
over expected, remains the same.
It's just a manner of how we get to the expected.
Before we go into all of this, I just want to assure you
that NHSN will calculate these SIRs for you,
so don't get too scared
at the calculations you are about to see.
We're just -- we just want to explain it so you understand
where these calculations come from,
but if you report your procedure data to NHSN,
we do all the calculation for you.
We have a lot of SSI SIR options, I'll explain some
of those towards the end of this,
and each of those can contain different results.
So for today we're going to use something that's called the
"all SSI SIR report" because it's going
to be the most inclusive of data that we've reported, okay.
The other options could be considered a subset
and they have different risks calculated.
So, again, we'll discuss that a little bit later on.
Okay. So for those in the room, you have a results handout,
you know, as I mentioned earlier, and on page 5,
you actually can see the results --
again, we're not going to talk about the modifications,
very similar to what you saw yesterday.
There's not too much that we did.
We are looking at the first half of 2011.
And so what I want to point out is
that that's indicated by 2011 H1.
So that H1 represents half one, or the first six months of 2011,
that's a calendar year.
Again, in our SIR tables we have multiple tables
that you can get in your output.
I think in your results handout, I only included two.
But we include the overall for all of those procedures,
we've limited this SIR to our four procedures,
and then we also provide an SIR
for each individual procedure category.
So if you want to know what is my SIR just for colons,
you could obtain that.
Again, I'm going to point out the footnotes.
I know I sound like a broken record,
but I can't tell you how important it is especially
for your SSI data, because in here, we do include a footnote
that says the "SIR excludes superficial incisional secondary
and deep incisional secondary SSIs."
So your secondary SSIs still have to be reported; however,
we felt we would be unable to calculate an appropriate SIR
with those infections included because those incisions
from which those SSIs were identified from don't have some
of their own risk factors, like a procedure duration
or a wound class, so that's why the infections themselves have
been excluded in the infection count.
So that's -- you know, that's a key.
If you're looking at your infection count and you're like,
oh, hey, this is off a little bit, maybe by one or two,
and you're looking, let's say, at CABG procedures,
it's possible that you had a secondary --
like superficial incisional secondary infection
that was excluded.
So that's something you could look further on.
Also, I want to note that we list the source
of aggregate data as 2006 to 2008 NHSN SSI data,
but that's not referring to the annual report
with the risk stratified rates.
This is, instead, just the data
that were reported during that time frame.
So now that we've got this table up here,
let's take some time interpreting some
of the results that we have here.
Some of this will be a review for you.
Again, the columns that are shaded in yellow are the --
represent the NHSN data or your comparison to the NHSN data
or calculations using our NHSN data.
So let's see what you remember from yesterday.
This is a good review.
So if we look at the P value
and the 95 percent confidence interval, is the number
of observed infections statistically significantly
different from the number expected?
Yes, no, or not sure.
So we've got 34 infections that are identified,
we have 28 that were expected, we got an SIR of 1.212.
So when you look at this P value,
do you notice that's significant or not?
And polling is open.
[ Background voices ]
Ten seconds.
[ Background voices ]
All right.
Let's see how you did.
You guys are good.
Ninety-six percent said no, it's not statistically significant,
and you would be correct.
So great. You guys remember everything we learned yesterday.
That's awesome.
That makes me so happy.
So why is that [ chuckling ] --
I know, it's the little things, right?
-- so we say no, it's not statistically significant
because our P value's greater than 0.5,
and our 95 percent confidence interval includes a value
of one.
So, again, another scenario like the majority that we have
where we come to the same conclusion when looking
at both of these numbers.
So good job, guys.
So, again, you know, this is kind of a review
from what we looked at yesterday with CLABSI, and you'll notice
that this interpretation looks very similar
to what we had yesterday, okay.
So one example of how we could interpret this is,
we could say during the first half of 2011,
our facility observed 34 SSIs that were attributed to 1,088,
COLO, hysterectomy, hip, and knee procedures performed;
the number of expected SSIs during this time frame based
on national data was 28.059; and this yields an SIR of 1.212,
indicating that we observed approximately 21 percent more
infections than expected; however,
based on statistical evidence, we can conclude
that our SIR is no different than one, okay.
Again, very similar to what we saw with the CLABSI SIR
that we looked at yesterday.
However, as I mentioned a few minutes ago,
we do give you an SIR for each procedure as well.
So it's nice to know what you have overall.
Right? It's nice to know how are we doing overall
with these four procedures, but is there anything I need to know
about what's going on within each procedure category,
because certainly, you're going to have different surgeons,
different services, different types of patients.
So we provide that for you.
And, again, just like you saw
with the CLABSI SIR spine location, these SSIs SIRs
by procedure will have a P value
and a 95 percent confidence interval;
you can see each procedure category's contribution
to the overall SIR including the number of expected infections;
and then you can view changes in SIR for each procedure category
over time if that's something --
if you're looking at it by quarter
or every six-month interval, you want to know
if there's any change in the volume of procedures
or the number of infections, you can do that.
I keep saying expected, and, you know, again, how many --
how do we know how many are expected?
And you know, I already told you we don't use rates,
and yesterday for CLABSI we based a number expected
on rates.
But we're no longer using rates, so what do we do?
Well, we calculate the number of expected
by summing the procedure risk for all --
for each individual procedure included
in the summarized calculation.
So, for example, all procedures in the first half of 2011;
we calculate and total up the risk for every single procedure.
The risk is calculated from the improved risk models
which I have been alluding to.
So, again, basic risk index, no longer used.
So we do not base the number of expected based
on those stratified rates.
Instead, we use what we call new risk models
that provide the improved risk adjustment
in the prediction of SSIs.
And so I've included my colleague's paper here
on the bottom.
It's also on our website if you're interested
in all of the details.
But let's talk about how we calculate
that for the procedures.
So before we go into anything, I just want to see what you think
about this table and the data that we have in this table.
These are just four example patients.
These data include the significant risk factors
for a selection of patients
that undergo a procedure category that we have.
So given the data in this table, which patient do you think is
at highest risk of SSI?
Do you think it's 1, 2, 3, or 4?
So in here we have patients of varying ages.
Right? We have patients in their 80's,
we have a 42-year-old and a 25-year-old.
We have the ASA score.
We have a procedure duration.
We have an indication of whether
or not the procedure was performed
in endoscopic approach.
We even have some facility level factors here,
like if these procedures were performed in a medical --
in a hospital affiliated with a medical school,
how many beds are in the hospital.
We even have wound class.
So go ahead and vote.
And I just want to see what you think.
Who would be at highest risk of SSI?
[ Background voices ]
Ten seconds.
[ Background voices ]
Okay. Let's see what everybody thought.
Okay, 92 percent of you felt that patient No.
3 would be at highest risk.
Does somebody want to shout out why you thought that.
>> [ Inaudible ]
>> Okay. I heard a couple of things.
Somebody said because they have the longest procedure duration;
it's 282 minutes.
That -- that's true.
But somebody else said and what I heard a lot of people say is
that the probably of SSI is the highest for this patient.
So that is correct.
That is why patient No.
3 has the highest risk, because their calculated probability
or risk is the highest.
It's not based just on procedure duration.
That -- yes, it is the highest, but, you know, you may think,
well, it's not the oldest patient,
so why are they at highest risk?
They don't have the highest level of wound class.
They're clean contaminated, but there's others who are older
and have contaminated wound class.
So that's what we're going to get into now is, well, you know,
you figure some factors have more of a risk than others,
but yet this patient has the highest probability.
So let's get into some of these details.
All right.
There's a lot of risk factors.
If you've been performing an SSI surveillance in NHSN
and you've been entering your procedures,
you know there's a lot of data that are included,
which gives us a lot
of potential risk factors to look at.
So now, you know, remember I said the basic risk index only
used three factors, but now we have all
of these that we can look at.
We can look at things like whether
or not the procedure performed was considered an
emergency procedure.
We can look at the patient's age and gender.
We can look at hospital level factors.
And for some of our other procedures,
we have additional risk factors.
Like for C-sections we have height and weight;
for spinal fusions we can look at the spinal level.
So there was work done to analyze all
of these risk factors for each procedure category
and to determine which of these were considered statistically
significant in predicting risk of SSI
for that -- for each patient.
This is the results of some of that work, and if you --
if you're interested in taking a look at that paper,
I recommend at least printing it out,
having it as a reference, glancing at it.
It will be helpful to you to have that handy
if you start presenting these SSI SIRs within your hospital
and to surgeons, they're going to ask what is this based on,
and then you can have that information available with you.
So we're going to talk about a few of these things,
but this is for vaginal hysterectomies,
this is just one example of how we calculate risk
for patients following vaginal hysterectomies.
We look at the patient's age, and we look at whether
or not they are 44 years of age or less versus greater than 44,
we look at their ASA score, we look at the procedure duration,
and we look at whether or not their hospital was affiliated
with a medical school.
This is just for vaginal hysterectomies.
And we're going to talk
about specifically the parameter estimates and how those are used
in coordination with calculating risk.
All right.
Try not to get too overwhelmed by betas and logits
and what we call that little thing is a P-hat,
the p with the little hat.
So try not to get too cross eyed looking at that.
This is all just to show you that this is the type of magic
that happens in NHSN when you report your data, okay.
So in the upper right-hand corner we can see the risk
factors that we just saw in the previous slide.
We can see our parameter estimates.
And so what we have is a logistic regression model here,
and through this functionality using those parameter estimates,
we can actually calculate a risk.
So if a risk factors is present, it gets a one.
So if ASA is greater than two, that get a point --
that gets one point, and if it's not, it gets zero.
So how does that translate?
Let's say we had an example patient, right; 40 years old,
the ASA is 4, the duration is 117 minutes,
and the medical school --
it was performed in a hospital affiliated
with a medical school.
Again, here's all of our little P-hats and e's
and logits and everything.
So when we put all of this together --
now, if you look that second line,
the second logit calculation there, and you look
at the numbers in parentheses, all of those are one.
That's because this example patient had every risk factor
present, okay.
So we can add up all of the parameter estimates,
everything is multiplied by one.
If something had not been present there would be a zero
and that risk factor, it would just fall out, right,
because they didn't have that risk factor.
So for this example patient, what we do is we calculate all
of this up, and we eventually get to the fact that based
on these data, this patient's risk of SSI was .032
or 3.2 percent, is how you could interpret that, okay.
[ Inaudible ]
Okay. I'm going to go ahead and repeat the question.
So the question is: This patient was under 44, so shouldn't
that have been a zero in this calculation,
so that is referring to this .66 by 1,
shouldn't that have been a zero instead of a one?
Now, what I want to point out -- let's back up.
Everything that's listed first here, less than or equal to 44,
ASA of 2, duration greater than 100,
if those first values are present,
those first risk factors, that's a one.
So you're thinking this is counterintuitive.
You have younger patients at higher risk
of SSI, and that's right.
In the data that we have available
for vaginal hysterectomies, patients that were 44 years
or less were at a higher risk of SSI
than those older than 44, okay.
So that's why -- since this patient was 40,
that's why there was a one, and that's why this risk factor
of age was included in their overall risk.
So that's a great question.
[ Pause ]
So let's look at this again when we take a look
at expected infections for SSI.
So let's say you had 100 patients here --
obviously, we don't see all of them here, but we include all
of their risk factors here, and we calculate the probability
of SSI, which is what we saw in that question, right,
I asked you about probability of SSI,
so this is calculated for every patient.
And if we were to total it up, that's what --
that's how we get the expected.
Notice in this right-hand column, probability of SSI,
at the bottom we have e equals 2.91.
So in our 100 made up patients,
we could get an expected of 2.91 infections.
We add up the probability for every single patient to get
to that total expected for this category.
We see that they observed -- we identified three infections,
so we could calculate the SIR and we get about one;
it's 3 over 2.91 okay.
So, again, calculate the risk for every patient
in this procedure, total of this probability up to get
to the number expected.
So that formula that you saw is done for every single patient.
This is just an example I just wanted to highlight.
You know, I had been mentioning earlier
that different risk factors are used for different procedures
and they're weighted differently.
So what I'm showing here is an example of colon procedures,
and in the upper right I include all of the risk factors
that were deemed to be significant
for this procedure type.
So the first one I want to point out is age ten,
that means every ten-year increase in age.
So remember with vaginal hysterectomies we saw
that the risk factor was really where the patient was 44 years
or less versus greater than 44, and here we're looking
at every ten-year increase in age.
So it's a different way to use age
to calculate the patient's risk of infection.
Here we're also using the facility bed size
and we're using wound class.
And so this table, this line listing that I've included here,
is actually a line listing of the procedures
that were performed, and the very right-hand column is the
risk using this all SSI models --
the one we're talking about today --
so the patient's calculated risk given the factors
in the upper right-hand corner, what their probability
of SSI is, what their risk is, okay.
So you can get this information.
One of the reasons I wanted to point this out as well is
because you can get this level of detail out of NHSN.
If you want to know, you know, okay,
here's my number expected but, you know,
what do my individual patients look like?
What's the calculated risk?
What's my procedure duration?
You know, are we noticing procedures all of a sudden
that are much longer than they have been in the past?
And you can get that level of detail here, okay.
Okay. So now let's translate all of that, okay.
So first of all, we talked about overall SSI SIR.
Then we looked at, okay, we have procedure level SIFs,
but let's talk about how we calculate the expected for each.
Well, now let's translate this into how we --
how we get back up to the top.
So I've mentioned this a few times already
that the number expected is calculated
by summing the estimated risk for each procedure
in that category and time period.
So, for example, if I were to add up the risk
for every procedure for my COLOs in the first six months,
I sum all up of those patients' risk, I get 15.855,
and that's the number of expected infections that I have
for COLOs for that time period.
Again, like what we saw with CLABSI yesterday, we can take
and total up, for every procedure category,
we can add up all of the procedures that were performed,
we can add up all of the infections that were identified,
and we can add up all of the expected infections, okay.
So out of all of the patients undergoing these four procedure
categories, when we add up all of their probabilities
for over a thousand procedures, we get a little more
than 28 expected infections, okay.
So that's how we calculate all of that risk.
But, again, the overall SIR of 1.2 is not a total
of the individual SIRs.
Right? Instead, we get the overall SIR by taking
that 34 total infections divided by the 28 expected infections,
and that's what gets us to 1.2.
All right.
So let's get on to our next question.
So this is, again, getting at, okay,
getting at the story here, okay.
We want to look at how are we doing
in individual procedure categories.
So here's our table for each of the four.
We've already looked at this a little bit.
Based on the table and the information in this table,
which procedure category do you think has the highest
contribution to the overall SIR?
Do you expect it to be hips, colons, knees,
or abdominal hysterectomies.
And the voting is open.
[ Pause ]
Whoops. I'm sorry.
I thought I had a timer here.
I thought that problem
from yesterday was fixed but it's not.
So I have about half of the votes here.
I apologize.
So we seem to be a little bit, you know,
mixed on what we think here.
Fifty-seven percent felt
that hysterectomies had the highest contribution
to the overall SIR; 30 percent of you felt
that colons were the highest contribution to the overall SIR.
So who thinks -- I want to hear why we think
that hysterectomy may have been the highest contribution.
Is anyone willing to shout out why they think that may be?
>> [ Inaudible ]
>> It's the highest SIR for hysterectomy.
That's great.
And what about for COLOs?
>> [ Inaudible ]
>> Highest number of infections, okay.
Okay. So let's see what I said.
I said COLO.
All right?
And why did I say the colon procedures?
Well, even though we don't have the highest procedure count,
and even though we don't have the highest SIR in this case,
we contribute the most to the overall SIR
because of the number of infections
and the number expected, okay.
So remember, our expected count was I think about 28,
and of those 28, 15 -- 15 of our expected infections are
from colons, and 19
of our infections are coming from colons.
And you may expect that because of the type of procedure
that it is, but this is what's resulting
in the highest contribution, because remember,
the overall SIR takes the total observed divided
by the total expected.
It's not adding up all of the SIRs together.
Does that make sense?
Maybe? Okay.
So now that we've spent some time on SIRs,
I'm going to add a little bit more something to the mix.
And this you could use as the -- as kind of like a --
you can put it up on your board or have it --
this one page as a reference to you
when you're looking at your SIRs.
I mentioned early on that we have more than one SIR model.
We calculate risk differently.
We have different options.
We have three basic models here,
and so this outlines some of the differences.
Now, I mentioned that we're using the all SSI model today
because it was the most inclusive
of everything that we have.
So basically, that includes superficial, deep,
and organ space infections; however, of course,
the superficial incisional
and deep incisional are limited primary only, that's going
to be the same for all of our SSI SIRs.
And our all SSI model includes the SSIs that were identified
on admission, readmission, and via post discharge surveillance.
So it includes everything that we've identified.
We have something called a "complex AR model,"
and that's going to be basically a subset.
All right?
So this will include only the SSIs that were identified
on admission or readmission to the facility
where the procedure was performed,
it includes only inpatient procedures,
and it includes only deep incisional primary
and organ space SSIs.
So we're really getting more at those complex type
of SSIs identified on admission, readmission.
That's what the complex AR stands for.
So risk is calculated differently in the same patient
when you look at the complex AR versus the all.
All right?
Now, many of you may choose to just go with the all.
We have the complex AR available
if that's something you're interested in looking
in that subset specifically.
That is available.
The other option is the complex 30-day SSI model
that is actually used for the CMS reporting.
So for the SSI CMS reporting you have to report all of the COLOs
and hysterectomies in patient as part of the NHSN protocol.
You have to follow the protocol.
But when we calculate SIRs to be submitted to CMS,
we take a subset of those data.
And this is part of a harmonized measure that we have.
So this outlines what the differences are.
First of all, it has to be in-plan.
If you're reporting anything for CMS,
this in-plan piece is a big component.
And I just want to mention that if your data are not in-planned,
we don't use it for anything.
We don't use it in any NHSN aggregate analyses.
Those data are not submitted to CMS, we're not allowed to.
So you have to make sure that everything that you're required
to report for CMS is in your monthly reporting plan, okay.
If it's not, doesn't matter if you report it,
it will not get submitted.
So you have to make sure it's in your plan.
It will also -- this model will only include your inpatient
colons and hist -- abdominal hysterectomies
that were performed in adult patients; in other words,
in patients who were 18 years of age or older.
It includes only deep incisional primary and organ space,
so that's the complex part.
And those are SSIs with an event date within 30 days
of the procedure, so that's the 30 day part.
And then it uses only age and ASA to determine risk, okay.
So the probability of SSI for these patients,
if you're performing COLOs and hysterectomies and you look
at that probability of SSI for all of these three models,
it will be different, okay.
And that's just so you have an understanding of how we come
up with those numbers, okay.
So we're going to move on and we're going to --
actually, before we move on, I just want to point
out that paper I mentioned from my colleagues
that details the risk models.
I have a couple of snapshots here, and this is just
to show you that the first one is Table 5, and it's models
to predict all surgical site infections at the primary site.
So that's the all model that we used today.
If we look at Table 6, that's the --
those are the risk factors for the complex AR model.
So I have the same procedure here, I have appendectomies,
and I can see, first of all, in Table 5 that the number
of procedures here is over 6,000 and the number of SSIs
that were considered for this risk model is 85,
but when I look down at Table 6, it's a subset.
Right? I have 5,889 and 50 SSIs.
Additionally, the risk factors are slightly different, okay.
We're using emergency involved, we're using gender involved,
we're using bed size involved, but the wound class
and the amount of risk attributed
to wound class is different, okay.
And also our parameter estimates are different.
We can see that in the bottom model
that these risk factors have more weight
for appendectomy risk than the top one, okay.
So emergency, the estimate is .87; meaning,
it's going to contribute more to the risk model
than the other one which is .61.
So that's not to confuse you, it's just to show you
that there are slightly different risk factors
and weighting of the risk factors for each of the models.
So that may help you determine which one you want to use
and report out, but know that there is a difference,
and so if anybody is looking at it, then you can refer to this
and see, oh, okay, I see that kind
of the numbers of different.
We're looking at different population here.
Okay. This is -- I'm going to show you again,
I know I've already hit on this a few times already,
but this is a line list of colon procedures,
it's just a snapshot, and the right three columns here are the
procedure risk for each of the different models.
So the first one is for the all SSI SIR, and if we look
at that first patient, the risk is calculated as .0668,
so about a 6.7 percent risk of SSI.
When we look at the complex model,
the second to last column, the patient's risk is
at about 2.87 percent, okay, so it's less.
And then when we look at the complex 30-day, which is used
for CMS, the patient's risk is at about 4 percent.
So this is just to illustrate that there is --
there's, again, a different weighting
of the risk factors used, different risk factors used,
and therefore, the risk is going
to be different for each patient.
So that's why it's kind of important to understand
which SIR you want to look
at because you will get different results depending
on which one you look at for the same group of procedures.
So we're going to stay on the SIR train
for a little bit longer, and this is going
to highlight how you can investigate discrepancies
in your data, specifically in this case, for your CMS report,
but -- but you could apply similar methodologies
if you're looking at your overall SIR.
So we've gotten a lot of questions especially
with the first deadline that passed.
There were a lot of question about why am I --
I know I had reported more infections,
or I know I had reported more procedures,
and people really wanting to make sure that they --
that their data were accurate.
And so these are some of the steps that we can go through
and that we've gone through at CDC to help troubleshoot
and investigate, okay.
So we're just going to walk through some of these steps.
So let's say in preparation
for your second quarter data submission you decide
to check a special report into NHSN -- we have one of those,
I mentioned it yesterday.
It's a CMS SIR report --
to ensure that the data
that will be submitted are complete and accurate.
Here are some things that I already want to put up front.
One, you have already confirmed
that your monthly reporting plans include inpatient colon
and hysterectomy procedures for SSI.
That should be your very first step.
You want to make sure your procedures,
your inpatient procedures are in your monthly reporting plan
for every single month.
The second is that you have already confirmed
that all procedures have been reported
to NHSN for the full quarter.
So you know already, I have submitted all three months.
I know it.
I've checked that.
Now, I just want to check the numbers.
So first here is the report that we created and you want to run
that specialized report.
So this is in the advanced output options folder in NHSN,
and the very first folder now that you will see,
this is something new that we changed in the past couple
of weeks, it now says "CMS reports."
So you can go directly there to get all of the reports
that are relevant to the CMS reporting.
And, of course, we will be adding more for --
for the newest reporting coming up.
So the one we want to use is
"SIR complex 30-day SSI data for CMS IPS."
Wow, that is a mouthful, but we wanted
to be sure it was very clear what report
and what data are included here.
This will mirror the data that will be submitted to CMS
on behalf of your facility.
So if the numbers are incorrect in this report,
they will be incorrect when submitted to CMS on your behalf.
That's why it's really important, and I would --
I would really recommend that you run this report especially
as the deadline nears, not only to make sure that it's right,
but if it is accurate, save that report, okay.
Print it out, save it to your -- save it to your desktop.
You'll have the date and time stamp so you'll know, okay,
this is exactly what is in the database and what is submitted
on my behalf, so that if there's any discrepancy later on,
you have something to go back to.
Because remember, you can change your data any time,
but once you change it in NHSN after the deadline,
nothing gets changed for CMS, okay.
All right.
So we're going to ignore the first
and second quarter in this table.
I just ran this to show you how it comes up by default.
We run this report by quarter
because it's quarterly submitted data.
We're going to ignore the first quarter for COLO
and hysterectomies here.
It's zero across the board.
I was using one of our internal facilities
and we just didn't have any data entered.
So I'm highlighting on the second quarters,
which I've highlight in yellow.
So when we focus on that second quarter's worth of data,
you're concerned, let's say, that the number of procedures
and SSIs represented in this table are inaccurate.
Let's just put that out there.
You're like, you know, something's not right.
I know I had more because I ran my frequency table, let's say,
and I know that I should have more.
The first thing you want to check after you run
that report are the alerts.
This is extremely important.
I could not stress this enough.
So in our example let's say the number
of hysterectomy procedures, you think it's too low,
and in our report it said 50; you're concerned
that at least one month of data is missing
for the SIR so check your alerts.
Now, when you log into NHSN, you should have an action items box,
and in that box it will say you have five missing procedure
associated events, or you have two months
of missing summary data.
When you click on that number,
it will bring you to an alert screen.
Here I have missing procedure associated events as the tab
that I've opened, and the month and year, I have June 2012,
and I have abdominal hysterectomies,
and notice for SSI it says inpatient,
and then I have a report no events column
and then a checkbox.
If you do not check that box
and you have not identified any SSIs --
let's say you're looking at it and you say, I know as of today,
I have not identified any SSIs that are attributed
to hysterectomy procedures, you have to check that box.
If you don't check that box,
that month's data will not be submitted, okay.
This is to verify and validate that you're saying, yes,
at this moment there are zero.
It's not that I forgot to enter or just chose not to answer.
It really means that at this time there are none.
If you identify any later, you can enter them into NHSN, okay.
That's fine.
But as of this date you're saying, nope,
I don't have any events.
So you have to check that box.
Can I say that enough?
You have to check that box.
We get a lot of questions about it, so that's why I'm --
I'm reiterating it many, many times.
And the same would hold true for your CLABSI data,
for COUTI data, really any data that you have
in your monthly reporting plan, even outside the scope
of CMS reporting, anything that's
in your monthly reporting plan,
if you have no infections identified, you have to check
that box to even include those data in your own rates
and your own SIRs, okay.
So just keep that in mind.
If you're ever noticing a discrepancy, please check
that alerts and that action item screen first.
Okay. And this is beginning with 2012 data, okay, so beginning
with January 2012, that's when that takes effect.
Okay. So let's say we went ahead, we checked that box,
okay, whoa, got that done.
Now you know that your facility identified a total of four SSIs
for the quarter, two colons and two hysterectomies, yet only two
of those SIRs -- or SSIs are appearing in the SIRs,
so you're like, okay, well, now I'm worried
because if they ever validate this, you know,
my numbers are going to be off.
So the solution is to run the SSI line list
to determine why events were excluded.
You could probably actually run a frequency table too,
there's -- you know, there's more than one way to go
about this, but we're going to focus on the line list here.
So here's what I did with the line list, okay.
We talked about line lists yesterday.
What I did is I looked at my SSI line list and I limited it
to procedures that were performed
in the second quarter -- because remember,
we're looking specifically at procedures performed during
that time period -- I used a page by variable
of specific event -- because remember, earlier I mentioned
that all secondary infections,
the superficial incisional secondary
and deep incisional secondary, are excluded --
so I want to see if any were secondary.
There are other exclusions.
Right? Superficials are excluded from CMS entirely for this SIR.
You still have to report them,
but they're excluded from the SIR.
And there's some other exclusions.
So looking at only my colons and hysterectomies and running
that SSI line list, I see a few things.
Okay, first of all, there's only four SSIs on this page.
Right? That's good.
That's all I reported.
But the first one is a deep incisional primary,
so I would expect it to be included; however when I look
at the number of days from the procedure to the event, it's 34,
okay, and only those SSIs identified
within 30 days will be included in that SIR.
So I can look at that and say, oh, okay,
that's why that one's excluded.
Done. Check that off.
The other one, we have a superficial incisional primarily
table at the bottom and only one infection attributed
to a hysterectomy procedure, that will be excluded
because it's superficial.
Those are not part of the CMS reporting.
So that's why that's excluded, okay.
So I can take a look at this and know automatically.
Now, you may -- for your own recordkeeping, you may want
to go into the event record in NHSN and just write
in the comments, you know, 34 days from procedure
to event excluded from CMS, just so you have it, just so you know
for future reference, and you can make note of that.
But that's totally up to you.
These line lists will also help you determine the cause of that.
Okay. So now that we've done this --
so we've looked at our line list
to see why our SSIs were missing, we've looked
at our alert screen to see why we have procedures messing,
and we also noticed that while our SIR indicates
that 164 colons were reported, you know that you imported 166
for the quarter and you're just concerned with this discrepancy.
Again, this all goes back to verifying the accuracy of data,
really owning it so that you're not surprised
if somebody calls you on it.
So there's a two-part solution here.
First, check the SIR again
to see any procedures have been excluded due
to SIR exclusion criteria.
So there's a table at the bottom
that will say this is how many are excluded from the SIR
for reasons like the procedure duration is extremely long
or the wound class was indicated as unknown.
All of that is in Appendix C of the SIR newsletter.
You have the SIR newsletter in your resource guide.
Appendix C outlines the additional exclusion criteria
for SIR's, okay.
So take a look at that when you get a chance,
you know, when you get back.
And also the second thing is to check a line list
or frequency table to see how many procedures are outside the
scope of CMS reporting requirements
and therefore excluded from the SIR, okay.
So there's a couple of pieces here.
This is, again, just to check for your data accuracy,
just to make sure everything checks out okay.
So step 4A I mentioned, there should be --
if any are excluded for exclusion criteria,
that's the Appendix C in the SIR newsletter,
we will give you a count for each procedure code
and time period of the number of procedures
and infections excluded.
Now, I know this says "incomplete procedures."
They could be incomplete or they could be excluded, okay.
So you may say, I know I filled in every single field,
but they could be excluded for other reasons.
So you can look at that and then run a line list that is specific
to those exclusion criteria.
Again, that's all outlined in Appendix C. Step 4B is
to run a procedure line list,
include the variable model risk complex 30D, okay.
Again, that's the probability of SSI for each procedure.
And at a glance you'll be able to see
which procedures are excluded.
Basically, anything where the risk is not calculated,
and you notice a little period in that column,
all of those patients are excluded from the SIR.
That means that we could not calculate risk.
So you can see at a glance if you sort that list
by model risk complex 30D,
all of the ones we're missing will be at the top,
and you can see, okay, here are my procedure procedures
that are excluded.
And here's an example of that.
Remember, I thought that there were two procedures missing
from my procedure count in the SIR, so when I run
that line list and I sort it by that risk variable,
which is on the right-hand side,
the first two have a period in that that column.
That means missing.
So it was not calculated.
And if I look closer at it, I can --
I can see that one of them was an outpatient procedure, okay,
so that's not part of -- that's not in the scope;
and the other one was a 12-year-old patient.
If we look at that second column,
the age on procedure date is 12.
So even though I had to report that to NHSN, it's not in scope
for the CMS SSI reporting,
and so we don't just calculate the 30 --
complex 30-day risk for that patient,
so we can sure it will not be submitted.
Those data will not be submitted, okay.
I know I talked about all those exclusion criteria,
and your brain is probably
in a flurry thinking how am I going to remember all this.
Guess what, guys?
It's in the footnotes.
We have a footnote to the table, so we say, in-plan,
inpatient colon and hysterectomy in patients greater
than 18 years of age; it includes SSIs
within an event date within 30 days, and we also list those
that are excluded, okay, so you can see the scope
of the CMS SSI reporting right below the table.
So that is your key of the things that you can look
at if you notice a discrepancy.
After you've checked the alerts, you can look
at that and say, oh, okay.
Now I can look at my line list of SSIs and see if there's any
that were superficial just to assure yourself.
So there are plenty of details about the SIR.
I'm not going to go into all of them today.
But I keep mentioning that SIR newsletter.
Again, it's in your resource guide for those in the room.
For those on the Web, it is on our website
on the NHSN patient safety analysis resource page.
Please take a look at that.
It talks about a lot of the things that we talked
about today, but it also includes that Appendix C
which is very important.
So I'm going to move on to a couple of other things.
So we're going to give our brains a rest, okay.
We're going to -- we're going to take a rest from the math
and the calculations and the interpretation.
We will have plenty of time for SIR questions at the end
of today's presentation, so if you have those question,
please write them down and we will get to them.
But for now I want to show you some of the advanced features
in analysis that will help you later on so you can kind
of take a little bit of a breather for your brain.
All right.
The first thing I want to talk about are output sets, okay.
So we know that there may be reports that you wish
to run simultaneously on a regular basis.
One example could be these CMS reports.
Right? You're reporting let's say CLABSI, COUTI,
and SSI for your facility; you know you have to look
at it every quarter; and you're thinking,
so I have to run each report, that's three reports that I have
to run on a regular basis.
And it's not a huge deal, but wouldn't it be nice
if you could run them all with the click
of a single button instead of three buttons?
So what we have are output sets, and that will allow you
to run multiple reports with a single click of the run button.
And I'm going to show you how you could do this
with the CMS related data.
But surely, if you are interested
and you're not reporting those data,
let's say you're not participating in CMS
but you still want to run a CLABSI line list
and a CLABSI rate table at the same time, or you want to,
I don't know, run your COUTI data at the same time,
you can use these options to do so.
So here's example, I already mentioned this,
that we're looking at all of the three CMS reports from NHSN.
So first what you'll want to do is underneath --
so in the output options preview there's --
at the bottom we have advanced
and then we have my custom output.
When you open my custom output there's a folder called
"output sets" and then there's a link that says
"create now output set," and you want to click on that link.
And when you do that, you'll be given an output set screen
where you can provide a name.
So for this one we're calling it "SIRs for CMS IPPS Reporting."
You can give it a title, and I made that the same in this case
so when I print out my report, I have the title at the top.
And then you have output options,
but notice right now I don't have any output options
under the output name.
There's nothing here.
So I can click on a button that says "add output options,"
and when I do that, I'm given a really long list
because it will include every output option
for NHSN including any custom options that you have,
but you can sort this list.
So I recommend sorting the list.
You can just click on the column header
and it will sort it alphabetically.
[ Pause ]
And when I scroll to the bottom of that,
all of my CMS ones are --
begin with SIR so I know automatically I can go towards
the bottom of the list.
And basically, I have my three options here,
and I just check the box next to each
of the output options I want to include in this set.
So I'm checking the box next to the three SIRs related
to CMS reporting, and once I do that, I click submit.
And after I click submit, I'm brought to a screen
that will now list all three of my options
under the output name.
And you can see I have a few options.
I have up, I have down, I have a modification button,
and I have a delete button.
What I want to tell you about these reports that are specific
to the CMS reporting, yes, you can modify them,
but we've set them up in a way that you can run it
with no modification, okay.
It's automatically going to be by quarter,
it's automatically going to be your in-plan data,
and all of that, so there should be very little, if any,
modification that you would make to these reports.
So once you make any changes, you click save.
And, of course, you get that little green checkmark
that you're probably very familiar
with from entering the data, and then you'll --
the other option I want to mention to you
after you save this, is you're give an option to publish.
Publishing means that this custom --
this is basically a custom output set.
Right? You have a custom template now,
and you can share it with other users
in your facility who use NHSN.
So if you know your colleague may want
to run these same reports in the same output set,
you just click publish and they can run it
on their generated data sets.
They don't have to create this as well.
So you can only have -- you can basically make sure
that just one person creates it, everybody else can use it
on their data sets, and you don't have to run
through this process of making sure everybody's,
you know, template matches.
And once you've made the changes, you'll now notice
that your output set is saved under the output set folder
for SIRs for CMS IPPS Reporting.
And when you click run --
which I actually don't have a screen shot of that.
I thought I did -- but when you click run,
it will have all three reports,
it's just all in one window, okay.
So you only have to do that once.
You're not going to get three pop-ups.
You're just going to get one with all of your data.
And, of course, you can further modify it or you can remove it
and delete it if you no longer need it.
Let's talk about a few other advanced output options.
I've mentioned the advanced folder a few times
in the past couple of days.
And the advanced -- just the title
of it can be a little intimidating.
But what I want to show you today are just some things,
some reports that you can get that are only available
in the advanced section, okay.
So these are just a few, it's not everything,
but these are the ones that we get the most questions
about from our hospitals who say how do I get this information.
[ Pause ]
Okay. The first one, let's say you want a line list
of procedures.
I've already showed you line list of procedures
where I had the calculated risk for every patient.
So in order to get that, you actually have to go to advanced
and there's a procedure level data folder,
and within that folder there's an option
for line listing all procedures.
So that's what you can use to get the detailed information
for every procedure performed and entered into NHSN regardless
of whether they resulted in an SSI.
Also, if you take a close look,
that's where we've hidden the rate tables that are based
on the legacy basic risk index.
So if that's information you'd still like,
it is in that folder.
Let's say you're interested
in obtaining a line list with the organisms.
You want to know for each one of my infections,
what were the pathogens identified for each one.
That's another example where you have to go
to the advanced folder.
This is not going to be in your regular CLABSI line list.
This is something you have to go to advanced and go
to the event level data option.
You'll notice that we have a few line listings
in here for event level data.
We have all infection events, we have all dialysis
and non-infection events, and then we have all events.
If you're interested in just getting the pathogen information
for your HAIs, I recommend using all infection events.
If you use the all events, that third option,
it will include lab ID events, it will include --
if you report central line insertion practices data it will
include those events, it will include dialysis events.
It -- it's really literally all events.
So limit to all infection events.
But what I want to make note of is
that because it does include all HAI events, you may want
to limit that line list to certain event types
or a time period or a location, okay,
unless you are interested in all of your HAIs.
But if you're interested in just your CLABSIs,
just your counties, I recommend making those modifications
and saying event type equals VSI, or event type equals UTI.
All right?
And I think, if I remember correctly,
we have a quick reference guide in your resource book
that talks just about how to do this.
Okay, the other one -- and this is just a change
to the screen shot you guys have in your folder,
and we've already just talked about it,
is where you can find your CMS reports.
Again, these are going to mirror are the data that we submit
to CMS on your behalf.
Those are in the advanced folder.
All right.
The other option we have is an antibiogram, and we get asked
about this a few times where can I --
how can I get an antibiogram.
And that is, of course, in the advance said option and it's
in pathogen level data.
And there's only one option in there; line listing antibiogram.
So it will include it for -- you'll have one row per organism
and event reported, and you can have up to three rows
for a single event, because when you're reporting to NHSN,
you can report up to three pathogens.
So just keep in mind, you may notice the same event ID more
than once if there was more -- more than one pathogen reported.
But that's where you can get your event level data
or pathogen level data.
Again, you may wish to limit it to a time period
because the list will be very long
and it will include all the drugs and results
that we have available.
Another option is our summary data line list.
And this will provide denominator data
such as patient days or admission days
if you're doing the MDRO surveillance, device days,
for every location and month in a list format.
So even though this information is included in your rate tables,
we do have plenty of people who are interested,
I just want to look at just my denominator data for every event
in like just one long list.
I don't want to see all the other information
in a rate table.
Sometimes it's just to assure
that you have reported all the data you need to report
for a month or location.
So that is under advanced summary level data,
and we have the option line listing all summary data, okay.
Again, you may want to limit by time period or location
because the list will be very long,
but it will include a record for every location,
month, and event type.
Another option -- and this is probably going
to be more relevant to group users such as QIOs
or state health departments,
we do have a monthly reporting plan line list, and this is just
to see what data are included in a plan for every month,
and it gives row for the month, the location, the event type,
or the procedure type, whether it's inpatient or not.
This is also helpful in groups --
for groups to see where there have been --
where the report no events box has been checked.
So if a group, like a state health department is looking
to see if the facility no events, have they checked
that box, and it will say yes in there for no events.
So that's where you can go to get your plan data.
One of the other things I want to mentioned
in the advanced output options, and I realize this has come
up for a couple of people, at least who are here today,
and probably some on the Web, is that you want to know --
you want to see the date that a record was entered into NHSN,
maybe the date it was changed.
You can get that.
We do store a date-time stamp on every record that is stored
in NHSN, so we can see when anything was added.
Those variables are found in your advanced options
and it's called "create date" and "modify date," okay.
The thing is, any time a record is updated,
we update that modify date.
It's always going to be updated.
So if you make any changes to a record, it will be updated.
That goes the same for a monthly reporting plan.
When you check that box for report no events,
it actually updates the date --
the modify date on your reporting plan.
So if you need to obtain that information on create date
for your events that were entered,
you can run the event level data line list
and include create date and modify date.
Same thing for procedures.
Same thing for your summary level data, okay.
If you want to know what date your summary level data were
entered 'cause you have to give that somebody to prove
that your data went in, use the summary level data line list,
okay.
So, again, those variables are event date -- I'm sorry --
create date, and modify date.
All right.
[ Pause ]
We have numerous additional resources for you.
I've already mentioned the risk model paper
and the SIR newsletter many, many, many, many times.
We also have -- we have a couple of trainings that are online.
They're -- they were just updated this year.
They are very similar to the content that you learned
over these past couple of days,
however there are some additional content in there.
They're just slides so if you want to take a look
at that those for future reference.
For those on the Web, you could refer to those as well.
One of the things I would actually
like to show before we get to questions is something
on our website that will be extremely helpful and I fear
that it is underutilized.
And we actually have quite a bit
of resources right now related to the CMS reporting.
And we worked very closely
with the Quality Improvement Organization Support Contractor,
the QIOSC, in getting this content prepared and ready
for the Web to help everybody.
So what I'm going to go is on our home page --
on our NHSN home page, I'm going to go to resource library,
and we have on this page CMS reporting.
And when I click on that, we have a lot of documents here.
We try to organize it by the event type.
So let's say for CLABSI, we have a document
that will detail how you can report no events
for CLABSI reporting for this reporting initiative, okay.
Print that out.
Have it as a reference.
We have a helpful tips document.
It is one page.
I'm going to pull it up because this will be handy
for you every month or quarter.
You can use it as a checkbox.
So we have one, you verify your CMS certification number.
You check your monthly reporting plan.
You enter your denominator.
You have your no events.
If you enter events -- or if you've identified events,
you have to enter them and then use the analysis tools.
And we have additional resources and links in this document.
So you can have that handy, like, okay,
what things do I need to check before this deadline
so that I know that I'm going to be compliant.
This -- this is has been available --
I think we've e-mailed it out a couple of times,
but it is on our resource library for every event type
for the acute care hospitals.
And then finally, we have a document called
"Using the SIR Output Option."
We have one for each event type.
So, you know, please utilize these resources.
We also have operational guidance,
so this is where we take the rule that was published by CMS
and we translate it into how it relates to your NHSN reporting.
Yes, you have to report the protocol.
This is what's submitted to CMS at this day and time.
So it's a little more technical,
but it is a good reference for you.
And I'm sure, you know, we --
I believe there's couple more documents that we're working on,
so please take a look at these documents as well
as when we send out e-mails to let you know
that something is available, please read it and take a look.
That would be -- that would be great, because we do this
for you to help you ensure compliance with these measures.
So I think at this time I am ready to take any questions.
It is a little early, I apologize for that.
But any questions about the SIR or any of these reports,
I'm happy to answer them.
Hi. Oh, hold on for mics.
[ Pause ]
>> Try it again.
>> Okay, we're on good.
>> Working for QIO and we have several health systems
that have multiple facilities.
>> Okay.
>> Is there any way to get an SIR
of multiple facilities at one time?
>> Yes, there is.
And that requires the use of a group feature.
So if it's -- and you may already use that for the QIO,
but a facility or a health organization
with multiple facilities could use that same functionality.
They can send us an e-mail, we'll help them with that
and explain that, but they would be able to run an SIR
at one time for all of their hospitals.
>> So I've tried putting all the different organizations
under org ID under the grid --
>> Uh-huh.
>> -- and it doesn't group it all together.
It still lists them out individually.
>> For the SIR?
>> Uh-huh.
>> Okay. Send me an e-mail.
We can talk about that.
Yeah, 'cause you should still get an overall one, but if not,
we can talk, and if there's something we need
to fix, we can fix that.
Yes?
>> Did I understand correctly for what's going to CMS
for COLOs, specifically, that it says here
that you use only age and ASA.
So you're not using wound class?
>> Right. So for that risk model for the CMS measure,
the only risk factors that are used to calculate the number
of expected and the patient's risk is age and ASA.
>> Okay.
>> Yeah. That was part of a measure
with the American College of Surgeons.
Mary?
>> Actually, I want to follow-up
that question just a little bit is,
I know we're all very excited
about having a much better risk model
for surgical site infections.
So we have this outstanding model,
and why is that not what we send to CMS?
>> Right. Yeah.
I -- I understand.
I guess all I can say --
>> I'm sorry.
>> You know, I wasn't part of the discussions,
but I know that there was a lot of work done in order
to harmonize things that would be acceptable
for this reporting.
So I guess that's all, unfortunately,
I can offer up at this time but --
>> Okay. I have one more really quick question,
and it's about as basic as you can get.
I certainly appreciate the concept of the SIR
and what it can do and it's really a very simple
and powerful tool that I think our hospitals,
once we can educate our infection control committees
about how it functions, I --
we understand how to interpret the SIR,
we understand what 1.64 means, we understand the concept
of whether or not it's statistically significant.
But how do we operationalize that?
How do we -- so if I see to my infection control committee,
you know, we have an SIR of 1.64,
which means we have 64 percent more infections
than we're expected, but this isn't statistically significant.
Where do we go from there?
>> Right. Yeah.
>> I mean, we can say, wow, look at this,
but it really doesn't mean anything.
>> Yeah. I mean, part of that gets to --
gets to the precision and the volume of procedures
that -- that are reported.
So that's part of it.
But, you know, I think there should be some consideration
for it.
Yes, there is some statistical evidence
that it may not be different,
but there may still be some practical significance,
and you still may want to say, yeah, okay.
We're not significantly higher,
but I still care that we're higher.
It doesn't matter to me.
And so it's all up to you as the IP for the --
what do you want to do with that information?
Are there additional steps?
Do you want to see, okay, is this 1.6, are we higher
because of -- even though it's not significant,
but is it do due to a procedure category?
Do we need to look at these data by surgeons?
You know, are we seeing a change, a shift over time?
So those are some additional things that you can look
at that may push more towards the practical significant
and towards the decision that you may need to make.
Does that help?
>> Yeah, absolutely.
I think that's an excellent answer.
Excellent presentation.
Thank you.
>> Thank you.
All right.
I'm going to take the right and the left, and yeah.
>> Okay, thanks.
Yeah, excellent presentation.
I just was wondering if within the NHSN you can calculate
surgeon specific rates?
>> You can't.
You can get surgeon specific SIRs.
>> Okay. And then normally, what we have done at our facility
and calculate a [ inaudible ] statistic -- -
>> Okay.
>> -- for that SIR.
>> Okay.
>> Do you have a suggestion on that
or should we just use the P value?
>> You know, that's up to you.
I mean, we provide you with the P value
and the confidence interval; however,
if your facility prefers to use some other statistics
to determine significance or difference, then,
you know, you can do that.
It's just you won't be able to do it within NHSN.
>> Okay. And is it just a matter of highlighting a column
and sorting the data by surgeon to calculate that?
Is it in the advanced [ inaudible ] --
>> Actually, we have an option -- do you want to me pull it up
and show you real quick?
>> Yes.
>> Okay. Not a problem.
I can do that.
It's something that I think I failed to show an option for.
[ Pause ]
Now we're rolling off the page with this.
It's a bit large.
There we go.
[ Pause ]
Okay, it's thinking.
But I'll go ahead and once this pulls up,
we can see that we have multiple --
for every single risk model we have,
we have a we have a surgeon option.
We often get asked, is there a way
to get surgeon SIRs by service?
Let's say I want one overall SIR for my orthopedic surgeons.
And you can do that by using selection criteria
and the surgeon code.
So if you -- as long as you report the surgeon code
and you set that up ahead of time and report that to NHSN,
we can get you those options.
So here let's say I have my SIR all SSI data by surgeon, if I --
let me just run this so you can see what it looks like.
You'll first get there overall for all of the data included
and each time period, but then you'll get a table
that will list an SIR per surgeon and time period,
and you can even get per surgeon and procedure category.
So see here, I have surgeon 400 for 2009 half 1, I get my SIR,
and if I go -- this is really long 'cause we've got quite a
bit of data in here -- then I can look and I say, okay,
for surgeon 400, let me look at it by procedure,
so I've got CVBGs, I've got CVGCs, so it does break it up.
And if I wanted to look at a group of surgeons for a service,
what I would have to do is know which surgeon codes are
within that service,
and basically just make this selection surgeon code,
and then I could see my in operator
and select my -- select my surgeons.
Does that make sense?
And so then you'd get one overall for those group
and then each individual.
>> Okay, thank you.
>> You're welcome.
Okay.
>> Hi. This is just a clarification question.
If, for an example, with a hist,
if you're submitting your quarterly hist data --
>> Uh-huh.
>> -- and for a particular month all your hysterectomies are
superficial incisional, they're excluded from CMS,
but that doesn't mean you would check off the no event --
>> Right.
>> -- box because you're still reporting them globally?
>> Right. So the report no events is
if there are zero identified at all.
You actually won't be alerted to even check that box
if all you have is superficial.
As soon as one is entered, it's not going
to ask you to check it.
Great question.
>> In the past when I've run different reports based
on different stratification, I'd get different data included
in those reports, and I wanted to know
if I run an advanced report with the pathogen level data,
if it will include procedures
where no pathogens were identified such as an SSI
where they don't request the culture?
>> Right. Yeah.
Well, if you run the event level data to include the pathogen,
it will include that SSI,
but the pathogen will just be missing
because there was none reported; however,
if you run the antibiogram, it's going to be excluded
because there's no organism.
Okay. Hi.
>> Thanks for your presentation.
And thinking about another NHSN module, have we already
or will we move towards calculating SIRs
for [ inaudible ]?
>> Actually, that is a great question, and yes.
The answer is yes.
We are just in the final stages of risk adjustment
for MRSA blood lab ID events, and C. diff lab ID events.
We prioritized that because of the reporting
that will begin in January.
And so we will have some details out on our website this fall,
and we will -- we will calculate those with the first version
of NHSN next year in 2013.
Those will be included for you.
>> Thank you.
>> You're welcome.
Yes.
>> [ Inaudible ] question.
On the case report forms for hips and knees, I'm in Maryland
where we don't have to report yet --
>> Okay.
>> -- colons and hysterectomies because we have a waiver.
>> Right.
>> We still fill out a long case report form --
>> Okay.
>> -- for every case in the denominator.
Now, if for CMS we made some arrangement
with the American College of Surgeons to only use ASA score
and age, is it really necessary for us to do all that legwork
to fill in wound class and all that?
>> It is, because the other SIRs prove --
they provide additional risk adjustment
that I think include variables that we have, in NHSN,
found to be significant.
So it's important to recognize that --
that the all SSI model and the complex AR model,
all of those risk factors are significant in predicting risk.
And unfortunately, I can't make any additional comments
on the -- the model that is used for CMS.
I wasn't a part of that discussion.
I just know that there was a lot of work done to come to a point
where an agreement could be made
for this very specific reporting.
And remember, we are looking at a subset of data.
You know, we are looking at SSIs within 30 days.
You know, we are excluding superficials.
So, you know, it is different
from the other two models as well.
Yes?
>> Hi, Maggie.
I wanted to ask, I noticed that the risk to the coefficients
for the medical school was like a .89 if you had one
and a .14 if you didn't.
>> Right.
>> Is that for the -- that's for the SSI.
Is it the same coefficient factors results
for the COUTI and CLABSI.
>> That's a great question.
So for COUTI and CLABSI we don't go through that big risk model.
But the expected and the risk is calculated based on the rates
that we have published, and medical school affiliation comes
into account with a couple of locations.
So that's the medical ICUs
and the medical surgical ICUs, but that's it.
So a medical school affiliation does not take into --
is not taken into account for any other type
of location reported, okay.
>> Are the coefficients the same then as that --
that I see in the SSI example then?
[ Inaudible ]
>> Is the coefficient the same for --
>> For the model, for a med surge ICU for CLABSI?
>> Well, we don't really have a model.
>> The coefficient and the logistic regression --
>> Right. We don't use the logistic regression modeling
for CLABSI and COUTI.
Instead --
>> How is the hospital characteristic included?
>> So the -- I'm sorry.
I didn't hear the last part of your question.
>> The hospital characteristic for CLABSI/COUTI --
>> Right. So we basically just say, if you have a medical --
if you're a hospital that is considered major teaching
and you have a medical ICU
for which you've reported CLABSI data,
we calculate the number expected based on the rate,
the CLABSI rate, for medical ICUs
in major teaching hospitals and then we cal --
>> [ Inaudible ]
>> -- yeah.
Yup. Okay.
So if there are no further questions, we are ending
about ten minutes early for this presentation.
Thank you -- oh, is there one more question?
Okay. One more question.
>> The only question I have is the download.
Can we download this in, say,
our inbox like you can with QNet.
>> You mean, save your results -- your reports?
Yes, absolutely.
In fact, there's a couple of ways to do it,
and there are some -- there's a document
in your resource guide called "how to export data,"
but one of the ways I could do that, let's say I have an SIR
for all SSI data by surgeon, let's say I wanted to put this
into a Word document, and when I click run, it will ask me
if I want to save the file or if I want to open it,
and it would save it as a Word document on my computer.
So, yeah, that is available for everything
that is not graphical output.
So you can't do that for bar charts, pie charts,
and run charts, but you could do it for your line list,
rate tables, frequency tables SIRs.
So all right.
Well, thank you all --