Data Quality

Patient Safety Component Modules

Addressing NHSN data quality issues is integral to NHSN’s ability to help facilities collect the data needed to identify areas needing prevention efforts, measure progress of prevention efforts, monitoring antibiotic use and resistance, and push toward healthcare-associated infection elimination. The NHSN Team routinely reviews the data reported to NHSN and will contact facilities to resolve confirmed and suspected data quality flags.

The NHSN team performs routine and ad-hoc data quality analysis and conducts outreach with facilities where needed, and as frequent as monthly per HAI. Our direct data quality outreach is not intended to replace internal and external data quality checks performed by the facility, state health department, or CMS.

Data quality quick tips and updates will also be presented in the NHSN Quarterly Newsletters, under ‘NHSN Data Quality Corner’.

Routine Data Quality Outreach

Instructions to address these data quality flags pdf icon[PDF – 1 MB]

LabID
Addressing Outlier MDRO/CDI Denominators

MDRO/CDI denominator reported as 0 patient days and/or 0 admissions. Suspected data entry error.
Facility Count (FAQ)
Denominator Reporting for LabID Event [Video – 17 min]

Guide to Accurately Reporting CDI Test Type

CDI test type reported as ‘Other’ should be avoided when applicable value is available within list. NHSN will recommend an appropriate CDI test type.

Guide to Accurately Reporting CDI Test Type

CDI test type reported on the FacWideIN and IRF unit’s denominator forms for a given quarter should match.

FacWideIN Location on Monthly Reporting Plans

MDRO protocol requires FacWideIN location to be included on monthly reporting plans for MRSA and CDI reporting.

Patient Safety Component SSI
Addressing Procedure Duration Data Outliers

Outreach is conducted for procedures reported with procedure duration outliers. A procedure duration is considered an outlier if the duration is less than 5 minutes or greater than the interquartile range (IQR5) value for the procedure category. The IQR5 is listed in the SSI section of the SIR Guide.
Universal Exclusion Criteria: Procedure Duration pdf icon[PDF – 500 KB]

Addressing BMI Data Outliers

Outreach is conducted for procedures reported with BMI outlier. A procedure is considered as having BMI outlier, if the following is true: procedures are reported with any of the following:

  • Procedures in adults 18 years and older with BMI of less than 12 kg/m2 or greater than 60 kg/m2
  • Procedures in pediatric patients (under 18 years) with BMI of less than 10.49 kg/m2 or greater than 65.79 kg/m2 (following confirmation of biological plausibility)

Universal Exclusion Criteria: Outlier BMI Values pdf icon[PDF – 400 KB]

Annual Facility Surveys

Confirmation of data entry for survey variables used for risk-adjustment in the SIR calculation. Facilities with significant differences in reporting from the prior year will be contacted.

DA Events
Addressing Denominator Data Quality

Routine checks on denominator data e.g. missing patient/device days, patient days less than device days, patient days equal to device days, locations reporting zero patient days.
Reporting of zero DA events pdf icon[PDF – 700 KB]

Addressing Event-level Data Quality

Routine checks for the following: date of event before date of admission, event date is less than 3 days of the date of mechanical ventilation, date of mechanical ventilation is before date of birth, date of mechanical ventilation after the event date.

Outpatient Procedure Component SSI
Addressing BMI Data Outliers

Outreach is conducted for procedures reported with BMI outlier. A procedure is considered as having BMI outlier, if the following is true: procedures are reported with any of the following:

  • Procedures in adults 18 years and older with BMI of less than 12 kg/m2 or greater than 60 kg/m2

Universal Exclusion Criteria: Outlier BMI Values pdf icon[PDF – 400 KB]

Addressing Outpatient Procedure Duration Data Outliers

Outreach is conducted for procedures reported with procedure duration outliers. A procedure duration is considered an outlier if the duration is less than 5 minutes or greater than the interquartile range (IQR5) value for the procedure category. The IQR5 is listed in the OPC  SSI section of the SIR Guide.
Universal Exclusion Criteria: Procedure Duration pdf icon[PDF – 500 KB]

Targeted Data Quality Outreach

Data quality outreach to address changes in reporting and the NHSN application.

AUR
Missing AR Option Priority Data
Initial Outreach: 3/16/2021

Missing Priority AR Option Pathogen/Antimicrobial Data for 2019 AR Option Benchmarking

How to Review 2019 AR Option Data pdf icon[PDF – 600 KB]