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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 – 1 MB]
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]
CDI test type reported as ‘Other’ should be avoided when applicable value is available within list. NHSN will recommend an appropriate CDI test type.
CDI test type reported on the FacWideIN and IRF unit’s denominator forms for a given quarter should match.
MDRO protocol requires FacWideIN location to be included on monthly reporting plans for MRSA and CDI reporting.
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 – 500 KB]
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 – 400 KB]
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.
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 – 700 KB]
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.
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 – 400 KB]
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 – 500 KB]
Targeted Data Quality Outreach
Data quality outreach to address changes in reporting and the NHSN application.
Outreach is conducted for procedures identified as duplicate procedures in NHSN. Duplicate procedures are identified as multiple procedures reported for the same patient with the same procedure category, and same procedure date, for those procedure categories for which there are not multiple body sites. These duplicate procedures are assigned distinct procedure IDs in NHSN.
Assessing Data Quality (Line Listing – Duplicate Procedures) [PDF – 261 KB]
Outreach is conducted to facilities that have reported all their 2019 -2021 YTD caesarean section procedures with 0 hours duration of labor. The purpose of the outreach is to alert facilities to check and apply the reporting instructions for duration of labor for caesarean section procedures. While it is likely that some caesarean section procedures do have 0 duration of labor, its less likely that all procedures over 3 years have 0 duration of labor.
Instructions for Completion of Denominator for Procedure Form (CDC 57.121) [PDF – 250 KB]
Data Quality Resources
- Data Quality Guidance Manual [PDF – 1 MB]
- Data Quality Corner within NHSN Quarterly Newsletter
- NHSN Patient Safety Component Alerts [PDF – 1 MB]
- Data Validation
Data Quality Webinars
- An Introduction to the Patient Safety Component Data Quality Activities [PDF – 3 MB]
- NHSN Data Quality: A Focus on Patient Safety Annual Facility Surveys, Alerts, and AUR DQ processes [PDF – 1 MB]
- August 2023: Patient Safety Data Quality Checks and AUR Outreach [PDF – 2 MB]
- September 2024 Data Quality Webinar [PDF – 3 MB]
