Reporting Dialysis Infections to NHSN for Medicare’s ESRD Quality Incentive Program

The Centers for Medicare & Medicaid Services (CMS) End-Stage Renal Disease Quality Incentive Program (ESRD QIP) uses data that dialysis facilities report to CDC's National Healthcare Safety Network (NHSN), the nation's most widely used system for tracking health care–associated infections. These are the main points of CDC's guidance.

Who must report

• The NHSN dialysis event measure applies only to facilities treating in-center hemodialysis patients; facilities treating 10 or fewer patients are excluded. CMS decides eligibility from its own records (SIMS and CROWNWeb).
• The health care personnel influenza vaccination measure has no patient-count or treatment-type requirement.

What to report, and when

Facilities follow the NHSN Dialysis Event Protocol and the Healthcare Personnel Influenza Vaccination Summary Protocol. Deadlines are quarterly (moved to the next business day if they fall on a weekend or holiday):

CDC also publishes nine recommended interventions to prevent bloodstream infections in dialysis; they're encouraged but not required.

Getting set up

1. Complete the required training: an enrollment video (about 23 minutes) for those enrolling a facility, a set-up video (about 13 minutes) for administrators, the self-paced dialysis event surveillance course and protocol for everyone who collects or enters data, and the influenza vaccination protocol for those using the personnel safety component. Each user's training completion date is required before access.
2. Enroll the facility as an "AMB-HEMO – Hemodialysis Center," allowing at least 4–6 weeks. Chain facilities should check with headquarters to avoid duplicate enrollments; ESRD networks can help.
3. Submit the annual Outpatient Dialysis Center Practices Survey, which asks about the first week of February — so collect that data in February whatever your enrollment date.
4. Enter the correct CMS Certification Number (CCN). Hospital-based units with both a hospital and a dialysis CCN may use either, but should register only once.
5. Activate the Dialysis and Healthcare Personnel Safety components.

Already-enrolled facilities should confirm their CCN under "Facility Info" and that they report according to the protocols. Each facility needs at least one trained staff member with NHSN access — ideally two administrators, so staff turnover doesn't lock the facility out; departing administrators should hand off the role, and former staff should be deactivated. Contracted services decide among themselves who reports. Facilities should check their own records against what they've entered in NHSN.

How performance is measured

CDC confirms enrollment against CMS's CCN list and shares with CMS the months of complete data and the bloodstream infection (BSI) standardized infection ratio (SIR) with its confidence interval. From 2014, CMS turned the measure from a reporting measure into a clinical measure based on the SIR — observed infections divided by the number predicted from national NHSN data, adjusted for the facility's mix of vascular access types:

Scoring criteria are set in the CMS ESRD QIP final rules; questions not about NHSN go to CMS.

Sources

Based on "NHSN and CMS End Stage Renal Dialysis Quality Incentive Program (ESRD QIP) Rule," National Healthcare Safety Network, Centers for Disease Control and Prevention; a work of the United States government in the public domain.