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Bloodstream Infection in Hemodialysis Outpatients

CBE ID
1460
Endorsement Status
E&M Committee Rationale/Justification

When the measure returns for maintenance, the committee would like to see: 

  • Update the BSI rate baseline year (2014 in current submission) by measure maintenance. 
1.0 New or Maintenance
Previous Endorsement Cycle
Is Under Review
No
Next Maintenance Cycle
Spring 2029
1.6 Measure Description

Annual standardized infection ratio (SIR) of bloodstream infections (BSIs) among children and adults receiving maintenance hemodialysis at outpatient hemodialysis facilities. BSIs are defined as positive blood cultures for hemodialysis patients which are reported monthly by participating facilities. The SIR is reported for a yearly period (calendar year) and is calculated by dividing the number of observed BSIs by the number of predicted BSIs during the year.

Measure Specs
General Information
1.7 Measure Type
1.7 Composite Measure
No
1.3 Electronic Clinical Quality Measure (eCQM)
1.8 Level of Analysis
1.9 Care Setting
1.9b Other Care Setting
Dialysis Facility
1.10 Measure Rationale

The use of this measure will promote blood stream infection (BSI) prevention activities in the outpatient hemodialysis setting, which will lead to improved patient outcomes including reduction of avoidable medical costs, patient morbidity and mortality through reduced need for antimicrobials, and hospital admissions.  

1.25 Data Source Details

Data is submitted by dialysis facilities using the National Healthcare Safety Network (NHSN), web-based application (accessed securely via the Secure Access Management Service). 

 

Instructions and protocol for completing dialysis event reporting are available at the following website: https://www.cdc.gov/nhsn/dialysis/event/index.html 

Data Collection Forms and Instructions:

  • Dialysis event reporting form: https://www.cdc.gov/nhsn/forms/57.502_DIAL_BLANK.pdf 
  • Instructions for completion of the dialysis event surveillance form (CDC 57.502): https://www.cdc.gov/nhsn/forms/instr/57_502.pdf 
  • Denominators for dialysis event surveillance (census form – completed once per month; CDC 57.503): https://www.cdc.gov/nhsn/forms/57.503_DenomOutpatDialysis_BLANK.pdf 
  • Instructions for completion of the denominators for dialysis event surveillance (CDC 57.503): https://www.cdc.gov/nhsn/forms/instr/57_503.pdf