HealthApril 07, 2023

Antimicrobial use and resistance: Updates to NHSN and CMS reporting

Antimicrobial Use and Resistance reporting (AU and AR reporting – together referred to as AUR) is becoming increasingly important as a part of a high-performing AMS program for healthcare facilities.

Reporting AU and AR data to the National Healthcare Safety Network enables the CDC to better understand and benchmark antimicrobial use in the nation’s hospitals, track and identify potential antimicrobial resistance emergence, and drive national progress on minimizing antimicrobial resistance.

One major benefit of submitting antimicrobial use data from your hospital is the provision of standardized antimicrobial administration ratio (SAAR). At a high level, SAAR benchmarks your antimicrobial use against other hospitals submitting AU data to NHSN, using advanced statistical methodology to account for the hospital’s unique characteristics, such as location, hospital size, types of patients serve, the proportion of beds dedicated to intensive care, etc. Pharmacists can leverage SAARs to better understand how their observed antimicrobial use differs from the predicted usage and identify areas of strength and improvements.

AUR reporting updates

While AUR reporting has been voluntary through the National Health Safety Network (NHSN) for several years, Centers for Medicare & Medicaid Services (CMS) programs like Promoting Interoperability are beginning to require AUR reporting. Joint Commission has been auditing components of antimicrobial stewardship (AMS) for several years and will begin to require AMS programs to track antimicrobial use using Days of Therapy (DOT) or AU reporting in surveys as a required element of performance beginning in January 2023.

What does the Joint Commission recommend for NHSN AU submission?

AU reporting to NHSN has been identified as a compliance option under the Joint Commission Medication Management chapter MM.09.01.01 Element 16. Effective Jan. 2023, new and revised Antimicrobial Stewardship requirements will apply to all Joint Commission–accredited hospitals and critical access hospitals. The 12 elements of performance (EPs) are included in the “Medication Management” (MM) chapter (Standard MM.09.01.01) and expand upon the current expectations for Antimicrobial Stewardship programs in the hospital setting.

EP 16 (new): The Antimicrobial Stewardship program monitors the hospital’s antibiotic use by analyzing data on days of therapy per 1000 days present or 1000 patient days, or by reporting antibiotic use data to the National Healthcare Safety Network’s Antimicrobial Use Option of the Antimicrobial Use and Resistance Module.

What should we know regarding the AUR submission with CMS?

If your hospital is participating in CMS' reimbursement program, submitting AUR data can help you gain additional points towards reimbursement. In 2024, AUR submission will be part of the Medicare Promoting Interoperability Program and required to satisfy the Public Health and Clinical Data Exchange objective. Hospitals must use an ONC-certified vendor to submit.

Based on historical data, financial adjustments have been:

  • Hospitals that do not meet mandatory reporting risk a 75% reduction in the annual rate increase approved under the inpatient prospective payment system rules
  • CAH risk 1% reduction in their Medicare payment reimbursements for non-compliance

What is the ONC Health Certification?

The Office of National Coordinator for Health Information Technology (ONC) Health IT Certification Program is a voluntary certification program established by the ONC to provide for the certification of health IT. It certified that vendors are a qualifying solution for organizations to use products to meet certain CMS reimbursement requirements.

In 2024, AUR submission will be part of the Medicare Promoting Interoperability Program and required to satisfy the Public Health and Clinical Data Exchange objective. Hospitals must use an ONC-certified vendor to submit. Sentri7® Pharmacy Antimicrobial Stewardship is certified and listed on the Certified Health IT Product List (CHPL).

How to prepare for AUR reporting updates

Pharmacy teams should be taking steps now to prepare for AUR reporting updates with NHSN (Jan 2023) and CMS (Jan 2024). With Sentri7 Pharmacy, our customers can seamlessly submit AUR data to support Antimicrobial Stewardship requirements for the Joint Commission, CMS reimbursement opportunities, and NHSN reporting.

Using an ONC-certified solution such as Sentri7, pharmacists can confidently submit AUR data with a few simple clicks and know that the data will be securely sent to NHSN on your behalf. As submission requirements become more complex and reporting requirements change (such as new antimicrobials, eligible organisms, and resistance phenotypes), turning to a trusted partner frees the pharmacists up from the tasks of reporting and instead allows that time for AMS improvement efforts that make a difference at the bedside. Sentri7’s robust analytics provide easy-to-understand dashboards to trend and monitor antimicrobial uses and SAARs.

If you don’t have a pharmacy surveillance solution that allows for seamless reporting to NHSN, we strongly urge you to consider one. Many pharmacy teams will attempt to gather and submit this data themselves, but the complex reporting and submission process makes this difficult. Consider a solution, like Sentri7, that automatically gathers and calculates the data and allows for one-click submission to the NHSN.

Understanding AUR reporting requirements and options is complex and ever-evolving because of their importance to a high-performing AMS program. Rely on solutions, and the experts behind them, to give you confidence that you can seamlessly report on and maximize opportunities for reimbursement and easily navigate regulatory accreditation.

Access Webinar | Implementing 2023 Updates to Your Antimicrobial Stewardship Program
Manager of Pharmacy Services and Fellowship Director
Dr. Steve Mok has over a decade of experience in the areas of antimicrobial stewardship, infectious diseases and clinical pharmacy management. He has practiced in a variety of settings.
Sentri7® Pharmacy
Sentri7 Pharmacy identifies patients early and accurately to improve patient care, safety, and drive pharmacy cost savings by optimizing medication therapies.
Empower your pharmacy team to impact patient care through evidence-based recommendations, standardizing practices via pharmacy-specific workflows, and using robust analytics to drive improvements in medication therapy, Opioid Stewardship, and Antimicrobial Stewardship.
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