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Written by: Darlene D'Altorio-Jones (1959-2015) on Tuesday, December 6, 2011 Posted in: Inpatient Rehab


For each of you that tuned into the Open Door Forum on Nov. 29 to once again review the newest requirements for IRF regarding quality reporting for CAUTI and wounds, I wonder if that call left you feeling prepared and ready to move ahead? Did the call serve its purpose and are you closer to working toward this requirement for October 2012 implementation?

If not, this blog is for you.

I listened in on the Open Door Forum to hear more specifically about how CAUTI and wound quality reporting would be rolled out for 2012 so that as a documentation company, capable of extracting discrete data elements, we could roll out the necessary solutions for our clients to gather data electronically rather than by manual abstraction of the necessary elements.

I believed that in listening to this call I could have many questions answered as we begin NEW abilities to monitor and share patient safety data specific to facility types by location as mandated by the Affordable Care Act Section 3004 (b) and the Quality Reporting Program for IRF.

What I heard were messages that appeared to mix criteria as posted by NHSN. I heard that IRF’s would be required to report CAUTI; broken down by adult and pediatric whenever the unit population was a minimum of 80 percent rehabilitation. This statement confused me, because rehabilitation facilities/units have 100 percent of the population admitted for rehabilitation. Where did 80 percent come into play? I went directly to the NHSN website to see if I could get further clarification and I found this table:

The NHSN table shows reporting criteria for acute care hospitals that will begin in January 2012 for CAUTI measures and those are broken down by adult and pediatric ICUs. Is it possible that the open door forum was mixing information on these two different requirements?

It is clear that inpatient rehabilitation facilities do not show this distinct separation on this table. I wrote to the email address that permitted reporting comments: I advise that you do the same.

What I discovered is that long term care hospitals have their own specialty care area reporting designation, whereas rehabilitation hospitals and units do not. It appears that if we do not get a separate designation our data will be aggregated along with inpatient acute care facilities making it difficult for us to recognize information specific to IRFs; excluded exempted units designated by federal classification criteria as units and free standing facilities. Without a separate area to aggregate data, how can we compare similar populations that define the patients screened specifically for our level of care?

Why do I feel our data will be aggregated with non-licensed units? Because presently there are rehabilitation hospitals that report data to NHSN. Those facilities appear to be aggregated with all other inpatient wards displayed in the 2009 Annual Report available for viewing at the Website. That report shows that 19 facilities were classified as rehabilitation hospitals. Data is displayed within the inpatient ward section rather than in the specialty care area where you can see LTAC has the ability to report separately with their peers.

Right now, while there is still time, those facilities that are uniquely licensed as an IRF/IRU must appeal to the Web address provided for comments that our data remain discretely comparable to like facilities. At the very least licensed IRFs, who by our 2012 regulations were asked to report as IRFs need a code added that defines this unique exempted level of care within the specialty care area of NHSN report capability. A long term care hospital has that ability, and IRF/IRUs should be provided the same capability.  A NEWLY defined specialty care area for IRF/IRU is necessary so that these patients are not co-mingled with rehabilitation inpatient ward data.


This is a call to action: Email to voice your concern, so that as we begin to gather and compare quality data we can do so in a manner that truly reflects the unique care provided in inpatient rehabilitation. Data specific to IRF/IRU should not be combined with rehabilitation wards within acute care facilities treating no less than 80 percent rehabilitation patients. IRF level of care is NOT THE SAME.

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