NHSN Data Entry for Long Term Care Facilities

Transcription

1 NHSN Data Entry for Long Term Care Facilities Event ID: Event Started: 6/20/2017 1:56:49 PM ET Welcome and Introduction Hello everyone and thank you for joining us today for our webinar on data entry for long-term care facilities. Our agenda will have opening remarks, general housekeeping and then we will do a presentation on how to enter your data into NHSN each month. We will have a question and answer session with our NHSN expert and then we will have final closing remarks after that. First, I want to introduce you to atom Alliance, in case you are new. I want to show you a photo these are the five states that are part of our Alliance, which are Alabama, Mississippi, Tennessee, Kentucky and Indiana. Thank you for calling in from all of the states today. I will now turn it over to Brandi who will give you information on housekeeping items, today. Thank you. All phone lines have been muted. During the presentation, we will enable the ability for you to unmute your phone line to share with the group. You may use star 2 to unmute yourself and star 9 to raise your hand, if you would like your line to be taken off mute to participate during the presentation. We encourage your participation throughout through the chat feature. You can select to send your questions or comments to all participants are certain individuals from the drop-down menu. Advisors will be monitoring the chat box for questions or feedback and will respond either in the chat box or during the call. You may also use the Q&A function to direct questions to certain individuals privately throughout the presentation. I will be posting a link to download the slides from this presentation in the chat. Thank you, Brandi. My name is Sarah Potter. I will introduce those of us on the call. I am Sarah Potter, I will be facilitating the call. We also have Angela Antilla from the CDC, our NHSN expert, on the call to answer your questions. Please take advantage of her knowledge and ask questions. We also have Brandi and she will be our chat monitor. Any questions that you would like to put into chat, she will be watching those for us. Our objectives today for the call-we will demonstrate the process for entering data in the longterm care NHSN module and we will have a question and answer session with our NHSN experts. NHSN Project Background I want to go over the timeline for our NHSN project. This is to get started with our small cohort you are a part of. The goals are to develop a baseline for C. difficile infections in long-term care facilities. Across the nation, we did not have a lot of data for C. difficile in long-term care. The goal is to increase that amount of data to develop a baseline and see where we are in long-term

2 care. The date for the baseline is 10 consecutive months of data entry from March 2017 through December That is not to say that you cannot report data that is before that or after that, going forward we expect to continue. These 10 months are those that atom Alliance will work with you closely on. Don't be alarmed if you haven't put in March, April or May. You can do that retrospectively and we will help you. NHSN Monthly Steps I want to start with giving you an overview of the three steps you must complete each month for your data to be complete in NHSN. Even if you have zero C. difficile events at your facility, you are expected to do two of these things. If you do have C. difficile events at your facility, you will need to complete all three. Those are the monthly reporting plan, which we will cover, and also if you have C. difficile events you will need details and summary data will need to be completed for the month that is information that has to do with admissions. Briefings need to be completed monthly to report. Reporting Plan We will go over your monthly reporting plan. This is you telling the CDC that you are going to be doing surveillance and tracking C. diff infections for your facility for that month. You need to tell them that C. diff is what you are reporting that month. We will see that there are other options, in the long-term care module, for you to report. For this project, we are focusing on C.diff and that is what we are requiring. When you login to NHSN, these screenshots have been updated in the system has been updated since these screenshots were taken. It will look different but the information is still the same and still available as on the screen we are showing. When you login to NHSN, you will first report your reporting plan. You will see a menu in blue and the option reporting plan. When you hover over reporting plan you will see the options add and find show up. To add a new reporting plan you will click that. If you have already done a reporting plan for the month and you need to edit or you would just like to see what you have entered, you can choose the find option. You will be able to pull it up that way. Monthly Summary Data The next step for the reporting plan will be that you choose the month and year that you are telling the CDC you will be doing surveillance. For this project, we started in March 2017 and in these menus, you would choose the month and year that you are reporting for. If for some reason you have access to more than one facility, you can also choose that from the drop-down menu. Once you have chosen a monthly rate, you will see these three options. You have HAI Lab ID Event Module, and the Prevention Process Measure Module. For this we only have C. diff. This is where you would choose what you are going to track for that month. In the middle is the C. diff option, a Lab ID event module. You will see a drop-down arrow, this is where you will choose the specific organism type. When you do the drop-down you will see several different organisms to choose from. You can just choose C. diff. This box on the right will be checked and

3 that needs to remain checked. That means you will be looking at all your lab specimens for that month. When you click save at the bottom, it will know that C. diff is the only thing you are reporting on that month. That is how you do your monthly reporting plan. Do we have any questions, so far, about that part? You can enter them into chat or you can unmute your phone and ask. Entering a CDI Event That will be your first step of the month. I will skip and show you entering the C. diff event information and we will go back to summary data. As you are watching your lab specimen results throughout the month and you are tracking your C. diff. If you get a positive C. diff event for the month, you will need to go into NHSN and enter more details about that event. It will be the same blue menu on the left, when you login, and you will see the event options. Underneath, you see similar options of add or find or if you have any incomplete that need to be completed, those can be found. You will click add, it will bring up a page to enter information about the resident. Make sure before you enter this event into NHSN, that you have resident information available to you. Whether it's the chart in front of you or on the face sheet, you will need this. The red asterisk fields are required. I recommend you fill in as much information as you can. The facility ID will be automatically entered. The resident ID is the next option and that will be the ID number that you use at your facility to identify that resident. Perhaps, your medical record number. You will need the Social Security of the resident and the name is not required, however you can enter that for easier identification. Gender and date of birth are required. At the bottom, you will see more required fields and these are about admission dates and resident type. You will choose long stay or short stay in this is based on 100 days. The date of first admissions is the facility. This is described as the date the resident entered and stayed without interruption for greater than 30 consecutive days. If the resident leaves the facility for greater than 30 days and returns, we will enter the date of return. 30 days is our number to go by. On the right is the date of current admissions. This will be the most recent date the resident entered the facility. If the resident is not left for greater than two calendar days, the date of current admission might be the same as the date of first admission. If they are admitted to the hospital and have gone for five days, you would then enter the date that they come back from the hospital as the current admission date. You would leave the date of first admission the same. If you have questions about that, the CDC has a lot of tip sheets and we at atom Alliance have those on our website with the video describing it. If you forget, we have a lot of resources when it comes time to enter your events. Specimen Collection You will next see more specific information about specimen selection. It's going to have the event type as a CDI event and the date the specimen was collected, this is very important. The specific organism type, when you choose C. diff is a specific organism type, it will automatically fill in that it was digestive system and stool specimen. Within that, you will need to choose where the resident was at your facility. When you first prepare your NHSN for reporting, you

4 match your location to facility. If you have not done that, we have a great video on our website and the CDC has tools to walk you through. When you get to this, you will have a drop-down menu that are the locations within your facility to choose from, you can choose where the resident was and when the specimen was collected. Also, what was the primary service type. If they were in 200 Hall for example, you would choose what is 200 Hall, is it long-term general nursing or that sort of thing. You will be asked if the resident has been transferred from an acute care facility in the past 4 weeks and if that is so what was the date and the specific organism type. And, was the patient on an antibiotic for this specific organism at the time of transfer to your facility. You will need all of that to enter your C. diff event. Once you complete that, you will need to do your monthly summary data. This will be your denominator information. You will need information from your admissions office, you will need admission numbers, census numbers and things like that. The summary data is the same menu on the left, the blue menu. You will see the options for summary data and underneath, same as before, add, find or incomplete. We will do add as the summary data. We will say we are still in March, we did our monthly reporting plan for March and we will now do our summary data, now that we have entered our event. We will choose March 2017 and NHSN will know what you chose to report for that month, based on your reporting plan. On the screen, once you choose month and year, you should only see the options that you have chosen to report on. If you see other options that you are not doing surveillance on that month, you might need to go back and update your reporting plan to make sure it is accurate. Since we have entered our reporting plan for March and we chose C. diff, when we do our summary data, the only option we have to do is the MDRO and CDI lab event reporting. In this section, there are three boxes on the left and that is where you will enter your numbers for that month. The top is total resident admissions for the month. Any resident admitted to your facility that month, you would put them in that box. In the middle box, you have resident stays and in the bottom box we have the number of admissions on C. diff treatment. This is will you enter the number of residents who were admitted to your facility, already being treated for C. diff. You would enter that number there. Those will be the three pieces of information you will make sure you have in front of you before you log into NHSN to enter this information. Also, on the screen, if you did not have any C. diff events for the month, you need to report to the CDC you had zero. This is where you would do that. After you have done your monthly reporting plan and summary data, if you have zero events, you would need to make sure you check this box under C. difficile and report no evidence. That will be your option, if you are reporting zero. If you have events for the month and you have entered those events, you do not need to check this box. This is only if you are reporting zero. That is basically what I wanted to show you in NHSN to make sure that you complete each month for your data to be complete. Does anyone have any questions about those pieces of information? Or, Angela is there anything you would like to add? There are no questions.

5 Hello, this is Angela. I think that was phenomenal. I don't have anything to add. I am happy to answer any questions the audience may have. Please press star nine if you would like to raise your hand and ask a question. Everyone, please take advantage of us having Angela on the call, she is our NHSN expert, and we really want to make sure that she was available for you to ask any questions about this reporting that you may have. I will move on. If you think of anything enter it into the chat or you can press star 9 and raise your hand and you may speak. Demonstration of the Infection Tracking Tool The next thing that I want to go over is the Infection Tracking Tool from the National Nursing Home Quality Campaign. This is a tool I want to show you in case you want to use it to track your infections throughout the month. There are several options for you to do that. I'm sure most of you are already keeping track in some way at your facility. The CDC has Paper tools on their website that are really good. This is an Excel spreadsheet tool that matches NHSN pretty well to assist you in entering. I want to give you a quick overview, if you want to utilize that you may. This is the link where it can be found and Brandy has posted that in chat so you can download it, if you wish. I will share my screen with you. Finding the Tools The first thing I will show you is the website where you can find the tools. This is the national nursing home quality improvement campaign website. Most of you are probably familiar with this, it has really great quality improvement tools that are free to use in long-term care. I will show you the Infections Tracking Tool which is specific to C. diff. There is a goal section and in the infection goals, this will take us to this page that will talk about C. diff and some of the definitions and improvements that you can work on around C. difficile. To get to the tool, you will need the identified baseline option. Here it has the Infections Tracking Tool, it's an Excel workbook and there are PDF instructions on how to use it. I have already downloaded some. I will go if you a quick overview. We have a video on our website where I go through this tool in very much detail. We will give you that link, as well. If you decide this is something you would like to utilize. This will be used for tracking your C. diff infections throughout the month. You are probably already doing this, this is a really good tool. The algorithm will fill in so you don't have to do a lot of looking at dates and knowing when to enter things into NHSN. When you open up the tool, there are several tabs on the bottom. There are common questions and answers. This is a good page if you have questions about your C. diff event and whether you are tracking them appropriately or if they are nursing home onset or community onset or duplicate, this page can help answer some of those questions for you. The definitions are listed on this tab as well. It has the information to help you identify whether it's an incident or a return. This algorithm is already built-in to the spreadsheet, when you enter your specimens it will tell you whether it is a recurrence. This next tab is where you will enter

6 your resident. I have been recommending, when you get a positive lab result for C. diff and you are entering the information. I have entered myself as Brandi is our residents today. The next tab is your specimen log, this is where you will go to enter information when you get a positive C. diff result. You can use this tool for an entire year. At the top, you can choose, I chose March 2017, I can use it for the entire year. I also did some entering of information prior to the call. I will show you so you can see how I did that. You start with the resident name and choose from the drop-down, it will be the resident that you enter on the C. diff tab. The columns with the red asterisk are those that are required. Date of current admission, March 1, 2016, I chose long stay as type of stay and it recommended and ordered to look at your facility and check 13 and improvements to enter this other information. What was the date of diarrhea onset, what was the date of contact and you can keep an eye on your facility and whether interventions are happening in a timely manner. The date the stool specimen was collected is the last required piece of information. I put March 5, if she was admitted on the first and her positive specimen was on the 5th. This spreadsheet then highlighted this resident positive specimen as red and tells me that red indicates nursing home onset incident CDI Lab Event. It's nursing home onset, because it was four or five days after she was admitted. That was when the positive specimen came back. It tells me it's nursing home onset. On the left, it tells me that this needs to be entered into NHSN. I had change this, it will be yellow and it will say need to do. That way, when you are entering into NHSN, you can keep track, if you had five positive events and you have tracked them on this spreadsheet, as you go into NHSN and enter them, you can mark it as completed. You can be sure you have entered all events. Entering Multiple Events I entered the next one on the same resident with the same admission date, she is still long stay and in than this time we got a positive specimen on March 12. We have the one on the 5th and antibiotics were given and now they have tested again and it was positive again on March 12. However, this time it did not highlight it, it's telling me it's a duplicate positive. That's because it was within 14 days of the previous positive result. On the left, this spreadsheet is automatically telling you, no-you do not need to report that to NHSN. This time we will do Brandi, I will choose her name from the drop-down. We will say she was admitted on April 10th, she is long stay, when she arrived at the facility we took a specimen and it came back positive within two days of her admission, April 12 th. Once I have entered that in, as you can see, it highlighted that yes I need to put this into NHSN. It is community onset, it let me know that because we got a positive result within 72 hours of admission to our facility, that is considered a community onset. The CDC will know that, when you enter this information into NHSN, you are reporting it because the positive specimen happened at your facility. However, because it was within 72 hours of admission, it is a community onset. That is important.

7 This is where you will keep your specimens and the next tab will be your admissions incentive information that you will need that for the summary data page in NHSN. I have entered random numbers from March. I put there were 20 total admissions and 5 were already on treatment at the time of admission. Our average daily census was 120. The spreadsheet already knows that there are 31 days in March, it calculated your resident date for you. I really like that about this spreadsheet. I think it's helpful. That is what you would need to do, enter these three pieces of information and it will produce a resident date for you. Q and A with NHSN Expert That is all I wanted to go over on the spreadsheet, today. Does anyone have any questions about tracking C. diff or which C. diff events do you need to report or anything like that? Please, ask away. We really want Angela to be able to share that with everyone. As Karen said, you may press star 9 to raise your hand and you will be un-muted or you can enter your question in the chat, whichever you prefer. If there are no questions, Angela I don't know if you would want to share some frequently asked questions that you get from long-term care facilities? Tracking Resident Days Yes, sure. One question that we often get is, how do facilities track the resident days. I don't know that there is a question, I think Sarah did a good job of tracking dates. For those of you who are unclear, resident days is the sum of the daily total of residents in your facility, that's for every day in the month. I want to back up. There are two ways you can do it, you can estimate your resident days by the beds in the facility times the number of days in the month and the other way is to by each day counting how many residents are bedded in your unit and at the end of the month, take the total of that count and that is the total you would enter into the NHSN application. I am pointing this out because sometimes facilities will take the number of residents that are in the facility on the day that the facility is entering the data into NHSN. That is an underestimate of the number of resident days, if you incorrect the number of resident days it will impact your overall infection rate. For example, if your resident days are too low and you do report a C. difficile infection for that month, your infection rate will be higher than it would be if you entered the correct number of resident days. It's important that you are entering the resident days as close to possible, to represent the number of bedded residence in your facility each day of that month. I would like to ask a question of the group, has anyone on the call had the opportunity to enter a CDI lab ID event into the NHSN and if so, what was your experience with entering that event? You can press star 9 to raise your hand or type it into the chat if you prefer. Anyone? I will continue. If you decide you want to respond, press star 9 to raise your hand or put a response in the chat.

8 Patients Already Being Treated for CDI Another question that we sometimes get from users is relating to a resident who comes to your facility on treatment for C. difficile. If that resident counted as a CDI event for the facility? The answer to that question is no. Unless the resident has the lab collected from your facility, the lab does not get counted as a CDI Lab ID Event for your facility. There is one exception, if the resident in your facility and he or she goes to an outpatient setting for a day, let's say Mrs. Jones must be transferred to the emergency department and while in the emergency department a stool specimen is collected and comes back positive for C. difficile. Your facility would report that positive specimen just as if Mrs. Jones was in your facility, if she returns back, either on the day that she left her facility to go to the emergency room, or the same calendar day. Or if she returns to your facility the very next calendar date. Those outpatient specimens are allowed only if the resident is only out of your facility no more than two calendar days. Do you have any questions about that? If the resident goes to the hospital and is admitted as an inpatient in that hospital, no specimen collected in that hospital setting are to be reported by your facility. You are only reporting specimens that are either collected in your facility or collected while your resident is seeking treatment from an outpatient center. It sounds like we are having audio difficulties, Angela we can no longer hear you. Hello, Angela can you speak now? This is Sarah. I have a question Sarah. Okay. Reporting No Evidence It's not a question, this is Brandi and I have input. Our facility has been fortunate to have to report no evidence in the monthly summary. Congratulations for that. I think a lot of nursing homes have not had to report any events so far, that is great. Yes. I think that if Angela comes back on she can continue. I think she had gotten through what she was trying to say about the one exception to the rule, if the resident leaves your facility for an outpatient visit or it could even be a visit that they are not admitted and they come back within two calendar days, you do then report that specimen as being from your facility. I know there have been questions about that. I am glad she elaborated. Just remember, any resident that is admitted to your facility already on treatment for C. diff, you enter those in your monthly summary data, just those numbers. Currently, you do not have to worry about entering specific information about the antibiotic or duration. Keeping track of that is beneficial and there is a spot in NHSN where you can enter it into the comments when you do enter an event. I have seen some nursing homes do that. I think that is helpful.

9 Sarah, can you hear me now? Yes, we can hear you now. For some reason, I have to keep calling and, I can hear you. I apologize. I did hear that a facility reported in that they had not had any CDI events and that is awesome. Congratulations. Setting Up Monthly Reporting Plan This is Brandi, I have a question about something I have had a lot of questions about. Can they set up their monthly reporting plan for the year? Can they do that all at once and get that done? That's a great question and it's a great idea. Yes. The monthly reporting plans can be set up for the full year in advance. When you set up one, you can keep copying that for every month of the year. I actually recommend that. It is one more step that you can mark off of your list of things you have to do. And if you decide, I know you will laugh at this, if you decide in the future that you want to add another module to do surveillance. Let's say are you doing C. diff surveillance, but you want to get excited about entering your UTI data, you can always go back and edit your monthly reporting plan and add modules if you want to. That's great. I think that would save time too. That is very efficient. Reporting Residents Admitted on Treatment Another question that I get from some nursing homes, I hope I can articulate this without confusing you. On your denominator reporting, in your summary data, there is a question that asks how many residents admitted on C. difficile treatment. That question, I just want to point out, the number of admissions on C. difficile treatment, that question is exclusive of C. difficile event reporting. In other words, you could have a resident who was admitted into an acute care facility and then that resident is transferred to your facility and they are being treated for C. difficile. That resident would count in the monthly summary number. But, that does not mean that you have to also enter a C. difficile lab ID event for that resident. The only time you would enter the C. difficile lab ID event for the resident is if the resident had another specimen collected while in your long term-care facility. Those are exclusive of each other. The number will likely be different. You could have zero C. difficile lab ID events reported for the month, but you could have five residents who were admitted on C. difficile treatment for the month. I hope that makes sense. Lab Test Methods I do see a question and the chat, this is an excellent question. Some facilities have questions about C. difficile lab test methods as documented in the annual facility surveyed that you complete once a year. Some facilities are using PCR testing but selecting other because they did not realize that the NAAT is considered testing. What we have done, we cannot go back and fix this current year, starting next calendar year, when you do your annual survey, we have added PCR in parentheses to the annual survey so facilities will not get confused. I agree, that is

10 confusing. The good news is that if your facility does PCR testing or sends out to a lab that does PCR testing and that is the primary or most popular method of testing for C. difficile. If you selected other and typed in PCR on your annual survey, if you would go back to your annual survey and edit the survey, delete the selection for other and select the NAAT testing. You can always send us an if you need help and we are more than happy to help you. Our is NHSN@CDC.gov. If you put in the subject line LTCF it can get triaged to our group. That is NHSN@CDC.GOV. Reporting Rolling Years Can reporting plans only be pre-entered for the year or can you do a rolling year? Everything that we do in terms of updating protocols and updating the NHSN application is done in a calendar year. From January 1 through December 30 or December 31, you can only do it for the calendar year. For the remainder of the year you can put a plan in place through December of Lab ID Event Reporting I have another question. We have hospitals that have protocols to routinely check residents for CDI, they are treated and return to your facility from the ED do you have to count that as CDI even though a nursing home at previously treated and it's colonized? It's a tricky question that brings controversy, unfortunately. The protocol is set up in a way that we tried to simplify the process and streamline the process as much as possible for those users entering data. We really try to limit the amount of time that the users have to spend digging through a medical record. With that said, that can decrease the specificity of lab ID event reporting. To answer your question, if the test is done on a loose stool specimen, the result should be considered if positive in lab ID event reporting, even if that resident had been previously treated for C. difficile. We know that a lot of times it could be colonization, it could also be that it's a different strain, maybe the strain the resident was treated for has cleared, but maybe the resident was exposed to another strain of C. difficile. If you know for a fact that the C. difficile test was not done on a loose stool specimen, if they did a formed stool specimen and you have documentation of that, you do not have to report that. I don't know how well that documentation or that will be documented for you, if nursing homes and hospitals make it a practice of documenting the consistency of the stool. If they do, you can use that to your advantage. I do want to bring up -- no I don't. I was going to bring up, let me ask you. In the case that you just presented, if a resident leaves the facility and receives treatment in an emergency department, the resident leaves and goes to the emergency department and a specimen is collected and is positive for C. difficile and then the resident returns to your facility on the same calendar day. Yes, you would report the positive C. difficile lab ID event, but would you report that resident on your summary data in the question number of admissions in C. difficile treatment? What you think about that?

11 You can just type it in the chat box if you would like. Are there any guesses? I know your reporting is new and you may not have had this situation come up yet. I will give you the answer. Unless that resident is admitted back to your facility, the resident was in an inpatient admission and is admitted back, you would not count it. The resident is just going for an outpatient visit and comes back on treatment, that is not a new admission. That is just considered outpatient and the resident is coming back. That was a great question. I'm sure it will come up at some point, if it hasn't already. Shared Tracking Practices I want to ask, if you could just share in the chat so that we can know best how to assist you, could you share how you are currently tracking, are you checking on paper, electronically or with the spreadsheet or in NHSN only. Would you mind sharing that with me in the chat? If you have any questions for Angela or Angela if you have anything you wanted to share. I am glad you asked. I think we are all interested in knowing how nursing homes are tracking their C. difficile. Once we better understand how you all are doing your surveillance, we are going to be in a better position to help you and give you the tools that you need. The reporting into NHSN is really new for most nursing homes. We had, I believe 200 nursing homes reporting before 2016 and now we have close to 3000 nursing homes. That is a huge jump. We are trying to understand how to best help nursing homes and by you participating in this CDI project, this is the first step in helping us to help you. We appreciate you joining calls like this and we appreciate any feedback that you provide to us or Sarah's team. Just know that we read everything that you send us and take into consideration every single bit of feedback we received from our nursing homes. I do see Robin said that their facility tracks on factions. You are busy. I'm so sure. You check on paper and you transfer the data into the CDC. My guess is, you are in the same boat with many, if not most of the nursing homes. Are you using the NHSN paper forms to document your infections? The facility has a tool. Excellent. I like that. Resources and Closing Thank you for your input and everyone on the call if you would not mind sharing if you are doing the same thing as Robin or if you are doing something different. We won't necessarily call you out. We are interested, so that we can better assist you. We are getting close to the end. I want to thank you Angela, so much for being on the call and available to answer questions. Any time you have questions you can reach out to them at their which we will put into chat and also reach out to us, in your individual state you have a Quality Improvement Advisor who is happy to assist you at any time. If you don't have any other questions for Angela, I will go ahead and just provide you with some quick resources. atom Alliance has a website here at the top. This is our specific site for our long-term care facilities. On that page, I have recorded several webinars. They are short PowerPoints about how to do the things that we talked about today. How to use the tools and how to enroll your facility in NHSN. I think most of you are already enrolled. There is a video for that. There's also setting up your NHSN, mapping locations and doing your reporting plans and things

12 like that. We also have a great webinar series that we did with the Department of Health in Tennessee. It would work across the board in any state. It's a five-part series about C. difficile and identifying it and treating it appropriately. That is a great series and also, I included a link to the CDC's training resources for NHSN. I know you just recently updated those and they have great PowerPoints and videos that can help you. Please, utilize those. We will provide the slides to you at the link that was provided in the chat in a few days. Please complete the survey after this call. We have an on-demand learning page, if you are interested in other things besides C. difficile, we have a lot of information on those as well on our on-demand learning page on our website. You can also connect with us on social media, we are on all platforms. It looks like there are no other questions in the chat. Another nursing home did say that they are using a facility tool as well. Thank you for that. There are number questions. I would like to thank everyone for calling in and thanks to Angela for being available to us. Thank you for inviting me.