Mandatory Reporting: Getting Started

1. Mandatory Reporting: Getting Started Presented: APIC-Coastline June 5, 2008 Sue Chen RN, MPH, CIC HAI Program Coordinator California Dept of Public Health Sue.Chen@cdph.ca.gov

2. Objectives Progress report • AFL 08-10: CDPH Group • Registration into group • CLIP reporting • SCIP • Other • Anticipated AFL follow-ups • General discussion: pending legislation, updates from SHEA

3. Mandatory Disclaimer • Oscars are not guaranteed • Neither are all the answers (in advance) • Sometimes the answers evolve in response to constituent feedback

4. Update: 5/27/08 • 235/~435 (54%) hospitals enrolled into NHSN • 90% compliance w/ name of facility administrator • 71% compliance w/ return of SCIP surveys • 235/1408 NHSN hospitals from CA (16.6%) • HAI-AC accomplishments • Heavy duty collaboration w/ ICPs through CACC and corporate/public health entities

5. Response to Public Reporting: Consumers Don’t Seem to Care….. Source: CHCF sponsored survey of Californians, 2004 and 2007

6. Impact of CMS Non-payments Budget Reduction Act of 2005 created a value-based purchasing plan • Reimbursement based on average cost, which includes some unavoidable infections • Payment includes incremental costs of those infections • No, I don’t know how infection rates were determined • Yes, this may lead to differently-practiced medicine • Yes, there are plans to add to the list of non-reimbursable adverse events ~$20 million estimated to be saved in first year

7. IC Issues Under Discussion @ CMS for Non-reimbursement in 2009 • SSIs following total knee replacement • Legionnaires’ disease • Ventilator-associated pneumonias • Staph aureus septicemia • Clostridium difficile-Associated Disease

8. All Facilities Letter (AFL) 08-10 • How to join the CDPH Group • Mandate to begin reporting of CLIP on July 1, 2008 even if module not yet released by NHSN • SCIP data will be collected • Registration for LTACH* and Surgery Centers • Specification of patient identifier * LTACH – Long Term Acute Care Hospital

9. Join the Group. If unable, • After obtaining your digital certificate, your hospital must be registered into NHSN • “How to Enroll” tab to steps 5 and 6 • Collect needed information for NHSN survey • Will require signature from “C-suite” mailed to NHSN • NHSN will email that your hospital has been activated • Then follow directions in AFL (almost) • Go to SDN website, NHSN reporting • Click on “Group” (not “join Group”); enter secret password and code • If process takes more than 2 minutes, something is amiss.

10. HAI-AC: Central Line Insertion Practices (CLIP) • Option 1: fill out all asterisked data points on CLIP form • In ICUs x 6 months • OR Option 2: fill out 6 areas AND do outcome module for one ICU unit AND • Documentation of daily assessment of line necessity by a clinician.

11. Demographics plus Occupation of inserter Hand hygiene performed prior Used sterile barrier precautions? Type of skin prep Location of insertion site Type of CL inserted Advantages: CA data contributed to national database Not that much more work Disadvantages: CA data not part of national database Must do additional outcome reporting Details of Option 2

12. Surgical Care Improvement Practices (SCIP): Quarterly Reports • If facility already reports to Lumetra (CA Quality Improvement Organization), no additional actions needed • If facility reports to The Joint Commission, but not Lumetra, instruct your 3rd party vendor to relay information to CDPH for inclusion • If surgeries performed and reporting not already done, Lumetra will train your facility to use CART (CMSAbstraction and Reporting Tool) • CDPH will download data from http://www.calhospitalcompare.org/, analyze, and report

13. Special Slide for LTACH and Surgery Centers • NHSN is developing groups for you • Modules may be released in fall 2008 • So as to maintain compliance, you must • Register into NHSN • **Send Name, full mailing address, and type of facility to CDPH at time of registration into NHSN** • NHSN will migrate those facilities who notify CDPH when group is available

14. Special Slide for Small Facilities • Yes, you still must register your facility into NHSN; there is no size-related legislative exemption • In absence of reporting for CLIP or SCIP if facility does not do those procedures, • Influenza module • MDRO module • Any type of outcome reporting

15. AFL 08-10 Frequently Asked Questions (FAQs) • With the requirement for daily assessment of line necessity, who must perform the assessment? Can it be an RN? • The line must be assessed by a licensed practitioner for whom ordering a line or discontinuation of a line is in their scope of practice. An RN can do so only if licensed for advanced practice. • Does assessment of necessity need to be documented for each line in an individual patient? • As multiple lines are counted as one line day, multiple lines can be covered under one assessment note. • It is not required to document compliance in the medical record. You must be able to show a surveyor documentation of assessment for a particular date if requested. • There is no requirement to collate compliance data.

16. AFL 08-10 FAQ – Slide 2 • Who must document that the assessment was completed? • Your hospital policy may direct this process. It is not required to be the physician. • What happens if a patient has their central line inserted in Radiology – do we have to fill out the CLIP form? • The current CLIP monitoring requirement is for all central lines inserted in ICUs (including PICUs and NICUs) between July 08 and Dec 08. Monitoring of other areas where lines are inserted is your option. • At this point, monitoring for line necessity is required for patients w/ lines who are in ICUs only.

17. AFL 08-10 FAQs – Slide 3 • Do instructions in Attachment #3 supersede what is written in the actual AFL? • No – NHSN module instructions DO NOT supersede AFL directions • What do we need to do about our monthly “plan”? • Option 1: sign up to report CLIP module in all ICUs • Option 2: sign up to report BSIs in one ICU; report 6 data points in CLIP module for all central lines inserted in all ICUs • Mask/eyeshield is to be interpreted as mask OR mask and eye shield; there is no requirement for the inserter to wear goggles

18. AFL 08-10 – Miscellaneous • There is an asterisk on some versions of the NHSN draft CLIP form. This is an error and should be corrected in the final version. There is no requirement to report patient names. • Please use MRN as primary ID, not secondary as stated in the AFL

19. What is Not in this AFL (but in your future) • How to give CDPH permission to see mandated data • How and when to begin reporting of influenza vaccination/declination of employees (approved by HAI-AC 5/29) • When and mechanism through which to report MRSA bloodstream infections

20. Influenza Vaccination Reporting for 2007-2008 Season • Season ends March 31, 2008 • Covers employees only • ‘Report by’ not yet specified

21. More “In Flew Enza” and Beyond • By Sept 1, 2008 develop a strategy to reach healthcare personnel • 2008-09 season: • Use part of NHSN influenza module • Phase towards goal of all HCP • 2009-2010: improve on prior benchmarks

22. Recommendations for Influenza Vaccination for High Risk Patients • Vaccination of patients w/ community acquired pneumonia is already reportable to CMS • Expand group to include high risk patients >50 years young • Begin reporting rates through CMS for 2009-2010 season

23. HAI-AC Recommendations for Mandatory Reporting of MRSA • Report all laboratory-confirmed MRSA bloodstream infections identified in hospitalized patients • Classify as community-onset (day 1-3) or hospital onset (day 4+) • Publicly report as of July 1, 2008*: • Number of community-onset • Rate of hospital-onset/1000 inpatient days • Mechanism for reporting to be determined • No further characterization required at this time * Impossible deadline; think November?

24. CDPH Tasks for Reporting • Determine and promulgate formats for how to report: • Compliance w/ influenza vaccination/declination • Design method for public reporting of above • Specify reporting vehicle for MRSA BSIs • Data analysis for all mandated measures • Design, populate, update, and maintain public reporting website

25. More CDPH Tasks • Implement a statewide infection prevention and control program: • Epidemiological and laboratory support • Update Title 22 • SB 158 proposes adopting CMS Conditions of Participation • Educate health facility surveyors • 2 surveyors currently being cross-trained in infection control [Surveyor education is a high priority for L&C ]

26. Future HAI-AC Directions • Public Reporting Subcommittee* • Systemic review of websites reporting HAIs • Goal: comparable, easy for public to navigate and understand • MDRO Module Subcommittee* • Public Education Subcommittee* • Recommendations for outcome reporting of SSI and CLABSIs*, VAP process measures * Current subcommittees

27. Do Hospitals Have to Comply with Expanded Reporting Requirements? • Any statute-required reporting is, by definition, a requirement for licensure • A written deficiency would be issued, requiring a plan of correction • Passage of SB 1312 set precedent for fines for non-IJ (immediate jeopardy) violations of up to $17,500 • This issue is specifically under discussion within L&C

28. Pertinent Updates from SHEA • HICPAC Guidelines in process: • Update on CA-UTI (last reviewed in 1981) • GL for Management of Norovirus • Issues related to goal towards and meaning of “Zero Tolerance” • Is eradication a realistic target? Can we get there? • Does a linguistic association such as 1980s “zero tolerance for drug use” contribute to an punitive culture around HAIs?

30. Waxman Hearing 4/16/08 “A Preventable Epidemic” • GAO Report • Many guidelines for infection prevention and control; no clear prioritization of practices • Many HHS programs • Collect different data • Lack of integration of databases constrains use of data • No clear cut national estimates of burden of HAI disease

31. Waxman #2 • Support not-for profit IC programs, financial incentives, > transparency • IC improvement is multifactorial, including work climate • Use sound evidence properly packaged to decrease CLABSIs (checklist), fund biomedical research, train more people into IC • Restaurants have higher standards for cleanliness than hospitals; penalties should be imposed for not following 15 steps to prevent HAIs • PA Healthy Hospitals Act 2005

32. Success (reduction of HAIs) will depend on • Team intervention focused on prevention • If can reduce number of steps, can reduce error rate; steps must be accurately applied • Training alone is insufficient; knowledge must be translated into awareness • Must live the vision • The process of changing behaviors is not simple • Recognition and acceptance that the solution will not be a one-shot wonder

33. Closing Thoughts • We must better articulate to the public what is preventable vs. what is not. • Resources dedicated to the prevention of HAI are not commensurate with the public health burden. • We must live within our resources – the world is not well served if we pursue more initiatives than resources can serve.

34. Vision of Practice of Infection Prevention and Control • Quality initiatives pull resources into data collection • Reevaluate how we do business • ICPs are consultants w/ a unique body of technical expertise • Best use of above is not sitting behind a desk • Readjust vision to encompass the forest, not just the trees • Work through alliances to regain control over our area of expertise

35. Conclusion “Toto – I have a feeling we’re are not in Kansas anymore.” Thank you