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SB 739. Where the Rubber Meets the Road. Jan ’08 version (2) presented: (insert your chapter, current date here) Sue Chen RN, MPH, CIC HAI Program Coordinator California Dept of Public Health [email protected] Objectives. SB 739 in context History of mandatory reporting

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Where the rubber meets the road

SB 739

Where the Rubber Meets the Road

Jan ’08 version (2) presented:

(insert your chapter, current date here)

Sue Chen RN, MPH, CIC

HAI Program Coordinator

California Dept of Public Health

[email protected]


Objectives

Objectives

  • SB 739 in context

    • History of mandatory reporting

    • Making the business case

    • Review of SB 739 requirements

  • Your role in implementation of SB 739(devil is in the details)

    • Introduction to NHSN

    • Sequence of events/specific activities

    • Updates from HAI-AC to CDPH

  • Say “amen” and escape


Where the rubber meets the road

Number of nosocomial pathogens, according to infection site, identified in the hospital-wide component of the NNISprogram from January 1990 to March 1996

HAIs- The Big Four

  • Urinary tract infections

  • (catheter-associated)

  • Surgical site

  • Infections

  • Bloodstream infections

  • (central line-associated)

  • Pneumonia

  • (ventilator-associated)


Healthcare associated infections numbers and costs

Healthcare-Associated Infections – Numbers and Costs

* From Klevens et al..Public Health Rep. 2007;122:160-6 +12% of U.S.


Cost of hai vs infection control duke infection control outreach network

Cost of HAI vs. Infection ControlDuke Infection Control Outreach Network

  • 28 community hospitals (30-616 beds)

    $25,072 for VAP – $23,242 per CLA BSI

    $10,443 per SSI – $758 per CAUTI

  • Ave cost of infections $594,683/year

  • Ave annual budget for IC $129,000

  • Decreasing HAIs by 25% would save $148,667 per hospital

    Anderson et al. Underresourced Hospital Infection Control and Prevention Programs: Penny Wise, Pound Foolish. Infect Control Hosp Epidemiol 2007; 28:767-773


What hospitals don t get

What Hospitals Don’t Get

Two economists are walking down the street. One sees a dollar lying on the sidewalk, and says, “Look, there is a dollar lying on the ground!” “Obviously not,” says the other. “If there were, someone would have picked it up!”

from Hollenbeak, APIC 2007


Who pays

Who Pays?

  • Patients with HAI are disproportionally Medicare but only 50% Medicare-paid


Glimpse of the future from centers for medicare medicaid services

Glimpse of the Future: From Centers for Medicare & Medicaid Services

Effective October 1, 2008, hospitals will no longer receive higher payments for the additional costs of treatment associated with following HAIs*

  • Catheter-associated urinary tract infections

  • Vascular catheter-associated infections

  • Surgical site infection: mediastinitis after coronary artery bypass graft surgery

    * Unless condition is present upon admission


History of reporting of hais

History of Reporting of HAIs

  • Florence Nightengale: descriptive epidemiology during Crimean War documented causes of mortality*

  • National Nosocomial Infections Surveillance (NNIS)

    • Epidemiology of HAIs, describe antimicrobial resistance, enable inter-hospital comparisons

  • Study on the Efficacy of Nosocomial Infection Control (SENIC) Study – 1970s

*Gill C, Gill G. Nightengale in Scutari: Her Legacy Reexamined. CID 2005:40.


Public reporting background

Public Reporting – Background

  • The quality and safety of healthcare in the U.S. needs to improve

  • Public reporting is one of a number of quality improvement methodologies adopted

  • Public reporting of health care performance information is intended to:

    • Provide information to enable consumers to obtain safer care

    • Stimulate and provide basis for quality improvement by reporting providers


Public reporting slide 2

Public Reporting – Slide 2

  • Indicators for public reporting can be:

    • Outcomes (e.g. mortality, infections)

    • Processes (e.g. aspirin for MI, antibiotic within 4 hours of admission for community-acquired pneumonia, appropriate antibiotic prophylaxis prior to surgery)

  • Public reporting for myocardial infarction, coronary bypass graft surgery (CABG), and community-acquired pneumonia has been in place >10 years

    • Reductions in the rate of death associated with CABG in New York and Pennsylvania have been attributed, in part, to public reporting


Trend over time in bloodstream infections associated w catheters in pediatric icu

Trend over time in bloodstream infections associated w/ catheters in pediatric ICU

Nov 1998: use of maximal barrier precautions

July 1999: use of antibiotic-impregnated catheters

March 2000: annual hand washing campaigns

April 2003: move to new unit with private rooms

May 2003: introduction of skin disinfection with chlorhexidine

U Arkansas Children’s Hospital Bhutta et. al., BMJ 2007;334:362-5


Leapfrog report 9 18 07

Leapfrog Report – 9/18/07

  • 87% hospitals (n=1256) do not take all recommended steps to prevent HAIs

  • 35.6% do not always follow hand hygiene practices

  • 30.7% vaccinate staff against flu

    http://www.leapfroggroup.org/


Consumer s union

Consumer’s Union

Focus on obtaining data on HAIs so consumer can make an informed choice; also

pressures hospitals to improve

  • legislation for mandatory reporting

  • active surveillance cultures for MRSA

    “Rep. Tim Murphy (PA) is sponsoring the "Healthy Hospitals Act of 2007" (HR1174). The bill will make you safer during a hospital stay by requiring public disclosure of hospital-acquired infection rates. If hospitals must tell you about their infections, they will work harder to reduce them.”

    “Please ask your representative to co-sponsor this bill!”


Experience with legislated mandatory public reporting

Experience with Legislated Mandatory Public Reporting

  • Pennsylvania

    • Have been reporting data since 2004

    • Areas for improvement

      • Use of administrative data

      • Law of Unintended Consequences

  • Pittsburg Regional Healthcare Initiative

  • Found error-prone systems that did not focus on the patient at the point of care.

    • “Healthcare must focus on delivering perfect healthcare to every patient.”


Response to public reporting consumers don t seem to care

Response to Public Reporting: Consumers Don’t Seem to Care…..

Source: CHCF sponsored survey of Californians, 2004


Quality of care heart attack

Quality of Care - Heart Attack

But Hospitals Do…

Numberof hospitals


California ancient history

California Ancient History*

  • Little Hoover Commission report April 10, 2003: recommended increased capacity to fight HAIs

  • HAI-AWG met from July ‘05-Feb ’07

    • Recommendations for Reducing Morbidity and Mortality in California: Final Report to CDPH December 31, 2005

    • Result was SB 739 signed into law September 28, 2006

* For those w/ attention deficit or CRS


Sb 739 mandates

SB 739 Mandates

  • Implement an HAI surveillance program

    • Electronic database: NHSN

  • By July 1, 2007

    • Appoint an HAI Advisory Committee

    • Hospitals must implement respiratory hygiene/cough etiquette program, employee flu vaccine program, disaster plan w/ pandemic flu component in conjunction w/ local health dept

  • Educate health facility evaluators in HAI


Mandates cont d

Mandates cont’d

On or after Jan 1, 2008:

  • Revise infection control-related portions of Title 22

  • GAC shall implement and annually report process measures which are to be made public within 6 months

    • Central line insertion practices

    • Influenza vaccination of HC personnel and high risk patients

    • Surgical antimicrobial prophylaxis


Current tasks and further directions slide 1

Current Tasks and Further Directions – Slide 1

  • Facilities must enroll in NHSN; soft deadline Jan 31, 2008

  • Be prepared to join CDPH group and give CDPH permission to see appropriate data elements

    Specific directions will be forthcoming from CDPH with details and start dates for mandated reporting.


Where the rubber meets the road

Slide 2

  • Use CLIP practice module to get process in place for data collection

  • Be prepared to report vaccination rates for 2007-08 flu season (model is TJC requirements)

  • Respond to SCIP questionnaire by Jan 15. SCIP data will be required to be reported through CMS/Lumetra


Update on hai ac recommendations

Update on HAI_AC Recommendations

  • Central Line Insertion Practice (CLIP)

  • Influenza vaccine for

    • Employees

    • High risk patients

  • Antimicrobial prophylaxis (SCIP)

  • Legal

  • Reporting of healthcare-associated MRSA infections


Hai ac central line insertion practices clip

HAI-AC: Central Line Insertion Practices (CLIP)

  • Option 1: fill out all asterisked data points on CLIP form

    • In ICUs x 6 months

  • Option 2: fill out 6 areas AND do outcome module for those units

    AND

  • Documentation of daily assessment of line necessity by a clinician.


Hai ac influenza vaccination for employees

HAI-AC: Influenza Vaccination for Employees

  • Publicly report influenza vaccination/ declination rates for employees for ’07-’08 season

    • Differentiates between employees and healthcare workers

    • Non-employee HCW should be offered vaccine; a rate for this not mandated at this time

  • Forms may only be obtained Sept-Mar


Hai ac surgical care improvement project scip

HAI-AC: Surgical Care Improvement Project (SCIP)

  • Will be reported through CMS/Lumetra

  • Facilities currently reporting data will not have more work

  • Facilities not currently reporting must work w/ Lumetra to establish reporting pathway or

  • If facility does not perform surgeries, no reporting will be required.

  • CDPH will begin downloading CMS data at a to-be-announced date.


Hai ac recommendations for mandatory reporting of mrsa

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

  • No further characterization required at this time


What is nhsn

What is NHSN?

  • CDC-sponsored voluntary, confidential system for monitoring events associated with health care

    • Initial focus on infections in patients and healthcare personnel

    • Expanding to include noninfectious events (such as process measures)

  • Accessed through a secure, web-based interface

  • Open to all US healthcare entities at no charge


Nhsn is a partnership

NHSN is a Partnership!

NHSN participation was never designed or intended to be the sole responsibility of Infection Control.


Where the rubber meets the road

Am J Infect Control 2007;35:290-310


Where the rubber meets the road

  • Device-associated

  • Procedure-associated

  • Medication-associated

modules


Where the rubber meets the road

Percentage of Hospitals in AHA Survey Enrolled* in NHSN

*613 facilities

Status as of June 18, 2007


Where the rubber meets the road

National Healthcare Safety Network (NHSN)for State Reporting

Heavily* Plagiarized by CDPH from

CSTE 2007 Annual Conference presentation

June 2007

R. Monina Klevens, DDS, MPH

Division for Healthcare Quality Promotion

National Center for Infectious Diseases

* Heavily is not an infestation


Characteristics of nhsn surveillance methodology

Characteristics of NHSN Surveillance Methodology

  • Active, patient-based, prospective, priority-directed collection of data

  • Results in risk-adjusted incidence rates; will allow comparison between yourself or group against national average.

  • Intended to be used as a quality improvement tool to be of mutual benefit to facilities and NHSN; goal to eventually link processes with outcomes


Authority and confidentiality for nhsn

Authority and Confidentiality for NHSN

  • Public Health Service Act (42 USC 242b, 242k, and 242m(d))

  • Confidentiality Protection

    • Sections 304, 306, and 308(d) of the PHS Act

“The information contained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306, and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).”


Strengths built on nnis experience

Strengths – Built on NNIS Experience

  • NNIS System is a model for patient safety1,2

    • High quality data can be used for performance improvement. Reductions in national infection rates have been achieved.

  • Scientific credibility: Definitions and methods adopted internationally

  • Timely: data can be immediately downloaded

  • Aggregate comparisons by unit or procedure across states ensure greater numbers

1Leape LL. Reporting of adverse events. NEJM 2002;347:1633-8.

2Burke JP. Infection control—a problem for patient safety. NEJM 2003; 348:651-6.


Registration process follow the balloons and arrows

Registration Process:Follow the Balloons and Arrows

Accept Rules of Behavior

NHSN sends email w/ instructions for digital certificate

You read and follow directions – carefully; complete modules

NHSN sends further instructions

You read and follow directions – carefully; sign away first born

Etc. Etc. Etc.

(From Facility Administrator

Enrollment Guide)


Process for hospitals to register

Process for Hospitals to Register

  • http://www.cdc.gov/ncidod/dhqp/nhsn_members.html

  • Accept rules of behavior

    • Part of registration is to complete 8 modules (~2 hrs each)

      • On R side of page NHSN Resources, click on Training, then “Archived Training”, follow stepwise directions

  • Name a facility administrator [person with all rights to all data for your facility]


Registration process cont d

Registration Process Cont’d

  • Obtain (and don’t lose) digital certificate

    • If firewalls prevent access, own IT dept must clear site

  • Fill out online form and survey

    • Name group/groups

    • Send to NHSN

  • CDC will activate facility

  • Facility must join CDPH group, give rights to see mandated data


Summary of nhsn rules

Summary of NHSN Rules

  • Every month, the facility must submit a surveillance plan

  • Facility must report data to NHSN 6 of every 12 calendar months within 30 days of end of reporting period

    • Failure to adhere to reporting can result in loss of member status

    • Loss of member status puts facility at odds w/ mandates of SB 739

  • All data fields marked w/ an asterisk must be filled out for record to be counted if in plan


Where the rubber meets the road

I certify that I completed

the required training to participate

in the

National Healthcare Safety Network

Registration Nirvana?

Name of participant

Name of facility

Dates of training:


How cdph accesses data in nhsn

How CDPH Accesses Data in NHSN

  • Groups: e.g., healthcare corporations, State Health Departments

    • A facility “nominates” CDPH

    • Facilities join the group and confer some/all rights to data

    • Facilities within the group cannot see each other’s data

    • Group sees data from all facilities as granted

  • After joining, a facility can use any NHSN module (ex: outcome measure) they choose; data not visible to CDPH except w/ permission


Limitations

Limitations

  • Primary experience with voluntary, confidential reporting

    • Validation methods in development

  • Labor intensive

    • And deadlines for data reporting

  • No special protocols for small hospitals

  • Not tied to utilization or billing data directly (DRGs, ICD9/10, etc.)

  • Must follow NHSN rules


Support for states users

Support for States & Users

  • Collaboration with APIC/CACC, CSTE, SHEA, IDSA

  • NHSN State Users Group

    • Conference calls monthly/Webboard to share materials, including users newsletter

  • Training for all members

    • Webinars

    • Interactive distance learning

    • nhsn.cdc.gov


What and when states using nhsn are reporting

What and When States Using NHSN are Reporting

PA

CA

VA

WA

NY

VT

SC

CO

TN

OK*

DE

Jan 2007

2008

* Undefined measures


Anticipated additions

Anticipated Additions

  • Process modules for CLIP and immunizations (for both employees and patients) to be released – Feb ‘08

  • Introduction of 23 modules of interactive computer training (20-30 min ea) – Jan ‘08

    • In addition to original modules

    • Number required will depend on ‘rights’ conferred

    • Goal to set up CEUS for module completion

    • Will contain post-test to document knowledge; minimal score of 80% to pass


What cdph would like to see

What CDPH would like to see

  • Formulation of a model for reporting of “never events” for nationwide use

  • Downloading capacity from 3rd party vendors directly into NHSN

    • Discussion between CMS, CDPH, and NHSN for direct download of SCIP data already reported to CMS

      Disclaimer: While willing, CDC lacks personnel and monetary resources to develop these capacities at this time.


Challenges

Challenges

  • What are the evidence-based reporting best practices?

    • Balance use of existing data with accuracy and ownership

  • How to gain necessary resources for implementation of reporting?

    • State and hospital levels

    • More efficient methods

  • How will reporting impact quality of care?

    • Integrity of processes will drive decrease in infection rates

    • Provider and consumer behavior


Questions

Questions?

Answers Cheap


Acknowledgements

Acknowledgements

  • Jon Rosenberg

  • Centers for Disease Prevention and Control

  • New York State

  • Audiences for

    refining the

    program


Where the rubber meets the road

Infectious Diseases Experts Applaud Bill Against "Bad Bugs"

With extensively drug-resistant tuberculosis, life-threatening drug-resistant respiratory and skin infections, and other “bad bugs” routinely making headlines, infectious diseases physicians are applauding Rep. Jim Matheson (D-UT) and Rep. Michael Ferguson (R-NJ) for introducing H.R. 3697, Strategies To Address Antimicrobial Resistance (STAAR) Act  


S 2278 durbin bill h r 4214 chai reduction act of 2007

S.2278 Durbin Bill/H.R. 4214CHAI* Reduction Act of 2007

  • Establish best practices guidelines for IC plans to treat and control CHAI in GAC

  • Hospitals to begin reporting through NHSN within 90 days

  • CDC to be given authority to make rules

  • Institute pay for performance

  • Public awareness and education

  • Ongoing interagency workgroup

*Community-Associated and Healthcare-Associated Infections


H r 4352 assistance to school districts to combat mdro towns

H.R. 4352 Assistance to School Districts to Combat MDRO* (Towns)

  • $30 million to Dept of Education for prevention, outreach, educational activities in grades K-12 for qualifying pathogens

  • MRSA, CDC-identified life-threatening bacteria

  • Money may cover personal hygiene supplies and disinfectants if school district lacks a sufficient budget.

*Introduced Dec 11, 2007; D-NY


H r 4451 mrsa research and study act of 2007 stearns

H.R. 4451 MRSA Research and Study Act of 2007* (Stearns)

  • Establish 6 year grant program under auspices of Sec Health & Human Services

  • Eligibility: under university or u-affiliated teaching hospital

  • Minimum 25 grants awarded during each 2 year period: $5 million ea

*Introduction Dec 11, 2007; R-FL


S 2526 worker infection protection act menendez durbin kennedy

S. 2526 Worker Infection Protection Act* (Menendez, Durbin, Kennedy)

  • Proposal covers HCW, first responders, other workers @ risk against exposure to infectious agents and drug-resistant infections [avian influenza, MRSA]

  • Sec of Labor to develop temporary exposure control plan w/ in 6 months; permanent 6 mo later [OSHA]

    • plan, PPE, training, medical surveillance, immunization if available

*Introduced Dec 19, 2007; D-NJ, IL, MA


Sb 1058 medical facility infection control prevention act alquist

SB 1058 Medical Facility Infection Control & Prevention Act* (Alquist)

Health facilities and residential care facilities for the elderly must implement procedures for screening, prevention, and reporting of specified infections

  • ASC for specified conditions

  • Reporting

    • Laboratory reporting of facility-acquired positive cultures to CDPH

    • reporting of 2 or more cases MRSA within a 7 day period

    • Facility must post that report on its website

  • Cleaning of pt care equipment/environmental surfaces

  • Adequate infection control staffing: 1:100 occupied inpatient beds, 1:200 outpatient visits. Same ratios of IC required for residential care facilities.

  • Staff must be adequately trained

    * Introduced Jan 8, 2008 by E Alquist, D-Santa Clara


Definition of reportable ca staph

Definition of Reportable CA Staph

  • Severe staph infection resulting in death or ICU admission in a previously healthy** person

    • Covers both MRSA and MSSA

    • Will be reported through local health dept via CMR

    • Estimated burden of reporting 100-200 cases/year in CA

  • Primary responsibility for reporting belongs to local health departments

    **CDC definition of “previously healthy”:

    Persons “who have not been recently (within the past year) hospitalized or had a medical procedure (such as dialysis, surgery, catheters)…”


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