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Illinois Healthcare-Associated Infections (HAI) Plan. Mary Fornek January 21, 2010 Metropolitan Chicago Healthcare Council. American Recovery and Reinvestment Act of 2009 (ARRA). Four Components of the HAI Plan. HAI Program Infrastructure Surveillance, Detection, Reporting and Response

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Illinois Healthcare-Associated Infections (HAI) Plan

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Illinois healthcare associated infections hai plan

Illinois Healthcare-Associated Infections (HAI) Plan

Mary Fornek

January 21, 2010

Metropolitan Chicago Healthcare Council

American recovery and reinvestment act of 2009 arra

American Recovery and Reinvestment Act of 2009(ARRA)

Four components of the hai plan

Four Components of the HAI Plan

  • HAI Program Infrastructure

  • Surveillance, Detection, Reporting and Response

  • Prevention

  • Evaluation, Oversight, and Communication

Hai program infrastructure

HAI Program Infrastructure

Key points

Key Points

  • Illinois has created a HAI Prevention Advisory Council

  • Specific HAI targets have been identified

    • Clostridium difficile (C. difficile)

    • Methicillin-resistant Staphylococcus aureus (MRSA)

    • Central line Associated Bloodstream Infections (CLABSIs)

    • Surgical Site Infections (SSIs)

Surveillance detection reporting and response

Surveillance, Detection, Reporting and Response

Central line associated bloodstream infections cla bsis

Central Line Associated Bloodstream Infections (CLA BSIs)

  • Statewide reporting of CLABSIs in adult medical and/or surgical ICUs using National Healthcare Safety Network (NHSN) began January 1, 2009.

  • Statewide reporting of CLABSIs in Pediatric and Neonatal ICUs began October 1, 2009.

Clabsi continued

CLABSI continued

  • Baseline CLABSI standardized infection ratios (SIRs) for various ICU types for the first twelve months of NHSN surveillance will be available by March 1, 2010.

  • The IHA is a participant in John Hopkins University’s nationally recognized multistate “Stop BSI” initiative, in which forty-one Illinois hospitals are enrolled.

Clostridium difficile collaborative

Clostridium difficile Collaborative

  • Implementation in March 2010

  • 20 hospitals will be asked to participate

    • 10 hospitals from the Chicago area

    • 10 hospitals from Southern Illinois

  • Hospitals participating in the C. difficile collaborative will be required to use the NHSN (C. difficile Associated Disease) CDAD module for reporting.

Methicillin resistant staphylococcus aureus mrsa

Methicillin Resistant Staphylococcus aureus (MRSA)

  • October 1, 2007 – hospitals identify patients colonized and/or infected with MRSA.

  • MRSA data available on the IDPH website in an annual report and on the Hospital Report Card.


  • IFMC-IL MRSA Collaborative

    • Includes 8 hospitals, all reporting MRSA through the NHSN MDRO module

Surgical site infections ssis

Surgical Site Infections (SSIs)

  • Statewide Reporting will be required in APRIL 2010

  • 2 Procedures

  • Total Knee Arthroplasty (TKA)

  • Coronary Artery Bypass Graft (CABG)

Ssi workshops

SSI Workshops

  • Mary Andrus presenting SSI Module of NSHN

    • February 5, 2010 MCHC

    • February 12, 2010 Elmhurst Health Center

    • March 5, 2010 New Sherman Hospital

  • Two 4 hour sessions each day

    • (8am – 12pm) and (1pm – 5pm)

    • 30 participants per session

    • IT Webinar – date to be determined

Illinois healthcare associated infections hai plan


SSI Denominator Data

Electronic lab reporting elr surveillance

Electronic Lab Reporting (ELR) Surveillance

  • Automated reporting of reportable diseases to public health agencies

  • Development of software modules to increase the efficiency and reliability of reporting to CDC’s National Healthcare Safety Network

  • Linking together hospitals to identify transfers of patients for whom a multi-drug resistant organism (MDRO) has been detected

Key points1

Key Points

  • Two priority prevention targets for surveillance have been identified (e.g. CLABSI and SSI).

  • Illinois hospitals with adult, pediatric, and/or neonatal ICUs are required to report CLABSIs through NHSN.

  • Illinois hospitals are required to report TKA and CABG SSIs through NHSN beginning April 1, 2010.



Development of 5 workgroups

Development of 5 Workgroups

  • MDRO Workgroup

    • Will explore making all or some of the specific emerging multidrug-resistant gram negative organisms of epidemiologic importance reportable in the State of Illinois.

  • HAI Workgroup

    • Establish outbreak reporting requirements

    • Explore methods to electronically achieve notification of HAI outbreaks

    • Explore developing a separate module for reporting HAI clusters within the current reporting systems

Workgroups continued

Workgroups continued

  • Outbreak/Breaches of IC Practices Workgroup

    • Explore developing processes and tiered response criteria to handle increase reports of serious infection control breaches or suspect cases/clusters, and outbreaks

    • Decide on actions that will be taken when serious infection control breaches have been identified

  • Surveillance Workgroup

    • Explore developing legislation to mandate use of qualified electronic surveillance system and minimum Infection Preventionist staffing levels

Workgroups continued1

Workgroups continued

  • Long Term Care Workgroup

    • Assist in developing a statewide needs assessment and profile

    • Establish educational standards for LTC and LTACH healthcare workers

    • Develop standardized educational tools

    • Implement the educational sessions

    • Explore current and future collaboratives between local health departments and LTCF, LTACHs and hospitals

Evaluation and communication

Evaluation and Communication

Key points2

Key Points

  • IDPH will be measuring progress towards targets through NHSN data.

  • Validation activities will be implemented throughout the year.

  • Consumers have access to healthcare quality measures through the Illinois Hospital Report Card Web Site

Illinois healthcare associated infections hai plan


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