Hospital-Acquired Infection Reporting

1. Hospital-Acquired Infection Reporting Rachel L. Stricof rls01@health.state.ny.us

2. Chapter Laws 284 & 239 • Enacted in 2005 • “Hospital-acquired infection” = any localized or systemic condition that • (a) resulted from the presence of an infectious agent(s)/toxin(s) as determined by clinical examination or by lab testing; and • (b) was not found to be present or incubating at admission unless related to a previous admission to the same setting

3. Who Has To Report? • “General hospitals” – not residential facilities, not public health centers, not diagnostic and treatment centers • General hospitals must have programs for identifying and tracking HAI for reporting purposes under this law and also for quality improvement (QI)

4. Hospital Responsibilities • The program must have capacity to identify: • Specific infectious agents/toxins; • The site of infection; • Location where patient became infected; • Patient diagnoses; • Any relevant surgical, medical and diagnostic procedures during current stay • The hospital must identify and regularly report HAIs to NYSDOH [or designated agent (e.g., CDC/NHSN)] as directed by Commissioner.

5. NYSDOH Responsibilities • Establish guidelines, definitions, criteria, standards and coding for hospital identification, tracking and reporting of HAIs; • Consistent with NHSN or other recognized center of expertise • Establish data collection and analytical methodologies that meet accepted standards for validity and reliability • Initially require reporting of central line associated blood stream infections and surgical site infections associated with critical care units • Subsequently, may require tracking and reporting of other HAIs in consultation with technical advisors

6. NYSDOH Requirements • Report annually to governor, legislature & the public (on the web) • Pilot project and data (Year 1 – hospitals de-identified) • Annually thereafter, hospital risk-adjusted rates • Quality improvement efforts • Prior to release, department will consult with various groups to ensure summary tables are easily understandable and accurately reflect HAI rates. • Audit hospitals for completeness and accuracy of reporting. • Department may award grants (if funding is made available).

7. Hospital Reporting • NYS cannot require reporting more often than once every six months. • Reporting must occur within 60 days of the end of the reporting period.

8. The data will support quality improvement and prevention efforts. The aggregate data will be made available to the public, providers & insurers for their use. What is to be Done With Information?

9. When is this Going to Happen? • 7/1/06–DOH must have a reporting system • 1/1/07-Hospitals must begin collecting data for reporting • 1/1/07-12/31/07- Pilot Year • DOH will publish report but will not identify hospitals • Only DOH will know the identity of hospitals

10. What About Patient Privacy? • Patient identifying information governed by PHL 206(1)(j) • - The most stringent assurance of confidentiality in the PHL. • - Hospital identifying information is not protected after the pilot year.

11. PHL 206(1)(j): a) information must be kept confidential and used solely for research or QI through medical audits PHL 206(1)(j): b) information when received by Commissioner/ designee is “not admissible as evidence in any action of any kind in any court or before any other tribunal, board, agency or person.” Confidentiality

12. Confidentiality Patient information submitted by hospitals under PHL 2819 to the DOH or designee (NHSN) is not reachable by subpoena or court order.

13. NYS Public Health Law 2819 • Critical care/intensive care units • Central line associated blood stream infections • Surgical site infections • DOH may require reporting of other types of HAIs

14. Selection of Indicators • Central-line associated blood stream infections in ICUs • Surgical Site Infections – Which Procedures ? • Frequency • Severity • Preventability • Likelihood that they can be detected and reported accurately • Cardiac • Colon

15. Reporting System • CDC’s National Healthcare Safety Network (NHSN) • Standard definitions, surveillance, risk adjustment • Protocols in place • Post-discharge Surveillance • Sub-workgroup established

16. WHY??????

17. Regulatory – Historical Perspective • Adverse event reporting system [PHL 2805-l, October 1, 1985] • Definition of occurrences: • patients' deaths or impairments of bodily functions in circumstances other than those related to the natural course of illness, disease or proper treatment in accordance with generally accepted medical standards • Confidentiality prevents disclosure of incident reports under the Freedom of Information Law [PHL 2805-m ]

18. New York Patient Occurrence Reporting and Tracking System (NYPORTS) • Electronic internet-based system • Created to simplify reporting and coding • Coordinated with other reporting systems to reduce duplication • Designed to provide feedback on reporting patterns and compare facilities in the region and the State • Initiated in 1995 – implemented statewide April, 1998

19. Health Care Reform Act - 1996 • Hospital Report Cards • Infection indicators sought • Limited to existing data sources only • Discharge database not valid for HAI indicators • Studies revealed poor sensitivity and specificity • Not able to distinguish between community, nosocomial or other healthcare facility-related events • No evidence in record to support diagnosis • Post-discharge events not detected • No other existing data source • Let’s investigate……….conduct a study

20. Iroquois Project • Iroquois Healthcare Consortium • 57 hospitals, 31 counties • NYSDOH funded project 4-1-99 to 3-31-03 • Goal • Identify appropriate nosocomial infection indicators for potential public reporting • Feasible and useful • Design, develop, implement and evaluate • Hospital-associated infection indicators • Antimicrobial-resistant organism indicator

21. Bed Size

22. Surgical Site Indicators • Ideal: high volume and high risk procedures • Difficulty identifying common surgical procedures • Hysterectomy • Sufficient volume • Performed across spectrum of hospitals • Relatively low infection risk • Required adopting standardized definitions and surveillance methods, including post-discharge surveillance

23. Hysterectomy • Needed to control for type (vaginal, laparoscopic vs. abdominal), complexity (single vs. multiple procedures, risk index), and conditions (elective vs. emergency) • 2949 procedures in 1 year • Vaginal hysterectomy – 1.0% infection rate • 75% not cultured • Abdominal hysterectomy – 3.0% infection rate • 42% not cultured • 82% of infections identified post-discharge • 2/3 via physician survey • 1/3 upon readmission

24. Lessons Learned • Cannot compare unless: • Standardized definitions • Standardized surveillance methods • Comparing same procedures • Adjusted for risk • Existing data could not be used • Administrative (SPARCS) database would not detect post-discharge events • Laboratory-based surveillance not adequate • Highly resource dependent • Not sustainable without additional resources

25. Infection Control Resources Survey New York State Department of Health Analysis, December 2004

26. Response Rate • 167/234 (71.4%) • 148 Infection control professionals (ICPs) responded • Representing 167 acute care facilities • ICPs may cover more than one acute care facilities • Survey only sent to acute care facilities

27. Professional Resources • 218 full-time equivalent (FTE) ICPs • 158 were dedicated to routine surveillance activities • 11% of infection control programs cover more than one acute care facility • Less than ½ of the facilities (45.8%) had a hospital epidemiologist (HE) • For those facilities with a hospital epidemiologist, the individual devoted an average of .35 FTE to HE activities.

28. Organizational Placement Number Percent Quality Assurance 48 32% Nursing 43 29% Administration 20 14% Infectious Disease 8 5% Internal Medicine 6 4% Laboratory 3 1% Other/Unknown 20 14%

29. ICP-Surveillance Responsibilities

30. Total House Targeted Bloodstream 57% 40% Surgical Site 51% 44% Pneumonia 36% 57% Urinary Tract 28% 41% Routine Surveillance Activities

31. ICPs Responsibilities* • Employee/Occupational Health 68% • Central Supply/Sterile Processing 52% • Staff Education 73% • Risk Management 45% • Emergency/BT preparedness 70% • Quality assurance 55% * At least partial responsibility

32. Support and Services for IC Program Percent Facilities • Some Secretarial Support 57% • FTE, if secretarial support 0.7 FTE • Computer for ICP 96% • Internet Access 99% • Fax 86% • Computerized Medical Records, incl. partial 53% • Computerized Laboratory Records 93% • Computerized Radiology Reports 86%

33. Laboratory No Part Yes Unk Inhouse Clin Micro 20% 11% 69% Inhouse Mycobacteriol (TB) 45% 20% 34% 1% Inhouse Viral Culture 68% 11% 20% 1% Inhouse Rapid Viral Testing 29% 26% 45% 1% Inhouse Fungal Testing 51% 15% 32% 2% Most Recent Antibiogram prior to 2003: 7%

34. Hope to continue to monitor resources Why Infection Control Resources?

35. Julian et al. Hershey Medical Center SHEA 2005

36. ICD-9 vs. Active Surveillance –Validation Study, PA Sherman et al Children’s Hospital of Philadelphia - SHEA 2005

37. NYSDOH Goals and Objectives Develop and implement meaningful and useful HAI reporting system for Department, Facilities & Public The ultimate goal is the prevention of the HAI indicators selected. The system will be used to evaluate potential interventions, risk factors, and risk adjustment strategies for those factors that are not amenable to change. The NYSDOH may, in the future, consider supporting regional research efforts in the area of infection prevention and control. The HAI reporting system will be used to evaluate impact of quality initiatives.

38. https://commerce.health.state.ny.us/ hpn/cch/hosp_infection/