Implementation of Hospital-Associated Infection HAI Reporting and Public Disclosure: What we have learned in South Carol

1. Implementation of Hospital-Associated Infection (HAI) Reporting and Public Disclosure: What we have learned in South Carolina Jerry Gibson MD, MPH SC State Epidemiologist and Director of Disease Control Thanks to Dixie Roberts MPH, ARPN, Amber Taylor MPH, Stan Ostrawski RN, MS MT, Eric Brenner MD

5. �It�s the Politics, Stupid� Many stakeholders in HAI public disclosure, with very different interests and levels of sophistication Statutes were often passed because of political advocacy by citizens harmed by HAI: anger, mistrust of hospitals, rigid agendas, lack of medical sophistication Legislators� first interest: satisfy public advocates Advisory Committee task: I.D. education of stakeholders

6. Does publishing patient care performance data improve quality of care? The unintended consequences of publicly reporting quality information Werner RM, Asch DA, JAMA 2005 Review: Evidence that publishing patient care performance data improves quality of care Fung CH et al, Annals of IM 2008 ��the usefulness of public reporting in improving patient safety and patient-centeredness remains unknown��

7. Public disclosure of HAI: Classic example of the Law of Unintended Consequences Advocates want reporting of counts, or of dramatic cases of HAI: Bias against large and tertiary institutions Failure to adjust HAI rates for patient, procedure, or institutional risks of infection: Bias against referral/teaching hospitals Failure to validate reporting completeness Powerful perverse incentive for hospital to make less effort Honest hospitals appear unsafe

8. Public Disclosure: Unintended Consequences II 4. Overemphasis on reporting inadequate time for prevention by scarce ICP staff rates worse 5. Report only more easily counted infections exclude counting difficult to define infections (VAP) No data on major classes of preventable infections 6. Failure to search for HAI onsets post-D/C late-onset HAI undercounted inadequate $ for prevention (e.g. joint replacement SSI) 7. Denial of admission or of aggressive therapy to high-risk patients, to reduce infection rate

9. Acute-Care Hospital Size Distribution in SC (67 hospitals)

10. Other problems with effective HAI reporting and disclosure HAI are uncommon events (table): �Searching for a needle in a haystack� Active surveillance for HAI is expensive: Numbers of ICPs are insufficient �Surveillance on the cheap� (using routinely collected databases, e.g. administrative claims data) Seductively simple-appearing Claims data are insensitive and non-specific (next) Counting & risk-adjusting HAIs is complex, prone to errors, and a lot of work

11. This slide illustrates the basic structure of the Patient Safety Component of NHSN. The Device-associated Module is shown on the left part of the diagram in brown. As you can see, there are four separate options in the Device-associated module: Central Line-associated Bloodstream Infections (CLABSI), Ventilator-associated Pneumonia (VAP) Catheter-associated Urinary Tract Infection (CAUTI) and Dialysis Incident (DI). We will discuss only the first three of these during this session. The �Dialysis Incidents� option is used only by chronic outpatient dialysis centers and will be covered in a separate training session.This slide illustrates the basic structure of the Patient Safety Component of NHSN. The Device-associated Module is shown on the left part of the diagram in brown. As you can see, there are four separate options in the Device-associated module: Central Line-associated Bloodstream Infections (CLABSI), Ventilator-associated Pneumonia (VAP) Catheter-associated Urinary Tract Infection (CAUTI) and Dialysis Incident (DI). We will discuss only the first three of these during this session. The �Dialysis Incidents� option is used only by chronic outpatient dialysis centers and will be covered in a separate training session.

12. CLABSI 200,000 CLABSIs occur in the US each year Hospital stay, cost and risk of mortality are all increased Prevention through proper insertion and management of the central line CDC Guideline for the Prevention of Intravascular Catheter-Related Infections An estimated 200,000 CLABSIs occur in US hospitals every year. Primary bloodstream infections are serious infections that typically cause a prolonged hospital stay along with increased cost and risk of mortality. The CDC HICPAC Guideline for the Prevention of Intravascular Catheter Related Infections gives very specific recommendations for the proper management of patients with central lines. If followed, these measures can prevent, or at least greatly reduce the problem of bloodstream infections in patients with central lines. The link to the guideline is at the bottom of the screen.An estimated 200,000 CLABSIs occur in US hospitals every year. Primary bloodstream infections are serious infections that typically cause a prolonged hospital stay along with increased cost and risk of mortality. The CDC HICPAC Guideline for the Prevention of Intravascular Catheter Related Infections gives very specific recommendations for the proper management of patients with central lines. If followed, these measures can prevent, or at least greatly reduce the problem of bloodstream infections in patients with central lines. The link to the guideline is at the bottom of the screen.

13. Central Line Next, we�ll define Central Line. [read slide]Next, we�ll define Central Line. [read slide]

14. Studies of Accuracy of Administrative Claims Data Poor specificity (PPV= 0.14 - 0.51) Am J Infect Control 2008; 36:155 Tennessee data on MRSA surveillance � poor sensitivity State of Pennsylvania example SC study of predictive value of hospital claims, for validation: both PPV and NPV borderline (before CMS policy change) Effect of CMS changes in payment policy for HA-UTI, CABG

15. The Problems of Small Numbers, in a Median-Population State HAIs are uncommon, and many smaller hospitals must now begin reporting. Low infection rates require large sample sizes for effective validation of reporting. Small number of cases in smaller hospitals makes it hard to show rates are statistically different.

16. NHSN Pooled Means of CLABSI Rates by location

17. Incidence of Surgical Site Infections: NNIS 1992-2004 (AJIC 2004; 32:470

21. Reporting Infection Control Processes Process Measures � Survey of Practices Facility Profile: Bed Size, IC Resources, etc. IC Policies / Procedures/ Structure/ Surveillance Methods IC Process Monitoring Hand Hygiene Transmission Based Precautions SSI Prevention (includes SCIP) CLABSI Prevention VAP Prevention MRSA Prevention Other Formal IC Prevention Programs Antibiotic Stewardship Program (other?)

22. Example: IC Process Reporting Hand Hygiene (check all that apply) Who is monitored? (nurses, physicians, lab, x-ray, etc.) How is hand hygiene monitored? (video, direct observation) Who performs hand hygiene monitoring? (secret shopper, ICP, etc.) How often is hand hygiene monitoring conducted? What is the total number of hospital wide monthly observations? (select range) N/A 1 to 10 11 to 29 30 to 45 > 45

23. Hospital Validation VisitWhat are we going to Validate? ASA Score Wound Class Length of Surgery Date of Birth SSIs CLABSIs Infection Control Processes

24. Our Preparation Print out reported SSI and CLABSI information from NHSN Determine the number of control charts to review Random selection of control charts FAX a list of the charts to hospital

25. In Hospital, Before We Arrive Have the Charts we requested pulled If possible, have one chart marked with sticky tags so we can find information quickly If Records are computerized, make arrangements with Medical Records, IT, etc.

28. In Hospital,When We Arrive-SSI We will ask to have Medical Records do a search for all the ICD-9 Codes for the Operative Procedures for the validation period If done by Discharge Date, run an extra month to capture all the cases We will compare the Medical Records list with what was entered into NHSN

29. When We Arrive-CLABSI Microbiology lab: List of all Positive Blood Cultures from the Unit(s) during the Validation Period If the ICP has a line listing of the Patients that had Central Lines, we will compare it to the Positive Blood Culture List If there is no line listing, we will ask you to pull some charts of Patients with Positive Blood Cultures to see if they had a Central Line, and if the BSI was line related

30. CLABSI How are Central Line Days collected? Who Collects the Line Days? Do you keep a line listing of the Patients? If you don�t keep a line listing, how do you assure that the count is accurate? If you collect the line day data yourself, who collects the Line Days when you are not there?

31. Minimum Expected Post Discharge Surveillance Check for Readmissions and ER visits Inform the ICP at another Hospital if Surgery was done there (send documentation Enter report of infection received from another hospital (with documentation) --------------------------------------------------------- Physician reports Patient complaints

32. What Do We Do About These Problems? Get involved with the legislators early. Ask for a pilot year, and funding for it Emphasize reporting processes over infections Contact your stakeholders � help with politics & funding 5. State APIC, ID docs, Hosp Assoc, AARP, CDC Train the hospitals- and train again (and again)! Plan your method of validation � not optional

33. What Do We Do About These Problems? II 8. NHSN system created for voluntary use; may require Regulations; this will be very difficult for small hospitals 9. Plan your post-discharge surveillance method, with the hospitals 10. Don�t underestimate complexity of reporting the data: calculating rates, how to compare hospitals, hosp. stratification, making data understandable 11. Aiming at a moving target: Legislative expectations, evolving prevention processes, Federal involvement 12. Manage the press to educate consumers � - initial data release may be the best opportunity

35. MRSA Surveillance Using Merged Routinely Collected Data Sets - SC

37. HIDA ChallengeOutcome and Process Measures Outcome Measures SSI Rates (selected- CABG, HYS, VHYS, CHOL, Hip, Knee) CLABSI Rates (selected locations: Med-Surg ICU, PICU, all locations in < 150 bed facility ) MRSA Rates (invasive- bloodstream infections) Phase in others (other SSI procedures, VAP)