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  1. TITLE OF PRESENTATIONSubtitle of Presentation Infection Prevention in New York City Successes, Challenges & Opportunities David P. Calfee, MD, MS Associate Professor of Medicine and Public Health Chief Hospital Epidemiologist

  2. Outline • A “look-back” at the past 10 years of infection prevention in the Greater New York area • Successes • Challenges • Opportunities

  3. and did A Lot Can Happen in 10 Years ^ • Outbreaks of old pathogens • Mumps (2009) • Measles (2011) • Outbreaks of new pathogens • SARS (2003) • Pandemic influenza H1N1 (2009) • Emergence and dissemination of new resistance patterns among healthcare-associated pathogens • Multidrug-resistant Acinetobacter • Carbapenem-resistant Enterobacteriaceae (e.g, K. pneumoniae)

  4. A Lot Can Happen in 10 Years • Bioterrorism • Anthrax (2001, and few days of panic in 2006) • NYC small pox vaccination program (2003) • Disasters • Blackout (2003) • Hurricanes (Irene 2011, Sandy 2012)

  5. A Lot Can Happen in 10 Years • Public reporting of HAI in New York State • Public health Law 2819: 2005 • First year of hospital reporting: 2007 • First public report of hospital-specific data: 2009 • Flu vaccine • HCW vaccine mandate (and subsequent lawsuits): 2009 • Pay-for-performance • Core measures • Hospital-acquired conditions • Value-based purchasing • National Patient Safety Goal 7 • Hand hygiene, CLABSI, CAUTI, SSI, MDROs

  6. Greater New York Infection Prevention Successes

  7. “Physicians cannot wait for operational excellence to justify their commitment; they need to achieve excellence through influence, example, and leadership.” • Stephen C. Beeson, MD Beeson SC. Practicing Excellence: A Physician’s Manual to Exceptional Health Care. 2006

  8. GNYHA-UHF CLABs Collaborative • 2005-2008 • 49 ICUs from 36 hospitals throughout the region • This collaborative represented a paradigm shift in infection control practice and perception: preventing infections is everyone’s responsibility. • Interdisciplinary teams • Regular team meetings • Implementation of a central line “bundle” • Plan-Do-Study-Act (PDSA) model Koll BS, Straub TA, Jalon HS, Block R, Heller KS, Ruiz RE. Jt Comm J Qual Patient Saf 34(12): 713–23

  9. Outcomes of the CLABs Collaborative • Mean rate decreased by 54%. • Some hospitals observed reductions as great as 88%. • 56% of hospitals observed a reduction of at least 50%. • The greatest reductions were seen in hospitals with the highest baseline rates. Koll BS, Straub TA, Jalon HS, Block R, Heller KS, Ruiz RE. Jt Comm J Qual Patient Saf 34(12): 713–23

  10. CLABSI Rates in NYS ICUs Continue to Decline • Comparing 2011 data to 2007 data: • Surgical ICUs: 57% reduction • Neurosurgical ICUs: 48% reduction • Cardiothoracic surgery ICUs: 46% reduction • Medical ICUs: 45% reduction • Medical-surgical ICUs: 34% reduction • Pediatric ICUs: 31% reduction • Coronary ICUs: 25% reduction • Neonatal ICUs • Regional Perinatal Centers: 49% reduction • Level 3 and 2/3 ICUs: 17% reduction NYS DOH. Hospital-acquired infections, 2011. September 2012. http://www.health.ny.gov/statistics/facilities/hospital/hospital_acquired_infections/2011/docs/hospital_acquired_infection.pdf

  11. CLABSI Rates in NYS ICUs Continue to Decline • NY State CLABSI SIR significantly decreased between 2009 and 2010. • 2010 SIR was 0.858 (versus 1.029 in 2009) CDC. National and state healthcare-associated infections standardized infection ratio report, 2010. http://www.cdc.gov/hai/pdfs/SIR/national-SIR-Report_03_29_2012.pdf

  12. GNYHA-UHF C. difficile Collaborative NYS DOH funded Phase I of Collaborative: 7/2007 to 3/2009 • Goal: to reduce C. difficileinfectionrates through standardized clinical infection prevention practices (a “bundle”) and environmental cleaning protocols • Planning began in July 2007 • Collaborative began in 3/2008 • Data reporting ended in 12/2009

  13. Interventions • Assessment of baseline practices • Use of standardized clinical case definitions* • Implementation of a clinical infection prevention “bundle” • Development of a standardized environmental cleaning protocol • Checklist • Bleach • Distribution of monthly data reports • Educational and practice-sharing opportunities • Site visits *Prior to availability of NHSN MDRO/C. difficile module definitions

  14. The C. difficile Prevention “Bundle” • Contact precautions initiated at time of symptom onset • Contact precautions sign on door • Personal protective equipment (i.e., gowns and gloves) readily available • Hand hygiene • Strategy for optimal patient placement (e.g., single room, cohorting with other CDI patient(s)) • Dedicated thermometers for CDI patients if rectal thermometers are used.

  15. Outcomes: C. difficile Infection Rates 20% reduction **p<0.001 CDC. MMWR 2012;61:157-62

  16. Intrahospital Comparisons Hospital Identification Number

  17. C. difficile Prevention Strategies Cohen SH. Infect Control Hosp Epidemiol 2010; 31:431-55 Gerding DN. Infect Control Hosp Epidemiol 2008;29(S1):S81-92

  18. GNYHA-UHF Antimicrobial Stewardship Project • The overall objective was to develop and test strategies and tools that can be used by health care facilities to implement an effective and sustainable antimicrobial stewardship program. • Specific objectives included: • To establish antibiotic stewardship programs (ASP) in acute care hospitals and LTCF using existing personnel and resources • To establish acute care hospital-LTCF collaborations related to ASP • To develop and pilot tools for ASP development and implementation in other health care facilities • To identify best practices for and challenges associated with ASP implementation

  19. GNYHA-UHF Antimicrobial Stewardship Project 3 acute care hospitals were selected from among those participating in the C. difficile collaborative. Chosen hospitals were required to recruit a long-term care facility partner to participate in the project. October 2009-June 2010

  20. Interventions • Develop a stewardship team. • Participate in meetings and conference calls. • Assess current practices and resources. • Identify and prioritize ASP target areas. • Select and implement interventions.

  21. Project Outcomes • In a short period of time and without additional resources, hospitals and long-term care facilities were able to introduce antimicrobial stewardship programs into their facilities. • Qualitative data suggest that the programs were beneficial.

  22. Outcomes: Examples of Success • Successful hospital interventions: • Expansion of activities to 3 new units (acceptance ~100%) • Completion of an IRB-approved study of practices related to UTI diagnosis and treatment, involving students and residents, resulting in development and revision of guidelines • Successful LTCF interventions • Presentation of baseline data on inappropriate antimicrobial use for asymptomatic bacteriuria to Medical and Nursing Directors, leading to a facility-wide PI Project with development of a protocol for UTI diagnosis and treatment • Development of a restricted antibiotic list • Review of urine culture results with subsequent interaction with clinicians

  23. Outcomes: Examples of Success • Hospital-LTCF Collaborations • At least one hospital-LTCF team began having joint ASP meetings that involved LTCF medical director. • At one site, hospital pharmacists were granted access to LTCF resident drug profiles to assist with stewardship activities.

  24. Educational materials • Marketing materials • Tools for stewardship teams

  25. Outcomes: Lessons Learned • Antimicrobial stewardship is complex: there is not a “one size fits all” bundle. • Keys to success: • A motivated team • Support from administration and medical leadership • Data • Access to ready-made tools to assist ASP activities • A forum to discuss challenges and best practices

  26. Greater New York Infection Prevention Challenges

  27. General Challenges • Space constraints • Hospital closures • Permanent • Temporary • Infection Prevention staffing • NYSDOH annual survey showed stable IP to bed ratio, but certainly no increase over past few years despite greater demands. • How do we ensure that best practices are consistently applied? • We are improving, but so is everyone else.

  28. Ongoing CLABSI Challenges • The 2011 NYC CLABSI rate is significantly higher than the NYS average. • SIR 1.15 (1.05-1.25) • The New York State CLABSI rate is higher than the US average. • 2010 NYS SIR was 25% higher than that of the US overall. • In 2009, 17 states used NHSN to satisfy a state-specific CLABSI reporting mandate. • New York had the fourth highest CLABSI SIR. • The 5 states that had a data validation program had the 5 highest SIRs among the 17 states. • CLABSI prevention efforts in non-ICU settings are lagging. NYS DOH. Hospital-acquired infections, 2011. September 2012. http://www.cdc.gov/hai/pdfs/SIR/national-SIR-Report_03_29_2012.pdf http://www.cdc.gov/HAI/pdfs/stateplans/SIR_05_25_2010.pdf

  29. NYS DOH. Hospital-acquired infections, 2011. September 2012.

  30. Multidrug-Resistant Organisms (MDROs) • MRSA • CMS will require reporting of MRSA bacteremias beginning January 2013. • National target for MRSA bacteremia in hospitals: 25% reduction by 2013 • National data suggests that invasive MRSA infections are decreasing. Kallen AJ. JAMA 2010;304:641-8

  31. US Targets for C. difficile Prevention, 2013 • U.S. data • C. difficile hospitalizations • Goal: 30% reduction (vs 2008 rate of 11.7 per 1,000 discharges) • 2011 rate:11.9 (1.7% increase from baseline) • C. difficile infections • Goal: 30% reduction • No progress report available National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination. http://www.hhs.gov/ash/initiatives/hai/infection.html

  32. C. difficile Infectionin US Hospitals, 2009 CDI stays per 100,000 Lucado, J. Clostridium difficile Infections (CDI) in Hospital Stays, 2009. HCUP Statistical Brief #124. January 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb124.pdf

  33. Ongoing C. difficile Challenges • NYC hospital-onset C. difficile SIR (compared to state average) was 1.01 (0.98-1.04). • New York State hospital-onset C. difficile rates • 2010 NYS rate of 8.2 per 10,000 patient-days was significantly higher than the national average of 7.4. • The 2011 rate was 8.48 cases per 10,000 patient days, a 3% increase compared to 2010. • Note: The percentage of hospitals using certain highly sensitive tests (i.e., PCR) increased from 10% to 41%. NYS DOH. Hospital-acquired infections, 2011. September 2012.

  34. MDR Gram-Negatives Isolate Kl pneumoniae ANTIBIOTICS Mic SYSTEMIC URINE ________ _____________________________ Ampicillin >16 R Amox/K Clav'ate >16/8 R Aztreonam >16 R Ceftriaxone >32 R Ceftazidime >16 R Ce fotaxime 32 I Cefoxitin >16 R Cefazolin >16 R Ciprofloxacin >2 R Cefepime >16 R Amikacin 32 I Cefuroxime >16 R Tigecyline 1.5 S Ertapenem >4 R Gentam i cin <4 S Imipen e m >32 R Levofloxac i n >4 R Meropenem >8 R Piperacillin/tazo >64 R Trimethoprim/Sulf >2/38 R Tetracycline <4 S Tobramycin >8 R Polymyxin B 64 R

  35. Outcomes Associated with MDR-GNR Infections: Invasive K. pneumoniae Infection p<0.001 p<0.001 38 48 CRKP: carbapenem-resistant K. pneumoniae CSKP: carbapenem-susceptible K. pneumoniae 20 12 Patel G. Infect Control Hosp Epidemiol 2008;29:1099-106 37

  36. Carbapenem Resistance among Health Care-Associated K. pneumoniae Isolates • Sporadic cases in the 1990’s • <1% of all K. pneumoniae isolates reported to NNIS in 2000 • Rates of carbapenem-resistance among K. pneumoniae isolates reported to NHSN (2006-2007) • All US states except NY: 5% • New York: 21% Hidron AI. Infect Control Hospital Epidemiol 2008; 29(11):996-1011

  37. Prevalence of CRE Among Inpatients in Two NYC Hospitals The overall prevalence of CRE was 5.4%. The average monthly prevalence was 7.4%. 68% of carriers were identified by active surveillance alone. Calfee DP. Unpublished data.

  38. Frequency of and Risk Factors for Acquisition of CRE • Independent predictors of CRE acquisition included: • Pulmonary disease (OR 11.53, p=0.02) • Mechanical ventilation (OR 5.19, p=0.04) • Days of antibiotic therapy (OR 1.04, p=0.003) • CRE colonization pressure (OR1.15, p=0.01) • The odds of acquiring CRE increased by 4% for every day of antibiotic therapy received and by 15% for every 1% increase in the colonization pressure to which a subject was exposed. Calfee DP. Unpublished data.

  39. Compliance with Infection Control Measures Reduces Risk • Compliance with infection prevention policies can reduce the association between prevalence and incidence of CRE. Schwaber MJ. Clin Infect Dis 2011;52(7):1-8

  40. Regional MDRO Control Initiatives • Intervention included: • Mandatory reporting of all CRE patients • Mandatory isolation of hospitalized CRE carriers • Contact precautions (index and subsequent admissions) • Cohort nursing • National Task Force with authority to collect data and intervene as needed. National guidelines for active surveillance and intervention in LTCF issued Schwaber MJ. Clin Infect Dis 2011;52(7):1-8

  41. Antimicrobial Stewardship Programs Johannsson B. Infect Control Hosp Epidemiol 2011;32:367-74 • Despite evidence of benefit, not all health care facilities have introduced such programs. • 79% of university hospitals • 40% of community hospitals • Almost unheard of in long-term care facilities • Lack of funding and personnel are the most commonly reported barriers.

  42. Policy Statement on Antimicrobial Stewardship: SHEA, IDSA, PIDS • Antimicrobial stewardship programs should be required through regulatory mechanisms. • Antimicrobial stewardship should be monitored in ambulatory healthcare settings. • Education about antimicrobial resistance and antimicrobial stewardship must be accomplished. • Antimicrobial use data should be collected and readily available for both inpatient and outpatient settings. • Research on antimicrobial stewardship is needed. SHEA, IDSA, PIDS. Infect Control Hosp Epidemiol 2012;33(4):322-7

  43. CMS: Conditions of Participation for Infection Control • Facility has a multidisciplinary process to review antimicrobial utilization, local susceptibility patterns, and antimicrobial agents in the formulary and there is evidence that the process is followed. • Systems are in place to prompt clinicians to use appropriate antimicrobial agents (e.g., computerized physician order entry, comments in microbiology susceptibility reports, notifications from clinical pharmacist, formulary restrictions, evidenced based guidelines and recommendations). • Antibiotic orders include an indication for use. • There is a mechanism in place to prompt clinicians to review antibiotic courses of therapy after 72 hours of treatment. • The facility has a system to identify patients currently receiving intravenous antibiotics who might be eligible to receive oral antibiotic treatment. Currently, deficiencies in these criteria will NOT result in citation, but... CMS. October 2011. https://www.cms.gov/Surveycertificationgeninfo/downloads/SCLetter12_01.pdf

  44. HCW Influenza Vaccination • In a CDC survey of the 2011-12 season, 66.9% of HCP reported having received flu vaccine. • Physicians 85.6% • Nurses 77.9% • Others: 62.8% • Vaccination coverage was 76.9% among HCP in hospitals. • Only 44% of HCW in NY received influenza vaccine. • CMS-required reporting of healthcare worker influenza vaccination (via NHSN) begins January 2013. • Joint Commission requires hospitals to set incremental influenza vaccination goals, achieving 90% by 2020. • How will we get to >90%? NYCDOHMH. Advisory #38. Influenza advisory. December 14 2012. CDC. MMWR 2012;61(38):753-7

  45. Greater New York Infection Prevention Opportunities

  46. New Appreciation for Healthcare-Associated Infections • HAIs are an important cause of morbidity and mortality among patients in US hospitals. • HAIs are not inevitable consequences of health care. • HAIs are largely preventable. • A “very low” rate of infection isn’t low enough for the patient that develops the infection. • Everyone shares the responsibility for preventing these infections.

  47. Opportunities and Obligations • Advocacy and engagement • Professional societies: APIC, SHEA • Organizations: healthcare facilities, GNYHA, HANYS • Individual involvement: local, state, federal level • Epidemiologic, clinical, and basic research • Eliminate knowledge deficits • Optimize use of limited resources • Multicenter, high-quality studies • Develop new technology • Cost-effectiveness research • Utilize new sources of funding for research • NIH, AHRQ, CDC, NYSDOH, foundations, industry

  48. Opportunities and Obligations • Innovative approaches to improving practice • Implementation science • Systems engineering • Bundles and checklists • Behavioral science • Root cause analysis • Positive deviance • Collaboration