Healthcare Associated Infection Prevention and Control Program: Update on DPH Campaign December 4, 2007

1. Healthcare Associated Infection Prevention and Control Program:Update on DPH Campaign December 4, 2007 Massachusetts Department of Public Health Betsy Lehman Center for Patient Safety and Medical Error Reduction JSI Research and Training Institute, Inc.

2. Problem • Healthcare-associated infection (HAI) has been increasingly identified as a cause of preventable illness and death. • In the United States, HAIs adversely affect approximately 2 million hospitalized patients and result in 90,000 deaths each year. • The occurrence of and accountability associated with HAI has become a priority issue for patients, consumer groups, patient safety organizations, regulatory agencies, professional practice advisory committees and state and federal policy makers.

3. Legislation

4. Impact in Massachusetts • Using various sources, annual HAI costs in MA are approx. $200 million • 88% of costs come from three infections: • Surgical Site Infections - $87 million • Blood Stream Infections - $72 million • Pneumonia - $40 million

5. In response: Lehman Center Report on Healthcare Associated InfectionsIdentified Needs Released August, 2007

6. I. Develop Optimal Infection Control Programs • Reviewed and provided feedback on available literature and standards • Surveyed hospitals regarding current practices • Formulated recommendations based on available information on critical components and key activities of an Infection Control program

7. Findings from Survey of Infection Control Staff at State Hospitals • Vast majority feel management is “supportive” • Split on whether resources are adequate • ~60% do not feel management has a good understanding of the Infection Control Program’s key tasks and responsibilities • 96% would like more support or different type of support (including more staff and IT resources)

8. II. Offer Concrete “Best Practice” Recommendations

9. Best Practice Guidelines • Adapted from nationally accepted standards of care (CDC, HICPAC, APIC, SHEA and the American Thoracic Society). • Guidelines will provide Massachusetts hospitals with a comprehensive list of updated recommendations to promote improvement.

10. Example of Best Practice Guidelines:Ventilator Associated Pneumonia • Elevate HOB 30-45°. A-I • Document degree of elevation using validated instruments or bed markings every 8 hours. A-I • Daily interruption or lightening of sedation. A-II • Orotracheal intubation and orogastric tubes preferred over nasotracheal intubation and nasogastric tubes. B-II 5. Endotracheal tube should be of proper size and cuff pressure should be maintained at the minimal occluding volume to prevent leakage of bacterial pathogens around the cuff into the lower respiratory tract without inducing tracheal injury. B-II

11. III. Provide Direction on Public Reporting and Communication • Reviewed available literature, recommendations and reports on public and across-hospital reporting of individual HAIs • Reviewed current approaches to communication and education of public on HAI, including consideration of risk adjustment • Formulated recommendations for MDPH and Lehman Center on public reporting and communication

12. In Response to the Report:DPH Program Goals • Implement prevention oriented educational, training and technical assistance efforts at hospitals • Require hospitals to report on HAIs as well as on Prevention and Control activities • Prepare consumers/patients to be well-informed and active participants in the elimination of HAIs

13. Goal 1: Implement Prevention-Oriented Educational Programs and Consultative Support for Hospitals • Engagement of hospital leadership: designate an improvement team, review results, and share strategies • Improvement Advisory Group: advise on curriculum and improvement strategies • Learning Sessions: hospital teams hear from experts, share materials and report lessons learned

14. Goal 1: Implement Prevention-Oriented Educational Programs and Consultative Support for Hospitals • Resources: • Develop toolkits based on local and national programs • Revise toolkit through testing by the improvement teams • Share toolkits at educational programs, on listserve, and on website

15. Goal 1: Implement Prevention-Oriented Educational Programs and Consultative Support for Hospitals 5. Other Support Services: • Review and discuss monthly hospital reports • Regular conference calls with national models and MA hospital teams • Statewide listserve for consultation among improvement teams • On-site visits 6. Strategies for patients & families: materials for hospitals to provide to patients and families to be active partners in care, and sharing successful strategies

16. Goal 2: Mandatory Reporting • Regulations will require hospitals to report selected outcome and process measures to the National Healthcare Safety Network (NHSN). • Reporting hospitals will provide three levels of access to the data: • DPH will have access to data that it will prepare for public reporting • The Betsy Lehman Center will have access to data that are not quite ready for public reporting • Individual hospitals will see their own data and aggregate data from other hospitals

17. Reporting Recommendations: Level 1: Reporting to the public Outcome measures: • Bloodstream infections assoc. with central venous catheters in ICU patients (pathogens) A-IV • Surgical site infections from total hip and knee replacements B-IV Process measures: • Influenza vaccination of healthcare workers (pending final Task Group approval)

18. General Public--- Themes: • HAIs are a frightening concept; interest limited to immediate and direct personal relevance • HAI rates rank lower in importance than experiences (family, friends, personal) for selecting a hospital • In reports, • using summary safety scores may be most effective • numbers are preferred over summary symbols (i.e., consumer reports approach) • simple graphs are useful • risk adjustment and statistical aspects are confusing • keep things brief

19. Reporting Recommendations: Level 2: Reporting to oversight agency Outcome measures: • Bloodstream infections assoc. with central venous catheters in all ICU patients (common skin contaminants) B-II • Surgical site infections from CABG and total vaginal and abdominal hysterectomies B-IV • Process measures: • VAP prevention --- head of bed elevation and daily assessment of readiness to wean B-II • MRSA point prevalence (pending final Task Group approval)

20. Reporting Recommendations: Level 3: Reporting within hospital only Outcome measures: • Bloodstream infections assoc. with central venous catheters outside of ICU’s (pathogens and common skin contaminants) B-IV • Rates of ventilator-associated pneumonia A-II

21. Goal 2: Oversight • Inspection of hospitals on a regular basis by Department of Public Health surveyors - rates of infections - best practices - policies and procedures • Compliance with State Licensing and Federal Medicare and Medicaid regulations • Protocols specific to infection prevention and control

22. Goal 3: Consumer Education Activities • Task Group on Reporting & Communication with previous assessment of available materials and needs • Ongoing formative research and testing of approaches to conveying HAI outcome data to public • Hospital survey data from ICPs on current practices and tools for educating patients/families • Guidance from Expert Panel on needs and gaps • Current discussions about best approaches, involving outside groups focused on patient education and empowerment

23. Collaborate with many other partners on this critical issue • Health Care Quality and Cost Council • Massachusetts State Legislature • Massachusetts Hospital Association • Coalition for the Prevention of Medical Errors • JSI Training and Research • Massachusetts Medical Society • Health Care for All • Betsy Lehman Center