Healthcare-Associated Infection (HAI) Prevention

1. Healthcare-Associated Infection (HAI) Prevention Jane Carmean, RN, BSN, CIC Ohio Department of Health Bureau of Disease Investigation and Surveillance Outbreak Response Bioterrorism Investigation Team (ORBIT) (614) 995-5599 (ORBIT phone) (614)-644-2709 (desk phone) jane.carmean@odh.ohio.gov

2. How Do HAIs Impact Ohio? • Based on national estimates¹, HAIs affect 5 to 10 percent of hospitalized patients annually • For Ohio this translates into over 80 thousand infections • nearly 4 thousand deaths • adds $180 to $230 million to healthcare costs ¹ McKibben, L., et.al., AJIC 205:33:4, 217-226.

3. CDC Statement: Public Reporting of Healthcare-Associated Infections • The Centers for Disease Control and Prevention (CDC) believes public reporting of healthcare-associated infections (HAIs) is an important component of national HAI elimination efforts • Research shows that when healthcare facilities are aware of their infection issues and implement concrete strategies to prevent them, rates of certain hospital infections can be decreased by more than 70%

4. CDC Statement: Public Reporting of Healthcare-Associated Infections, cont • “Eliminating HAIs is a top priority for CDC.” • “The tracking and reporting of HAIs is an important step toward healthcare transparency.” • “Infection data can give healthcare facilities, patients and public health agencies the knowledge needed to design and implement prevention strategies that protect patients and save lives.” Quotes of Denise Cardo, director of CDC’s Division of Healthcare Quality Promotion

5. HAIs—National Attention • US Department of Health and Human Services (HHS) developed an action plan to prevent healthcare-associated infections • Support for HAI prevention has been enhanced through the American Recovery and Reinvestment Act (ARRA)

6. Congress Allocated $40 Million Through CDC • Support state health department efforts to prevent HAIs by enhancing state capacity for HAI prevention • Leverage the CDC’s National Health Care Safety Network (NHSN) to assess progress and support the dissemination of the HHS evidence-based practices within healthcare facilities • Pursue state-based collaborative implementation strategies

7. How the Congress- Allocated Money Flows • American Recovery and Reinvestment Act, (ARRA) • U.S. Department of Health and Human Services (HHS), • Centers for Disease Control and Prevention (CDC) • To the State Health Departments by way of the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) grant • Healthcare-Associated Infections - Building and Sustaining State Programs to Prevent Healthcare-associated Infections

8. Ohio’s Piece of the Pie • Ohio Department of Health submitted a letter of intent in May, 2009 • The grant application was submitted the following month • The Ohio Department of Health (ODH) was awarded $373,868

9. Three Activities Offered in the Grant • Activity A • Coordination and Reporting of Healthcare-Associated Infection (HAI) Prevention Efforts • Activity B • Detection and Reporting of Healthcare-Associated Infection Data - HAI Surveillance • Activity C (not funded in Ohio) • addressed the formation of a prevention collaborative among hospitals

10. Activity “A” • ODH will compute Ohio’s baseline measurements for at least two HHS prevention measure targets • Measures were selected based on recommendations by the multidisciplinary ODH Director’s Advisory Committee on Emerging Infections

11. Activity “B” • ODH will create infrastructure for electronic laboratory reporting for up to 11 Ohio hospitals • Participating hospitals will map and successfully submit an acceptable standardized health level (HL) 7 message to the ODH HL7 gateway

12. Reporting HAIs in Ohio • The OAC 3701-3-02-C-3 was revised in 2008 to explicitly include healthcare-associated outbreaks effective January 1, 2009 • This consequently strengthens the infrastructure of Ohio’s HAI prevention plan

13. Reporting HAIs in Ohio • The Ohio Department of Health Director’s Advisory Committee on Emerging Infections has assumed a leadership role in the statewide effort to reduce HAI in acute care facilities across Ohio. • This committee is a well established multidisciplinary group of individuals first brought together in the mid 1990s to address current and emerging infectious disease concerns.

14. Reporting HAIs in Ohio • Membership includes representatives from the Infectious Diseases Society of Ohio, five Ohio Association for Professionals in Infection Control and Epidemiology (APIC) chapters, local public health departments, academia, the Ohio Hospital Association and the Ohio Nurses Association. • For the purpose of developing a State healthcare-associated infection prevention plan, representation from KePRO, Ohio’s quality improvement organization, and additional stakeholders interested in the reduction of HAIs have joined the committee.

15. Four Top Concerns Facing Ohio Hospitals • A September 2009 survey of Ohio’s hospital infection preventionists identified: • Methicillin-resistant Staphylococcus aureus (MRSA) • Clostridium difficile (C. difficile) infections • Surgical site infections • Non-MRSA multi-drug resistant organisms (MDRO) as the

16. Measures Being Monitored • ODH will be implementing these activities for three of the HAI measures that are required for Ohio House Bill 197 compliance and outlined in Ohio Administrative Code 3701-14-04: • Laboratory identified Hospital-acquired Clostridium difficile • Laboratory identified Hospital-acquired Methicillin Resistant Staphylococcus aureus bacteremia • Laboratory identified Hospital-acquired Methicillin Susceptible Staphylococcus aureus bacteremia

17. Evaluation and Oversight • Program evaluation is an essential component of public health • Communicating the evaluation results allow for learning and ongoing improvement to occur • Evaluation activity of the prevention targets will be discussed and determined during future meetings of the Director’s Advisory Committee

18. CDC Surveillance for HAIs Voluntary system for monitoring nosocomial infections (1970 - 2004) Voluntary system for monitoring healthcare- associated events and processes (2005 - ) Increasingly used to comply with State legislation that mandates reporting of HAI data (2007 - ) Also being used as a tool for prevention collaboratives

19. Why use NHSN for HAI Reporting? • Provides standard definitions, protocols and methodology • Not just a reporting tool, comparative rates used for performance improvement • Useful analysis tools are included • CDC provides training and user support • Use of the application is free • Ability to share data with a Group

20. Reporting to aNational Data Base • Surveillance data collection must use • sound epidemiologic principles • scientifically credible and validated data • Surveillance systems must be able • to document the impact of HAIs • monitor trends • evaluate the effectiveness of prevention efforts

21. NHSN Demographics • 125 “Groups” in NHSN • 22 state health departments • 45 QIOs and QIOSC • 4 state hospital associations • 22 hospital systems • 1 Emerging Infections Program (EIP) site

22. Why Enroll with NHSN? • Enrolling in NHSN allows a facility to compare its data to national aggregated data, which helps drive the prevention process • Unlike facility-based systems, the maintenance and support for NHSN is conducted by CDC … so there is no additional cost for the facility

23. Data Sharing in NHSN: Groups • CDC does not send NHSN data to state health departments or other entities • Health departments or others obtain data directly from NHSN facilities – By becoming a group in NHSN – • Facilities join the group and confer rights to certain data

24. What is a “Group” in NHSN? A Group is a collection of facilities that have joined together within the NHSN framework to share some or all of their data at a single (group) level for a mutual purpose (e.g., performance improvement, state and/or public reporting)

25. Data Sharing in NHSN: Groups, cont • The group can analyze the data of its member facilities • Facilities within the group cannot see each other’s data • Facilities may join multiple groups

26. Steps to form a Group in NHSN Complete required reading and training for the Group Administrator or Group User An NHSN facility “nominates” the Group The Group Administrator obtains a digital certificate

27. Steps to form a Group in NHSN, cont 4. The Group Administrator adds additional users to the group and sets a Group joining password. 5. The Group Administrator sends the Group ID and Group joining password to facilities and invites them to join the Group. 6. Facilities join the Group and confer some/all rights to data.

28. CDC Support for the Group-Level User Consultation on experience from other States Presentations to Advisory Groups Collaboration with CSTE, SHEA, APIC, IDSA, other Federal agencies including CMS and AHRQ Access to “test” facilities NHSN State Users Group Conference calls monthly Web Board to share materials Consultation on analysis, HAI comparison metrics

29. Summary of the NHSN Group Function • Any entity can form a Group in NHSN • An NHSN facility “nominates” the group • Facilities join the group and confer some/all rights to data • The group can analyze the data of its member facilities • Facilities within the Group cannot see each other’s data • Facilities can join as many Groups at they like

30. Components of NHSN

31. Components of NHSN

32. Patient Safety Component Modules • CLABSI • CLIP • CAUTI • VAP • DE • SSI • PPP • AUR Pharmacy • AUR Microbiology • MDRO/CDAD Infection • Lab ID • Processes • Method A • Method B

33. Benefit of Reporting into the MRDO-lab identified event • Laboratory testing results can be used without clinical evaluation of the patient, allowing for a much less labor-intensive means to track MDROs. • When denominator data are available from electronic databases, these sources may be used as long as the counts are not substantially different (+ or – 5%) from manually collected counts.

34. Benefit of Reporting into the MRDO-lab identified event, cont • This method allows the facility to rely almost exclusively on easily obtained data from the clinical microbiology laboratory. • However, some data elements, such as date admitted to the facility would require other data sources.

35. How Data Are Used • In aggregate, CDC analyzes and publishes surveillance data to estimate and characterize the national burden of healthcare-associated infections • At the local level, the data analysis features of NHSN that are available to participating facilities range from rate tables and graphs to statistical analysis that compares the healthcare facility’s rates with the national aggregate metrics

36. Laboratory And Admission Data To Calculate Proxy Measures • admission prevalence rate • MDRO bloodstream infection incidence rate • Overall facility-wide: report only one denominator for the entire facility

37. Data Analysis • NHSN will categorize LabID Events as healthcare facility-onset vs. community-onset • This is realized • by classifying positive cultures obtained on day 1 (admission date), day 2, and day 3 of admission as community-onset (CO) LabID Events • and positive cultures obtained on or after day 4 as healthcare facility-onset (HO) LabID Events.

38. Laboratory-identified (LabID) Events reporting for CDI • Data collected without clinical evaluation • Limited admission date data required • Proxy measures of C. difficile provides • healthcare acquisition, • exposure burden, • and infection burden

39. Question, Needs and Resources • Are Ohio IPs interested in face to face training in our State (CDC sponsored) for NHSN use? • ODH is requesting an NHSN facility to “nominate” ODH to form a “Group” • http://www.cdc.gov/hai/recoveryact/map.html • http://www.cdc.gov/nhsn/