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Surveillance Outside the Hospital: Monitoring Home Health Outcomes

Surveillance Outside the Hospital: Monitoring Home Health Outcomes. Regina Nailon RN, PhD Clinical Nurse Researcher The Nebraska Medical Center. State of the Art Conference April 22, 2013. Portions of this work were supported in part by a grant from the Cardinal Health Foundation.

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Surveillance Outside the Hospital: Monitoring Home Health Outcomes

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  1. Surveillance Outside the Hospital: Monitoring Home Health Outcomes Regina Nailon RN, PhD Clinical Nurse Researcher The Nebraska Medical Center State of the Art Conference April 22, 2013

  2. Portions of this work were supported in part by a grant from the Cardinal Health Foundation.

  3. Session Objectives • Explain the role of outcomes data in the current health care delivery system. • Review a case study demonstrating how to achieve measurement of outcomes in outpatient settings.

  4. Partnering Agencies • Alegent Creighton Health at Home • Children’s Home Healthcare/Children’s Hospital & Medical Center • Home Nursing with Heart • InfuScience, a Bioscrip Company • Methodist Home Health and Hospice • Visiting Nurse Association of the Midlands • The Nebraska Medical Center • Nursing Research & Quality Outcomes Department • Peggy C. Cowdery Patient Treatment Center • University of Nebraska Medical Center • Department of Infection Control and Healthcare Epidemiology

  5. A much more difficult issue to address is the monitoring of CVC care processes and outcomes after patients leave the hospital Increased emphasis on reducing hospital LOS Increase in patient care in out patient and home health settings Increased incidence of patients discharged from hospital with CVC in place Lack of research examining standardized maintenance care and its association with CVC outcomes Preventive measures have largely concentrated on CVC insertion or the use of technologic improvements

  6. Significance of CLABSI • 78,000 central line-associated bloodstream infections are estimated to occur yearly In United States hospitals and dialysis units1. • CLABSI are associated with an estimated mortality rate of 12.3%2 and excess healthcare costs between $7,288 and $29,156 per episode3. 1. Srinivasan A, et al. MMWR 60: 2011 2. Umscheid CA, et al. Infect Control Hosp Epidemiol. 2011; 32:101-114. 3. Scott RD. Division of Healthcare Quality Promotion, CDC, 2009.

  7. CVC Adverse Eventsin Out of Hospital Settings • CLABSI rates in home settings range from 0.771 to 6.72 per 1,000 central line days. • Thrombosis rates range from 0.063 to 1.354 per 1,000 central line days in pediatric and adolescent populations, as high as 9.3 in adults5. 1. Gorski, L. (2004). Jnl Infusion Nsg, 27(2), 104-111. 2.Tokars et al. (1999). Ann Int Med; 131: 340-7. 3. Pinon et al. (2009). European Jnl Ped; 168(12), 1505-12. 4.Revel-Villk, S., et al. (2010). Cancer, 116(17), 4197-4205. 5.Beckers, M.M. et al. (2009). Thrombosis Research; 125(4), 318-21.

  8. HAI Prevention Outside Hospital • Healthy People 2020 • Prevent, reduce, and ultimately eliminate healthcare-associated infections (HAIs) • Focuses on acute care, surgical centers, outpatient clinics • National Action Plan to Prevent HAI: Roadmap to Elimination, 20091 • Phase II (Draft April, 2012) extends to ASC, outpatient dialysis • Phase III (Draft July, 2012) extends to long term care 1. Department of Health and Human Services, rev. 2012

  9. Ambulatory Care HAI Prevention Aims1 • Proactive HAI prevention at the clinic level • Increase education and training in HAI prevention for providers, as well as patients and families • Sustain and expand improvements in oversight and monitoring • Develop meaningful HAI surveillance and reporting procedures 1. Department of Health and Human Services, rev. 2012. National Action Plan to Prevent HAI: Roadmap to Elimination.

  10. "Measurement is the first step that leads to control and eventually to improvement. If you can't measure something, you can't understand it. If you can't understand it, you can't control it. If you can't control it, you can't improve it." - H. James Harrington

  11. Central Venous Catheter Use Outside the Hospital • Deficiencies with tracking patients who leave hospital with CVC • No national surveillance mechanism to monitor CVC-related outcomes in home health or non-acute long term care

  12. “Whenever you can, count.” - Sir Francis Galton

  13. CVC Procedure Volumes *7/1/10-7/31/12. Excludes repair and replacement procedures.

  14. Dismissed from Hospital with CVC * CVC insertions and replacements 7/1/10-7/31/12.

  15. Standardizing Central Venous Catheter Care in the Outpatient Realm: Care from Hospital to Home(SCORCH)

  16. SCORCH Surveillance System • Engage stakeholders • Describe system • Gather evidence of system’s performance • Lessons learned – ensure use of findings • Conclusions/recommendations CDC. Updated guidelines for evaluating public health surveillance systems: Recommendations from the guidelines working group . MMWR 2001; 50 (RR13); 1-35.

  17. Engaging Stakeholders • Six Omaha area home health/home infusion agencies • Consensus building sessions May-November, 2011 • Developed guidelines to standardize CVC care • National Guidelines Clearinghouse • The Nebraska Medical Center website: http://www.nebraskamed.com/central-line-care • Surveillance data • Monthly since January 2012 • 2011 data to serve as baseline • June 2012 revised data • More granular analyses

  18. “A public health surveillance system can…be useful if it helps to determine that an adverse health-related event previously thought to be unimportant is actually important” (CDC, 2001).

  19. Public Health Importance of Surveillance System • Delayed treatment • Costs • Hospital admissions/readmissions • Preventability • Standardizing care in out of hospital settings

  20. Admissions/Readmissions with CLABSI POA Data source: University Healthsystems Consortium, 10/11/12.

  21. Purpose and Operation of System Purpose • Monitor impact of implementing standardized CVC care practices across the continuum of care • BSI and thrombosis rates using standardized denominator data across HHA/HIA Objectives • Quality improvement • Formation of research hypotheses

  22. Operation of System • System resides at TNMC • Data use agreements to ensure data confidentiality • System components • Patients receiving CVC-related care from home health agency nurses • CLABSI as defined by CDC that occur in patients 48 hours after admission to home care • CVC occlusion events/use of fibrinolytic agents

  23. "In God we trust, all others bring data." - W. Edwards Deming

  24. Data Elements • Pediatric (18 and younger) and adult (19 and older) • # of patients on service with CVC in place – receiving CVC care from agency • Central line (CL) device days • CL-associated blood stream infection count • Type of CVC* • # lumens* • CL line occlusion event count • Type of CVC* • # lumens* • # of doses of a fibrinolytic used to dissolve line thromboses • # of patients who received a fibrinolytic to dissolve line thromboses * Added these more granular data after Q1 reports disseminated

  25. Operation of System • Data imported into Excel spreadsheet for descriptive analyses • BSI rate/1,000 device days • Occlusion rate/1,000 device days • Ratio of fibrinolytic doses/occlusion event • Quarterly benchmarking reports • Agency performance compared to aggregated mean • No agency identifiers are exchanged

  26. Table P1. Pediatric Central Line Days, Adverse Events and Use of Fibrinolytic Agents

  27. Table A1. Adult Central Line Days, Adverse Events and Use of Fibrinolytic Agents

  28. Table P2. Pediatric Central Line Associated Blood Stream Infections per 1,000 Central Line Days

  29. Table A2. Adult Central Line Associated Blood Stream Infections per 1,000 Central Line Days

  30. Table P3. Pediatric Central Line Occlusion Rate per 1,000 Central Line Days

  31. Table A3. Adult Central Line Occlusion Rate per 1,000 Central Line Days

  32. Pediatric Patient Data Q1 12 Adjusted and Unadjusted

  33. Adult Patient Data Q1 12 Adjusted and Unadjusted

  34. Resources to Operate System • First year supported in part by grant from Cardinal Health Foundation • In-kind support provided by stakeholders: • The Nebraska Medical Center - Clinical nurse researcher, Department of Nursing Research and Quality Outcomes • ~ 6 - 8 hours/quarter • University of Nebraska Medical Center – Director Infection Control and Epidemiology • Co-Lead/Consultant ~1- 2 hours/quarter • Omaha region home health agency personnel • Monthly data submission • 1 - 2 hours/month (Manual versus automated) • Other resources • Telephone, computer, Internet connections, hardware and software maintenance

  35. Data Management Resources

  36. Evaluating SCORCH Surveillance System • Data elements refined after Q1 2012 reports • Events tracked by CVC device type and # lumens • Clarified data for patients receiving agency RN care • Ratio of occlusions to fibrinolytic doses given • Were non-occluded lumens being treated? • Consensus that all use CDC BSI definition • Communication gaps in knowing BSI occurred • Generated list of patient-centered research ideas

  37. Table A1. Adult Central Line Days, Occlusion Events and Use of Fibrinolytic Agents Same agency with 36 occlusions (61%) Q4 1 agency with 32 occlusions (55%) Q1 21 patients (44%) 23 patients (51%) Q4 45 doses (58%) Q4 48 doses (50%)

  38. “Surveillance for outcome measures in ambulatory care settings is challenging because patient encounters may be brief or sporadic and evaluation and treatment of consequent infections may involve different healthcare settings (e.g., hospitals)” CDC. Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care, 2012, p. 7.

  39. Conclusions and Recommendations • Home health outcomes are measurable • Develop system of data validation • Lab data • Claims data • Communication system from receiving hospital to HHA when CLABSI present on admit • Focus in on specifics of CVC care to better drive QI • Agency use of reports • Continue monitoring use of standardized care guidelines

  40. “When you are face to face with a difficulty, you are up against a discovery.” - Lord Kelvin, British physicist

  41. Next Steps • Extramural funding • Refine/further develop surveillance system • BSI rate/1,000 device days by device type • Patient demographics • Capture in real time hospital admissions/ readmissions attributed to BSI • Close loop/communicate BSI to HHA/HIA

  42. Next Steps • Patient-centered outcomes research • Collaborate with 3rd party payer, HHA/HIA, ambulatory/outpatient clinic providers • Infection control practices • Reporting structures • Clinician CVC-related behaviors/competencies

  43. Next Steps • Complete production of patient education DVD aimed at empowering patients to understand what CVC care should look like • Complete patient-focused study, “Day in the Life of a Line” • 14-day diary of who/when/where/why CVC care is being provided

  44. Next Steps • Extend surveillance to long term care settings • CLABSI • CAUTI • Admissions / readmissions • Standardize urinary catheter care

  45. Standardizing Central Venous CatheterCare in the Outpatient Realm: Care from Hospital to Home SCORCHHAI’s

  46. Questions?

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