HAI Program Update

1. HAI Program Update Meredith Kanago, MSPH TDH Statewide CEDEP Meeting 30 April 2014

2. Outline • Background • HAI Burden • HAI Surveillance • Tennessee • National • Public Reporting In Tennessee • HAI Prevention Progress • Antimicrobial Stewardship • Recent HAI Outbreaks

3. Background • For the purpose of surveillance, a healthcare-associated infection (HAI) is a localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that was not present on admission to the facility. • HAIs occur in all types of care settings, including: • Acute care within hospitals • Same-day surgical centers • Ambulatory outpatient care in health care clinics • Long-term care facilities (e.g., nursing homes and rehabilitation facilities) http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=17

4. HAI Burden • In 2011, there were ~722,000 HAIs in U.S. acute care hospitals • Significant additional burden in other settings • Nearly 75,000 deaths associated with HAIs • 6th leading cause of death in the US • $33 billion in added healthcare costs CDC, 2014

5. HAI Surveillance in TN

6. National HAI Surveillance • Facilities are required to report HAIs and other events to CMS for payment incentives • Examples: • Acute care hospitals: IPPS • Dialysis clinics: ESRD QIP • Failure to report -> loss of 1% annual payment update • Pay-for-reporting -> pay-for-performance • Revenue neutral: bonus if in top 25%; money comes from bottom 25% • TDH aligns requirements closely with CMS to minimize reporting burden while maximizing available data

7. National Healthcare Safety Network • A secure, Internet-based surveillance system for collecting and utilizing data on HAIs • Requires active, patient-based (or laboratory-based), prospective surveillance of events and corresponding denominator data • Surveillance is conducted by infection preventionists (IPs) at healthcare facilities

8. NHSN for Regional Epidemiologists • Good news – you don’t actually have to use (or know how to use) the NHSN application! • What you do need to know: • Which HAIs and MDROs are reportable in NHSN according to TN rules/regs • Which MDROs are reportable in NBS • What to do if you receive questions about NHSN • (HAI.health@tn.gov)

11. Public Reporting in Tennessee • Tennessee’s first public report on HAIs was published in December 2009 • Included aggregate state data and facility-specific CLABSI data • Published semi-annually, and includes facility-specific data on: • CLABSI in adult/ped ICUS NICUS • CAUTI in adult /ped ICUs • SSI (COLO and HYST) • LabID Events (MRSA and CDI) in acute care

12. Standardized Infection Ratio Observed (O) HAIs Predicted (P) HAIs • To calculate O, sum the number of HAIs among a group • To calculate P, requires the use of the appropriate aggregate data (risk-adjusted rates) (e.g., national NHSN data for 2006–2008) • SIR > 1.0: # infections are HIGHER than predicted • SIR= 1.5: # infections = 50% HIGHER than predicted • SIR < 1.0: # infections are LOWER than predicted • SIR= 0.4: # infections = 60% LOWER than predicted SIR =

13. CAUTI Standardized Infection Ratio (SIR) for Adult and Pediatric Intensive Care Units in Facilities with ≥1 Predicted CAUTI, Tennessee, 01/01/2013 - 06/30/2013 Data Reported from adult/pediatric ICUs as of January 30, 2014. N = number of types of intensive care units reporting OBS = observed number of CAUTI PRED = statistically 'predicted' number of CAUTI, based on NHSN baseline data SIR = standardized infection ratio (observed/predicted number of CAUTI) UCD = number of urinary catheter days NA = data not shown for hospitals with <50 urinary catheter days ** Significantly higher than national baseline Significantly lower than national baseline * Zero infections, but not statistically significant

17. CLABSI –Adult/Pediatric ICUs Over Time Provisional Data

18. CLABSI – NICU SIRs Over Time Provisional Data

19. CAUTI – A/P ICU SIRs Over Time Provisional Data

20. MRSA – ACH SIR Over Time Provisional Data

22. TN: 3rd Highest Outpatient Antibiotic Use (TN: 1,159 Rx vs 801 Rx per 1,000 persons) http://www.cddep.org/resistancemap/use/all

23. Antimicrobial Stewardship Collaborative Prevalence of Antimicrobial Use in Hospitalized Patients (10 States (EIP), 2011) • GOALS: • Improve appropriate antibiotic use • Reduce unnecessary antibiotic use • Reduce emergence & spread of multidrug resistant organisms • Reduce Clostridium difficile

24. Antimicrobial Stewardship (continued) • Simplified monthly point prevalence survey • Monthly webinar topics include: • Assessing the Gaps and Identifying Champions for Antimicrobial Stewardship • Multidisciplinary Efforts in Antimicrobial Stewardship • Creating and Utilizing Antibiograms • Dose Optimization and Kinetic Dosing • Antimicrobial Stewardship in Small Hospitals • De-Escalation • Measurement in Stewardship Programs and Reporting Metrics to Stakeholders

25. Recent HAI Outbreak • MSSA joint injections at an outpatient clinic • September 9, 2013: TDH is notified of 3 joint infections among patients who received injections of triamcinolone acetate and lidocaine at a single outpatient clinic on the same day • Triamcinolone was produced in out-of-state compounding pharmacy • Medications were sequestered and injections were stopped

26. Recent HAI Outbreak • MSSA joint infections (continued) • Follow-up showed 4/5 pts receiving injections on 9/5 had evidence of a joint infection • MSSA isolated from 3 cases (PFGE-indistinguishable strains); cultured meds negative • Site visit revealed suboptimal med prep and hand hygiene; no separate clean area for med prep • Recommendations provided, including avoiding use of multi-use vials

27. Questions? • HAI.health@tn.gov