Zintars Beldavs

1. Quantitative validation of central line-associated bloodstream infections (CLABSI) in Oregon intensive care units (ICU) 2009 ZintarsBeldavs Manager HAI Program, Acute and Communicable Disease Section, Oregon Public Health Division, Oregon Health Authority June, 2012

2. CentralLine-Associated Bloodstream Infection (CLABSI) Deadly: 18% mortality 14,000 deaths/ year in ICU patients Prolong hospitalization by mean of 7 days Expensive: $3,700 - $29,000/episode Preventable: hand hygiene, barrier precautions, skin antisepsis, catheter site selection PittetD, Tarara D, Wenzel RP. Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs, and attributable mortality. JAMA. 1994;271:1598-1601. Soufir L et al. Infect Control Hosp Epidemiol 1999 Jun;20(6):396-401.

3. Mandated Reporting in Oregon • Reportable as of 1/1/2009 • CLABSIs in ICU • SSI knee prostheses and coronary artery bypass grafts • More reportable surgical site infections as of 1/1/11 • Colon surgery • Hip prosthesis • Laminectomy • Abdominal hysterectomy

4. 2009 Oregon CLABSI Pathogens

5. CLABSI Rate 2009-2011

6. CLABSI Rate Change 2009-2011

7. CLABSI Count by Hospital Size

8. Validation for Accurate Data • Concern: surveillance definitions applied inconsistently by IPs • Poor inter-rater reliability: kappas .30 to .58 • Previous validation studies: potentially > half of cases not reported (Connecticut)

9. Objectives • Evaluate quality of reported data • Assess under- and over-reporting • Gauge the reliability and consistency of surveillance case definitions • Provide feedback to facilities on surveillance case definitions and reporting methods

10. Methods • Study period: 2009 • Included: 44 acute care hospitals • 28 with < 50 beds • 10 with > 200 beds • Median central line days 210, range 4-4956 • OPHD validation team: • HAI Program Manager • Epidemiologist • EIS Officer/Physician • 3 public health nurses Map: Oregon Association of Hospitals and Healthcare Systems, oahhs.org

11. Methods • All blood culture (+) • Drawn in ICU or up to 48 hours after and • Organism not isolated in 14 days before admit

12. Methods Unit of analysis: Single bacteremia episode More than one CLABSI/patient possible

13. Methods 37 Hospitals 7 Hospitals All reported CLABSI and random sample 60 (+) culture not reported as CLABSI All (+) culture reviewed Reviewers blind as to reported CLABSI status

14. Methods Adjudication Discussion NHSN Hospital Determination Validator Determination

15. Methods • 1926 (+) cultures received on line lists • 1204 from 7 highest volume facilities • 722 from 41 facilities < than 60 (+) cultures

16. Methods • 1199 medical records reviewed • 477 sampled at 7 highest-volume facilities • 722 at small- and medium- volume facilities

17. Results 817 included in final analysis Hospitals included cultures not requested: (+) blood cultures obtained prior admit or > 48 hours after discharge from ICU • 382 of 1199 reviewed censored

18. ResultsDiscordant Cases • 35 records with disagreement • 18 (51%) adjudicated as CLABSI • 17 (49%) adjudicated as not CLABSI • Hospital correct in 13 (37%) • OPHD correct in 22 (63%) • 4 required NHSN consult (2 CLABSI)

19. Reasons for discrepancies • For CLABSI “just missed”: at some facilities, IP staff had changed since 2009 and current staff unaware of rationale for previous reporting decisions.

20. ResultsValidation outcome, unadjusted

21. Example Calculation to Adjust for Sampling Fraction • 60 Records sampled at hospital • 142 Total BSI • 2 BSI reported as CLABSI • Sampling fraction: 60/140=.43 • True positive and false positive remain (all reported CLABSI reviewed) • False negative and true negative results divided by sampling fraction

22. Results Estimated # of CLABSIadjusted for sampling fraction 72% of true CLABSIs had been reported (Sensitivity = 0.72) 99% of true non-CLABSI were correctly not reported (Specificity = 0.99) 92% of CLABSIs reported were true CLABSI (Positive predictive value = 0.92) 98% of cases not reported CLABSI were not CLABSI (Negative predictive value = 0.98) 8% of positive cultures were CLABSIs (Prevalence = 0.08 )

23. Validation Impact on CLABSI Rate Validation increased the statewide ICU CLABSI rate from 1.21 (95% CI: 0.95–1.51) to 1.54 (95% CI: 1.25–1.88) CLABSI per 1,000 central-line days a 23/33 had no CLABSI identified either before or after the validation. b 3/6 had no CLABSI before the validation.

24. Importance of Inter-Agency Follow-up Discussion • Of 27 unreported cases identified as CLABSI by OPHD, 16 (59%) true CLABSI • Sensitivity of reporting: • 72% based on follow-up adjudication • vs. 60% based on OPHD review alone (P= 0.07), closer to some previous validation efforts

25. Limitations • Denominator data not rigorously assessed • Did not adjudicate cases when reviews concordant with reported data • Unbiased 3rd party not involved in adjudication discussions

26. Conclusions • Validating hospital CLABSI reporting improves accuracy of hospital-based CLABSI surveillance • Discussing discordant findings improves the quality of validation

27. Future Work • Currently completing coronary artery bypass graft validation of all 14 hospitals • Similar adjudication procedure • Sampling higher duration procedures • Given funding: comprehensive baseline and yearly sampled validation other HAIs

28. Acknowledgments OPHD HAI program staff and others assisting • Paul Cieslak – Public Health Physician • Ann Thomas – Public Health Physician • Margaret Cunningham – HAI Epidemiologist • Diane Roy – HAI Administrative Assistant • John Oh – EIS Officer • Steve Moore – Public Health Nurse • Jennifer Tujo – Infection Preventionist • Valerie Ocampo – HAI Public Health Nurse Oregon Patient Safety Commission Office for Oregon Health Policy and Research Association of Professionals in Infection Control, Oregon-SW Washington Chapter Questions? 971-673-1111 zintars.g.beldavs@state.or.us

29. Questions?