APIC 2011: Current State of Infection Prevention and Control. Baltimore, Maryland June 27-29 th

1. APIC 2011: Current State of Infection Prevention and Control. Baltimore, Maryland June 27-29th D’Anna L Stekli, BS, MT(ASCP, CIC D’Anna L. Stekli BS, MT (ASCP), CIC Photp Courtesy of www.bccenter.org

2. Opening Plenary- Dr Richard Wenzel- Medical College of Virginia, Virginia Commonwealth University • 2011- 50% of all healthcare associated infections preventable • Esp containing strain of Staph epidermidis 70% less risk for Staph aureus nasal carriage • 40% of all SSIs preventable with chlorhexidine prep • Horizontal approach superior over vertical for effective MDRO control Wenzel et al, ICHE 2008: 29: 1012-8

3. Let’s Look at an Example….

4. 3M Symposia- “ Clean Hands, Clean Surfaces: Discussion on Interdependency of Hand and Environmental Hygiene”- Janet Haas and Michael Phillips • Risk of MRSA, VRE, and C diff to patient 40%, 40%, and 140% when prior room patient positive for germ • Goal of program was to decrease hospital associated C diff • Strategy: Floroquinolones discouraged 96 hr review of targeted antibiotics Interventional efforts to improve hand hygiene Clean team- Goal of 5 daily room visits- Two to disinfect high touch surfaces, others for spot cleaning Result= C diff from 1.28/1000 pat days to 0.66 per 1000 pat days Courtesy of www.postmanpatel.blogspot.com

5. “Case Studies in Culture Change” – Dr Jonathan Perlin, Clinical Services Hospital Corporation of America 1.Communicate to compel action 2. Use evidence to compel action 3. Measure to compel action 4. Understand and address personal & institutional resistance to change 5. Be opportunistic in using external context to move agenda 6. Build executive support; build the business case 7. Specify desired outcomes, create constructive tension, don’t overmanage process 8. Move the mean 9. Engage the patient 10. Sometime you just have to get started . . .

6. Making a Case for Universal Influenza Vaccination • Showed H1N1 and seasonal flu distribution scenarios over season • Displayed projected levels of H1N1 scenarios vs bed capacity. • Provided stats of efficacy of vaccine in HCW • Provided clear serologic evidence that many workers infected subclinically. • Strived to understand national pushback and issues raised. • Provided data on effect of national availability of H1N1 vaccine on new case numbers • Met with CEO and Board to discuss past effects of flu on their healthcare system • Engaged patients in conversation- 87% surveyed believed universal vaccination was good idea Result: 144,278 of 150,043 employees vaccinated, other required to wear mask during season! www..healthcarefineart.com

7. Other Points of Interest from Culture Change Presentation • Surgeons have HH rates of 3% before touching patient, 90% after • 4.5% of patients affected by HAIS, 9.3 infections per 1000 pt days on average • 1 in 5 Medicare patients readmitted within 30 days with pneumonia as # 1 reason • Data should be displayed from best to worst • Performance data optimally displayed next to financial data to create constructive tension and inspire change efforts • Physicians alienated by focus on quality measures. They prefer focus on problem and discussion regarding proposed solutions • Quality in today’s society is how we make budget! www.nypost.com

8. CDC/NHSN Surgical Site Infections- Teresa Horan, Mary Andrus, and Gloria Morrell • NHN procedures involve only incisions closed skin to skin • Probing of wound with cotton swab-= deliberate reopening of wound • Superficial SSIs count only for 30 days after surgery even if implant present • In 2012, we will be required to report SSI information for certain surgery types- most likely colons and abdominal hysterectomies to start • Will be required to report info on all surgeries done in procedure type in order to calculate risk and SIR- no more risk index • If potential CLABSI present at same time as SSI and organism Id’d from blood is commonly found in part of body involving SSI, CLABSI is to be rules secondary to SSI and SSI is reported with organism id’d from blood as causative SSI organism • Staples to be counted as implant per Teresa Horan and CDC Biofilm expert www.louisianabindinservice.com

9. “Preventing SSIS” Dr Richard Wenzel • SSIs= 14% of adverse events • Presence of remote infection= 2-3 fold risk for SSI • As surgical procedures of certain type SSI rates • SSI rates when surgeons given own data • Silk sutures reduce dose of Staph aureus needed for infection by 4 logs • Patients with AIC > 7% have 2 fold risk of postoperative infection, including SSI than normal • Glucose should be maintained postop between 140-180 mg/dL

10. Wenzel Continued • 40% of nasal MRSA carriage = community strains • 10-15 % of MRSA carriage in throat only • Preop screening and treating for Staph aurues associated with 60% reduction in Staph aureus SSI • Use of CHG as prep decreases S sureus SSI by 50% • Dr Wenzel believes we now have enough evidence to show CHG as the superior in 2011 and says it should be standard preop skin prep www.hpnonline.com

11. “Administrative Data vs Clinical Data” –Dr Kurt Stevenson , Ohio State University • Administrative data traditionally used for CMS reporting- trend is turning toward use of NHSN data • CDC and CMS in discussions concerning CLABSI data validation for 2012 • Joint Commission is considering utilization of NHSN data as component of site visits. • Direct comparison of 89 bloodstream cases using AHRQ Patient Indicator # 7 identifying criteria and CDC/ NHSN criteria showed only 8 of these cases identified by both methodologies. • 15 % of cases identified as VAPS, UTIs, and SSI by administrative data meet CDC/NSH definitions • In study done by speaker where 5674 cases at risk for SSI, VAP, or BSI reviewed by examining how cases coded and application of NHSN definitions, 879 cases discordant ( 15.5%) and 59/769 (7%) of cases missed by IC team. PPV of administrative data was 23%

12. Dr Stevenson presentation continued • Other studies show PPV value of administrative data= app 20%, NPV=99% using CDC/NHSN definitions as reference standard • Good NPV may make administrative data useful for screening data for surveillance purposes • Examining receipt of antibiotics post operatively of potential benefit as well www.evidentnet.au

13. “ Show Us the Numbers” A New Approach to Using Administrative and Clinical Data” Dr Cliff McDonald (CDC) and Terry Berger • Primary purpose of administrative data is use for billing • Administrative data does not look at infection cause and therefore can’t be used for improvement efforts • Project done through Medicare Monitoring System in 2005-2006 comparing coded data for CAUTIS a versus use of medical record algorithm showed coded data had PPV of 16%. Incidence of CAUTI by coded data= 18/1000 cath days, incidence of CAUTI by medical record algorithm 4.2/1000 cath days • Issues seen in IC surveillance data as well. 2010 study showed ICPs identified incidence rates of CLABSI on average of 3.3 CLABSI per 1000 line days while computer algorithm designed to detect CLABSI detected average of 9.0 CLABSI per1 000 line days. Lowest ICP center rate was directly correlated with highest computer CLABSI rate between facilities!

14. Coded vs. Clinical Administrative (Coded) Data CDC/NHSN Surveillance Data – Scientifically driven – Risk adjusted – Standardized definitions – Validation studies – Predictive value – Timely manner – Comparative database – Systems to collate data in place – Minimal programming changes – POA added to improve risk adjustment – Financial association Terry Burger, APIC National Conference 2011

15. Our Responsibility and Commitment as Infection Prevention and Control Professionals www.canstockphoto.com www.projectassistants.com To collect the data to the best of our ability and report as accurately as possible To possess understanding of administrative data and find a way to utilize it in surveillance practice To allow stakeholders to engage us in case conversations to ensure all of facts of case are known and to increase buy in Educate stakeholders as much as possible regarding surveillance methodology wwwww w www

16. “Changing Epidemiology of MRSA”- Dr Luke Chen, Duke University Medical Center • MRSA highest in July-Sept, lowest in Jan-March for reasons unknown • 35.4 % of people with MRSA BSIs die within 12 weeks, compared to 12.4% of people with Staph aureus BSIs • MIC creep seen in vancomycin close to 2.0 ug/ml from 2001-2005 • Compared with MRSA BSIS involving Vancomycin MIC of 1 ug/ml, vanc MIC of 1.5 associated with 2.9 fold risk of mortality, MIC of 2= 6.4 fold higher risk • 8 of 11 cases of VRSA in US occurred within 50 mile radius of Detroit. Michigan-. Note sure why, maybe increased ability of VRE strain to transfer vanco resistance to MRSA? • Healthcare acquired MRSA plateaued in 2000 and remains around 50% of all MRSA strains over last several years

17. Dr. Luke Chen Continued • MRSA CLABSI peaked in 2001, then dropped every year after • Different strains of CA-MRSA have been circulating in different parts of the world. Not known why this is going on simultaneously. • VA MRSA Study vs ICU MRSA Study- VA showed fall of HA MRSA from 1.64 to 0.62 per 1000 pat days, ICU study no sig change. VA study better overall but truth probably someone in between • Now seeing a novel cattle derived strain of MRSA in UK in humans with genetic component that can’t be detected by PCR. This may be seen more often as MRSA continues to evolve. www.therablogblogspot.com

18. “Using Data to Drive and Sustain Improvement”- Dr Deverick Anderson and Evelyn Cook, Duke University Medial Center • Providing individual data regarding SSI rates to surgeons reduces subsequent SSI rates by up to 30% • Data ideally should be used to discover potential issues and identify opportunities for improvement • Data should only be given to people who can utilize it to improve processed • Presentation of data should be done in as much of a collaborative manner as possible • Data is used for punitive reasons more often than necessary. Infection Prevention and Control: Data Driven and Patient Centric

19. SSI Prevention- Maureen Spencer, Universal Health Services • Patient with MRSA SSIS 12x more likely to die than other SSI patients • MRSA SSI app $ 60,000, MRAS orthepedic SSI can exceed $ 100,000 • Patients with >= 3 discharge diagnoses have increased risk of SSI • Current upswing in surgical hematomas , which can increase risk. Not known why, may be Lovenox • Skull caps- Shouldn’t allow to be worn in OR- hair in wound vs restaurant • Should convert from buckets and wipes in OR to microfiber mops and cloths- JC increasingly looking for this, Wipes= not enough disinfectant contact time • Leg tourniquets, bar coded equipment, and COWS need to be cleaned between cases as well as other shared case equipment.

20. Maureen Spencer Presentation Continued • Non sterile people need to stay at least 3 feet away from sterile field • Speaker maintains that Irisept is superior to povidone-iodine and Bacitracin polymixin as irrigation agent • Switch to antibacterial sutures were associated with a 45% reduction in SSI cases in 1 year in speaker’s institution • CHG has superior persistence of microbial killing activity compared to Duraprep and povidone iodine and should be surgical prep of choice • Dermabond provides 3 days of wound healing strength after 3 minute application • Staples should be avoided as much as possible www.newser.com

21. “Ventilator Associated Pneumonia and Current Efforts to Clarify and Streamline Surveillance Definitions” Dr Shelley Magill, CDC • Currently only device related infection for which there is no proposed metric in US Dept of Health and Human Services Action Plan for Prevention of HAI- due to lack of reliable VAP definition • Definition’s original purpose was for internal QA, not bench marking and public reporting • Chest film review outside of ICP skill set- must rely on physician input regarding reads that varies between and within facilities • Differences in diagnostic techniques in facility play major role in whether cases found and reported. • Experts agree that current pneumonia definition too burdensome and there is too much inconsistency in case finding • Need for definition that is objective, streamlined, and potentially automatable. Definition should not be strictly clinical, but possess clinical credibility.

22. Dr Shelley Magill Presentation Cont • See handout for proposed S VAP definition • Period of stability on vent= Stable or improving FIO2 or PEEP • Respiratory deterioration = >= 2 day period of worsening oxygenation ( FIO2 >= 15 %, PEEP ?= 2 cm H2O. Change in MAP • >= 2 signs of infection/ inflammation are WBC < 4,000 or > 12,000, temp < 36 degrees C or > 38 degrees C, or purulent respiratory secretions • Incorporation of chest films can be utilized to change case classification from possible sVAP to probable sVAP • Definition will probably be subject to further modification, need feedback from critical care and pediatric fields, evaluate preventability, and measure interrater reliability Will take minimum of additional 1 year. Changes usually come out at beginning of calendar year

23. UVMC Infection Prevention and Control Department Wishlist • Hand hygiene pledge to be signed annually be all UVMC employees, similar to corporate integrity pledge • Conversion of surgical prep to 100% use of Chloraprep • Greater opportunity to interface with physicians at section meetings , etc to educate and gain buy in for infection prevention and control activities and data • Pursue trial of pre-op glucose testing and management for obese patients not known to be diabetics who will be admitted after surgery • Set up trial of continuous subglottic suctioning for ventilated patients • Support multidisciplinary program to identify patients at increased risk for pneumonia with preventative measures incorporated into careplan • Institute 2% CHG daily baths for patients with central lines and ICU patients • Devise system in EPIC to monitor care given to patients with indwelling devices, with real time unit alerts if lack of documentation seen • Examine feasibility of Swabcaps for central lines if CLABSI rates do not decrease

24. Thank Yous • APIC Chapter 26 and the Sandy Iames Family • UVMC Foundation • Kay Rickey, UVMC Director of Nursing Excellence and Education • Dr Ron Manis, UVMC Medical Director of the Infection Prevention and Control Department • Elizabeth ( Betsy) Snyder RN, BSN – Infection Control Specialist • Judy Snyder, UVMC Chief Nursing Officer www.prahicshunt.com