Healthcare-Associated Infections (HAIs): Reporting and Validating Data across the Nation

1. Healthcare-Associated Infections (HAIs): Reporting and Validating Data across the Nation Tyler Whittington

2. Texas Information • Health and Safety Code, Chapter 98 • SSIs related to 10 procedures and CLABSI • Required to review reporting activities to ensure data are valid • Currently: 390 licensed Ambulatory Surgical Centers and 512 licensed hospitals in Texas

3. Goal of Report • Compile a comprehensive source of state-specific information related to HAI reporting and data validation • Qualitative surveys were chosen as the method to extract this information

4. Methods • Basic understand of HAI reporting • “First State-Specific Healthcare-Associated Infections Summary Data Report” • Compiled a list of preliminary questions to learn about other state mandates for HAI reporting • Conference calls with subject matter experts • Rachel Stricof • Mary Andrus • Becky Heinsohn and Karen Vallejo

5. Subject Matter Experts: Take Home Points • Both numerator and denominator data are extremely important for calculating infection rates • It is imperative to understand the processes that facilities use to capture data • Central line days are one of the most inconsistently measured and reported components used to determine SIRs • Despite creating a sample size determination for auditing records the bottom line is how many records can be audited in a given day • Administrative databases can be very valuable to provide monthly checks on data

6. State-Specific HAI Information • Taken from the CDC: http://www.cdc.gov/hai/stateplans/required-to-report-hai-NHSN.html • Compiled the following information into tables: • Contact information • Reporting status • Reporting indicators • Facilities required to report

7. Reporting Survey • Do you currently audit HAI reporting in your state? • If you do audit, may we contact you again later to discuss more specifics about this proposed audit methodology? • Do you plan to audit any of the reported HAI data in the next six months? • May we contact you again later to discuss more specifics about this proposed audit methodology? • If you do not plan to audit in the next six months, what led you to this decision? • If you are not auditing due to lack of resources, what resources would you need (e.g. more FTEs, staff with infection prevention experience, travel funds, etc.)? • How many FTEs do you currently have to implement mandatory reporting? • Did your state ever attempt to create a method for auditing facilities to validate reported data?

8. Reporting Survey Results

9. Reporting Survey Results • Rhode Island, Delaware, West Virginia and Arkansas: all pointed to limited resources as the reason behind the lack of an auditing plan • There is a need for improved funding and increased staff

10. Auditing Survey • How do you select facilities to be audited? • How do you select procedures to be audited? • How do you select medical records to be audited? • What is the timing cycle of the audit (Do you visit every facility every year, every three years, variable depending on findings)? • What is the ratio of auditors to facilities? • Is the audit performed blinded? • What is the actual number of charts you review per as many units of time as they can tell you (e.g. per visit, per facility, per day, per year…)? • What are the error rates that you have found for specific variables?

11. Auditing Survey Results • Connecticut, Maryland, and Washington: CLABSIs • New York and South Carolina: CLABSIs and SSIs • NY: SSIs for hip, colon, and CABG procedures • SC: SSIs for hip, knee, CABG, and hysterectomy procedures in all facilities. Colon and abdominal hysterectomies in facilities with <200 beds • Pennsylvania: CLABSIs and CAUTIs

12. Auditing CLABSIs: Connecticut • One auditor reviews all positive blood cultures from every facility reporting CLABSIs to NHSN (~30) • Blinded audit: all medical record reviews occur from January 1st – April 30th • For 2008 audit: 35-day time period with 770 positive blood cultures and 476 septic events

13. Auditing CLABSIs: Maryland • Contracted with APIC • Five auditors complete blinded medical record reviews in all facilities reporting CLABSIs to NHSN (~45) • Review 5 charts in ICUs in the top and bottom 11 (25th percentile) facilities of their ranking list (based on CLABSI rates) and 4 charts in all other ICUs • Audit study time period: July 1, 2008 to June 30, 2009 • Charts audits completed from December 9, 2009 – January 8, 2010

14. Auditing CLABSIs: New York • Complete medical record reviews for at least 90% of the facilities reporting CLABSIs to NHSN (~200) • Facilities with high rates of HAI and low rates of HAI are given priority for their audit • Six auditors divided into regions of the state • 5 auditors each responsible for 35-39 facilities • 1 auditor responsible for 9 facilities in the capital region

15. Auditing CLABSIs: New York • Each facility submits: • Line list of NHSN CLABSIs • Laboratory list of positive ICU blood cultures • Randomly select patient records from the most recent ICU positive blood cultures • Currently, they select a total of 20 records to audit

16. Auditing CLABSIs: Pennsylvania • Contracted with APIC: 4 CIC IP auditors • 12 facilities are selected to validate their CLABSI data • 8 records are selected at each facility and auditor is blind to results

17. Auditing CLABSIs: South Carolina • Two auditors to review records in 60/75 facilities required to report • No specific methodology for selecting records to review • Attempt to review between 20 and 30 records at each facility

18. Auditing CLABSIs: Washington • Annual internal validation performed by all (62) facilities required to report • External validation done by state health department depending on results • Currently has two auditors to complete external validation • External Validation: • Select 40 records from most recent positive blood culture list • List of all CLABSI records (based on discharge data) within same time period • Review both lists and note if any record meets NHSN definition of CLABSI • Compare the lists to check for discrepancies

19. Auditing SSIs: New York • Treat each SSI indicator as a separate audit (hip, colon, CABG) • 9-18 medical records selected for each procedure (depending on volume of procedures done) • Case-control format • Cases: taken from NHSN • Controls: • Hip and colon surgeries from NY State Wide Planning and Research Cooperative System (SPARCS) not in NHSN • CABG surgeries from the Cardiac Surgical Reporting System (CSRS) that do not appear in NHSN

20. Auditing SSIs: South Carolina • Hip, knee, CABG and abdominal hysterectomies in all hospitals and colon surgeries for facilities with less than 200 beds • Stratified random method to select records to audit • Review roughly 20-30 charts per facility • Variable depending on size of facility and volume of procedures performed

21. Common Error Rates • Connecticut: improper understanding of CLABSI rules • minimum time period, patient transfer, and two or more blood cultures drawn on separate occasion rule

22. NY and SC: wound class, procedure duration, ASA score, and improper classification of surgeries as clean versus clean-contaminated Common Error Rates

23. Conclusion • Lessons can be learned from other states and their validation programs • However, Texas has drastically larger numbers of facilities without increased funding • It is vital for Texas to create an efficient validation plan • Think long-term goals with limited funding

24. Questions?