Validation of Central-Line Associated Bloodstream Infection (CLABSI) Data Reporting, Oregon, 2009

1. Validation of Central-Line Associated Bloodstream Infection (CLABSI) Data Reporting, Oregon, 2009 ZintarsBeldavs, MS Manager Healthcare-Associated Infections Program Acute and Communicable Disease Prevention Section Office of Disease Prevention and Epidemiology Public Health Division Oregon Health Authority October 13, 2011

2. Oregon HAI OPHD OHPR OPSC NHSN Validation NHSN Reporting Multi-hospital Collaborative CLABSI SSI HAI EIP Projects Candidemia Surveillance HAI Point Prevalence Denominator Simplification MDRO Surveillance C. difficile Surveillance

3. Validation for Accurate Data • Research indicates surveillance definitions applied differently by different IPs • Demonstrated by poor inter-rater reliability (agreement between different people reporting on same case): kappas of .30 to .58 • Previous validation studies: potentially more than half of cases not reported

4. CentralLine-Associated Bloodstream Infection (CLABSI) • Attributable mortality ~18% • 14,000 deaths/ year in ICU patients • Estimated cost per episode $3,700 to $29,000 • Prolong hospitalization by mean of 7 days • Preventable through hand hygiene, barrier precautions, skin antisepsis, catheter site selection Pittet D, 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.

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

6. Methods • Study period: calendar year 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: • Research analyst • Epidemiologist • EIS Officer/Physician • 3 public health nurses Map: Oregon Association of Hospitals and Healthcare Systems, oahhs.org

7. Methods • March 2010 - April 2011: on-site hospital visit for chart review • Retrospective record review by 1-4 reviewers • At 37 hospitals: all ICU patients blood culture(+) • At 7 largest hospitals: all reported CLABSI plus random sample of 60 patients with ICU blood-culture(+) not reported as CLABSI • Validators blinded as to whether cases reported as CLABSI

8. Methods • After visit, allcases with discordantCLABSIdeterminations (suspected false positives or false negatives) adjudicated by phone with hospital staff • Participants • Hospital IP staff • Hospital physician • OPHD validators • OPHD physician • Review of all findings for final CLABSI determination • If no consensus reached, case referred to CDC staff • This step unique to Oregon’s validation project (not previously attempted by other states)

9. Results • 1199 medical records reviewed • 549 at 7 highest-volume facilities (records sampled) • 722 at small- and medium- volume facilities • 817 record reviews included in final analysis • 382 records censored as could not meet ICU CLABSI case definition due to timing rules (positive blood cultures were obtained prior admit or > 48 hours after discharge from ICU)

10. CLABSI rate before and after validation 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.

11. ResultsValidation outcome, unadjusted

12. Results Estimated number of CLABSIadjusted for sampling fraction Sensitivity = 0.72 (95% CI: 0.62–0.81); Specificity = 0.99 (95% CI: 0.99–1.00). Positive predictive value = 0.92 (95% CI: 0.83–0.77). Negative predictive value = 0.98 (95% CI: 0.96–0.98). Prevalence = 0.08 (95% CI: 0.07–0.10).

13. Importance of Inter-Agency Follow-up Discussion • Of 27 unreported cases initially identified as possible CLABSI by OPHD, 16 (59%) actual 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

14. Reasons for discrepancies • 6 CLABSI “just missed”: at some facilities, IP staff had changed since 2009 and current staff unaware of rationale for previous CLABSI reporting/ non-reporting decisions.

15. CLABSI Pathogens before and after validation Before validation (n=76) After validation (n= 86)

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

17. 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