“Patient Safety First” May 24-25, 2011

Visalia & Sacramento

Teresa Nelson, RN, BSN, CICLynn Janssen, MS, CIC

HAI Liaison ProgramCalifornia Dept of Public Health

“A Decade of HAI Prevention Progress”

Disclaimer

• The positions expressed in this presentation are those of the author and not necessarily of the California Department of Public Health

• Enhance participation in the National Healthcare Safety Network (NHSN) for HAI surveillance and reporting, and support the use of NHSN data for local HAI prevention efforts

• Develop and implement protocols for NHSN data validation (to start July 2011)

• Support existing prevention collaboratives and initiate new HAI prevention collaboratives where gaps may exist

HAI Liaison Program Activities

• Over 90 HAI educational programs, including 3-hour SSI workshops in 30 locations throughout California

• Onsite consultations to >370 hospitals

• Ongoing consults, 1-on-1 assistance, by phone or visit

• Since Jan 2011, monthly update calls by each Liaison IP for his/her region

• Prevention collaboratives for LTACs and prison hospitals (to expand to hospital jail units)

• Announcing prevention initiatives for small/rural hospitals in June

1. Review HAI trends over past decade

2. Describe key drivers for HAI prevention since 2000

3. Discuss progress toward national HAI prevention targets and next steps

4. Reflect on steps for advancing HAI prevention in California

Growing populations at risk • Immunocompromised individuals

• Low birth-weight, premature neonates

• Transplant recipients on immunosuppressive therapy

• Increasing obesity and diabetes

Special environments • Intensive Care and Burn Units

• Long-term acute care

• Ambulatory surgery, endoscopy, and infusion services

Changing Landscape of Healthcare

Changing Landscape of Healthcare

• Organizational factors affect HAI prevention

▫ Administrative policies

▫ Staffing

▫ Education

▫ Antimicrobial utilization

• Increasing prevalence of antimicrobial-resistant pathogens

Outbreaks vs Endemic problems

Endemic problems represent the majority of HAIs

• Device-associated infections CAUTI 32%

CLABSI 14-16%

VAP 15%

• Procedure-associated infections SSI 22% (3-4% of all surgeries)

• Adherence problems Antimicrobial stewardship, Hand hygiene (compliance-?)

State of Prevention Knowledge/Science:

HICPAC/CDC Recommendations

• Guidelines developed for each HAI type based on systematic reviews of the medical literature▫ Prevention of central line associated blood stream infections

▫ Prevention of catheter associated urinary tract infections

▫ Prevention of surgical site infections

▫ Prevention of healthcare associated pneumonia

▫ Management of multi-drug resistant organisms

• Recommendations are graded according to evidence basis

• Guidelines contain many recommendations

(How to prioritize interventions that are most effective)

HICPAC= Healthcare Infection Control Practices Advisory Committee

Following CDC Guidelines Reduces CLABSI: Success in Pennsylvania

MMWR 2005;54:1013-16

Modifiable Risk Factors for Prevention

Characteristic Risk Factor Hierarchy - high > low

Insertion circumstances Emergency > Elective

Skill of inserter General > Specialized

Insertion site Femoral > Subclavian

Skin antisepsis 70% alcohol, 10% povidone-iodine >

2% chlorhexidine

Catheter lumens Multilumen > Single lumen

Duration of catheter use Longer duration > short duration

Barrier precautions Submaximal > Maximal

CLABSI Risk Factor

Prevent Infection

Bundles (sets of infection control recommendations) to prevent infection when inserting devices or performing procedures.

The CVC Insertion Bundle

• Hand hygiene

• Maximal barrier precautions

• 2% chlorhexidine/70% isopropol alcohol skin prep (duration of prep dependent on site)

• Optimal site and catheter selection

• [Insertion kit]

• [Anchoring of catheter]

Ventilator Bundle Elements

• HOB elevated > 30 degrees

• Scheduled readiness to wean assessment

• Sedation vacation/appropriate sedation

• DVT prophylaxis

• Stress ulcer prophylaxis

• Oral Care

Level of Reliability (with all 5 elements)

Reduction in

VAP Rate

Unchanged 22%

<95% compliance 40%

>95% compliance 61%

Impact of Adherence to VAP Bundle

Possible mechanisms of success • Implementing a standardized “bundle” of care results

in better overall care • Interventions are synergistic

Institute for Healthcare Improvement http://www.ihi.org/IHI/Programs/Campaign/VAP.htm

Successful Prevention of VAP in an ICU setting

Marra et al, ICHE

Sustained Reduction in ICU CLABSIs

Berenholtz SM et al. Crit Care Med 2004;32:2014-20.

Pronovost P. New Engl J Med 2006;355:2725-32.

CLABSI Prevention Culture Change

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

Pooled Mean CLABSI Rate per 1,000

Central Line Days or %MRSA

*

N

o

2

0

0

-49.6%

-70.1%

P=0.02

Rates of Methicillin-Resistant and Methicillin-Susceptible Staphylococcus aureus CLABSIs - United States, All ICU Types, 1997-2007

Burton et al. JAMA 2009; 301:727-36.

MRSA CLABSI

MSSA CLABSI

P<0.0001

Urinary Catheter Use

• As high as 15-25% of hospitalized patients

• Often placed for inappropriate indications

• Physicians frequently unaware of urinary catheter

• Surveys of U.S. hospitals:

▫ >50% did not monitor which patients catheterized

▫ 75% did not monitor duration and/or discontinuation

Givens & Wenzel, J Urol 1980;124:646-8Green MS, J Infect Dis 1982;145:667-72Weinstein, Clin Inf Dis 1997;24:584-602Saint S. Am J Inf Control 2000;28:68-75Foxman B. Am J Med 2002;113:5S-13S

** URINARY CATHETER REMINDER **

Date: __ __ / __ __ / __ __

This patient has had an indwelling urethral catheter since __ __ / __ __ / __ __.

Please indicate below EITHER (1) that the catheter should be removed OR (2) that the catheter should be retained. If the catheter should be retained, please state ALL of the reasons that apply.

Please discontinue indwelling urethral catheter; OR

Please continue indwelling urethral catheter because patient requires indwelling catheterization

for the following reasons (please check all that apply):

Urinary retention

Very close monitoring of urine output and patient unable to use urinal or bedpan

Open wound in sacral or perineal area and patient has urinary incontinence

Patient too ill or fatigued to use any other type of urinary collection strategy

Patient had recent surgery

Management of urinary incontinence on patient’s request

Other - please specify: ___________________________________________________

__________________________________________ _____________ Physician’s Signature Doctor Number

Monitor Hand Hygiene

• Hand hygiene when caring for central lines▫ Before and after palpating catheter insertion sites

▫ Before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter

▫ When hands are obviously soiled or if contamination is suspected

▫ Before and after invasive procedures

▫ Between patients

▫ Before donning and after removing gloves

▫ After using the bathroom

• Increase in hand hygiene “oversight” technology

• Generates a lot of data with real-time feedback

• Ongoing research to evaluate sustainability, cost-effectiveness, and optimal use of data

Technological Innovation in Hand Hygiene Measurement

Hospital Video AuditingAlcohol “Sniffers”

Wireless Sensors

Prevent Transmission

Hand hygiene

Isolation

Disinfection etc

CDC Recommendations to Prevent Clostridium difficile infections (CDI)

• Contact Precautions for duration of diarrhea

• Hand hygiene in compliance with CDC/WHO

• Cleaning and disinfection of equipment and environment

• Laboratory-based alert system for immediate notification of positive test results

• Educate about CDI: HCP, housekeeping, administration, patients, families

• Antibiotic stewardship

Dubberke et al. ICHE 2008;29:S81-92.

HAI Prevention Success Story

• 58% reduction in CLABSI for ICU patients between 2001 and 2009

• Since 2001

▫ 27,000 lives saved (3,000-6,00 per year)

▫ $1.8 billion in costs averted ($414M in 2009 alone)

• More needs to be done

▫ 41,000 CLABSI in non-ICU hospital patients

▫ 37,000 in dialysis centers

• A model for other infections: SSI, CAUTI, VAP, MRSA, CDI

CDC, 2011

Key drivers for HAI Prevention

Patients want to feel safe and assured that we are doing

everything possible to eliminate infections

Video, NBC patient channel, available at www.cdc.gov/handhygiene

Patients want to know what they can do to improve their care.

Cultural Change

“Many infections are inevitable but some may be preventable“

“Each infection is potentially preventable unless shown otherwise”

Preventability of HAI through the years

• 1980: Study on the Efficacy of Nosocomial Infection Control (SENIC)Showed 32% reduction of infections in hospitals with▫ Infection control program▫ HAI Surveillance▫ 1 ICP for every 250 beds

• 2003: Up to 70% of infections are preventable

• 2010: Moving towards HAI elimination

MMWR, 1980; Harbath et al, J Hosp Infection 2003;54:258

Policy Changes for Transparency and Accountability

State Legislation for Public Reporting of HAIs

2004

2010

Public Report of Healthcare-associated Infections in New York State, 2008

• Used NHSN for reporting

• Report includes

▫ Bloodstream infections in intensive care unit (ICU) patients

▫ Surgical site infections

• From 2007 to 2008

▫ Bloodstream infection rates increased

▫ Surgical site infection rates decreased

▫ Targeted prevention efforts

http://www.health.state.ny.us/statistics/facilities/hospital/hospital_acquired_infections/

• Establish measurable national goals

• Improve coordination for prevention, research, surveillance, incentives/oversight, and messaging strategies

• Approach problem in phases

• Phase 1 – Hospitals

• Phase 2 – Ambulatory surgical centers and dialysis centers

• Phase 3 – nursing homes

• Congressionally mandated State HAI Plans▫ States are required to have a formal HAI prevention

plan

Federal Action Plan to Prevent HAIs, 2009

Federal Action Plan Implementation

Metric SourceNational 5-year

Prevention TargetCoordinator

Bloodstream infections NHSN 50% reduction CDC

Adherence to central-line insertion practices NHSN 100% adherence CDC

Clostridium difficile (hospitalizations)NHDS

HCUP30% reduction CDC/AHRQ

Clostridium difficile infections NHSN 30% reduction CDC

Urinary tract infections NHSN25% reduction

CDC

MRSA invasive infections (population) EIP 50% reduction CDC

MRSA bacteremia (hospital) NHSN 25% reduction CDC

Surgical site infections NHSN 25% reduction CDC

Surgical Care Improvement Project Measures SCIP 95% adherence CMS

Patient Safety and Affordable Care Act

• Section 3001- Hospital Value Based Purchasing Program

• “The Secretary [of HHS] shall establish a hospital value-based purchasing program . . . Under which value-based incentive payments are made in a fiscal year to hospitals that meet the performance standards . . .”

• For fiscal year 2013, the Secretary shall select measures that cover at least the following 5 conditions, including healthcare-associated infections as measured by the HHS Action Plan to Prevent HAIs

• National public reporting of HAIs

▫ CLABSI starting in 2011, SSI in 2012

▫ Full HHS HAI Action Plan over time

▫ NHSN - public health surveillance system

• Links reduction of HAIs to federal payment

▫ Use NHSN to report quality measure data as part of CMS’s pay-for-reporting program

▫ De facto national mandate

CMS Inpatient Prospective Payment System (IPPS) Rule

39

CMS Incentives for Quality Reporting

* IPPS / Hosp Inpt Quality Reporting (formerly RAQDAPU)

**Hospital Value-Based Purchasing (ACA)

Payment Year

Pay for Participation*

Pay for Performance**

FY 11 2% APU

FY 12 2%

FY 13 1% 1%

FY 14 0.75% 1.25%

FY 15 0.5% 1.5%

FY 16 0.25% 1.75%

FY 17 0% 2%

Blue Cross Pay for Performance FY09

Patient Safety Program Full Weight Potential Final Weighted Score

Anticoagulation Mgt 15% 8.5

Boards on Board 15% 15.0

Vent Assoc Pneumonia 25% 24.2

Urinary Tract Infections 0% 0

Central Line Infections 30% 30.0

Surg Care Improvement 15% 13.8

Hospital X achieved a final effective score of 94 out of 100 for the FY09 contract year. This equates to $5.3M in total revenue, an increment of approximately $1M from FY08.

CDC and State Public Health Role in HAI Elimination?

Data for Action!

National Healthcare Safety Network (NHSN)

Internet based reporting system through CDC’s Secure Data Network

4000+ US healthcare facilities currently participate from all 50 states

Standard definitions, methods, and protocols

Manual data entry with transition toward electronic data capture

• Think beyond public reporting and hospital comparisons*

• Focus on changes/progress within facility over time

• Set HAI prevention goals and targets

• Adopt/adapt State HAI Plan (not regulatory! patient-focused!)

* Insist on electronic data advances for denominator collection; establish systems’ approaches for identifying infections

Believe Most HAIs are Preventable

Requires consistent / reliable implementation of practices currently known to reduce HAIs

Prevented

Preventable

Unknown

prevention

scauses

Hea

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are

-ass

oci

ate

d Inf

ect

ion

Continued research to identify additional prevention strategies

Monitor and reinforce prevention strategies until all become routine care

HAI Elimination White paper ICHE 2010;31:1101-5

“Pause, think, and discuss every time there is an HAI”

Focus interventions outside of ICU

• Central line use increasing

▫ 24% of non-ICU patients have a line

▫ 70% of hospitalized patients with central lines are

outside the ICU

• CLABSI rates outside ICUs may be similar to rates of these infections in ICUs

▫ 5.2 per 1,000 catheter-days for medical ICU

▫ 5.7 per 1,000 catheter-days in 4 inpatient wards

Marschall et al. ICHE 2007;28:905-9

Climo et al. ICHE 2003; 24:942-5

Focus on C difficile prevention

Elimination of HAIs requires

• Effective use of existing interventions

• Strong surveillance

• Prevention tools

• Engaging all partners, including the public

• Political will

• Research to address unknowns

Safe Healthcare is Everyone’s Responsibility

Payors

Consumers

Patients

Medical Professionals

Government

Public Health

HealthcareFacilities

See also CDC HAI website - www.cdc.gov/hai/ for HAI prevention toolkits, link to State HAI plans. NHSN www.cdc.gov/nhsn/

www.cdph.ca.gov/HAI

Web Resources

Questions ?

HAI Liaison Program

Teresa Nelson RN BSN CICSouthern California Coordinator

Teresa.Nelson@cdph.ca.gov

Lynn Janssen MS CICProgram Coordinator

Lynn.Janssen@cdph.ca.gov