HAI Program UpdateMeredith Kanago, MSPHTDH Statewide CEDEP Meeting30 April 2014

Outline

•Background•HAI Burden•HAI Surveillance

▫Tennessee▫National

•Public Reporting In Tennessee•HAI Prevention Progress•Antimicrobial Stewardship•Recent HAI Outbreaks

Background

• For the purpose of surveillance, a healthcare-associated infection (HAI) is a localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that was not present on admission to the facility.

• HAIs occur in all types of care settings, including:▫Acute care within hospitals▫Same-day surgical centers▫Ambulatory outpatient care in health care clinics▫Long-term care facilities (e.g., nursing homes

and rehabilitation facilities)http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=17

HAI Burden

• In 2011, there were ~722,000 HAIs in U.S. acute care hospitals▫Significant additional burden in other

settings•Nearly 75,000 deaths associated with

HAIs▫6th leading cause of death in the US

• $33 billion in added healthcare costs

CDC, 2014

HAI Surveillance in TN

National HAI Surveillance

• Facilities are required to report HAIs and other events to CMS for payment incentives▫Examples:

Acute care hospitals: IPPS Dialysis clinics: ESRD QIP

• Failure to report -> loss of 1% annual payment update

• Pay-for-reporting -> pay-for-performance▫Revenue neutral: bonus if in top 25%; money

comes from bottom 25%• TDH aligns requirements closely with CMS to

minimize reporting burden while maximizing available data

National Healthcare Safety Network

•A secure, Internet-based surveillance system for collecting and utilizing data on HAIs

•Requires active, patient-based (or laboratory-based), prospective surveillance of events and corresponding denominator data

•Surveillance is conducted by infection preventionists (IPs) at healthcare facilities

NHSN for Regional Epidemiologists•Good news – you don’t actually have to

use (or know how to use) the NHSN application!

•What you do need to know:▫Which HAIs and MDROs are reportable in

NHSN according to TN rules/regs▫Which MDROs are reportable in NBS ▫What to do if you receive questions about

NHSN (HAI.health@tn.gov)

Public Reporting in Tennessee

• Tennessee’s first public report on HAIs was published in December 2009▫ Included aggregate state

data and facility-specific CLABSI data

• Published semi-annually, and includes facility-specific data on:▫ CLABSI in adult/ped ICUS

NICUS ▫ CAUTI in adult /ped ICUs▫ SSI (COLO and HYST)▫ LabID Events (MRSA and

CDI) in acute care

● To calculate O, sum the number of HAIs among a group● To calculate P, requires the use of the appropriate

aggregate data (risk-adjusted rates) (e.g., national NHSN data for 2006–2008)

● SIR > 1.0: # infections are HIGHER than predicted ▫ SIR= 1.5: # infections = 50% HIGHER than predicted

● SIR < 1.0: # infections are LOWER than predicted ▫ SIR= 0.4: # infections = 60% LOWER than predicted

SIR = Observed (O) HAIsPredicted (P) HAIs

Standardized Infection Ratio

CAUTI Standardized Infection Ratio (SIR) for Adult and Pediatric Intensive Care Units in Facilities with ≥1 Predicted CAUTI, Tennessee, 01/01/2013 - 06/30/2013

Data Reported from adult/pediatric ICUs as of January 30, 2014.N = number of types of intensive care units reportingOBS = observed number of CAUTIPRED = statistically 'predicted' number of CAUTI, based on NHSN baseline dataSIR = standardized infection ratio (observed/predicted number of CAUTI)UCD = number of urinary catheter daysNA = data not shown for hospitals with <50 urinary catheter days** Significantly higher than national baselineSignificantly lower than national baseline* Zero infections, but not statistically significant

Provisional Data

CLABSI –Adult/Pediatric ICUs Over Time

Q1-200

8

Q2-200

8

Q3-200

8

Q4-200

8

Q1-200

9

Q2-200

9

Q3-200

9

Q4-200

9

Q1-201

0

Q2-201

0

Q3-201

0

Q4-201

0

Q1-201

1

Q2-201

1

Q3-201

1

Q4-201

1

Q1-201

2

Q2-201

2

Q3-201

2

Q4-201

2

Q1-201

3

Q2-201

3

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

Tennessee SIRNHSN 2006-2008 Baseline SIRHHS 5-Year Goal

Quarter

SIR

CLABSI – NICU SIRs Over Time

Provisional Data

Q3-2008

Q4-2008

Q1-2009

Q2-2009

Q3-2009

Q4-2009

Q1-2010

Q2-2010

Q3-2010

Q4-2010

Q1-2011

Q2-2011

Q3-2011

Q4-2011

Q1-2012

Q2-2012

Q3-2012

Q4-2012

Q1-2013

Q2-2013

Q3-2013

Q4-2013

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

Tennessee SIR

NHSN 2006-2008 Baseline SIR

HHS 5-Year Goal

Quarter

SIR

CAUTI – A/P ICU SIRs Over Time

Provisional Data

Q1-2012 Q2-2012 Q3-2012 Q4-2012 Q1-2013 Q2-2013 Q3-2013 Q4-20130

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8Tennessee SIRNHSN 2009 Baseline SIRHHS 5-Year Goal

Quarter

SIR

MRSA – ACH SIR Over Time

Provisional Data

Q1-2012 Q2-2012 Q3-2012 Q4-2012 Q1-2013 Q2-2013 Q3-2013 Q4-20130

0.25

0.5

0.75

1

1.25

1.5

1.75

2Tennessee SIRNHSN 2010-11 Baseline SIRHHS 5-Year Goal

Quarter

SIR

TN: 3rd Highest Outpatient Antibiotic Use

(TN: 1,159 Rx vs 801 Rx per 1,000 persons)

http://www.cddep.org/resistancemap/use/all

Antimicrobial Stewardship Collaborative

•GOALS:▫Improve appropriate

antibiotic use ▫Reduce unnecessary

antibiotic use

▫Reduce emergence & spread of multidrug resistant organisms

▫Reduce Clostridium difficile

0%

10%

20%

30%

40%

50%

60%

70%

46.4%

59.0%

51.9%

Prevalence of Antimicrobial Use in Hospitalized Patients(10 States (EIP), 2011)

Antimicrobial Stewardship (continued)

• Simplified monthly point prevalence survey• Monthly webinar topics include:

▫Assessing the Gaps and Identifying Champions for Antimicrobial Stewardship

▫Multidisciplinary Efforts in Antimicrobial Stewardship

▫Creating and Utilizing Antibiograms▫Dose Optimization and Kinetic Dosing▫Antimicrobial Stewardship in Small Hospitals▫De-Escalation▫Measurement in Stewardship Programs and

Reporting Metrics to Stakeholders

Recent HAI Outbreak

•MSSA joint injections at an outpatient clinic▫September 9, 2013: TDH is notified of 3

joint infections among patients who received injections of triamcinolone acetate and lidocaine at a single outpatient clinic on the same day

▫Triamcinolone was produced in out-of-state compounding pharmacy

▫Medications were sequestered and injections were stopped

Recent HAI Outbreak

•MSSA joint infections (continued)▫Follow-up showed 4/5 pts receiving

injections on 9/5 had evidence of a joint infection

▫MSSA isolated from 3 cases (PFGE-indistinguishable strains); cultured meds negative

▫Site visit revealed suboptimal med prep and hand hygiene; no separate clean area for med prep

▫Recommendations provided, including avoiding use of multi-use vials

Questions?

•HAI.health@tn.gov