HAI Surveillance and Investigations in California CACDC Annual Meeting Oakland, California HAI Surveillance and Investigations in California CACDC Annual

HAI Surveillance and Investigations HAI Surveillance and Investigations in Californiain CaliforniaCACDC Annual MeetingCACDC Annual Meeting

November 1, 2012Oakland, CaliforniaOakland, California

Kavita K. Trivedi, MDPublic Health Medical Officer

California Department of Public Health

Agenda• Burden of Healthcare Associated

Infections (HAIs)• Role of Public Health• CDPH HAI Program• Federal HAI Requirements and

Messages• HAI Outbreak and Infection Control

Management• Collaboration with LHDs

Burden of Healthcare Associated Infections (HAIs)

Historically hospitals were not the safest places

The Current Problem

Annual U.S.

Total HAIs* 1.7 million

Deaths* 99,000

Average additional direct cost to hospital

$13.6 billion

Overall net hospital cost

$8.5 billion

* From Klevens et al..Public Health Rep. 2007;122:160-6

Major HAIs

• 75% are accounted by four categories

HHS National Action Plan for the Prevention of HAIs

Major HAIs• Most are procedure related

Old Paradigm

• Many HAIs cannot be prevented because patients– Older– Immunocompromised– Multiple comorbidities and acute illnesses– One or more indwelling devices

• Low number of HAIs in any one institution renders prevention efforts not cost effective

New Paradigm• HAIs can be prevented

– Contamination of many devices can be prevented at time of placement and during maintenance

– Devices can be removed as soon as they are no longer needed

– Systems can be implemented to ensure that these steps are taken and if patient safety culture develops

– Saves lives and money

New Paradigm?• If you can’t measure it, you can’t prevent it• If you measure and report it, it will decrease

MSNBC article June 27, 2012: 14 Worst Hospital Mistakes to Avoid

1. If you have a choice of hospitals, ask if your doctor knows your options' infection rates, which are measured using "catheter days," meaning every 24 hours that a tube is inserted in a patient's blood vessels. "The best hospitals' rates have been zero in one thousand catheter days for a year or more," says Dr. Pronovost. "If it's risen above three, I'd be worried."

Stakeholders in HAI Prevention

• Patients/residents

• Family members

• Community members

• Healthcare personnel

• Public health providers

Role of Public Health

Role of Public Health in HAI Surveillance and Prevention

• Abides by core functions of public health:– Monitor and detect HAIs in all healthcare settings; in

some states report findings– Educate healthcare systems, providers and public on

HAI prevention measures– Partner with healthcare providers and CDC to support

HAI prevention efforts– Identify best practices and share across healthcare

systems

Role of Public Health in HAI Surveillance and Prevention

• Abides by core functions of public health:– Interpret laws and regulations to improve public health

by preventing HAIs– Ensure competent healthcare systems in HAI

prevention and state surveyors– Evaluate and improve Infection Prevention programs

including antimicrobial stewardship– Research innovative solutions through prevention

collaboratives with stakeholders

California Department of Public Health HAI Program

• Authorized by California Senate Bill 739 (2006) to provide HAI surveillance, prevention and annual reporting from all general acute care hospitals

• Established December 2009• Mission is to improve care quality and patient safety

through the prevention of infections in licensed California healthcare facilities– Assist with surveillance and prevention activities– Develop and disseminate infection prevention recommendations

and guidelines– Implement mandatory public reporting of HAI data

CDPH HAI Program

• Enforcement (L&C) is separated from all HAI Program functions

• HAI Program does not share information from healthcare facilities with L&C unless there is an imminent threat that is not being addressed

• HAI Program informs facility of need to report outbreaks and breeches to L&C (and LHD)

Licensing and Certification (L&C) and HAI Program Relationship

http://www.cdph.ca.gov/programs/hai/Pages/default.aspx/

• A close working relationship between oversight and prevention programs enhances the effectiveness of each.

• It is helpful to have a structure that facilitates the relationship.

Enforcement and Prevention

HAI Program Consultation and Guidance

• Provide infection prevention, outbreak management and antimicrobial stewardship recommendations with education at facility and county level per request of LHD and in partnership with CDPH Division of Communicable Disease Control

• Provide coordination with other state agencies• Develop infection prevention guidance• Provide onsite assistance when/if possible• Educate L&C surveyors

Mandatory HAI Public Reporting in California

• Since April 1, 2010, CDPH only accepts data entered through CDC’s National Healthcare Safety Network (NHSN) for:• Central line-associated bloodstream infections (CLABSIs), MRSA

and VRE bloodstream infections, Clostridium difficile infection – public 2011

– Must be risk-adjusted using methodology “consistent with NHSN”• 29 surgical site infections (SSIs) – public 2012

• Healthcare personnel influenza vaccination, central line insertion practices (CLIP), and surgical antimicrobial prophylaxis (SCIP measures 1-3) – within 6 months of receipt beginning in 2008


• 434 general acute care hospitals with 390 reporting entities– Law applies to licensed general acute care

hospitals– No exemptions (size, nature, etc)

Mandatory HAI Public Reporting in California


• Reports are available at: http://www.cdph.ca.gov/hai/– Unclear how these are being used by LHDs to

target prevention activities– HAI Program has offered at CCLHO meetings to

generate LHD specific reports if requested– To date, none have been requested other than Los

Angeles in 2010– All hospitals in Los Angeles County have joined their

NHSN group

Mandatory Public Reporting in California

Federal HAI Requirements and Messages

Health and Human Services HAI Action Plan - Strategy

• Prevention and Implementation– Prioritize recommended practices to facilitate implementation

• Research– Identify gaps and develop coordinated research agenda

• Incentive and Oversight – Evaluate compliance with infection control practices in hospitals

through required certification processes– Identify additional options for use of payment policies and

financial incentives to motivate organizations to provide better, more efficient care

• Information Systems and Technology – Make varied HHS data systems interoperable

• Outreach and Messaging

http://www.hhs.gov/ophs/initiatives/hai/infection.html

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American Recovery and Reinvestment Act (ARRA)

• $40 million over 2 years to increase state capacity and supplement existing programs– 49/50 states with HAI Programs– Through CDC Expanded Epidemiology and Laboratory

Capacity (ELC) Cooperative Agreement

• Tied to Federal HHS National Action Plan for the Prevention of HAIs– Required submission of state plan– Expand use of NHSN– Develop prevention collaboratives

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American Recovery and Reinvestment Act (ARRA) CDPH Funding

• $2.6 million over 2 years– Contract with Public Health Foundation Enterprises

• Supported up to 8 FTE infection preventionists• Regionally placed to facilitate onsite services

– LHDs including LA, San Diego, Stanislaus• Onsite consultation to most California hospitals• Prevention collaboratives

– Small/rural hospitals, LTACs, prison hospitals• Courses, trainings

Affordable Care Act (ACA)

• Jan 2011-July 2012– With additional funding supported 7 IP FTEs – Project oriented, across spectrum of care

(e.g. CDI in Imperial County)

• August 2012-July 2013– Funding for 6 IP FTEs– Restricted to across spectrum projects

except for 50 hospital SSI data validation

Current Center for Medicare and Medicaid Services (CMS) Requirements

• CMS IPPS Rule – CMS-1498-P: Changes to FY2011 Rates for acute care hospitals– National public reporting of HAIs through NHSN

• CLABSI and SSI initially (hip and CABG)• Implementation of HHS HAI Action Plan over time

– 6% of Medicare payments to hospitals contingent on reporting errors and provision of safety care, focus on HAIs and readmissions

• 9% by 2015, $70 billion

• Links reduction of HAIs to federal payment • De facto national mandate

Upcoming CMS RequirementsCMS Reporting Program HAI Event Reporting Specifications

Reporting Start Date

Long Term Care Hospital Quality Reporting (LTCHQR) Program

CLABSILong Term Care Hospitals *: Adult

and Pediatric LTAC ICUs and Wards

October 2012


CAUTILong Term Care Hospitals *: Adult

and Pediatric LTAC ICUs and Wards

October 2012

Inpatient Rehabilitation Facility Quality Reporting Program

CAUTIInpatient Rehabilitation Facilities:

Adult and Pediatric IRF WardsOctober 2012

Hospital Inpatient Quality Reporting (IQR) Program

MRSA Bacteremia LabID Event

Acute Care Hospitals: FacWideIN

January 2013


C. difficile LabID EventAcute Care Hospitals:

FacWideINJanuary 2013


HCW Influenza Vaccination Acute Care Hospitals January 2013


HCW Influenza Vaccination (proposed)

Long Term Care Hospitals* TBD

Ambulatory Surgery Centers Quality Reporting Program

HCW Influenza Vaccination Ambulatory Surgery Centers October 2014

Ambulatory Surgery Centers Quality Reporting Program

TBD (future proposal)Hospital Outpatient Departments and Ambulatory Surgery Centers

TBD

* Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN

Medi-Cal Non-reimbursement

• As of July 1, 2012 providers must report Provider-Preventable Conditions (PPCs)

• http://www.cdph.ca.gov/certlic/facilities/Documents/LNC-AFL-12-38.pdf

HAI Outbreak and Infection Control Management

HAI Outbreak and Infection Control Breech Investigations

• Major detriment to patient care and patient safety– Can be devastating for healthcare workers

• Can have massive financial and public relations impacts on healthcare facilities

• Sentinel events that help us understand and confront emerging challenges in healthcare

• Can play an important role in making recommendations that improve overall patient care and provide important opportunities for education

HAI Program and Outbreak Investigations

• Led the investigation of:– MDR Acinetobacter baumannii in LTCF (2010)– Candida spp. CLABSIs in acute care hospital

(2011)– Vascular-associated bloodstream infections in

hemodialysis (HD) patients from one company providing outpatient HD services (2011-2012)

– Clostridium difficile infections in LTCF (2012)– Hepatitis B virus exposure in an ambulatory

surgical center (2012)– National fungal meningitis outbreak due to

contaminated epidural/joint steroid injections

HAI Program and Telephone Consultations

• Invasive Group A Streptococcus in postpartum women

• Salmonella Newport in NICU• Norovirus, scabies, influenza management in

LTCFs• MDRO (CRE and ESBLs) management• HBV and HCV exposures associated with

licensed healthcare facility• Hospital realized they had been using wrong

% gluteraldehyde for endoscope disinfection for approximately 7 years

CDPH Outbreak and Infection Control Management

• Contact LHD• Encourage LHD/facility to report to L&C

– If unusual occurrence• Rely on our experience (Jon Rosenberg,

Infection Preventionists)• Conduct literature review• Contact CDC subject matter expert

– Other state clusters/outbreaks– Management expertise– FDA involvement

Worldwide HAI Outbreak Resource

http://www.outbreak-database.com/

http://www.outbreak-database.com/

Investigation Management• Case Finding

– Microbiology data– Infection control or surveillance records– Discussions with clinicians

• Linelist– Signs and symptoms- is this an outbreak?– Medications– Procedures– Consults– Location– Staff contact?– Host factors?

Caveat emptor!

• A limited line list can be misleading

• Not every case might be exposed to the source

• Many cases may be exposed to something that is only an associated factor

Observations

• Who and what to observe is generally driven by the line list

• Initial observations and review of procedures can be very informative and can help with the creation of a standard observation tool, if needed

Implementing Control Measures

• Ultimately, primary goal is to stop transmission, not necessarily find source

• It’s OK to implement a variety of control measures targeting various possibilities based on initial observations

Other Important Issues in HAI Outbreaks

• Aside from the patients, there will be other “interested parties”– Hospital administration– Media– Lawyers

Collaboration with LHDs

HAI Surveillance, Public Reporting and LHDs

• Important for LHDs to be aware of HAI prevention activity given reporting requirements and federal reimbursement policies

• HAI Program strives to improve utility of HAI public reports to LHDs by:– Providing dedicated education on how to use

reports– Assisting in targeting prevention activities at local

level

HAI Surveillance, Public Reporting and LHDs

• Prevention component is extremely important and not been main focus of HAI Program

• LHDs can assist with leading these efforts at the local level

HAI Outbreak and Infection Control Management and LHDs

• Important for LHDs to continue to be notified and manage these at the local level

• HAI Program will continue to provide telephone consultations and active involvement– First points of contact: Kavita K. Trivedi,

MD and Rebecca Siiteri, RN, MPH


• No distinction between LTCF and acute care• Acute care – safety net of hospital

epidemiologist and infection preventionist– If outbreak or breech, may consider quickly

contacting HAI Program

• LTCF – limited safety net and LHDs have much experience– Contact HAI Program if something unusual


• Important to remember that CDPH can only issue guidance if they are notified about infection control issues in LTCFs and acute care

• Even if LHD is able to manage, consider notifying HAI Program of investigation


• If observation or onsite assessment is requested of the HAI Program:– HAI Program will assess resources

• Note: Current travel of state employees is limited; 1 furlough day per month

– Assistance will be provided only if member of LHD is able to accompany HAI Program staff for education

• System should be sustainable so that if another similar infection control problem arises at same LHD, they are able to better manage

Discussion

• What is the role of LHDs in HAI investigations?

• Should a triage process be developed for HAI investigations and when CDPH is involved?

• Should a distinction be made between licensed and unlicensed facilities for investigation purposes?

Discussion

• Should an assessment of LHDs HAI resources and capabilities be done?

• Should we focus on HAIs with the greatest threat to public health?– Communicability vs. severity of illness

Questions/Comments?

• Kavita K. Trivedi, MD• [email protected]

• Rebecca Siiteri, RN, MPH• [email protected]

CDPH HAI Program