Healthcare-associated Infections: Overview and Policies

Michael Bell, M.D. Division of Healthcare Quality Promotion Centers for Disease Control and Prevention

Healthcare-associated infections (HAI)

•  1 out of 20 hospitalized patients affected •  Associated with increased mortality •  Attributed costs: $26-33 billion annually

HAIs occurring in all types of facilities, including: •  Long-term care facilities •  Dialysis facilities •  Ambulatory surgical centers •  Hospitals

Healthcare-associated infections

Data for action and improvement

•  CDC’s data -National Healthcare Safety Network (NHSN) •  CDC’s evidence-based Guidelines are the standards

•  for safe care in the US •  CDC supports State and Local Health Departments

and healthcare facilities by providing laboratory and prevention expertise

CDC’s Role in US Healthcare

Changing landscape of healthcare:

•  Organizational factors affect HAI prevention –  Administrative policies –  Antimicrobial utilization –  Staffing –  Education

•  Increasing prevalence of antimicrobial-resistant pathogens

Growing populations at risk •  Immunocompromised individuals •  Low birth-weight, premature neonates •  Transplant recipients on immunosuppressive therapy

Special environments •  Intensive Care and Burn Units •  Long-term care •  Ambulatory surgery, endoscopy, and infusion services

Healthcare has Moved Beyond Hospitals

Hospitals

Ambulatory facilities

Long-term care

Dialysis facilities

7

Surgical procedures are increasingly performed in outpatient settings

Source: Avalere Health analysis of Verispan’s Diagnostic Imaging Center Profiling Solution, 2004, and American Hospital Association Annual Survey data for community hospitals, 1981-2004. *2005 values are estimates.

All Outpatient Settings

Hospital

Inpatient

Pro

cedu

res

(mill

ions

)

Outbreaks Due to Errors in Outpatient Settings

•  Endoscopy clinic (HCV): NYC 2001, NV 2008 •  Private medical practice (HBV): NYC 2001

•  Pain remediation clinic (HCV): Oklahoma 2002, NY 2007

•  Oncology clinic (HCV): Nebraska, 2002 Ø State authorities notified and tested thousands of patients •  Common Theme:

–  “Obvious” violations in standard procedures –  Preventable with basic infection control practices –  HCWs not aware that practices were in error

HAI Prevention Implementation and Research

Need for complete implementation of practices known to prevent HAIs

Prevented

Preventable

Prevention approach unknown

HAIs

Need for ongoing research to identify new strategies to prevent the remaining HAIs

Antimicrobial Resistance

Historical perspective

•  Only a fraction of HAIs thought to be preventable

•  Since 1970s, voluntary confidential reporting to CDC

•  Information directed toward Infection Control programs

•  Little consumer or legislative interest

The world today:

•  Active, action-oriented consumer movement

•  Quality improvement programs •  Legislators and the public demand transparency

•  Preventability is greater than originally thought

Public health/health care collaboration Key opportunity of the next decade

Drivers

Data and measures

Delivery of services

Public health/health care collaboration Key opportunity of the next decade

Data and measures •  Public health use of clinical data •  Clinical use of community data and population health measures Services •  High-impact public health services (e.g., TB, STD, immunization) •  Clinical services with maximum health benefit •  Linked community and clinical services and activities Drivers •  Guidelines, regulations, and incentive systems •  Capacity •  Strategic partnerships •  Changing societal expectations

An Emerging Policy Framework for Eliminating Healthcare-Associated Infections

•  Transparency –  Data for consumers, policymakers, payors and clinicians

•  Accountability –  Adherence to prevention recommendations

•  Recognizing and promoting excellence –  Best practices and optimized bundles

•  New knowledge –  Research to develop new tools, and new prevention approaches –  Identifying and responding to new threats

Public Reporting of HAI rates

CDC Guidance on Public Reporting of HAI

•  HICPAC consensus opinion

•  Starting point in the process of public disclosure of HAIs

•  A guide to best practices

•  Endorsed by APIC, SHEA and CSTE

CDC Recommendations for public reporting of HAI data

•  Use established public health surveillance methods for mandatory HAI reporting

•  Create a multidisciplinary advisory panel to monitor planning, oversight, operations and products of HAI public reporting

•  Use process and outcome measures appropriate for facility type

•  Phase in measures over time and include ongoing evaluation of data validity

•  Provide regular, confidential feedback to healthcare providers

Potential Concerns related to Public Reporting Diversion of resources?

•  away from patient care and prevention programs

Creation of disincentives? •  to treat patients at higher risk for HAI

Misuse of current standard methods? •  for HAI surveillance, which were developed for voluntary use

Need for validation of data.

State HAI Public Reporting, 2012

HAI Policy Shifts in the US

.

DC*

Culture Change

“Many infections are inevitable; some might be preventable“

“Each infection is potentially preventable,

unless proven otherwise”

Adherence to CDC Guidelines Reduces HAIs Examplesof Success: Pennsylvania, Michigan

MMWR 2005;54:1013-16

0

2

4

6

8

10

0 18

BS

Is/1

,000

cat

hete

r day

s

ICUs at 103 Michigan hospitals, 18 months

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

Adherence to Infection Control Guidelines is Incomplete

• Many HAIs are preventable with current recommendations

•  Failure to use proven interventions is unacceptable

• Only 30%-38% of U.S. hospitals are in full compliance

•  Just 40% of healthcare personnel adhere to hand hygiene

•  Insufficient infection control infrastructure in non-acute care

settings has allowed major lapses in safe care

Adherence

•  Administrative involvement –  Staffing support –  Resource allocation

•  Systematic implementation •  Observation and enforcement •  Culture change: Infection control and prevention is everyone’s responsibility.

Patient Safety

Healthcare Personnel

Safety

Research & Development Hemovigilance

491 facilities enrolled 44% had 201-500 beds

2007

2008 2,003 facilities enrolled 19 States using NHSN for mandatory reporting

2014 >12,000 facilities enrolled 27 states using NHSN for mandatory reporting

Data for Action

Hospitals using NHSN are Preventing Bloodstream Infections

0

1

2

3

4

5

6

7

8

9

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

Poo

led

Mea

n A

nnua

l CLA

BS

I Rat

e pe

r 1,0

00 C

entra

l Lin

e D

ays

Medical Medical/Surgical--Major Teaching Medical/Surgical--Non-Major Teaching

Pediatric Surgical

Trends in Bloodstream Infections* by ICU Type, NHSN Hospitals, 1997-2007

Progress in healthcare-associated infections

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

aggregate data (risk-adjusted rates)

SIR = Observed (O) HAIs Expected (E) HAIs

Standardized infection ratio (SIR)

Increasing adherence to CDC guidelines: Recent successes

•  58% reduction in central line-associated bloodstream infections (CLABSI) for ICU patients between 2001 and 2009

•  In 2009 alone: 3,000-6000 lives saved; $414 million in costs averted

•  Since 2001: 27,000 lives saved; $1.8 billion in costs averted

•  More needs to be done:

–  41,000 CLABSI in non-ICU hospital patients –  37,000 in dialysis centers

•  This is a model for other infections: •  MRSA, Clostridium difficile, surgical-site infections, catheter-associated urinary tract infections, ventilator-associated pneumonia

ICU VA Pittsburgh

Hospital-wide

VA Pittsburgh

Southwest Pennsylvania Regional Collaborative

•  19 hospitals Maryland Initiative •  3 hospitals

Unit

Facility

Region

National Local

National VA Initiative •  150 hospitals

•  nationwide

Expanding local successes to the nation National

VA Pilot •  18 hospitals,

•  multiple states

RWJ Initiative •  6 hospitals, 4 states

> 50% Reduction in MRSA

NNIS System Methods

•  Focused on infections in critical care and surgery

•  Standard definitions for all data fields

•  Standard protocols to collect data –  infections and denominators

•  Revised protocols as needed

•  CDC published reports of aggregated data – www.cdc.gov/ncidod/hip/surveill/nnis.htm

National Healthcare Safety Network (NHSN)

•  Includes process measures •  Minimizes user burden

– Streamlines data reporting – Uses existing electronic data (e.g., laboratory information

systems, operating room, pharmacy, clinical, administrative databases)

•  All healthcare entities can participate •  Open to State health departments and other groups

•  Required selection of conditions that:

– are high cost, high volume or both

–  result in a higher payment when present as a

secondary diagnosis

– could “reasonably” be prevented by application of

evidence-based guidelines

Deficit Reduction Act - 2007

Present on Admission (POA) Indicator

•  New data element approved by the National Uniform Billing Committee (NUBC)

Noninfectious Conditions?

•  Falls •  Pressure ulcers •  Never events

– Retention of a foreign object after surgery – Surgery performed on wrong body part or patient – ABO-incompatible blood or blood products

Facility Ratings?

CDC’s National Healthcare Safety Network (NHSN)

•  NHSN is used by •  Facilities to track and prevent HAIs •  States for public reporting and regional prevention •  CMS for quality reporting •  HHS to measure national progress

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Health Reform

•  Congress: –  Bills proposing mandatory national public reporting –  HAI prevention tied to Medicare/Medicaid payment

•  Affordable Care Act –  Section 3001- Hospital Value Based Purchasing Program

“…value-based incentive payments are made in a fiscal year to hospitals that meet the performance standards . . .”

Requires 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 – Uses NHSN to report quality measure data

CMS Inpatient Prospective Payment System (IPPS) Rule

Proposed Changes to FY2011 Rates for Acute Care and Long Term Care Hospitals

HAI Prevention and Health Departments

Growing focus on the role of public health: •  Neutral, external oversight •  Implementation of public reporting •  Consultative resource for HAIs •  Coordination of regional and statewide HAI prevention

State Activities •  State HAI Elimination Plans

•  Recovery Act Investments: – $40M to CDC to fund State HAI activities

ü Enhancing HAI surveillance ü Establishing HAI prevention initiatives

– $10M to CMS for surveys in ambulatory surgical clinics ü CDC assisting by developing tools for enhanced surveys,

training surveyors, and assisting with onsite survey activities

•  State legislation – >40 states have introduced or passed HAI legislation

§  TN HD using data identify facilities with high infection rates and then working directly with those facilities.

§  Rates of CLABSIs have dropped state-wide.

Use of the NHSN Patient Safety Component is Mandated in 26 States and the District of Columbia

SC NY TN OK

CO VA

PA VT WA 2007 2008

CT DE MD MA CA

NJ 2009

WV IL OR NH NV

2010 2011

TX AL

2006

DC AR 2012

ME

Central line-associated bloodstream infections (CLABSIs)

AL, AR, CA, CO, CT, DC, DE, HI, IL, MA, MD, NC, NH, NJ, NV, NY, OK, OR, PA, SC, TN,TX, VA, VT, WA, WV

Surgical site infections (SSIs) AL, CA, CO, DE, HI, IL, MA, MD, NH, NJ, NV, NY, OR, PA, SC, TN, TX, VT, WA

Multidrug-resistant organisms and Clostridium difficile infections

CA, DC, ME, NJ, NV, NY, PA, TN, and other states considering its use (C. diff LabID FacWide—CA, NY, TN; MRSA Blood LabID FacWide—CA, DC, NJ, NV, TN; VRE LabID FacWide—CA; MRSA Infection—ME, NV, MRSA AST—NJ; PA facilities may chose a single pathogen and do infection surveillance or LabID or both in at least one location)

Ventilator-associated pneumonias (VAPs) OK, PA, WA

Catheter-associated urinary tract infections (CAUTIs)

AL, NJ, PA

Central line insertion practices (CLIP) CA, NH

Dialysis events CO

HI NC

Targeting Outliers using NHSN Data

Using NHSN data to identify facilities with excess HAIs •  Assessing outlier impact

o  High burden locations o  Largest potential for impact on healthcare quality

§ Interventions for improvement are delivered in partnership with State Health departments, CMS Quality Improvement organizations, Professional societies, and Accreditation organizations.

States use HAI data to assist facilities

Florida (CRE)

After an outbreak of CRE in an LTACH, the State and CDC assist the facility. CRE prevalence dropped from 60 percent to under 10 percent among hospitalized patients.

Tennessee (CLABSI) State data directs prevention resources toward hospitals with the highest prevention yield. State health department assisting hospitals with the greatest prevention needs reduced the overall rate for the entire state.

Involving patients……

Most Important Information to Consumers Choosing a Hospital

How important would that information be to you personally the next time you choose a hospital?

Source: Blue Cross Blue Shield of Massachusetts. Looking for Answers: How consumers make health care decisions in Massachusetts, a survey of Massachusetts adults. Presented at the High-Performance Health Care: What It Takes Conference, April 2, 2007. Available at: http://www.bluecrossma.com/common/en_US/pdfs/aboutUs/consumers-make-health-care-decisions-in-ma.pdf.

Effective clinical systems improvement program

Safe Healthcare is Everyone’s Responsibility

Payors

Consumers

Patients

Medical Professionals

Government

Public Health

Healthcare Facilities

More Information

www.cdc.gov/hai Thank you!

Outbreaks vs Endemic problems

Outbreaks are the tip of the Iceberg…but provide useful information

–  Dialysis – manufacturing flaws; procedural errors

–  Laboratory personnel with Tuberculosis

–  Transplant recipients – amoebae, viral encephalitis, hepatitis, HIV

–  Sterilization errors and failures – endoscopes

–  Syringe re-use transmitting hepatitis C virus

–  Multi-drug resistant organisms (MDRO)

Outbreaks vs Endemic problems Endemic problems represent the majority of HAIs

–  Device-associated infections

•  Catheter-associated Urinary tract infections (CAUTI)

•  Central line-associated Blood stream infections (CLABSI)

•  Ventilator-associated Pneumonia (VAP)

–  Procedure-associated infections

•  Surgical site infections (SSI)

–  Adherence problems

•  Antimicrobial stewardship, Hand hygiene