MQF HAI Subcommittee: HAI Plan Update

June 24, 2013Peg Shore, MT, MSPH, Ph.D., CIC

HAI Prevention Coordinator

Introduction to HAIs

• Healthcare-Associated Infections• 99,000 deaths/ year (more than breast cancer,

prostate cancer and AIDs combined!)• 1.7 million HAIs per year (2002)• Cost: total $36 billion to $45,000,000,000

(2007 dollars)/ year in U.S.

Types of HAIs

• Central line infections (CLABSIs)• SSIs: superficial and deep• Catheter-associated UTIs• Clostridium difficile• MRSA-HAI

Deaths by HAIs, U.S., 2002

• Pneumonia 35,000• Bloodsteam infection 31,000• UTI 13,000• C. difficile** 9,000• SSI 8,000

CDC estimates

• Could reduce between 33% to 50% of these infections, at a savings of $6.6 to 8.4 billion.

• Could save 33,000 lives/ year in U.S.

Changing Healthcare Landscape

• Since 2002, shift in philosophy: Public demand for:

• Accountability• Transparency

• Financial reimbursement (Medicare & MaineCare-Medicaid primarily)= no pay for HAIs

Maine State Reporting Mandates- All hospitals

• 2007: Central line associated bloodstream infections (CLABSIs), central line bundles, central line insertion practice (CLIP), surgical care improvement program (SCIP), ventilator associated pneumonia (VAP) bundle.

• 2011: Added MRSA-HAI and C. difficile (lab confirmed- inpatients only)

Current Medicare (CMS) Mandates: IPPS hospitals only (CAHs exempt)

• Central line infections (CLABSIs)• Catheter-associated UTIs (CAUTIs)• SSIs: colons, abdominal hysterectomies• MRSA bacteremias• C. difficile- Lab ID event• HCW influenza vaccination

Medicare Reimbursement: How Important is it?

• For larger hospitals, Medicare is 50 percent of hospital’s payment for services.

• Critical access hospitals, it is often 2/3rds of hospital reimbursement.

• Mandated reporting of HAIs (CMS): if miss deadline, reduce payment by 2%. (5.5 months lag)

Public Health & HAI Prevention: ARRA funding

• As 5th cause of death in the US, it has become a public health issue.

• 2009, American Recovery and Rehabilitation Act (ARRA) funded 49 states to build programs.

• HAI Prevention Programs: 1) infrastructure, 2) prevention & surveillance, 3) communication.

Maine HAI Prevention Program

• Initially, focus on hospitals with Maine Infection Prevention Collaborative as the advisory group.

• Expanded into LTC. Worked with QIO. Offered 10 day long seminars all over the state.

• Working on antibiotic stewardship to reduce C. difficile and resistant organisms (multiple drug resistant organisms-MDRO).

Data validation

• How do we know if the numbers reported are accurate?

• Must validate the data• State law: Maine CDC must validate C. difficile

and MRSA-HAI• Maine Quality Forum: validating CLABSI.

Being done by John Snow Institute (JSI)-Boston, MA.

Maine HAI Plan

• Create infrastructure• Surveillance & Prevention• Communication

• After 3 years of work, we are in a NEW place. We have created program in Maine CDc, gathered & validated data, are analyzing, and communicating with hospitals.

State of Maine HAI Plan

• We have accomplished all that was in the grant, and more:– LTC– ASP– Outbreak reporting and assistance– Distributed educational materials for patients– Surveillance and feedback to hospitals– Self-sustaining model for HH compliance– NHSN used by all hospitals/ validation of data

ASP

• Maine CDC is analyzing MaineGeneral antibiogram and creating pocket reference guide for outpatient prescribing.

• Working with MMA- Maine Independent Clinical Information Service to do academic detailing of antibiotics. Rollout is scheduled for November, 2013.

CLABSI validation

• JSI plans to do a 2 day visit to Peer Group A hospitals.

• Will do a 1 day visit to 2 of largest hospitals in Peer Group B (St. Mary’s and Mercy). Other B hospitals will be done by sharing data remotely.

Types of Communication

• Facility-specific dashboard reports to hospital• Hand hygiene compliance every 6 months• Influenza vaccination of HCW comparing all

hospitals, yearly.• Meet with MIPC monthly= all hospitals IP• Maine Quality Council: HAI subcommittee

State of Infection Control & Prevention(Maine CDC/ MQF Annual Report)

• CLABSI- adult and NICU: • CLABSI: high mortality rate 14%-25%

– majority of infections are in the 3 largest hospitals/ more complicated patient/ more CLs

– Device utilization statewide is low– MMC made huge progress in past 5 years but is

still above the national average for CLABSIs.

Statewide analysis: CAUTI

• CAUTI for IPPS hospitals: Mandated reporting by CMS/ Most common type of HAI.– A few larger hospitals had higher CAUTI rates,

sometimes in a single unit.– Most hospitals had decreasing urinary

catheterization utilization rates. Again, some units had high DU rates. Often these units also had high CAUTI rates.

SSI

• Very limited data, CMS requires only colon and abdominal hysterectomy data from IPPS hospitals.

• Critical Access Hospitals do not report any SSI data.

MRSA-HAI

• Rates varied widely between hospitals.• 50% in ICU and 50% in non-ICU• Highest type of MRSA-HAI

– SSI 42% (47)– Pneumonia 22% (25)– BSI 19% (22)

0.180.19

0.260.27

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0.100.11

0.140.15

0.270.37

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0.110.13

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0.490.000.000.000.000.000.000.000.000.000.000.00

0.150.25

0.360.75

CMMC (8/43,488)EMMC (20/106,194)MGMC (12/46,175)MMC (43/156,969)

Mercy (0/26,172)Aroostook (0/9,137)

St. Joseph (2/20,075)Mid Coast (2/18,911)

York (2/13,936)SMMC (3/20,127)

St. Mary's (4/14,732)Pen Bay (5/13,400)

Cary (0/4,261)Maine Coast (0/9,681)

Franklin (1/9,518)Goodall (1/7,821)

Inland (0/6,009)Miles (0/6,842)

NMMC (0/4,290)Parkview (2/4,046)Blue Hill (0/4,171)

Bridgton (0/3,830)CA Dean (0/4,360)

Calais (0/3,091)Down East (0/3,040)

Houlton (0/4,109)Mayo (0/4,620)

Millinocket (0/3,946)Rumford (0/5,294)

Sebasticook (0/4,368)Waldo (0/5,074)

Pen Valley (1/6,624)St. Andrews (1/3,927)

Red-Fairview (2/5,504)Stephens (4/5,306)

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0.19 cases per1,000 patient days

Lower rates are better

C. difficile

• Every peer group had one or more hospitals with higher than average rates.

• Rates varied from 0 to 19/10,000 patient days.• State average is 6.6/ 10,000 days. This will

become the threshold by which to measure progress.

• Rates included healthcare facility onset and community onset/ healthcare facility associated.

C difficile categories in NHSN

• Healthcare facility onset (HO:) Patient had positive specimen on day four or later.

• Community onset Healthcare Facility associated (CO-HCFA): specimen from patient who was discharged from the facility 4 weeks or less.

• Community Onset (CO): specimen occurs

MQF Annual Report

Three new pages (see handout or pages 33,35,36 of the report): •MRSA-HAI for 2011 (validated data) by hospital/ by peer group.•C. difficile LabID rates (2011Q4-2012Q3, all validated data). Does include both HO and CO-HCFA data. Is a proxy measure. When viewing all 3 (HO, CO-HCFA, CO) it shows the hospital burden of C. difficile.

5.36.1

7.812.0

0.91.6

4.55.7

6.912.5

13.717.9

4.34.4

6.0

10.4

0.05.3

7.210.0

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2.22.22.8

3.23.84.0

4.75.7

7.58.5

9.89.8

18.9

MMC (79/148,727)EMMC (60/97,854)MGMC (41/52,493)CMMC (44/36,662)

MidCoast (2/21,596)St Marys (5/31,119)

York (6/13,398)PenBay (7/12,339)SMMC (13/18,752)

St. Joseph's (23/18,395)Aroostook (12/8,754)

Mercy (38/21,288)

Cary (3/7,023)Franklin (4/8,997)Goodall (5/8,327)

MaineCoast (9/8,616)

Parkview (0/3,711)Inland (3/5,662)

NMMC (4/5,526)Miles (7/7,028)

Blue Hill (0/3,772)CA Dean (0/7,573)

Sebasticook (0/3,117)Stephen's (1/4,486)

Waldo (1/4,456)Bridgton (1/3,555)

Downeast (1/3,083)Rumford (2/5,265)

MDI (2/5,041)Calais (3/6,414)

St. Andrews (2/3,518)RFGH (4/5,334)Mayo (4/4,704)

Pen Valley (3/3,067)Millinocket (2/2,032)

Houlton (7/3,711)

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Peer Group

Statewide rate: 6.6 cases per 10,000

patient days

Rates per 10,000patient days

Lower rates are better

C. difficile Results 10/1/2011- 9/30/2012

• Total Inpatient positive labs (whole state): 780

• Total hospital-related C. difficile (HO & CO-HCFA): 397

• 397 C. difficile compared to 119 MRSA-HAI

Summary: C. diff bigger problem than MRSA

Prevention: Statewide Efforts

• HH: All hospitals doing internal and external audits. Slowly improving with each external audit. Median: 63% in Fall of 2011 to 81% in December of 2012.

Statewide analysis

Influenza vaccination of HCWs: •State average last year was 77%.•2012-13 state average improved to 84%.•(New Hampshire: hospitals w/o a policy=78%, hospitals with a policy=93%, hospitals that terminate unvaccinated HCW w/o an exemption=98% vaccination rate.)

MQF Annual Report

– HAI 3: Central line bundle: improved from 71% (2007-08) to 94%(2011-12)

– CLABSI rates: improved from 2.5/ 1,000 CL days (07-08) to 1.7/1,000 (2011-2012). National avg=1.2in 2010.

– NICU CLABSI rates: improved from 3.8/ 1,000 CL days (07-08) to 2.5 (11-12). National average=1.6 in 2010.

Are we seeing improvement in Maine?

• CLABSIs: Yes, although a few hospitals still above national average. Huge improvement since 2007 (66) to 2011 (47)= 19 less, 5 persons who didn’t die in 2011.

• MRSA and C. difficile: too early to tell, but we now have baseline.

• SSIs: not enough data, only following 2 surgeries.• CAUTI: only collected since 2012, but device

utilization is low in most hospitals and very good in nursing homes.

HAI program work continues

• Validation of NHSN MRSA-HAI • Validation of NHSN C. difficile lab ID• Continue working with hospitals to audit hand

hygiene.• Continue to analyze data, communicate

analysis to hospitals.• Increase efforts to LTC and physician offices.

New Efforts

• Collaboration with QIO to reduce C. difficile in the Augusta area: early diagnosis, contact precautions, environmental cleaning, antibiotic stewardship.

• ASP: Educating several hospitals, working with MICIS, developing physician pocket reference.

• CRE: include as a reportable, ASP as prevention. Develop state lab as reference to confirm.

• Outbreak assistance for LTC C. difficile outbreaks.

HAI Network• Maine CDC collaborates with:• Maine Infection Prevention Collaborative and

MIPC-CC• MHDO & MQF• UNE School of Pharmacy• Maine Medical Association- MICIS• Maine Healthcare Association (LTC)• QIO/MaineGeneral Med. Ctr./ 5 area NHs• Maine Health• Legislature/ rule making process.