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Tapping Into Strategies to Reduce Infections
Marion Kainer MD, MPH Pamela Talley MD, MPH
Director Deputy Director
Healthcare Associated Infections
and Antimicrobial Infections
TCPS Regional Networking Meetings April 2018
Objectives
• Review CAD metric for targeted HAI reduction
• Describe current efforts to reduce CLABSI, CAUTI and
CDI using TAP strategy
• Provide TAP resources for other interested facilities
• Describe MDRO containment experience in Tennessee
• Update findings and next steps for invasive MRSA
prevention
• Other HOT TOPICS
Targeted Assessment
for Prevention
Standardized Infection Ratio (SIR)
SIR = 1 Same # of HAIs as predicted by US baseline data
SIR > 1 More HAIs than predicted
SIR < 1 Fewer HAIs than predicted
SIR = Observed O HAIs
Predicted P HAIs
CAUTI 25% SIR = 0.75
SSI 30% SIR = 0.70
CDI LabID 30% SIR = 0.70
MRSA LabID 50% SIR = 0.50
HHS 2020 Goals
CLABSI 50% SIR = 0.50
nEW
CLABSI SIR in Adult/Pediatric ICUs
0.75
0.39
CLABSI in Acute Care Hospitals
Unit Year
No.
of
Facs
TN SIR
No. of Facs
with Sig.
LOW SIR
No. of Facs
with Sig.
HIGH SIR
Adult/Pediatric
ICUs
2015 82 0.88 3 5
2016 82 0.85 3 2
2017 83 0.87 2 0
Adult/Pediatric
Wards
2015 100 0.80 7 1
2016 100 0.75 6 1
2017 99 0.69 7 1
Neonatal ICUs 2015 25 0.92 0 0
2016 25 0.63 2 0
2017 25 0.73 1 0
CLABSI HHS 2020 Goal: SIR = 0.5
CAUTI SIR in Adult/Pediatric ICUs
1.05
0.68
CAUTI in Acute Care Hospitals
Unit Year
No.
of
Facs
TN SIR
No. of Facs
with Sig.
LOW SIR
No. of Facs
with Sig.
HIGH SIR
Adult/Pediatric
ICUs
2015 82 1.06 3 5
2016 82 0.96 5 5
2017 83 0.72 9 2
Adult/Pediatric
Wards
2015 100 0.70 4 1
2016 100 0.73 5 2
2017 99 0.76 6 1
CAUTI HHS 2020 Goal: SIR = 0.75
Healthcare-Onset CDI SIR
CDI in Acute Care Hospitals
Year No. of
Facs TN SIR
No. of Facs with
Sig. LOW SIR
No. of Facs with
Sig. HIGH SIR
2015 108 0.97 11 8
2016 108 0.88 23 11
2017 106 0.84 29 6
CDI HHS 2020 Goal: SIR = 0.7
How do we get there?
A New Metric…
Cumulative Attributable Difference (CAD)
CAD =
Observed− (Predicted x SIRgoal)
+ CAD (Number need to prevent)
number of infections in a location or facility in a defined
period of time that must be prevented to reach HAI reduction
goal
TAP Strategy
Targeted Assessment for Prevention: Using Data for Action
www.cdc.gov/hai/prevent/tap.htm
❶ Target ❷ Assess ❸ Prevent
• Generate TAP Reports using the
National Healthcare Safety
Network (NHSN)
• Identify facilities/units with
excess HAIs using the
Cumulative Attributable
Difference (CAD) metric
• Engage targeted facilities/units
to participate in focused
prevention efforts
Tools
• NHSN TAP Reports
• TAP ‘How To’ Guide
Tools
• TAP Facility Assessment Tools
• TAP Excel Databases and
User Guide
Tools
• TAP Feedback Report
• TAP Implementation Guide -
Links to Resources
• Assess targeted facilities/units
for potential gaps in infection
control using the TAP Facility
Assessment Tools
• Summarize responses and
calculate scores across units,
facilities, and groups to identify
gaps
• Present identified gaps and
data to facility using TAP
Feedback Report
• Utilize the Implementation
Guide to access Resources to
aid in addressing identified
gaps
• Implement proven prevention
strategies in the targeted
facilities/units to reduce
infection rates
CAD and HAI Reduction Goal: CLABSI
• SIR goal is “HAI Reduction Goal
– HHS 2020 goal for CLABSI = 50% reduction SIR 0.50
_________________________________________________________
Facility A Observed=30, Predicted=30 SIR=1.0 in 2016
_________________________________________________________
HHS Reduction Goal SIR CAD Formula CAD
(Reduction in reported) O- (P x SIR goal)
0% 1.0 30- (30 x 1.0) 0
50% 0.50 30- (30 x 0.50) 15
75% 0.25 30- (30 x 0.25) 22.5
CAD at the Location Level
17
Observed # HAIs – (Predicted # HAIs x SIR goal) = CAD
Facility
A
Observed Predicted SIR SIR goal CAD
Ward 30 20 1.5 0.50 20
ICU 0 10 0 0.50 -5
Facility 30 30 1.0 0.50 15
CAD Report Types
• TAP reports available in NHSN starting in January 2015
• As of 3/2017
– ACH & LTAC TAP reports: CAUTI, CLABSI, CDI
– IRF and IRF units reports: CAUTI and CDI
18
Helpful Hints
• Ensure that locations are mapped correctly https://www.cdc.gov/nhsn/pdfs/pscmanual/15locationsdescriptions_current.pdf
• Generate up-to-date data set
• Use time periods of at least 1 quarter
• Default NHSN goals based on HHS 2020 SIR goals
– CAUTI 0.75
– CLABSI 0.50
– CDI 0.70
• Custom SIR goals must be <1
19
Limitations
• Influenced by risk exposure volume (i.e., larger hospitals
may be preferentially targeted
• Should not be used as a comparative metric
• Facility-level CAD is summary measure that may mask
prevention needs at the location level because of
cancelling effect among positive and negative CAD
values in different locations. Therefore, facilities should
run location specific CAD for internal use.
TAP Strategy
Targeted Assessment for Prevention: Using Data for Action
www.cdc.gov/hai/prevent/tap.htm
❶ Target ❷ Assess ❸ Prevent
• Generate TAP Reports using the
National Healthcare Safety
Network (NHSN)
• Identify facilities/units with
excess HAIs using the
Cumulative Attributable
Difference (CAD) metric
• Engage targeted facilities/units
to participate in focused
prevention efforts
Tools
• NHSN TAP Reports
• TAP ‘How To’ Guide
Tools
• TAP Facility Assessment Tools
• TAP Excel Databases and
User Guide
Tools
• TAP Feedback Report
• TAP Implementation Guide -
Links to Resources
• Assess targeted facilities/units
for potential gaps in infection
control using the TAP Facility
Assessment Tools
• Summarize responses and
calculate scores across units,
facilities, and groups to identify
gaps
• Present identified gaps and
data to facility using TAP
Feedback Report
• Utilize the Implementation
Guide to access Resources to
aid in addressing identified
gaps
• Implement proven prevention
strategies in the targeted
facilities/units to reduce
infection rates
Assessment Tools
Sample Feedback Report
TAP Strategy
Targeted Assessment for Prevention: Using Data for Action
www.cdc.gov/hai/prevent/tap.htm
❶ Target ❷ Assess ❸ Prevent
• Generate TAP Reports using the
National Healthcare Safety
Network (NHSN)
• Identify facilities/units with
excess HAIs using the
Cumulative Attributable
Difference (CAD) metric
• Engage targeted facilities/units
to participate in focused
prevention efforts
Tools
• NHSN TAP Reports
• TAP ‘How To’ Guide
Tools
• TAP Facility Assessment Tools
• TAP Excel Databases and
User Guide
Tools
• TAP Feedback Report
• TAP Implementation Guide -
Links to Resources
• Assess targeted facilities/units
for potential gaps in infection
control using the TAP Facility
Assessment Tools
• Summarize responses and
calculate scores across units,
facilities, and groups to identify
gaps
• Present identified gaps and
data to facility using TAP
Feedback Report
• Utilize the Implementation
Guide to access Resources to
aid in addressing identified
gaps
• Implement proven prevention
strategies in the targeted
facilities/units to reduce
infection rates
Timeline for TAP Collaborative
TDH/THA Webinar
Jan 2018
Invitation Letters
Feb 2018
Self-assessment
On-site visits
April-Oct 2018
Interventions
Track Progress
2018-2019
Wrap-up Webinar
June 2019
Other Resources
• Detailed “how-to” guidance & FAQs https://www.cdc.gov/nhsn/ps-analysis-resources/reference-guides.html
• TAP tools
https://www.cdc.gov/hai/prevent/tap.html
26
STRIVE Resources
Antibiotic stewardship
Building a Business case for
Infection Prevention
CAUTI Prevention
CLABSI Prevention
CDI Prevention
Environmental Cleaning
Hand Hygiene
MRSA Bacteremia Prevention
Patient and Family Engagement
Personal Protective Equipment
Providing Feedback
http://www.hret.org/quality/projects/strive-community.shtml
Containment Strategy:
“Be on guard
to contain the first spark”
https://www.cdc.gov/vitalsigns/containing-unusual-resistance/infographic.html#infographic
https://www.cdc.gov/vitalsigns/containing-unusual-resistance/infographic.html#infographic
https://www.cdc.gov/vitalsigns/containing-unusual-resistance/infographic.html#infographic
https://www.cdc.gov/vitalsigns/containing-unusual-resistance/infographic.html#infographic
https://www.cdc.gov/vitalsigns/containing-unusual-resistance/infographic.html#infographic
https://www.cdc.gov/vitalsigns/containing-unusual-resistance/infographic.html#infographic
Vital Signs Report: Containment
https://www.cdc.gov/mmwr/volumes/67/wr/mm6713e1.htm?s_cid=mm6713e1_w
Percentage Reduction of Proportion of
ESBL vs CRE E. coli and K. pneumoniae 2006-2015
ESBL E. coli and K. pneumoniae
NHSN: CAUTI, CLABSI
~2% decrease per year
CRE E. coli and K. pneumoniae
NHSN: CAUTI, CLABSI
~ 15% decrease per year
Epidemic stages (modified from Grundmann et al.)
0 – No cases reported
1 – Sporadic occurrence – single cases not epi-related
2 - Single facility outbreaks - ≥2 epi-linked cases in 1 facility
3 – Regional spread - >1 facility cluster within 1 referral network
4 – Interregional spread – multiple clusters occurring within different referral networks
5 – Endemic – most facilities are repeatedly seeing cases admitted from unrelated
sources
Containment
INTERVENTIONS:
DETECTION INFECTION CONTROL CONTACT SCREENING
ARLN Regional Laboratories
Rapid Containment
Response in Tennessee
Day 1: Identification and Next Steps
“Dr. X: we have identified NDM in one of
your patients. This is a Tier 2 organism.
We will be following CDC’s guidance
document. Would like to have
conference call to discuss.”
Conference Call Joint Risk Assessment
NDM +
Klebsiella
pneumoniae
(CP-CRE)
30 minutes:
2 hours after
identification of
NDM:
Tier
1
Tier
2
Tier
3
Infection Control Assessment
Laboratory lookback
Prospective surveillance
Healthcare roommate screening
Broader healthcare contact
screening
Household contact screening
Environmental sampling
Healthcare personnel screening
https://www.cdc.gov/hai/outbreaks/mdro/
NDM= New Dehli Metallo-betalactamase
CP-CRE Carbapenemase producing Carbapenem resistant
Enterobacteriaceae 40
Day 1: Joint Risk Assessment
Hospital Day 20
41
Recommendations:
Based on CDC’s Containment Guidance
Tier
1
Tier
2
Tier
3
Infection Control
Assessment
Lab Lookback
Prospective Surveillance
Healthcare Roommate
screening
Broader Healthcare
Contact Screening
Household Contact
Screening
Environmental Sampling
Healthcare Personnel
Screening
Yes Sometimes Nohttps://www.cdc.gov/hai/outbreaks/mdro/
42
Day 1 continued; Day 2: Collect Swabs
Hospital Leadership Logistics
• Confirm best address for shipment of
swabs
• Point of contact for swabs
• Email: Document packet, including
instructions, FAQ, sample assent,
specimen requisition form
Assent
Next Day…
https://www.cdc.gov/hai/outbreaks/mdro/
Regional Laboratory Collect Swabs
43
Day 3: Regional Laboratory: Testing
Dr. X notified of results
< 48 hours after initial NDM
notification
12/12 swabs negative • 11 patients on unit >3 days
• 5 patients on unit before contact
precautions initiated
Next Day…
44
Keys to Rapid Response
• Advance protocol knowledge
• Effective communications:
– Healthcare staff
– Hospital leadership
– Laboratory
– Health department
• Logistics
• ARLabNetwork:
– Report out results within 2 working days of specimen receipt
• CRE reportable, isolate submission required in Tennessee
45
ARLN Admission Screening
• Patients with hospitalization outside the U.S. in past
6 months
– Screen patient
– Place in Contact Precautions pending screening
result
– ARLN now can process these admission
colonization swabs
Day 1
CDCHAN 00341-02-14-2013
Distributed Feb. 14, 2013
How to operationalize? • Protocol for direct admissions
• Travel question (time interval)
46
MRSA
2016 TN “Rankings”
Acute Care Hospitals
• LabID – HO MRSA Bacteremia
US: 0.93 (0.92, 0.96)
TN: 1.33 (1.19, 1.47) (#49/50)
2015 TN: 1.24 (#46/52)
2014 TN: 1.01 (#41/51)
2013 TN: 1.13 (#42/51)
2012 TN: 1.44 (#33/39)
Q1 Q2 Q3 Q4
TN Acute Care Hospital SIRs, 2016
No. of Infections
Standardized
Infection Ratio (SIR) and 95% CI
Distribution of Facility-specific SIRs
HAI Unit/Type No. of Facilities
Obs. Pred. SIR Lower Upper No. of Facs with ≥1 Pred.
Infection
Facs
with
Sig.
Low SIR
Facs
with
Sig.
High SIR
CLABSI Adult/Pediatric ICUs
86 206 245 0.84 0.73 0.96 42 3 2
Adult/Pediatric Wards
104 175 232 0.75 0.65 0.87 44 6 2
Neonatal ICUs 25 37 59 0.63 0.45 0.86 12 2 0
CAUTI Adult/Pediatric ICUs 86 375 392 0.96 0.86 1.06 51 4 5
Adult/Pediatric Wards
104 174 240 0.72 0.62 0.84 51 5 2
SSI Colon Surgery 99 195 212 0.92 0.80 1.06 44 2 4
Abdominal Hysterectomy
99 62 59 1.04 0.81 1.33 16 0 1
MRSA Acute Care Hospitals
110 347 261 1.33 1.19 1.47 44 2 7
CDI Acute Care Hospitals
110 2,266 2,570 0.88 0.85 0.92 91 24 11
Data reported as of September 18, 2017
Adult/Pediatric ICUs exclude burn and trauma units for CLABSI
Adult Complex Admission/Readmission SIRs are presented for surgical site infections (SSI)
Green highlighting indicates an SIR significantly LOWER than the 2015 national baseline
Red highlighting indicates an SIR significantly HIGHER than the 2015 national baseline
Hospital Onset MRSA BSI in TN Hospitals, 2016
2016 SIR: 1.33
Standardized Infection Ratio:
Observed
Predicted
Hospital Onset MRSA BSI in TN Hospitals, 2016
2016 SIR: 1.33
2020 Goal: 0.50
Hospital Onset MRSA BSI in TN Hospitals, 2016
2016 SIR: 1.33
10% 25% 50% 75% 90%
0.28 0.77 1.08 1.72 2.98
Percentile Distribution of SIR in 2016
2020 Goal: 0.50
MRSA BSI Burden in TN
ED: 1586, 55% CO: 935, 33%
HO: 347, 12% 2,868 MRSA-
BSI LabID events
reported in 2016 in
TN hospitals
12%= HO HO= Hospital-onset; CO= Community-onset;
ED= Emergency Department
All HO-MRSA BSI LabID Events by Location-2016
54
CDC Location Observed Percent
ICU - Other Adult/Ped 159 28.3
Ward - Med/Surg 97 17.3
Ward - Medical 79 14.1
Stepdown 72 12.8
Ward - Other Adult/Ped 51 9.1
Hematology/Oncology 29 5.2
Ward - Surgical 24 4.3
NICU 21 3.7
ICU - Trauma 12 2.1
Mixed Acuity 11 2.0
ICU - Burn 7 1.3
MRSA Deep Dive Recommendations
Overall:
1. Leadership support for a culture of safety
2. Focused clinical interventions with compliance audits
depending on institutional MRSA performance using
the 2014 Compendium of Strategies to Prevent
Healthcare- Associated Infections in Acute Care
Hospitals (SHEA)
55
1. Leadership Support for a Culture of Safety
• Demonstrate a visible culture of safety within the
organization through safety huddles, safety briefings,
and executive rounding in which preventing the spread
of MRSA is emphasized.
• Designate infection prevention and control as a
focused priority of the organization.
56
Leadership Support for a culture of safety
• Provide ample resources for practice audits to measure the true
level of compliance with infection control practices related to
MRSA spread.
• Adopt accountability standards for all staff and physicians for
compliance with infection prevention practices.
• Allocate resources to assess overall infection control program
and increase infection prevention staff as needed to address
the added scope of work.
57
2. Monitor Compliance
2A. All hospitals should implement and monitor
compliance with basic infection prevention practices to
broadly address infections including MRSA.
– Hand hygiene
– Environmental cleaning
– Isolation precautions
– Correct use of personal protective equipment (PPE)
58
Require Training
2.B. Require training on the practices in 2.A. to any
healthcare providers involved in the specific action,
including staff, physicians and physician extenders.
e.g., all personnel involved with room cleaning (including preparation)
should be trained on proper practices. All personnel who enter isolation
rooms should be trained on use of the PPE. All personnel who have contact
with the patient and/or their environment should be trained on proper hand
hygiene practice.
59
Competency-based Training Programs for Acute
Care Hospitals (N=12)
60
17%
25%
50%
0% 20% 40% 60% 80% 100%
Hand Hygiene
PPE
Environmental Cleaning
Compliance Audits/ Isolation Rounds
2.C. Conduct isolation rounds and compliance audits with regular reporting to leadership on the following:
• Appropriate use of isolation precautions (i.e. appropriate patient placement)
• Donning/doffing of personal protective equipment (PPE) used for patients placed in Contact Precautions
• Environmental cleaning using objective assessments in a standardized fashion
• Safety huddles or other feedback methods to share audit data results to drive improvement
61
Medical Record Flags and Chlorhexidine
2.D. Use Information Technology to alert clinical staff of newly diagnosed
MRSA patients and readmission of prior MRSA patients
2.E. Special approaches should be considered- e.g., Chlorhexidine (CHG)
daily bathing of patients
• If utilized, consider targeting high-risk populations (i.e. based on review of
institutional MRSA data and may include ICU patients, patients with
vascular devices, patients with a history of MRSA, dialysis patients, etc.)
• If utilized, carefully train personnel administering the CHG bathing and
monitor compliance with correct practices
62
Hospital Onset MRSA BSI in TN Hospitals, 2016
2016 SIR: 1.33
2020 Goal: 0.50
Must
prevent
217
Hospital Onset MRSA BSI in TN Hospitals, 2017
2017 SIR: 1.10
2020 Goal: 0.50
Must
prevent
157
Excess* HO-MRSA BSI
65
52%
74%
0% 50% 100%
Top 5
Top 10
Excess = observed- (predicted *goal SIR)
62% (‘17)
42% (‘17)
HO-MRSA in
Tennessee and Kentucky
Conclusions: Summary
• Case-patients had long lengths of stay, multiple co-morbidities,
and high mortality
– Almost half with ICU admissions prior to BSI
• Most frequent locations of attribution for BSIs were ICUs and
Step Down Units
• Most common sources of infection were CVCs, Wounds, SSIs,
and Pneumonia
Conclusions
• Preventing infections caused by CVCs, CAUTIs, SSIs, and VAPs could substantially decrease MRSA BSI burden in these facilities
– Infections caused by CVCs appear more frequently related to maintenance, however many likely related to insertion
• Potential at risk populations include: surgical patients, patients with wounds, acute dialysis patients, those with indwelling devices, and those in ICUs and Step Down units
• Areas for improved prevention interventions
– Non-VAP Pneumonia (early ambulation post-op?)
– Wounds (i.e. burn wound care)
NHSN Surveillance Recommendations
(1) Surveillance of CLABSI in Step Down Units
(2) Capture presence of hemodialysis catheter
UP Campaign
70
http://www.hret-hiin.org/engage/up-campaign.shtml
Thank You!
Contact
TDH: (615) 741-7247
Report all Outbreaks