Implementation of HospitalAssociated Infection HAI Reporting and Public Disclosure: What we have lea

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Implementation of Hospital-Associated Infection
(HAI) Reporting and Public Disclosure What we
have learned in South Carolina

• Jerry Gibson MD, MPH
• SC State Epidemiologist and Director of Disease
  Control
• Thanks to Dixie Roberts MPH, ARPN, Amber Taylor
  MPH, Stan Ostrawski RN, MS MT, Eric Brenner MD

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SC was the second state after VT to report using
NHSN HAI data. IL, PA, FL, MO use other
methods
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Timeline for Activities Required for Compliance
with Hospital Infections Disclosure Law
Aug 06 1st Advisory Committee meeting
Nov 07 DHEC accesses 6-month of data in NHSN to
begin analysis
Feb 07 DHEC begins pilot analysis of data
Aug 06 CDC Training for DHEC
July 07 DHEC gets funding???
Feb 08 DHEC begins QA of data
Feb 09 DHEC submits 1st Report to legislature
6/29/06 DHEC internal meeting
1/31/08 DHEC publishes 1st report
May 06 Law passed
Nov 06 Begin Training for ICPs at APIC
Jan 07 ICPs begin to pilot NHSN
May 07 ICPs begin formal entry of data into NHSN
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Its the Politics, Stupid

• Many stakeholders in HAI public disclosure, with
  very different interests and levels of
  sophistication
• Statutes were often passed because of political
  advocacy by citizens harmed by HAI anger,
  mistrust of hospitals, rigid agendas, lack of
  medical sophistication
• Legislators first interest satisfy public
  advocates
• Advisory Committee task I.D. education of
  stakeholders

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Does publishing patient care performance data
improve quality of care?

• The unintended consequences of publicly reporting
  quality information
• Werner RM, Asch DA, JAMA 2005
• Review Evidence that publishing patient care
  performance data improves quality of care
• Fung CH et al, Annals of IM 2008
• the usefulness of public reporting in improving
  patient safety and patient-centeredness remains
  unknown

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Public disclosure of HAI Classic example of the
Law of Unintended Consequences

• Advocates want reporting of counts, or of
  dramatic cases of HAI Bias against large and
  tertiary institutions
• Failure to adjust HAI rates for patient,
  procedure, or institutional risks of infection
  Bias against referral/teaching hospitals
• Failure to validate reporting completeness
  Powerful perverse incentive for hospital to make
  less effort Honest hospitals appear unsafe

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Public Disclosure Unintended Consequences II

• 4. Overemphasis on reporting inadequate time
  for prevention by scarce ICP staff rates
  worse
• 5. Report only more easily counted infections
  exclude counting difficult to define infections
  (VAP) No data on major classes of
  preventable infections
• 6. Failure to search for HAI onsets post-D/C
  late-onset HAI undercounted inadequate for
  prevention (e.g. joint replacement SSI)
• 7. Denial of admission or of aggressive therapy
  to high-risk patients, to reduce infection rate

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Acute-Care Hospital Size Distribution in SC (67
hospitals)
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16
24
55
By number of active beds
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Other problems with effective HAI reporting and
disclosure

• HAI are uncommon events (table) Searching for
  a needle in a haystack
• Active surveillance for HAI is expensive Numbers
  of ICPs are insufficient
• Surveillance on the cheap (using routinely
  collected databases, e.g. administrative claims
  data)
• Seductively simple-appearing
• Claims data are insensitive and non-specific
  (next)
• Counting risk-adjusting HAIs is complex, prone
  to errors, and a lot of work

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Patient Safety Component Basic Structure
CDC NHSN
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CLABSI

• 200,000 CLABSIs occur in the US each year
• Hospital stay, cost and risk of mortality are all
  increased
• Prevention through proper insertion and
  management of the central line
• CDC Guideline for the Prevention of Intravascular
  Catheter-Related Infections

https//www.cdc.gov/ncidod/dhqp/gl_intravascular.h
tml
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Central Line

• An intravascular catheter that terminates at or
  close to the heart or in one of the great vessels
  which is used for infusion, withdrawal of blood,
  or hemodynamic monitoring.
• The following are considered great vessels for
  the purpose of reporting central line infections
  and counting central line days
• Aorta
• Pulmonary artery
• Superior vena cava
• Inferior vena cava

• Brachiocephalic veins
• Internal jugular veins
• Subclavian veins
• External iliac veins
• Common femoral veins

NHSN training for CLABSI requires 42 slides to
describe the Procedures Rules for counting
events correctly.
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Studies of Accuracy of Administrative Claims Data

• Poor specificity (PPV 0.14 - 0.51)
• Am J Infect Control 2008 36155
• Tennessee data on MRSA surveillance poor
  sensitivity
• State of Pennsylvania example
• SC study of predictive value of hospital claims,
  for validation both PPV and NPV borderline
  (before CMS policy change)
• Effect of CMS changes in payment policy for
  HA-UTI, CABG

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The Problems of Small Numbers, in a
Median-Population State

• HAIs are uncommon, and many smaller hospitals
  must now begin reporting.
• Low infection rates require large sample sizes
  for effective validation of reporting.
• Small number of cases in smaller hospitals makes
  it hard to show rates are statistically
  different.

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NHSN Pooled Means of CLABSI Rates by location
Source National Healthcare Safety Network
(NHSN) Report, data summary for 2006, issued June
2007. Am J Infect Control 2007,35290-301
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Incidence of Surgical Site Infections NNIS
1992-2004 (AJIC 2004 32470
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Source National Nosocomial Infections
Surveillance (NNIS) System Report, data summary
from January 1992 through June 2004, issued
October 2004. Am J Infect Control 2004 32
470-85
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Reporting Infection Control Processes

• Process Measures Survey of Practices
• Facility Profile Bed Size, IC Resources, etc.
• IC Policies / Procedures/ Structure/ Surveillance
  Methods
• IC Process Monitoring
• Hand Hygiene
• Transmission Based Precautions
• SSI Prevention (includes SCIP)
• CLABSI Prevention
• VAP Prevention
• MRSA Prevention
• Other Formal IC Prevention Programs
• Antibiotic Stewardship Program
• (other?)

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Example IC Process Reporting

• Hand Hygiene (check all that apply)
• Who is monitored? (nurses, physicians, lab,
  x-ray, etc.)
• How is hand hygiene monitored? (video, direct
  observation)
• Who performs hand hygiene monitoring? (secret
  shopper, ICP, etc.)
• How often is hand hygiene monitoring conducted?
• What is the total number of hospital wide
  monthly observations? (select range)
• N/A
• 1 to 10
• 11 to 29
• 30 to 45
• gt 45

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Hospital Validation VisitWhat are we going to
Validate?

• ASA Score
• Wound Class
• Length of Surgery
• Date of Birth
• SSIs
• CLABSIs
• Infection Control Processes

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Our Preparation

• Print out reported SSI and CLABSI information
  from NHSN
• Determine the number of control charts to review
• Random selection of control charts
• FAX a list of the charts to hospital

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In Hospital, Before We Arrive

• Have the Charts we requested pulled
• If possible, have one chart marked with sticky
  tags so we can find information quickly
• If Records are computerized, make arrangements
  with Medical Records, IT, etc.

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Sample Size Issues for HIDA Data Validation How
many charts said not to have infection must be
reviewed in order to have a high probability of
detecting any missed orunreported infections
should such exist?
Sample sizes for sampling universe of N100 charts
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(Biostat reminder http//en.wikipedia.org/wiki/Hy
pergeometric_distribution)
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In Hospital,When We Arrive-SSI

• We will ask to have Medical Records do a search
  for all the ICD-9 Codes for the Operative
  Procedures for the validation period
• If done by Discharge Date, run an extra month to
  capture all the cases
• We will compare the Medical Records list with
  what was entered into NHSN

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When We Arrive-CLABSI

• Microbiology lab List of all Positive Blood
  Cultures from the Unit(s) during the Validation
  Period
• If the ICP has a line listing of the Patients
  that had Central Lines, we will compare it to the
  Positive Blood Culture List
• If there is no line listing, we will ask you to
  pull some charts of Patients with Positive Blood
  Cultures to see if they had a Central Line, and
  if the BSI was line related

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CLABSI

• How are Central Line Days collected?
• Who Collects the Line Days?
• Do you keep a line listing of the Patients?
• If you dont keep a line listing, how do you
  assure that the count is accurate?
• If you collect the line day data yourself, who
  collects the Line Days when you are not there?

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Minimum Expected Post Discharge Surveillance

• Check for Readmissions and ER visits
• Inform the ICP at another Hospital if Surgery was
  done there (send documentation
• Enter report of infection received from another
  hospital (with documentation)
• --------------------------------------------------
  -------
• Physician reports
• Patient complaints

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What Do We Do About These Problems?

• Get involved with the legislators early.
• Ask for a pilot year, and funding for it
• Emphasize reporting processes over infections
• Contact your stakeholders help with politics
  funding
• 5. State APIC, ID docs, Hosp Assoc, AARP, CDC
• Train the hospitals- and train again (and again)!
• Plan your method of validation not optional

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What Do We Do About These Problems? II

• 8. NHSN system created for voluntary use may
  require Regulations this will be very difficult
  for small hospitals
• 9. Plan your post-discharge surveillance method,
  with the hospitals
• 10. Dont underestimate complexity of reporting
  the data calculating rates, how to compare
  hospitals, hosp. stratification, making data
  understandable
• 11. Aiming at a moving target Legislative
  expectations, evolving prevention processes,
  Federal involvement
• 12. Manage the press to educate consumers
• - initial data release may be the best
  opportunity

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CA-MRSA Skin Infections
MRSA infection on knee of college football player
--6 days warm compresses and DS TMP-SMZ
required ID
http//www.physsportsmed.com/issues/2004/graphics/
1004/news1.jpg
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MRSA Surveillance Using Merged Routinely
Collected Data Sets - SC
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HIDA ChallengeOutcome and Process Measures

• Outcome Measures
• SSI Rates (selected- CABG, HYS, VHYS, CHOL, Hip,
  Knee)
• CLABSI Rates (selected locations Med-Surg ICU,
  PICU, all locations in lt 150 bed facility )
• MRSA Rates (invasive- bloodstream infections)
• Phase in others (other SSI procedures, VAP)

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Data for first 5 months of reporting. All C.I.s
overlap!