Public Reporting of Healthcare-associated Infections in Texas

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Public Reporting of Healthcare-associated
Infections in Texas

• Neil Pascoe RN BSN CIC
• (aka the Messenger)
• Epidemiologist
• Infectious Disease Control Unit

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Outline

• A brief history of issue
• International overview
• National perspective
• Texas legislative session
• SB 288 Public Reporting of HAI
• Where it is going and who is taking us

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History of Issue

• HAI/Nosocomial infections are not recent issue
• Semmelweis in 19th century
• Hospital penicillin resistance
• MRSA, UTI, VAP, BSI, SSI
• Contaminated products and devices
• Invasive procedures
• Population changes

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Healthcare-associated Infections

• Are acquired as a result of a hospital stay
• 5-15 of all hospital patients acquire HAI

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Why HAI May Increase

• Sicker patients, older population
• More invasive procedures for longer duration
• Increasing immuno-incompetent population
• Staffing shortages
• Nursing
• Pharmacists
• Pharmacy Techs
• Radiology Techs

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Why HAI May Increase

• Resistant Organisms
• 1990s P. aeruginosa
• 1990s VRE/MRSA
• 2002 VRSA/MDROs
• Emerging Infectious Disease
• 1980s HIV
• 1990s hantavirus/HCV
• 2000s WNV/SARS/Pandemic Flu
• C. diff, GNRs

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Calculation of estimates of healthcare-associated
infections in U.S. hospitals among adults and
children outside of intensive care units, 2002
HRN high risk newbornsWBN - well-baby
nurseriesICU intensive care unitSSI
surgical site infectionsBSI bloodstream
infectionsUTI urinary infectionsPNEU
pneumonia
Klevens, et al. Pub Health Rep 2007122160-6
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Rates of Healthcare-Associated Infections in
Newborns, Adults, and Children by Site of
Infection, National Nosocomial Infections
Surveillance (NNIS) System
Well-baby nurserya High-risk nurseryb Intensive
care unitb (adults and children)Patient-days
c 7,436,520 4,835,702 30,236,811Major site of
infection Rate of infection per 1,000
patient-days Urinary tract 0.19 0.5
3.38 Bloodstream 0.76 3.06
2.71 Pneumonia 0.24 0.91 3.33 Surgical
site 0.003 0.2 0.95 Other 1.37 2.21
2.67 Total 2.56 6.88 13.04aFrom NNIS
hospital-wide surveillance, 1990-1995bFrom NNIS
surveillance 2002, high-risk nursery and ICU
componentcFrom the National Hospital Discharge
Survey (NHDS) for the U.S. population in
non-federal hospitals
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Consequences

• 2 million HAI annually
• 90,000 deaths
• 4.5-5.7 billion/ year
• 25 in Intensive Care Units
• 70 involve organisms with resistance to one or
  more antibiotics

J. Burke. NEJM 2003 348 7 Emerging Infect
Dis 1998 4 416-20 Infect Control Hosp Epi 2001
22 708-14
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The International Overview
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The National Overview
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Infection Control in the Headlines

• Lax Procedures put Infants at High Risk Simple
  Actions by Hospital Workers, Such as Diligent
  Hand-washing, Could Cut the Number of Fatal
  Infections.

Chicago Tribune 2002
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As of 5/14/07
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Texas

• The State Perspective

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Texas
Travis County Capitol
You are here
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80th Legislature Regular Session

• 4 bills introduced on HAI
• Only SB 288 passed related to HAI
• HB 1082

More Patients Suffering Infections At
Hospitals POSTED 310 pm PDT May 10,
2007 UPDATED 443 pm PDT May 10, 2007 --
Hospitals aren't supposed to make you sicker.
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Setting the Stage for HAI
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SB 872 (HAI portion)

• 79th Legislative session 2005
• Unfunded mandate directing the DSHS to
• Solicit persons to fill an advisory panel that
  will
• report back to the legislature by 11/1/06 with
• Recommendations on the public reporting of HAI
• 14 positions on the advisory panel
• First meeting November 2, 2005

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The Advisory Panel

• 2 ICPs, certified, 1 rural 1 urban
• 2 ICPs, certified and both nurses
• 3 MDs, SHEA members, IC experts in a healthcare
  facility
• CEO of an acute care facility
• CEO of an ASC
• 2 consumer representatives
• 3 nonvoting department members

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The Members of the Advisory Panel

• Susan Jones, Betsy Colvin
• Greg Bond/Lynda Watkins, Patti Grant
• Robert Haley, Luis Ostrosky-Zeichner, Jan
  Patterson
• Dan Schultz, Marilyn Christian
• Lisa McGiffert, Raquel Sanchez
• Neil Pascoe, Tom Betz, Nance Stearman

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HAI Ethical issues

• Legislation has potential to divert infection
  control staff away from disease prevention and
  control activities at patient level and have them
  focus on health care-associated infection
  reporting at administrative level.
• Reporting adjustments need to be made so that
  hospitals with higher risk patients or patients
  undergoing procedures placing them at higher risk
  for infection are not unduly penalized.

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HAI Ethical issues (cont.)

• Health care facilities that under-report may
  appear superior in infection control to others.
  Checks and balances need to be in place.
• Sample sizes of procedures reported need to be
  sufficiently robust to permit valid comparisons
  between institutions within reasonable limits of
  confidence. This is a serious potential problem.
  

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HAI Ethical issues (cont.)

• Health care institutions that in good faith
  report infections in an open and honest manner
  should not suffer undue medical-legal
  consequences for such openness.
• Increased perceived risk of litigation will
  seriously undermine reporting efforts.
• Potential patients who use the reporting
  information for selecting institutions need to
  understand the limits of such information.

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HAI Ethical Issues (cont.)

• System failure versus Personal Accountability-
  The Case for Clean Hands
• the hospital and its leaders are accountable
  for establishing a system in which caregivers
  have the knowledge, competence, time, and tools
  to practice perfect hygiene.
• But each caregiver has the duty to perform hand
  hygiene- perfectly and everytime.
• When this widely accepted, straightforward
  standard of care is violated, we cannot continue
  to blame the system.

Goldmann D. System failure versus personal
accountability. N Engl J Med 2006 355 2 121-2
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SB 288Mandatory Public Reporting of
Healthcare-associated Infections80th Regular
Session 2007
http//www.capitol.state.tx.us/tlodocs/80R/billtex
t/pdf/SB00288H.pdf
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The statement, Its worth it if it saves just
one life is dangerously false if the same
resources, used in a different manner, can save
more than one life.
Medical Ethics 101

• Wm. Haddon Jr.

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SB 288 Requires

• a 16 member Advisory Panel within the DSHS
  infectious disease epi and surveillance division
  to guide the implementation, development,
  maintenance and evaluation of the reporting
  system
• Hospitals, Ambulatory Surgical Centers (ASCs) to
  report specific HAI to DSHS

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SB 288 Advisory Panel

• 2 year term
• 2 ICPs certified and one from a rural hospital
• 2 ICPs certified and licensed nurses
• 3 MDs one with Pedi ID and Pedi epi exp. are
  SHEA members with expertise in IC
• 2 QA professionals-1 ASC 1 acute care

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SB 288 Advisory Panel

• 1 officer of a general hospital
• 1 officer of an ASC
• 3 nonvoting department members
• 2 members representing the public as consumers
• No lobbyists or HC trade association
• Reimbursement is allowed!

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SB 288 Requires DSHS

• To adopt rules that do not duplicate or conflict
  with federal reporting HAI rules
• Establish Texas Healthcare-associated Infection
  Reporting System to
• receive HAI reports
• publish HAI reporting to the public
• educate and train ICPs on the THIRS

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SB 288 Reporting

• Must begin no later than 6/1/08
• Quarterly or less frequent
• Must contain sufficient patient ID data
• avoid duplication
• verify accuracy and completeness
• allow for risk adjustment
• DSHS will review data for validity and unusual
  data patterns or trends

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SB 288 Reportable SSI Infections

• Acute care other than pediatric shall report SSI
  on 7 surgical procedures
• -colon surgeries
• -hip and knee arthroplasties
• -abdominal and vaginal hysterectomies
• -CABG and vascular procedures

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SB 288 Reportable SSI Infections

• Pediatric facilities will report SSI associated
  with
• Cardiac procedures excluding thoracic cardiac
• VP shunt procedures
• Spinal surgery with instrumentation
• And
• Pediatric HA RSV

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SB 288 Reportable CLABSI

• Lab confirmed from a patient in any special care
  setting in the hospital
• All Texas definitions from CDC case definitions

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SB 288- Alternative Reporting

• For facilities with an average of less than 50
  procedures/monthly
• Instead--report SSI related to the 3 most
  frequently performed procedures from the NHSN
  procedure list

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SB 288 DSHS Summary

• Public summary for each reporting facility
• Risk adjusted with a comparison of the risk-
  adjusted rates for each reporting facility
• Easy to read (consumer friendly)
• Annual summary minimum
• Concise facility comments on report will be
  allowed
• Posted on internet
• Option for public to report suspected infections
  to DSHS

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SB 288 Protections

• Confidential, de-identified, protected
• MAY NOT BE USED IN A CIVIL ACTION TO ESTABLISH A
  STANDARD OF CARE

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SB 288 Enforcement

• General Hospital under Chapter 241
• ASC under Chapter 243

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Funding

• For FY 2008 DSHS requested 4.5M
• 36 FTEs
• LBB calculated 1.1M and 5 FTE
• FY 2009 DSHS requested 3.7M LBB calculated 1.2M
  and 8 more FTE
• Status not currently funded

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Reporting

• Missouri Healthcare-Associated Infection
  Reporting System (MHIRS)
• Perseus
• NHSN
• Plan D

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Reminder What Dont You Do to the Messenger?
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Plan D- Reporting
American National Standards Institute,
Accredited Standards Committee X12N, 837 Health
Care Institutional Claim Implementation Guide
(version 004010X096A1).   Most people call it
the ANSI 837I or ANSI 837 Institutional version
4010.   DSHS has modified this HIPAA compliant
version by adding in Race code to the DMG05 data
field, thus we are HIPAA compatible.
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Reporting continued

• ICP generated attachment to the ANSI 4010
• Details should be in place by November 1, 2007
• Testing by January 2008
• Implementation.?

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Resources

• http//www.legis.state.tx.us/
• http//www.apic.org
• http//www.dshs.state.tx.us/idcu/disease/HAI/
• Gary Heseltine 512 458-7111 x6352
• Gary.heseltine_at_dshs.state.tx.us
• Neil Pascoe 512 458-7111 x2358
• neil.pascoe_at_dshs.state.tx.us