Where the Rubber Meets the Road - PowerPoint PPT Presentation

1 / 57
About This Presentation

Where the Rubber Meets the Road


... 38.5% Central venous catheter-related bloodstream infections: 35.4% Surgical site infections: 32.3% * Who pays attention to reports like the Leapfrog report? – PowerPoint PPT presentation

Number of Views:116
Avg rating:3.0/5.0
Slides: 58
Provided by: aboutinfec
Tags: meets | road | rubber


Transcript and Presenter's Notes

Title: Where the Rubber Meets the Road

Where the Rubber Meets the Road
SB 739
  • Jan 08 version (2) presented
  • (insert your chapter, current date here)
  • Sue Chen RN, MPH, CIC
  • HAI Program Coordinator
  • California Dept of Public Health
  • Sue.Chen_at_cdph.ca.gov

  • SB 739 in context
  • History of mandatory reporting
  • Making the business case
  • Review of SB 739 requirements
  • Your role in implementation of SB 739
    (devil is in the details)
  • Introduction to NHSN
  • Sequence of events/specific activities
  • Updates from HAI-AC to CDPH
  • Say amen and escape

Number of nosocomial pathogens, according to
infection site, identified in the hospital-wide
component of the NNISprogram from January 1990
to March 1996
HAIs- The Big Four
  • Urinary tract infections
  • (catheter-associated)
  • Surgical site
  • Infections
  • Bloodstream infections
  • (central line-associated)
  • Pneumonia
  • (ventilator-associated)

Healthcare-Associated Infections Numbers and
From Klevens et al..Public Health Rep.
2007122160-6 12 of U.S.
Cost of HAI vs. Infection ControlDuke Infection
Control Outreach Network
  • 28 community hospitals (30-616 beds)
  • 25,072 for VAP 23,242 per CLA BSI
  • 10,443 per SSI 758 per CAUTI
  • Ave cost of infections 594,683/year
  • Ave annual budget for IC 129,000
  • Decreasing HAIs by 25 would save 148,667 per
  • Anderson et al. Underresourced Hospital Infection
    Control and Prevention Programs Penny Wise,
    Pound Foolish. Infect Control Hosp Epidemiol
    2007 28767-773

What Hospitals Dont Get
  • Two economists are walking down the street. One
    sees a dollar lying on the sidewalk, and says,
    Look, there is a dollar lying on the ground!
    Obviously not, says the other. If there were,
    someone would have picked it up!
  • from Hollenbeak, APIC

Who Pays?
  • Patients with HAI are disproportionally Medicare
    but only 50 Medicare-paid

Glimpse of the Future From Centers for Medicare
Medicaid Services
  • Effective October 1, 2008, hospitals will no
    longer receive higher payments for the additional
    costs of treatment associated with following
  • Catheter-associated urinary tract infections
  • Vascular catheter-associated infections
  • Surgical site infection mediastinitis after
    coronary artery bypass graft surgery
  • Unless condition is present upon admission

History of Reporting of HAIs
  • Florence Nightengale descriptive epidemiology
    during Crimean War documented causes of
  • National Nosocomial Infections Surveillance
  • Epidemiology of HAIs, describe antimicrobial
    resistance, enable inter-hospital comparisons
  • Study on the Efficacy of Nosocomial Infection
    Control (SENIC) Study

Gill C, Gill G. Nightengale in Scutari Her
Legacy Reexamined. CID 200540.
Public Reporting Background
  • The quality and safety of healthcare in the U.S.
    needs to improve
  • Public reporting is one of a number of quality
    improvement methodologies adopted
  • Public reporting of health care performance
    information is intended to
  • Provide information to enable consumers to obtain
    safer care
  • Stimulate and provide basis for quality
    improvement by reporting providers

Public Reporting Slide 2
  • Indicators for public reporting can be
  • Outcomes (e.g. mortality, infections)
  • Processes (e.g. aspirin for MI, antibiotic within
    4 hours of admission for community-acquired
    pneumonia, appropriate antibiotic prophylaxis
    prior to surgery)
  • Public reporting for myocardial infarction,
    coronary bypass graft surgery (CABG), and
    community-acquired pneumonia has been in place
    gt10 years
  • Reductions in the rate of death associated with
    CABG in New York and Pennsylvania have been
    attributed, in part, to public reporting

Trend over time in bloodstream infections
associated w/ catheters in pediatric ICU
  • Nov 1998 use of maximal barrier precautions
  • July 1999 use of antibiotic-impregnated
  • March 2000 annual hand washing campaigns
  • April 2003 move to new unit with private
  • May 2003 introduction of skin disinfection
    with chlorhexidine

U Arkansas Childrens Hospital Bhutta et. al.,
BMJ 2007334362-5
Leapfrog Report 9/18/07
  • 87 hospitals (n1256) do not take all
    recommended steps to prevent HAIs
  • 35.6 do not always follow hand hygiene practices
  • 30.7 vaccinate staff against flu
  • http//www.leapfroggroup.org/

Consumers Union
  • Focus on obtaining data on HAIs so consumer
    can make an informed choice also
  • pressures hospitals to improve
  • legislation for mandatory reporting
  • active surveillance cultures for MRSA
  • Rep. Tim Murphy (PA) is sponsoring the "Healthy
    Hospitals Act of 2007" (HR1174). The bill will
    make you safer during a hospital stay by
    requiring public disclosure of hospital-acquired
    infection rates. If hospitals must tell you about
    their infections, they will work harder to reduce
  • Please ask your representative to co-sponsor
    this bill!

Experience with Legislated Mandatory Public
  • Pennsylvania
  • Have been reporting data since 2004
  • Areas for improvement
  • Use of administrative data
  • Law of Unintended Consequences
  • Pittsburg Regional Healthcare Initiative

Found error-prone systems that did not focus on
the patient at the point of care. Healthcare
must focus on delivering perfect healthcare to
every patient.
Response to Public Reporting Consumers Dont
Seem to Care..
Source CHCF sponsored survey of Californians,
Quality of Care - Heart Attack
But Hospitals Do
Number of hospitals
California Ancient History
  • Little Hoover Commission report April 10, 2003
    recommended increased capacity to fight HAIs
  • HAI-AWG met from July 05-Feb 07
  • Recommendations for Reducing Morbidity and
    Mortality in California Final Report to CDPH
    December 31, 2005
  • Result was SB 739 signed into law September 28,

For those w/ attention deficit or CRS
SB 739 Mandates
  • Implement an HAI surveillance program
  • Electronic database NHSN
  • By July 1, 2007
  • Appoint an HAI Advisory Committee
  • Hospitals must implement respiratory
    hygiene/cough etiquette program, employee flu
    vaccine program, disaster plan w/ pandemic flu
    component in conjunction w/ local health dept
  • Educate health facility evaluators in HAI

Mandates contd
  • On or after Jan 1, 2008
  • Revise infection control-related portions of
    Title 22
  • GAC shall implement and annually report process
    measures which are to be made public within 6
  • Central line insertion practices
  • Influenza vaccination of HC personnel and high
    risk patients
  • Surgical antimicrobial prophylaxis

Current Tasks and Further Directions Slide 1
  • Facilities must enroll in NHSN soft deadline Jan
    31, 2008
  • Be prepared to join CDPH group and give CDPH
    permission to see appropriate data elements
  • Specific directions will be forthcoming from CDPH
    with details and start dates for mandated

Slide 2
  • Use CLIP practice module to get process in place
    for data collection
  • Be prepared to report vaccination rates for
    2007-08 flu season (model is TJC requirements)
  • Respond to SCIP questionnaire by Jan 15. SCIP
    data will be required to be reported through

Update on HAI_AC Recommendations
  • Central Line Insertion Practice (CLIP)
  • Influenza vaccine for
  • Employees
  • High risk patients
  • Antimicrobial prophylaxis (SCIP)
  • Legal
  • Reporting of healthcare-associated MRSA infections

HAI-AC Central Line Insertion Practices (CLIP)
  • Option 1 fill out all asterisked data points on
    CLIP form
  • In ICUs x 6 months
  • Option 2 fill out 6 areas AND do outcome module
    for those units
  • AND
  • Documentation of daily assessment of line
    necessity by a clinician.

HAI-AC Influenza Vaccination for Employees
  • Publicly report influenza vaccination/
    declination rates for employees for 07-08
  • Differentiates between employees and healthcare
  • Non-employee HCW should be offered vaccine a
    rate for this not mandated at this time
  • Forms may only be obtained Sept-Mar

HAI-AC Surgical Care Improvement Project (SCIP)
  • Will be reported through CMS/Lumetra
  • Facilities currently reporting data will not have
    more work
  • Facilities not currently reporting must work w/
    Lumetra to establish reporting pathway or
  • If facility does not perform surgeries, no
    reporting will be required.
  • CDPH will begin downloading CMS data at a
    to-be-announced date.

HAI-AC Recommendations for Mandatory Reporting of
  • Report all laboratory-confirmed MRSA bloodstream
    infections identified in hospitalized patients
  • Classify as community-onset (day 1-3) or Hospital
    onset (day 4)
  • Publicly report as of July 1, 2008
  • number of community-onset
  • Rate of hospital-onset/1000 inpatient days
  • No further characterization required at this time

What is NHSN?
  • CDC-sponsored voluntary, confidential system for
    monitoring events associated with health care
  • Initial focus on infections in patients and
    healthcare personnel
  • Expanding to include noninfectious events (such
    as process measures)
  • Accessed through a secure, web-based interface
  • Open to all US healthcare entities at no charge

NHSN is a Partnership!
NHSN participation was never designed or intended
to be the sole responsibility of Infection
Am J Infect Control 200735290-310
  • Device-associated
  • Procedure-associated
  • Medication-associated

Percentage of Hospitals in AHA Survey Enrolled
613 facilities
Status as of June 18, 2007
National Healthcare Safety Network (NHSN)for
State Reporting
Heavily Plagiarized by CDPH from CSTE 2007
Annual Conference presentation June 2007
R. Monina Klevens, DDS, MPH Division for
Healthcare Quality Promotion National Center for
Infectious Diseases
Heavily is not an infestation
Characteristics of NHSN Surveillance Methodology
  • Active, patient-based, prospective,
    priority-directed collection of data
  • Results in risk-adjusted incidence rates will
    allow comparison between yourself or group
    against national average.
  • Intended to be used as a quality improvement tool
    to be of mutual benefit to facilities and NHSN
    goal to eventually link processes with outcomes

Authority and Confidentiality for NHSN
  • Public Health Service Act (42 USC 242b, 242k, and
  • Confidentiality Protection
  • Sections 304, 306, and 308(d) of the PHS Act

The information contained in this surveillance
system that would permit identification of any
individual or institution is collected with a
guarantee that it will be held in strict
confidence, will be used only for the purposes
stated, and will not be disclosed or released
without the consent of the individual, or the
institution in accordance with Sections 304, 306,
and 308(d) of the Public Health Service Act (42
USC 242b, 242k, and 242m(d)).
Strengths Built on NNIS Experience
  • NNIS System is a model for patient safety1,2
  • High quality data can be used for performance
    improvement. Reductions in national infection
    rates have been achieved.
  • Scientific credibility Definitions and methods
    adopted internationally
  • Timely data can be immediately downloaded
  • Aggregate comparisons by unit or procedure across
    states ensure greater numbers

1Leape LL. Reporting of adverse events. NEJM
20023471633-8. 2Burke JP. Infection controla
problem for patient safety. NEJM 2003 348651-6.
Registration ProcessFollow the Balloons and
Accept Rules of Behavior
NHSN sends email w/ instructions for digital
You read and follow directions carefully
complete modules
NHSN sends further instructions
You read and follow directions carefully sign
away first born
Etc. Etc. Etc. (From Facility Administrator Enrol
lment Guide)
Process for Hospitals to Register
  • http//www.cdc.gov/ncidod/dhqp/nhsn_members.html
  • Accept rules of behavior
  • Part of registration is to complete 8 modules
    (2 hrs each)
  • On R side of page NHSN Resources, click on
    Training, then Archived Training, follow
    stepwise directions
  • Name a facility administrator person with all
    rights to all data for your facility

Registration Process Contd
  • Obtain (and dont lose) digital certificate
  • If firewalls prevent access, own IT dept must
    clear site
  • Fill out online form and survey
  • Name group/groups
  • Send to NHSN
  • CDC will activate facility
  • Facility must join CDPH group, give rights to see
    mandated data

Summary of NHSN Rules
  • Every month, the facility must submit a
    surveillance plan
  • Facility must report data to NHSN 6 of every 12
    calendar months within 30 days of end of
    reporting period
  • Failure to adhere to reporting can result in loss
    of member status
  • Loss of member status puts facility at odds w/
    mandates of SB 739
  • All data fields marked w/ an asterisk must be
    filled out for record to be counted if in plan

I certify that I completed the required training
to participate in the National Healthcare
Safety Network
Registration Nirvana?
Name of participant
Name of facility
Dates of training
How CDPH Accesses Data in NHSN
  • Groups e.g., healthcare corporations, State
    Health Departments
  • A facility nominates CDPH
  • Facilities join the group and confer some/all
    rights to data
  • Facilities within the group cannot see each
    others data
  • Group sees data from all facilities as granted
  • After joining, a facility can use any NHSN module
    (ex outcome measure) they choose data not
    visible to CDPH except w/ permission

  • Primary experience with voluntary, confidential
  • Validation methods in development
  • Labor intensive
  • And deadlines for data reporting
  • No special protocols for small hospitals
  • Not tied to utilization or billing data directly
    (DRGs, ICD9/10, etc.)
  • Must follow NHSN rules

Support for States Users
  • Collaboration with APIC/CACC, CSTE, SHEA, IDSA
  • NHSN State Users Group
  • Conference calls monthly/Webboard to share
    materials, including users newsletter
  • Training for all members
  • Webinars
  • Interactive distance learning
  • nhsn.cdc.gov

What and When States Using NHSN are Reporting
Jan 2007
Undefined measures
Anticipated Additions
  • Process modules for CLIP and immunizations (for
    both employees and patients) to be released Feb
  • Introduction of 23 modules of interactive
    computer training (20-30 min ea) Jan 08
  • In addition to original modules
  • Number required will depend on rights conferred
  • Goal to set up CEUS for module completion
  • Will contain post-test to document knowledge
    minimal score of 80 to pass

What CDPH would like to see
  • Formulation of a model for reporting of never
    events for nationwide use
  • Downloading capacity from 3rd party vendors
    directly into NHSN
  • Discussion between CMS, CDPH, and NHSN for direct
    download of SCIP data already reported to CMS
  • Disclaimer While willing, CDC lacks personnel
    and monetary resources to develop these
    capacities at this time.

  • What are the evidence-based reporting best
  • Balance use of existing data with accuracy and
  • How to gain necessary resources for
    implementation of reporting?
  • State and hospital levels
  • More efficient methods
  • How will reporting impact quality of care?
  • Integrity of processes will drive decrease in
    infection rates
  • Provider and consumer behavior

Answers Cheap
  • Jon Rosenberg
  • Centers for Disease Prevention and Control
  • New York State
  • Audiences for
  • refining the
  • program

  • Infectious Diseases Experts Applaud Bill Against
    "Bad Bugs"
  • With extensively drug-resistant tuberculosis,
    life-threatening drug-resistant respiratory and
    skin infections, and other bad bugs routinely
    making headlines, infectious diseases physicians
    are applauding Rep. Jim Matheson (D-UT) and Rep.
    Michael Ferguson (R-NJ) for introducing H.R.
    3697, Strategies To Address Antimicrobial
    Resistance (STAAR) Act  

S.2278 Durbin Bill/H.R. 4214CHAI Reduction Act
of 2007
  • Establish best practices guidelines for IC plans
    to treat and control CHAI in GAC
  • Hospitals to begin reporting through NHSN within
    90 days
  • CDC to be given authority to make rules
  • Institute pay for performance
  • Public awareness and education
  • Ongoing interagency workgroup

Community-Associated and Healthcare-Associated
H.R. 4352 Assistance to School Districts to
Combat MDRO (Towns)
  • 30 million to Dept of Education for prevention,
    outreach, educational activities in grades K-12
    for qualifying pathogens
  • MRSA, CDC-identified life-threatening bacteria
  • Money may cover personal hygiene supplies and
    disinfectants if school district lacks a
    sufficient budget.

Introduced Dec 11, 2007 D-NY
H.R. 4451 MRSA Research and Study Act of 2007
  • Establish 6 year grant program under auspices of
    Sec Health Human Services
  • Eligibility under university or u-affiliated
    teaching hospital
  • Minimum 25 grants awarded during each 2 year
    period 5 million ea

Introduction Dec 11, 2007 R-FL
S. 2526 Worker Infection Protection Act
(Menendez, Durbin, Kennedy)
  • Proposal covers HCW, first responders, other
    workers _at_ risk against exposure to infectious
    agents and drug-resistant infections avian
    influenza, MRSA
  • Sec of Labor to develop temporary exposure
    control plan w/ in 6 months permanent 6 mo later
  • plan, PPE, training, medical surveillance,
    immunization if available

Introduced Dec 19, 2007 D-NJ, IL, MA
SB 1058 Medical Facility Infection Control
Prevention Act (Alquist)
  • Health facilities and residential care facilities
    for the elderly must implement procedures for
    screening, prevention, and reporting of specified
  • ASC for specified conditions
  • Reporting
  • Laboratory reporting of facility-acquired
    positive cultures to CDPH
  • reporting of 2 or more cases MRSA within a 7 day
  • Facility must post that report on its website
  • Cleaning of pt care equipment/environmental
  • Adequate infection control staffing 1100
    occupied inpatient beds, 1200 outpatient visits.
    Same ratios of IC required for residential care
  • Staff must be adequately trained
  • Introduced Jan 8, 2008 by E Alquist, D-Santa

Definition of Reportable CA Staph
  • Severe staph infection resulting in death or ICU
    admission in a previously healthy person
  • Covers both MRSA and MSSA
  • Will be reported through local health dept via
  • Estimated burden of reporting 100-200 cases/year
    in CA
  • Primary responsibility for reporting belongs to
    local health departments
  • CDC definition of previously healthy
  • Persons who have not been recently (within the
    past year) hospitalized or had a medical
    procedure (such as dialysis, surgery, catheters)
Write a Comment
User Comments (0)
About PowerShow.com