Implementation of Texas Healthcare-associated Infection and Preventable Adverse Event Reporting

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Implementation of Texas Healthcare-associated
Infection and Preventable Adverse Event Reporting

• Neil Pascoe RN BSN CIC
• Epidemiologist

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Today

• Federal Issues
• State Process
• Reporting (the who, what, when, and how)

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Federal Healthcare Reform

• Currently No Mandate for HAI Reporting

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Increasing Need for Public Health Approach Across
the Continuum of Care
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Current Landscape ofHAI Surveillance - Policy

• Emphasis remains mandatory HAI reporting and
  public reporting of hospital-specific data
• possible federal mandate
• coupled with renewed interest in data validation
• enabling greater public access to machine
  readable data sets

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Current Landscape ofHAI Surveillance - Scientific

• Increasing interest in MDRO
• Clostridium difficile-associated disease
• HAIs in non-hospital settings
• LTCF and ASC
• Algorithmic detection of HAIs
• Risk modeling
• Use of observed-to-predicted (expected) ratios as
  summary statistics for comparative purposes (SIR)

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Current Landscape ofHAI Surveillance -Technical

• Renewed calls for system simplification
• Increasing demand for technical solutions that
  make use of healthcare data in electronic form
• Harmonizing data and reporting
• Unprecedented federal support for healthcare
  information technology

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Healthcare-Associated Infections (HAIs)

• Problem
• Bloodstream infections, urinary tract infections,
  pneumonia, surgical site infections
• Annual Impact
• 1.7 million HAIs in hospitalsunknown burden in
  other healthcare settings
• 99,000 deaths and 28-33 billion in added costs
• Solution
• Implementing what we know for prevention can lead
  to up to a 70 or more reduction in HAIs

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National Initiatives

• TJC- Patient Safety/NPSG/EOC
• CMS- PAO/Reimbursement and Standards
• AHRQ improve the quality, safety, efficiency,
  and effectiveness of health care
• NQF setting priorities and goals for PI (SRE ?
  PAE)
• PSO The Patient Safety and Quality Improvement
  Act of 2005
• Consumer Advocates- Consumers Union- others
• CDC lead agency for many initiatives and
  coordination

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HHS Action Plan to Prevent Healthcare-Associated
Infections Development and Implementation
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See www.haitexas.org
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Tier One Priorities

• HAI Priority Areas
• Catheter-Associated Urinary Tract Infections
• Central Line-Associated Bloodstream Infections
• Surgical Site Infections
• Ventilator-Associated Pneumonia
• MRSA
• Clostridium difficile
• Implementation Focus
• Hospitals

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Measuring Success
Metric Data Target
Central line bloodstream infections NHSN ? 50
Adherence to CLIP NHSN 100
Hospitalizations with Clostridium difficile Admin gt ? 30
Clostridium difficile infections NHSN gt ? 30
Catheter-associated urinary tract infections NHSN gt ? 25
MRSA incidence rate (healthcare-associated) EIP gt ? 50
MRSA bacteremia (healthcare facility-wide) NHSN gt ? 25
Surgical site infections NHSN gt ? 25
Surgical Care Improvement Program adherence SCIP gt 95
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Successful Implementation of Evidence-Based
Guidelines Prevents Bloodstream Infections

• Successful Interventions
• Sustained rates in Michigan hospitals for 5 years
• HHS Action Plan CLABSI Strategies
• National Goal 50 decline in 5 years
• CDC Develops guidelines
• AHRQ National expansion of proven effective
  interventions (Keystone/CUSP)
• CMS Report infection rates publicly on Hospital
  Compare
• CDC AHRQ Standardize measures
• CMS Incorporate in Medicare Quality Improvement
  Organization portfolio

103 ICUs at 67 Michigan Hospitals
BSIs per 1,000 Catheter Days
Months
Pronovost P. New Engl J Med 20063552725-32
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Caveats

• There are some discrepancies in the legislation
• There are staffing and funding issues
• RULES HAVE NOT BEEN WRITTEN
• Composition of the AP will change
• We do not have all of the answers (or for that
  matter the questions)

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Background

• 78th legislative Session (2005) passed study bill
  
• Advisory Panel
• White paper
• www.haitexas.org

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Background

• 79th legislative Session (2007) passed
  legislation (SB 288)
• Advisory Panel
• Reporting provisions
• No appropriation
• White paper
• www.haitexas.org
• www.texashai.org

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Background

• 80th legislative Session (2009) passed
  legislation (SB 203) (Amended SB 288 (aka
  Chapter 98 HSC)
• Added two members to AP
• PAE (28 NQF and CMS)
• Causative agent
• Medicaid reimbursement
• Included appropriation

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81st Legislative Session SB 203

• Originally a MRSA Reporting Bill
• Finalized as reporting pathogens per 80th
  legislative session SB 288 (public HAI reporting)
  including MRSA, with
• SB-7 didnt become law however, portions were
  amended into SB 203 (which was moving),
  eventually signed into law 6/19
• Therefore, SB 203 combines SB 288 law from last
  legislative session with SB-7 (not passed into
  law itself)

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HEALTH AND SAFETY CODE CHAPTER 98. REPORTING OF
HEALTH CARE-ASSOCIATED INFECTIONS HEALTH AND
SAFETY CODE TITLE 2. HEALTH SUBTITLE D.
PREVENTION, CONTROL, AND REPORTS OF DISEASES
CHAPTER 98. REPORTING OF HEALTH CARE-ASSOCIATED
INFECTIONS Chapter 98, consisting of Secs.
98.001 to 98.151, was added by Acts 2007, 80th
Leg., For another Chapter 98, consisting of
Secs. 98.001 to 98.009, added by Acts 2007, 80th
Leg., R.S., Ch. 671, Sec. 3, see Sec. 98.001 et
seq., post. SUBCHAPTER A. GENERAL PROVISIONS
Sec. 98.001. DEFINITIONS. In this chapter (1)
"Advisory panel" means the Advisory Panel on
Health Care-Associated Infections. (2)
"Ambulatory surgical center" means a facility
licensed under Chapter 243. (3) "Commissioner"
means the commissioner of state health services.
(4) "Department" means the Department of State
Health Services. (5) "Executive commissioner"
means the executive commissioner of the Health
and Human Services Commission. (6) "General
hospital" means a general hospital licensed under
Chapter 241 or a hospital that provides surgical
or obstetrical services and that is maintained or
operated by this state. The term does not
include a comprehensive medical rehabilitation
hospital. and so on
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What has to be reported

• Bloodstream infections associated with central
  lines
• Surgical Site Infections
• 3 pediatric
• 7 adult
• Preventable Adverse Events
• National Quality Forum (SRE)
• Non-reimbursed Medicare event or condition

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Acute Care Reporting

• ..a health care facilityshall report to the
  department the incidence of surgical site
  infections occurring in the following procedures
• Colon surgeries
• Hip arthroplasties
• Knee arthroplasties
• Abdominal hysterectomies
• Vaginal hysterectomies
• Coronary artery bypass grafts, and
• Vascular procedures

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CLABSI

• NHSN definitions
• Laboratory confirmed
• include the causative organism
• special care setting in hospital
• ICU/CCU/BurnICU
• Not NICU

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Pediatric Reporting

• Cardiac procedures, excluding thoracic cardiac
  procedures
• Ventriculoperitoneal shunt procedures lt
• Spinal surgery with instrumentation
• Incidence of inpatient RSV

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Healthcare-associated Infections

• Patient and procedure information for each
  reportable surgery
• More than 10 reportable surgeries
• Each reportable surgery regardless of associated
  infections
• Over 72,000 knee replacement surgeries performed
  annually in Texas
• Over 38,000 hip replacement surgeries performed
  annually in Texas
• Infections occur with 1-2 of these surgeries

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Approximate number of reports based on 2008 3rd
quarter administrative (hospital) data
53,676 x 4 214,704
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Chapter 98

• Confidentiality
• Same protections as notifiable conditions
• Legal protections
• Enforcement
• Regulatory/licensing

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Who has to report

• 500 general hospitals
• Includes LTAC
• Includes Pediatric and Adolescent
• Excludes long term rehab hospitals
• 350 ambulatory surgical centers

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What does DSHS need to do?

• Establish a reporting system
• Provide education and training
• Prepare a summary by health care facility
• Succinct facility comments
• Publish a summary at least annually
• Make summary available on a website
• Accept reports from the public
• Perform data validations--validation tools
• Functionality to conduct and track audits at
  hospitals and ASCs

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SB 288 Funding (2007)

• For FY 2008 DSHS requested 4.5M, 36 FTEs
• LBB calculated 1.1M and 5 FTEs
• FY 2009 DSHS requested 3.7M
• LBB calculated 1.2M and 8 FTEs
• Other scenarios presented
• No appropriation

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HAI - Funding

• General appropriation
• 2,173,452 for the biennium and four new FTEs
• American Recovery and Reinvestment Act (ARRA)
• Awarded 710,872 to build surveillance
  infrastructure
• Provided funds for two FTEs

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TexasFunded Amount 1,233,977

• State Contact
• Wes Hodgson, MPA State Plan Project Coordinator
  Healthcare-Associated Infections (HAIs)
  Emerging and Acute Infectious Disease Branch
  Infectious Disease Control Unit Division of
  Prevention and Preparedness Texas Department of
  State Health Services PO Box 149347 Mail Code
  1960, Room T-809 Austin, Texas 78714-9347
• Phone [phone], extension 6364Fax (512)
  458-7616
• Wesley.Hodgson_at_dshs.state.tx.us
• www.haitexas.org
• Summary of Activity
• Activity ATexas has appointed a state
  healthcare-associated Infections (HAI)
  coordinator. This coordinator managed the
  convening of a multi-disciplinary group in late
  October to assist the state in the development of
  a statewide HAI plan. Comments and suggestions
  from this group were incorporated into the final
  draft of the Texas HAI Plan. The plan will be
  distributed to applicable facilities pending
  final approval, which is expected by mid-2010.
  However, many plan activities began
  implementation in late 2009 and others will begin
  in early 2010.
• Activity BBy the end of Year 2, Texas will
  target the enrollment of all Texas acute care
  hospitals (n517) into the National Healthcare
  Safety Network (NHSN) system. Reporting will
  begin following administrative activities.
  Monthly NHSN conferences are planned to address
  questions and issues. Facility reporting will
  enable the collection of state baseline data. In
  Year 2, aggregate reports and validation will
  begin, electronic reporting of laboratory data
  will be enabled, and quarterly statewide reports
  will be generated. A public Web site with
  facility-specific report-card information on HAIs
  will be made available as required by Texas law.
• Activity CTexas will convene a
  multi-disciplinary advisory group that will
  establish and demonstrate collaboration.
  Participating facilities will be defined and
  selected, and one multicenter prevention
  initiative will be initiated. Currently, Texas is
  planning to target two prevention initiatives
  central line-associated bloodstream infection
  (CLABSI) and surgical site infection (SSI),
  although more specific information for prevention
  targets will be identified.

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DSHS staffing

• Currently 5 IDCU staff work on HAI-related
  activities in addition to other duties
• (marilyn felkner, gary heseltine, wes hodgson,
  sky newsome, neil pascoe, jeff taylor)
• New staff not yet
• PS VI- manager
• PS V- clinical specialist (CIC)
• Epidemiologist
• Administrative Assistant
• IT support (larry beard, andy mauney)

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When to Report

• January 1, 2011
• April 1, 2011
• July 1, 2011

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How to Report

• Health care facilities shall report to a secure,
  electronic interface designated by the Texas
  Department of State Health Services.
• NHSN
• Health care facilities shall meet data reporting
  requirements and timeframes and utilize
  definitions as required by the secure, electronic
  interface.

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Education and Training

• GR funding will allow for contracted training
• State meeting in October 2010
• See www.haitexas.org
• CDC/NHSN training

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Reporting Mechanisms Considered

• Plan A Missouri Healthcare System
• Associated Infection Reporting System- large IT
  project
• Plan B National Healthcare Safety Network
• initially viewed as complex and burdensome to
  ICP
• currently recommended by HAI panel
• DSHS build IT system to receive/display NHSN data
• Plan C Use Texas Hospital Discharge Data Network
• Already reaches statewide except rural hospitals
  and will be expanded to all ASCs under existing
  legislation
• Problems include data definitions, legal ability
  to share, contracts
• Plan D as needed
• Option for public to report suspected HAIs to
  DSHS
• Poses significant challenges, particularly
  validation

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Reporting System Training

• Texas Healthcare Infection and Preventable
  Adverse Events Reporting System
• NHSN for HAI?? PAE???
• Training via contract (TSICP, APIC or ?)
• Initial, annual training and updates
• Separate Data Validation Contract

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How will Facilities Report? (The Reporting
System)

• National Healthcare Safety Network
• Used by over 2,000 healthcare facilities in 50
  states (2456 as of 1/18/10)
• Healthcare facilities may enter data on
• Device-associated adverse events
• Procedure-associated adverse events
• Medication-associated adverse events

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What is NHSN?

• National voluntary, confidential system for
  monitoring events associated with health care
• Initial focus on infections in patients and
  healthcare personnel (NNISS)
• 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

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NHSN

• Managed by the Division of Healthcare Quality
  Promotion (DHQP) at CDC.
• Open to all types of healthcare facilities in the
  United States, including acute care hospitals,
  long term acute care hospitals, psychiatric
  hospitals, rehabilitation hospitals, outpatient
  dialysis centers, ambulatory surgery centers, and
  long term care facilities.

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Data Sharing in NHSN Groups

• CDC does not send NHSN data to state health
• departments or other entities
• Health departments or others obtain data
  directly from
• NHSN facilities
• By becoming a group in NHSN
• Facilities join the group and confer rights
  to certain data
• The group can analyze the data of its member
  facilities
• Facilities may join multiple groups

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NHSN Eligibility Criteria

• US healthcare facility listed in or associated
  with a facility that is listed in one of the
  following national databases
• American Hospital Association (AHA)
• Centers for Medicare and Medicaid Services (CMS)
• Veterans Affairs (VA).
• high-speed Internet access
• digital certificate on computers
• willing to follow the selected NHSN component
  protocols exactly
• report complete and accurate data in a timely
  manner during months when reporting data for use
  by CDC
• willing to share such data with CDC for the
  purposes stated above.
• provide written consent from facilitys chief
  executive leadership (e.g., Chief Executive
  Officer).

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Challenges of NHSN

• Enrollment process takes time
• Digital Certificate installation can be
  cumbersome and must be done annually
• IT support can expedite this process.
• Standard definitions do not imply standard
  interpretations.
• For CLABSI What is the meaning of organism from
  blood not related to an infection at another
  site?

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Challenges of NHSN, contd

• Facility data collection must be standardized
  i.e. device days daily, at the same time of day
• Numerator and denominator data submitted within
  30 days of the end of the month
• Cannot participate in Procedure Associated Module
  unless all required data elements are entered
  for every procedure and there are many data
  elements required

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Advantages of NHSN

• Training is very thorough and explains, in
  detail, the rules for complying with NHSN
  surveillance protocols.
• Definitions of infections are standardized
• Software is user-friendly - minimal time spent
  entering event data and device days
• Only have to report one module for a minimum of 6
  months to maintain membership
• National comparative data is available when
  reporting infection rates

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Advantages of NHSN, contd

• Surgical denominator data can be downloaded if
  the user has an electronic surgical record and
  all required data elements are contained in each
  record
• Members are able to contact NHSN regarding
  surveillance questions and are able to receive
  assistance quickly
• Members have input into the usability of the
  definitions
• Members get advanced notice of any changes coming
  to NHSN surveillance criteria
• Likely the reporting mechanism for the State of
  Texas?
• Vendors have developed compatible software for
  uploading facility data

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NHSN Change Control Process
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Work Group Members and Liaisons

• NHSN sites Elise McKee (CA), Teresa Accuntius
  (OH), Connie Steed (SC), Ellen Smith (CA), Dana
  Trocino (OR)
• State Health Departments Rachel Stricof (NY),
  Steve Ostroff (PA), Neil Pascoe (TX)
• HICPAC Russ Olmstead
• CDC Chesley Richards, Joe Perz, Gautam
  Kesarinath, Ahmed Gomaa, Nancy Sonnenfeld
• CMS Barry Straube (or Paul McGann)
• AHRQ- Bill Munier (or Amy Helwig)
• SHEA Henry Blumberg (or Lisa Maragakis, Jesse
  Jacob)
• APIC Patti Grant
• AHA Kathy Ciccone (or Mary Therriault)
• CSTE Marion Kainer
• ASTHO James Kirkwood (or Belinda Haerum)

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Projected NHSN Data flows
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State-Summary Report of HAI Data Reported to NHSN

• As a Method of Measuring Progress
• Towards Elimination of HAIs

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CDC State Summary Report Intent and Timeline

• First Report
• Announcement of report in MMWR April 2
• CLABSI only report immediately available
• Replace with CLABSI/SSI by May
• Report on serial SIR, track progress
• Evaluate possible impact of ARRA

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Purpose of Report

• Enables CDC to evaluate progress using a summary
  statistic at the national, and State, level
• National Healthcare Safety Network (NHSN) used by
  hospitals in 50 States (plus Washington, DC and
  Puerto Rico) mandated in 21
• American Recovery and Reinvestment Act of 2009
  (ARRA)
• Included 50 million to support states in HAI
  prevention
• Requires regular reporting of impact
• HHS Action Plan towards the elimination of HAIs
  http//www.hhs.gov/ophs/initiatives/hai/actionpla
  n/index.html
• Enables states (without access to data) to gain
  insight into status of HAI/NHSN reporting, within
  current limitations of system
• Promote use of SIR as summary measure to HAI
  prevention community (other reports already in
  works)

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State-Summary Report of HAI Data Reported to NHSN

• Public report limited to states with mandate
• Sharing summary data with state officials
• Encouraging all facilities to work with state
  officials

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Data Tables in Report (DRAFT)
State B with mandate, high enrollment percent,
and high data submission percent
State D with no mandate, low enrollment percent,
and high data submission percent
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NHSN Performance and Usability Improvements
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Performance Measurement

• Installed performance widgets on every page to
  measure user wait times as a function of time of
  day, request type, location and server load
• Currently monitoring this dataset and have a
  baseline from which to measure progress.

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Performance Improvements(to be completed in the
coming months)

• Re-engineer the NHSN database
• Reduce page sizes so that pages will load faster
• Streamline data input screens so that entering
  data will be easier
• Move away from the use of digital certificates to
  passwords
• Increase our ability to receive electronic
  messages to reduce manual data entry burden

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The DSHS Data Display
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Data Display
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Roles of Local and Regional HD

• Education and Training
• Information and Data Validation
• Outbreak investigation
• Other activities???

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Preventable Adverse Events

• Health care-associated adverse condition or event
  for which the Medicare program will not provide
  additional payment to the facility under a policy
  adopted by the federal Centers for Medicare and
  Medicaid Services and
• Event included in the list of adverse events
  identified by the National Quality Forum that is
  not included under Subdivision (1).
• Different method for reporting
• Likely to have separate rules

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Summary

• SB 203 went into effect 9/1/09
• There will be more legislation
• Be watching in Texas Register for proposed and
  then adopted RULES to provide the how to of
  these new laws

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Thanks

• HAI and PAE AP (dont you love acronyms?)
• Sharon Williamson, Patti Grant and NHSN
• HAI IPT
• TSICP

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HAI Resources

• DSHS www.haitexas.org
• Consumers ww.stophospitalinfections.org/
• NHSN website http//www.cdc.gov/nhsn
• National Quality Forum www.qualityforum.org/
• AHRQ http//www.ahrq.gov/
• Centers for Medicare and Medicaid Services
• http//www.cms.gov/
• HICPAC Guidance on Reporting HAIs
• http//www.cdc.gov/hicpac/pubReportGuide/publicRep
  ortingHAI.html

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Questions or discussion?