On The CUSP of Elimination of HAIs: The Role of APIC & the Infection Preventionist in Spreading the belief in zero Central Line-Associated Bloodstream Infections (CLABSIs),

11/16/2010 Russ Olmsted, MPH, CIC - President-Elect, APIC, 2010 Peter J. Pronovost, MD, PhD, FCCM – Professor & Director, Adult Critical Care Medicine & Quality and Safety Research Group, Johns Hopkins

Today’s Objectives:

• Understand the On the CUSP Initiative • List select, updated recommendations in the upcoming

2010 CDC/HICPAC Guideline for the Prevention of Intravascular Catheter-Related Bloodstream Infection

• Describe the experience of the IP in CLABSI Prevention Collaborative.

• List an example that illustrates the importance of validation of CLABSI Detection

On The CUSP: HAI Prevention

• Coordinated by AHA’s Health Research & Educational Trust [HRET] under contract from Agency for Healthcare Research & Quality (AHRQ) • Nationwide initiative using Comprehensive Unit based Safety Program (CUSP) to prevent HAIs • HAIs of focus: – CLABSIs – Catheter associated UTIs (CAUTIs)

On The CUSP: HAI Prevention

Partnering Organizations:

Ann Arbor VA Medical Center / University of MI Patient Safety Enhancement Program

Hospital Recruitment:

Deborah Bohr, 646-678-4280, [email protected]

Project Management:

Marchelle Djordjevic, 312-422-2614, [email protected]

General Inquires:

[email protected]

On The CUSP: HAI Prevention Core Elements of CUSP:

1. Educate Staff on the Science of Safety 2. Identify Defects 3. Engage Executives 4. Learn from Defects 5. Implement Teamwork Tool

On The CUSP: HAI Prevention

 

The Stimulus for Prevention:

 State Hospital Association Survey on CLABSI Prevention Initiatives; all 50 responded  42 (84%) agreed CLABSI Prevention is a priority 11 (22%) provided statewide CLABSI rates Active collaboratives in 6 (12%); 7 (14%) planning  Need: national collaborative ; build capacity  Murphy DJ, et al. Am J Med Qual 2010;25(4):255-60.

http://www.safercare.net/ OTCSBSI/Participation.html

• No reimbursement for certain Hospital acquired conditions (HACs): 1) Serious preventable events: Object left in during surgery; air embolism; Delivering ABO-incompatible blood or blood products 2)

Catheter-associated urinary tract infections

3) pressure ulcers (stages III & IV) 4)

Vascular catheter-associated infection

5)

SSI: mediastinitis after CABG; certain orthopedic procedures, bariatric surgery

6) Patient falls 7) Manifestations of poor glycemic control 8) DVT/PE after total knee or hip replacement

• Hospital Inpatient Quality Reporting Program – for 2011:

• Requires providers to report outcome metrics to CMS using NHSN – – CLABSI events beginning in January 2011 for FY 2013 Medicare Payment Determination • Pay 4 Reporting: 2% reduction in reimbursement for Medicare beneficiaries if providers fail to report.

• For details on NHSN see: – http://www.cdc.gov/nhsn/cms-ipps-rule_training.html

Action Plan to Prevent HAIs, June 2009 http://www.hhs.gov/ophs/initiatives/hai/draft-hai-plan-01062009.pdf

Tier 1: See Targets/Metrics Tier 2: Ambulatory Surgery Clinics, Dialysis Centers, Influenza vaccine for Healthcare Personnel American Recovery and Reinvestment Act (ARRA), 2009.

Public Law 111-5

HAI Prevention Plan 5 yr. Targets; A Progress Report

TOPIC METRIC & TARGET Progress Report Central line-assoc. bloodstream infection (CLABSI) CLABSI Insert. Bundle C. difficile Infection (CDI) Catheter-assoc. UTI (CAUTI) MRSA SSI SSI CLABSI Std Infection Ratio (SIR); 50% reduction Proportion of insertions using bundle; 100% adherence Rate/1000 discharges; 30% reduction CAUTI rate ; 25% reduction Rate invasive MRSA/100k pop.; 50% reduction SIR; 25% reduction Proportion SCIP measures; 95% adherence 18% drop in 2009 – on target!

Sample of Hospitals = 92% - on target 8.9 in 2009; 9.4 in 2010 – not likely to meet target Estimate in ’08 = 5% reduction but new def. in ’09 - unsure 22.72 in 2009 = 13.4% drop compared to ’07-’08 – on target 5% fewer SSIs in 2009 – on target > 92% in 2009 – on target

National Patient Safety Goals (NPSG), Hospital, 2010 • •

NPSG.07.01.01:

Hand Hygiene

NPSG.07.03.01:

Prevent HAIs caused by multidrug-resistant organisms (MDROs) • •

NPSG.07.04.01: NPSG.07.05.01

CLABSI prevention : SSI prevention =============================== Coming attractions: CAUTI focused NPSG?

Other Successful CLABSI Prevention Collaboratives

New York: CDC guidelines basis for prevention implementation initiatives

– –

Greater New York Hospital Association prevention initiative Collaborative partnership with 46 hospitals

•

Focused on incrementally building infrastructure needed for BSI and other future prevention initiatives (e.g. C. difficile)

•

Communications to share best practices

•

Culture of accountability

–

CEO to support staff levels involved

–

Site visits, monthly reporting

•

Adopted bundles of practices

Contamination of insertion site

CLABSI Prevention

Healthcare Personnel Hand Contamination Hub Contamination Contaminated Infusate Extraluminal Contamination Hematogenous spread

More Common Mechanisms

1. Pathogen migration along external surface - more common early (< 7days) 2. Hub contamination with intraluminal colonization -more common >10 days

Less Common Mechanisms

1. Hematogenous seeding from another source 2. Contaminated infusates HICPAC. Guideline for Prevention of Intravascular Device-Related Infections. 2002

Select Highlights, CDC/HICPAC CRBSI Prevention Guideline, 2010 – in press • Section:

Catheter Site Dressing Regimens

– Use a chlorhexidine-impregnated sponge dressing for

temporary short-term catheters in patients older than 2 months of age if the CABSI rate has not been substantially

reduced despite adherence to basic prevention measures, including education and training, use of chlorhexidine for skin antisepsis, and MSB. Category IB

Select Highlights, CDC/HICPAC CRBSI Prevention Guideline, 2010 – in press

Section: Needleless Intravascular Catheter Systems

– When needleless systems are used, a split septum valve may be preferred over a mechanical valve due to increased risk of infection with some mechanical valves. Category II – Minimize contamination risk by scrubbing the access port with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol) and accessing the port only with sterile devices. Category IA

Select Highlights, CDC/HICPAC CRBSI Prevention Guideline, 2010 – in press Section: Skin Preparation • Prepare clean skin with a > 0.5% alcohol-based chlorhexidine preparation before central venous catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives. Category IA

A Model For Imple Mentation Science Saint S, et al ICHE 2010

•

Overcoming barriers: The Golytely

How active resisters and organizational

approach?

infection prevention efforts. Jt Comm J Qual Patient Saf 2009

–

Resisters: Benchmarking, champions, & collaboratives

–

Constipators: use golytely!

18 % fewer CLABSIs than predicted SIR =0.82

May 25, 2010

The Importance of Validation of CLABSI:

Lin MY, Hota B, Khan YM, et al.

JAMA 2010; 304 (Nov.10):2035-41.

Compared CLABSI identified by IP vs computer algorithm, 4 medical ctrs, 20 ICUs Findings: Median CLABSI 3.3 (2.0-4.5) by IP vs 9.0 (6.3-11.3) by algorithm Significant variation in detection by IP vs algorithm by facility

The Importance of Validation of CLABSI:

Niedner NF & 2008 NACHRI PICU Focus Group [N=16 PICUs / 14 facilities] Findings: Substantial variation in CLABSI Surveillance Practices Units with more aggressive surveillance program = higher CLABSI rate

Summary Thoughts

• Let’s Sustain the Momentum from Launch of “I believe in zero BSIs” at APIC 2010 • Use the On the CUSP tools and resources & encourage enrollment of your affiliate • Ingredients of the “secret sauce” of prevention – individual accountability, teamwork and behavioral change • Validation of identification of CLABSI is critical – Being built into ARRA fund HAI prevention initiatives – APIC education & training – Complete HAI Studies Project Modules: see Wright MO, et al. Am J Infect Control 2010; 38:416-8 – Practice, practice, practice….

THANK YOU FOR YOUR PARTICIPATION IN TODAY’s SESSION