Transcript Slide 1

APIC Chapter Excellence Award 2011
The submission of the Chicago
Metropolitan Area Chapter (002)
Marc-Oliver Wright, MT(ASCP), MS, CIC
President, Chicago APIC
A Brief Overview
• Founded in the Fall of 1975 (We’re # 2!)
• Current membership: 270
• Composition
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Acute Care Hospitals – 54%
Vendors – 23%
Ambulatory/Behavioral Health/Other – 8%
Nursing Homes – 3%
Other – 7%
Department of Health – 3%
# of Members by Year
4th largest chapter in APIC behind
265
New England, Minnesota, Indiana
260
262
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250
245
240
243
243
2008
2009
235
230
2010
Our membership area
Meetings are held
throughout the
city and suburbs
to distribute
transportation
distances for
members
Provides services that promote, retain and
serve their members
• Mentoring program initiated in 2010 in light of
our increasing membership
• Members can register for education events
online through the chapter website
• Scholarships for members to attend National
APIC routinely made available
Participates in infection prevention, control
and epidemiology activities that support the
profession
• Chicago APIC devotes one educational
meeting per year to Infection prevention in
long-term care
• Designated chapter Legislative Liaison to
monitor and inform members of legislative
activities at the regional, state and national
level
Criteria 2: Continued
• At least 5 educational
meetings are held each
year, with continuing
education credits
usually offered
• In 2010, 1st Statewide
conference partnered
with Central IL APIC
and IDPH
Provides timely mechanisms for
communication among members
• Chapter website: http://www.apicchicago.org
• Regular newsletter from the President/Board
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Upcoming events
Legislative updates
Abstracts and Publications from members
National updates
Provides mechanisms for assessing
Chapter needs and effectiveness of
programs
• Every education session includes evaluation forms
and results reviewed at subsequent Board Meeting
• Online assessments through Survey Monkey
– 2009: Online Chapter Learning Needs Assessment.
Developed educational programs for 2010-2011 based on
the results
– 2010: IL Statewide Conference Needs Assessment. Used
response to guide development.
– 2011: CBIC study group survey, ByLaws electronic voting,
Best use of chapter funds survey
In Summary
• Chicago APIC is a large and growing regional
chapter with diverse needs among its
members
• By streamlining information through the
chapter website and a regular newsletter, the
members are kept well informed of activities
pertinent to the chapter, the profession, and
the science
In Summary
• Recent partnerships with state health
agencies and another regional chapter lead
to Illinois initiating a statewide conference on
healthcare associated infections
• By using online survey programs, the chapter
actively assess the needs of its members and
develops activities based on these needs
A preliminary assessment of the national
data quality collaboration: the case studies
Association for Professionals in Infection Control and
Epidemiology, Inc. Annual Conference
June 28, 2011
Baltimore, MD
Marc-Oliver Wright, MT(ASCP), MS, CIC
Director of Infection Control
NorthShore University HealthSystem
Co-Authors
University of Maryland Medical Center
• Joan N Hebden, RN, MS, CIC
National Healthcare Safety Network; Division of
Healthcare Quality Promotion, Centers for
Disease Control and Prevention
• Kathy Allen-Bridson, RN, BSN, CIC
• Gloria C Morrell, RN, MS, MSN, CIC
• Teresa Horan, MPH
Disclaimers
• Excelsior Medical Corporation: Travel
expenses and honoraria
• Cardinal Health Infection Prevention Focus
Group: Honoraria
• Carefusion MedMined: Honoraria
• Sagittarius, proud father of an 11 month old
Background
• National Healthcare Safety Network (NHSN)
definitions for healthcare-associated
infections used for years
– Among NHSN participants
– Among non-participants looking to compare
internal data with external benchmarks
– For research and quality measures
– Recently as statewide initiatives for public
reporting of HAIs
– Now as part inpatient prospective payment system
Background
• Definitions are based on common clinical
presentation
– Simplified for widespread use
– Designed to maximize consistency for surveillance
– Not intended for diagnosis (surveillance definition
vs. clinical definition)
• Participants undergo initial training and are
informed of changes to definitions via
updates from NHSN
• Despite standard definitions, there was variation in
Infection Preventionists applying the definitions
• Began a series of case studies for IPs to test
their knowledge about applying the definitions
Objectives of the case study series
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To present challenging case scenarios that
will provide rationale and clarity in the use of
the NHSN surveillance definitions,
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To provide an opportunity for personal
competency assessment as well as for
assessment of consistency between IPs
within a facility,
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To meet the challenge identified 20 years
ago, namely, additional means of training
IPs.
Objectives of this study
• Assess competency among participants in
applying the NHSN definitions to uniform
cases
– Compare areas where participation (therefore
NHSN training) are required to areas with no such
requirement
• Identify opportunities for continuing
education, clarification and/or definition
review
Methods
• Initial drafts written by authors and circulated
among coauthors for review/revision
– Based on real-life examples of IPs or scenarios
brought to NHSN for clarification
• Circulated among NHSN/DHQP/CDC staff for
review, revision and approval
• Case studies developed in SurveyMonkey
online survey tool maintained by the authors
• Sent to AJIC Editorial Staff for publication
Methods continued
• Online anonymous surveys opened prior to
publication and remained open for 3-5
months
• After taking the survey, answers with
explanations and references were provided
• After closing the survey, site visitors were
instructed to contact one of the authors to
obtain copy of questions and answers
• Demographic data was voluntary
Analysis
• Proportions were calculated
(#correct/#answers)
• Relative risk and Pearson’s chi-square were
used for significance testing of differences
between scores of users from mandated
versus non-mandated states.
Respondents
• For Cases 2-4 the following categories of
respondents participated
– Infection preventionists = 91.1%
– Medical Directors of Infection Prevention = 2.3%
– Public Health (EIS, state based HAI program etc)
= 3.5%
– Other = 3.0%
• 2,847 individuals participated in the first 4 cases
• Overall, there were 6,369 correct responses
among 9,533 answers (66.8% correct)
Case Study #1
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A 27-year-old man is admitted on 8/22 from another hospital with
alcohol-induced pancreatitis. Admission abdominal CT showed
severe pancreatitis with peripancreatic inflammatory changes.
Patient is ventilator-dependent requiring a tracheostomy and has
vascular catheters in place in the right subclavian and right
internal jugular (IJ) veins.
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• On 9/3, an ultrasound-guided aspiration of pancreatic fluid revealed
few polymorphonuclear cells and a negative bacterial culture.
• On 9/11, a repeat abdominal CT revealed unchanged pancreatitis but
interval development of multi-loculated fluid collections in the abdomen.
• On 9/14, patient is taken to the OR for pancreatic debridement and
placement of drains. Later that evening, patient had a temperature
spike to 102° F. The right IJ line was discontinued and the catheter tip
and blood specimens x 2 were sent for culture.
• On 9/16, culture results were reported as follows:
o Pancreatic fluid = no growth
o Catheter tip = <15 CFU/ml of Enterococcus species
o Blood cultures = 2 for 2 positive for Enterococcus faecalis.
• No other sites of suspected infection were identified.
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Answered correctly most often
Answered least correctly
A Case Study Example: Case #2
• A 35-year-old man is involved in a multi-vehicular
accident and sustains multiple internal and external
traumatic injuries. On 12/5 in the emergency
department, a triple lumen subclavian line and Foley
catheter are placed and the stabilized patient is
transferred to the intensive care unit.
– On 12/8, the patient spikes a temperature to 101°F and is
“pan” cultured, including blood cultures x 2.
– On 12/10, the subclavian line is discontinued and the
catheter tip is sent for culture. Later that afternoon, the blood
culture results from 12/8 are reported as Staphylococcus
hominis in both sets. The physician notes: “Positive blood
culture = contaminant; no antibiotics required.” All other
specimens cultured are negative.
– On 12/12, catheter tip results are reported as
Staphylococcus epidermidis.
Answered correctly most often
Answered least correctly
Case #3
• An 86-year-old female with history of COPD is admitted for
cholecystectomy on 4/16. A chest x-ray (CXR) done that day is
reported as showing no active infection or pleural effusion. • On
4/21 at 11:33 a.m:. a CXR is done for shortness of breath and is
reported as possible left lower lobe infiltrate. Patient is afebrile
and white blood cell (WBC) count is 8,000/uL. Patient is started
on Prednisone 30 mg daily.
– At 12:00 p.m: partial pressure of Oxygen (PO2) = 84.9mm/hg.
Patient suffers respiratory failure and is intubated.
– At 13:15 p.m: CXR is re-interpreted and reported as “Previous left
lower lobe infiltrate actually represents an elevated hemidiaphragm.
Lungs are clear.”
– At 8:00 p.m: patient is febrile at 101.3 °F. Arterial blood gases
(ABG): Oxygen (O2) saturation is 75-96%, PO2 is 63mm/hg.
– 10:00 p.m: CXR report states that the Endotracheal (ET) tube
extended into the right main bronchus causing collapse of the left
lung. Tube is properly repositioned. • On the morning of 4/22
patient’s temperature ranges from 100.5-100.9 °F. WBC is
11,300/uL Piperacillin/Tazobactam and Vancomycin therapies are
begun. ET aspirate is white and thin.
Case #3 Continued
– 6:00 a.m: CXR states left lower lung (LLL) atelectasis/infiltrate persists.
– 6:30 p.m: CXR shows LLL has re-expanded. • 4/23 6:00 a.m: CXR: LLL
airspace disease and/or pleural effusion present.
– 12:30 p.m. Temperature: 100.4 °F. Bibasilar rales are present as is blood
tinged ET aspirate. • 4/24-4/26 CXR: LLL airspace disease and/or pleural
effusion unchanged. Patient is afebrile. WBC: 6,800-9,700/uL. Scattered
rhonchi and rales are heard over both lungs, ET aspirate is thick and yellow
and is sent for culture. ABGs: PO2 is 59-137mm/hg, O2 Saturation is 8597%.
– 4/27 04:40: a.m. CXR shows bilateral airspace disease and /or pleural
effusion.
» 8:00: p.m. temperature is 101.3 °F, moderate thick blood tinged ET aspirate, PO2
76.5mm/hg, O2 saturation 96%. ET aspirate culture positive for Pseudomonas
aeruginosa. • 4/28 8:00 a.m: temperature is 102.3 °F. WBC are 8,100/ul, CXR is
unchanged. • 4/29 - 4/30: CXR remains unchanged and patient is afebrile.
– • 5/1: ET aspirate collected for culture.
– • 5/3: ET aspirate culture positive for Pseudomonas sp.
– • 5/4: ET aspirate is clearing in color. CXR shows slight clearing of LLL.
Question 1
Question 2
Case #4 (new results)
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A 64 year-old man who is status-post orthotopic heart transplant 16
years ago is admitted on 2/1 for an elective percutaneous endoscopic
gastrostomy (PEG) tube placement. Medical history is significant for
respiratory failure due to H1N1 influenza pneumonia resulting in a
tracheostomy and ventilator dependency, end-stage renal disease on
hemodialysis three times/week, and hypertension. He was transferred
from the ventilator unit of a long-term acute care facility (LTAC). A left
internal jugular (IJ) tunneled catheter was in place for dialysis and a
condom catheter was present, draining clear amber urine.
• On 2/2 patient was taken to the Operating Room for elective
placement of a PEG feeding tube and tolerated the procedure well. He
was transferred to the Surgical ICU due to his ventilator requirement.
Temperature range: 37.2°C - 37.6°C. Lungs clear bilaterally. PEG site
oozing serosanguinous drainage. Call received from the LTAC facility
that a stool specimen collected for abdominal pain and diarrhea prior to
transfer was reported as positive for. C.difficile .Metronidazole started.
• On 2/4 the patient remains in the SICU due to lack of a bed at the
LTAC facility. At 2300, the patient has a temperature of 38.3°C. PEG
site is clean and dry. No evidence of inflammation or drainage at the
left IJ tunneled catheter site. Lungs clear bilaterally. Blood, urine and
sputum cultures are sent.
Case #4 continued
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• On 2/5 in the AM, the urinalysis is reported as 3+ leukocyte esterase,
WBC- too numerous to count and moderate bacteria. Patient continues
with fever to 38°C. Co-trimoxazole is initiated. Patient receives
hemodialysis.
• On 2/6, the urine culture from 2/4 is reported as positive for 60,000
CFU/ml gram–negative bacilli which are subsequently identified as
Providencia stuartii. Blood and sputum cultures are negative. Plans to
send the patient back to the LTAC facility are cancelled due to
increasing watery stools and complaints of abdominal pain with an
increase in peripheral WBC from 11,000 to 25,000. CT of the abdomen
suggestive of colitis. Continues with temperatures of 38°C.
• On 2/9 the patient is moved to the intermediate care unit. Late that
evening, he has a temperature spike to 38.8°C. Blood cultures are
repeated.
• On 2/10 the blood culture from 2/9 is reported as positive for gramnegative bacilli, which are subsequently identified as Providencia
stuartii.
Answered correctly most often
Answered least correctly
Right answer
Reporting vs non-reporting
• Presumably, states with mandated NHSN
participation might differ from non-mandated
states
– All respondents from mandated states would have
undergone initial NHSN training whereas some
unknown proportion of non-mandated respondents
may not have received the same training
– Cases 2 and 4 (CLABSI) used to compare
mandated vs non-mandated performance
(CLABSI reporting universal for mandated states)
Mandated States
• AL CA CO CT DC DE IL MA MD NH NJ NY NV OK
OR PA SC TN TX VT VA WA WV versus all other
respondents (includes international)
• Mandated states = 64.0% correct
• Non-mandated locales = 60.5% correct
• Answers from states with mandatory reporting are
1.06 times more likely to be accurate than responses
from areas without such requirements (RR 95% CI:
1.01 > 1.06 > 1.11 p=0.02)
NOTE: differs from abstract
• 2,847 individuals participated in the first 4 cases
• Overall, there were 6,369 correct responses
among 9,533 answers (66.8% correct)
So…how did WE do?
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About the same.
Case 2 = 82.9% Correct
Case 3 = 62.5% Correct
Case 4 = 56.8% Correct
A Comment on “Gaming”
• Recently there have been concerns
expressed with regards to the potential for
NHSN users to knowingly misreport
• These case studies address competency not
behavior
– In depth validation and assessment at the facility
or individual (IP) level are required
“Gaming” continued
• 74 year old female with ALL, syncope and ankle
fracture with historical port accessed during
hospitalization
– Day 5 single temp spike to 101.2; two sets of peripheral
blood cultures grow coagulase-negative Staphylococcus. No
other symptoms, fever reduced to baseline w/in 4 hours
– Discharged 4 days later with no antibiotic ever given, port
intact, no note of infection in the chart. Not readmitted.
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Did this patient have a line infection? Probably not.
Does she meet CLABSI definition? Yes.
Did we do a huddle/RCA? No.
Did we count and report it? Yes.
A reminder of the initial enrollment
The Magic of Zero
• Our goal is to strive for
elimination of HAIs
• We measure performance with
an imperfect tool where when
properly applied, cases may
meet criteria but not reflect
clinical infection or the true
cause (e.g. central line) to
which they are attributed
Limitations
• Demographic data self-reported, voluntary
and therefore incomplete (22.6% opted out)
• Participation not limited to IPs
• Recommendation from presentation at
National: Don’t set the answers to randomize.
Some folks fill out on paper and then enter
into the survey tool. Complete 7/11/2011
Conclusions
• Approximately two-thirds of the time,
participants answered the questions following
each scenario correctly
• Respondents from states with mandatory
reporting appear to answer correctly more
often than colleagues from non-mandated
locales
Conclusions Continued
• There remain opportunities for further training
and education among NHSN users specific
areas include
– Concurrent infections as independent events
– Device duration
– Symptom requirements (or a lack thereof)
Next Steps
• Case 5 (SSI) is in AJIC June 2011 issue
– http://www.surveymonkey.com/s/AJIC-NHSNCase5
• Case 6 (also SSI) is in press
• Cases 7-8 (pediatrics) are undergoing final
review
• Supplement issue of AJIC consisting entirely
of new case studies is in development
Grateful Acknowledgements
• American Journal of Infection Control
– Elaine Larson, RN, PhD, FAAN, CIC
– Manuel Cortazal and Christina Bunner
• APIC
– Denise Graham and Marilyn Hanchett
• Everyone at NHSN/DHQP/CDC
• All of the PARTICIPANTS
Questions and Comments
[email protected]