Transcript Slide 1

Infection
Prevention
in
TITLE OF PRESENTATION
New ofYork
City
Subtitle
Presentation
Successes, Challenges & Opportunities
David P. Calfee, MD, MS
Associate Professor of Medicine and Public Health
Chief Hospital Epidemiologist
Outline
• A “look-back” at the past 10 years of infection
prevention in the Greater New York area
• Successes
• Challenges
• Opportunities
A Lot Can Happen in 10 Years
^
• Outbreaks of old pathogens
– Mumps (2009)
– Measles (2011)
• Outbreaks of new pathogens
– SARS (2003)
– Pandemic influenza H1N1 (2009)
• Emergence and dissemination of new resistance patterns
among healthcare-associated pathogens
– Multidrug-resistant Acinetobacter
– Carbapenem-resistant Enterobacteriaceae (e.g, K. pneumoniae)
A Lot Can Happen in 10 Years
• Bioterrorism
– Anthrax (2001, and few days of panic in 2006)
– NYC small pox vaccination program (2003)
• Disasters
– Blackout (2003)
– Hurricanes (Irene 2011, Sandy 2012)
A Lot Can Happen in 10 Years
• Public reporting of HAI in New York State
– Public health Law 2819: 2005
– First year of hospital reporting: 2007
– First public report of hospital-specific data: 2009
• Flu vaccine
– HCW vaccine mandate (and subsequent lawsuits): 2009
• Pay-for-performance
– Core measures
– Hospital-acquired conditions
– Value-based purchasing
• National Patient Safety Goal 7
– Hand hygiene, CLABSI, CAUTI, SSI, MDROs
Greater New York Infection Prevention
Successes
“Physicians cannot wait for operational
excellence to justify their commitment; they
need to achieve excellence through influence,
example, and leadership.”
– Stephen C. Beeson, MD
Beeson SC. Practicing Excellence: A Physician’s Manual to Exceptional Health Care. 2006
GNYHA-UHF CLABs Collaborative
• 2005-2008
• 49 ICUs from 36 hospitals throughout the region
• This collaborative represented a paradigm shift in infection
control practice and perception: preventing infections is
everyone’s responsibility.
–
–
–
–
Interdisciplinary teams
Regular team meetings
Implementation of a central line “bundle”
Plan-Do-Study-Act (PDSA) model
Koll BS, Straub TA, Jalon HS, Block R, Heller KS, Ruiz RE. Jt Comm J Qual Patient Saf 34(12): 713–23
Outcomes of the CLABs Collaborative
•
•
•
•
Mean rate decreased
by 54%.
Some hospitals
observed reductions
as great as 88%.
56% of hospitals
observed a reduction
of at least 50%.
The greatest
reductions were seen
in hospitals with the
highest baseline rates.
Koll BS, Straub TA, Jalon HS, Block R, Heller KS, Ruiz RE. Jt Comm J Qual Patient Saf 34(12): 713–23
CLABSI Rates in NYS ICUs Continue to
Decline
• Comparing 2011 data to 2007
data:
– Surgical ICUs: 57% reduction
– Neurosurgical ICUs: 48% reduction
– Cardiothoracic surgery ICUs: 46%
reduction
– Medical ICUs: 45% reduction
– Medical-surgical ICUs: 34% reduction
– Pediatric ICUs: 31% reduction
– Coronary ICUs: 25% reduction
– Neonatal ICUs
• Regional Perinatal Centers: 49%
reduction
• Level 3 and 2/3 ICUs: 17%
reduction
NYS DOH. Hospital-acquired infections, 2011. September 2012.
http://www.health.ny.gov/statistics/facilities/hospital/hospital_acquired_infections/2011/docs/hospital_acquired_infection.pdf
CLABSI Rates in NYS ICUs Continue to
Decline
• NY State CLABSI SIR significantly decreased between 2009
and 2010.
– 2010 SIR was 0.858 (versus 1.029 in 2009)
CDC. National and state healthcare-associated infections standardized infection ratio report, 2010.
http://www.cdc.gov/hai/pdfs/SIR/national-SIR-Report_03_29_2012.pdf
GNYHA-UHF C. difficile Collaborative
• Goal: to reduce C. difficile infection rates through standardized
clinical infection prevention practices (a “bundle”) and environmental
cleaning protocols
– Planning began in July 2007
– Collaborative began in 3/2008
– Data reporting ended in 12/2009
NYS DOH funded Phase I of Collaborative: 7/2007 to 3/2009
Interventions
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•
•
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Assessment of baseline practices
Use of standardized clinical case definitions*
Implementation of a clinical infection prevention “bundle”
Development of a standardized environmental cleaning
protocol
– Checklist
– Bleach
• Distribution of monthly data reports
• Educational and practice-sharing opportunities
• Site visits
*Prior to availability of NHSN MDRO/C. difficile module definitions
The C. difficile Prevention “Bundle”
1.
2.
3.
4.
5.
6.
Contact precautions initiated at time of symptom onset
Contact precautions sign on door
Personal protective equipment (i.e., gowns and gloves) readily
available
Hand hygiene
Strategy for optimal patient placement (e.g., single room,
cohorting with other CDI patient(s))
Dedicated thermometers for CDI patients if rectal
thermometers are used.
Outcomes: C. difficile Infection Rates
Baseline
Intervention
Cases per 10,000 patient days
21.4
20%
reduction
18.8**
10.7
8.6**
7.8
7.5
3.0
2.8
**p<0.001
Total
CDC. MMWR 2012;61:157-62
HospitalOnset
NHA
CO-HA
Intrahospital Comparisons
Rate per 10,000 Patient Days
March 2008 - August 2008
September 2008 - December 2009
25
20
15
10
5
0
0
10
20
Hospital Identification Number
30
40
C. difficile Prevention Strategies
Strategy
Strength of Recommendation and
Quality of Evidence
Hand Hygiene
Soap and water
AII
BIII
Gloves
AI
Gowns
BIII
Single room
BIII
Environmental cleaning
(bleach-containing/sporicidal agent)
BII
Equipment cleaning
Antimicrobial Stewardship
Cohen SH. Infect Control Hosp Epidemiol 2010; 31:431-55
Gerding DN. Infect Control Hosp Epidemiol 2008;29(S1):S81-92
BIII-CIII
AII
GNYHA-UHF Antimicrobial Stewardship
Project
• The overall objective was to develop and test strategies and
tools that can be used by health care facilities to implement an
effective and sustainable antimicrobial stewardship program.
• Specific objectives included:
– To establish antibiotic stewardship programs (ASP) in acute care
hospitals and LTCF using existing personnel and resources
– To establish acute care hospital-LTCF collaborations related to ASP
– To develop and pilot tools for ASP development and implementation
in other health care facilities
– To identify best practices for and challenges associated with ASP
implementation
GNYHA-UHF Antimicrobial Stewardship
Project
• 3 acute care hospitals were selected from among those participating
in the C. difficile collaborative.
• Chosen hospitals were required to recruit a long-term care facility
partner to participate in the project.
• October 2009-June 2010
Interventions
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•
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Develop a stewardship team.
Participate in meetings and conference calls.
Assess current practices and resources.
Identify and prioritize ASP target areas.
Select and implement interventions.
Project Outcomes
• In a short period of time and without additional resources,
hospitals and long-term care facilities were able to introduce
antimicrobial stewardship programs into their facilities.
• Qualitative data suggest that the programs were beneficial.
Outcomes: Examples of Success
• Successful hospital interventions:
– Expansion of activities to 3 new units (acceptance ~100%)
– Completion of an IRB-approved study of practices related to UTI
diagnosis and treatment, involving students and residents, resulting in
development and revision of guidelines
• Successful LTCF interventions
– Presentation of baseline data on inappropriate antimicrobial use for
asymptomatic bacteriuria to Medical and Nursing Directors, leading to a
facility-wide PI Project with development of a protocol for UTI diagnosis
and treatment
– Development of a restricted antibiotic list
– Review of urine culture results with subsequent interaction with clinicians
Outcomes: Examples of Success
• Hospital-LTCF Collaborations
– At least one hospital-LTCF team began having joint ASP meetings
that involved LTCF medical director.
– At one site, hospital pharmacists were granted access to LTCF
resident drug profiles to assist with stewardship activities.
•
•
•
Educational
materials
Marketing
materials
Tools for
stewardship
teams
Outcomes: Lessons Learned
• Antimicrobial stewardship is complex: there is not a “one size fits all”
bundle.
• Keys to success:
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–
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A motivated team
Support from administration and medical leadership
Data
Access to ready-made tools to assist ASP activities
A forum to discuss challenges and best practices
Greater New York Infection Prevention
Challenges
General Challenges
• Space constraints
• Hospital closures
– Permanent
– Temporary
• Infection Prevention staffing
– NYSDOH annual survey showed stable IP to bed ratio, but certainly
no increase over past few years despite greater demands.
• How do we ensure that best practices are consistently applied?
• We are improving, but so is everyone else.
Ongoing CLABSI Challenges
• The 2011 NYC CLABSI rate is significantly higher than the NYS
average.
– SIR 1.15 (1.05-1.25)
• The New York State CLABSI rate is higher than the US average.
– 2010 NYS SIR was 25% higher than that of the US overall.
– In 2009, 17 states used NHSN to satisfy a state-specific CLABSI
reporting mandate.
• New York had the fourth highest CLABSI SIR.
• The 5 states that had a data validation program had the 5
highest SIRs among the 17 states.
• CLABSI prevention efforts in non-ICU settings are lagging.
NYS DOH. Hospital-acquired infections, 2011. September 2012.
http://www.cdc.gov/hai/pdfs/SIR/national-SIR-Report_03_29_2012.pdf
http://www.cdc.gov/HAI/pdfs/stateplans/SIR_05_25_2010.pdf
NYS DOH. Hospital-acquired infections, 2011. September 2012.
Multidrug-Resistant Organisms (MDROs)
• MRSA
– CMS will require reporting of MRSA bacteremias beginning January
2013.
– National target for MRSA bacteremia in hospitals: 25% reduction by
2013
– National data suggests that invasive MRSA infections are
decreasing.
Kallen AJ. JAMA 2010;304:641-8
US Targets for C. difficile Prevention, 2013
• U.S. data
– C. difficile hospitalizations
• Goal: 30% reduction (vs 2008 rate of 11.7 per 1,000 discharges)
• 2011 rate:11.9 (1.7% increase from baseline)
– C. difficile infections
• Goal: 30% reduction
• No progress report available
National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination.
http://www.hhs.gov/ash/initiatives/hai/infection.html
C. difficile Infection in US Hospitals, 2009
CDI 2009.
staysHCUP
per Statistical
100,000Brief #124. January 2012. Agency
Lucado, J. Clostridium difficile Infections (CDI) in Hospital Stays,
for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb124.pdf
Ongoing C. difficile Challenges
• NYC hospital-onset C. difficile SIR (compared to state average)
was 1.01 (0.98-1.04).
• New York State hospital-onset C. difficile rates
– 2010 NYS rate of 8.2 per 10,000 patient-days was significantly
higher than the national average of 7.4.
– The 2011 rate was 8.48 cases per 10,000 patient days, a 3%
increase compared to 2010.
• Note: The percentage of hospitals using certain highly sensitive tests
(i.e., PCR) increased from 10% to 41%.
NYS DOH. Hospital-acquired infections, 2011. September 2012.
MDR Gram-Negatives
Isolate Kl pneumoniae
ANTIBIOTICS
Mic SYSTEMIC URINE
_____________________________________
Ampicillin
>16 R
Amox/K Clav'ate
>16/8 R
Aztreonam
>16 R
Ceftriaxone
>32 R
Ceftazidime
>16 R
Cefotaxime
32
I
Cefoxitin
>16 R
Cefazolin
>16 R
Ciprofloxacin
>2
R
Cefepime
>16 R
Amikacin
32
I
Cefuroxime
>16 R
Tigecyline
1.5 S
Ertapenem
>4
R
Gentamicin
<4
S
Imipenem
>32 R
Levofloxacin
>4
R
Meropenem
>8
R
Piperacillin/tazo
>64 R
Trimethoprim/Sulf
>2/38 R
Tetracycline
<4
S
Tobramycin
>8
R
Polymyxin B
64
R
Outcomes Associated with MDR-GNR
Infections: Invasive K. pneumoniae Infection
Percent of subjects
100
90
80
70
60
CRKP
CSKP
p<0.001
p<0.001
50
40
30
20
10
48
38
20
12
0
Overall Mortality
CRKP: carbapenemresistant K. pneumoniae
CSKP: carbapenemsusceptible K. pneumoniae
Attributable
Mortality
Patel G. Infect Control Hosp Epidemiol 2008;29:1099-106
37
Carbapenem Resistance among Health CareAssociated K. pneumoniae Isolates
• Sporadic cases in the 1990’s
– <1% of all K. pneumoniae isolates reported to NNIS in 2000
• Rates of carbapenem-resistance among K. pneumoniae isolates
reported to NHSN (2006-2007)
– All US states except NY: 5%
– New York: 21%
Hidron AI. Infect Control Hospital Epidemiol 2008; 29(11):996-1011
38
Prevalence of CRE Among Inpatients in
Two NYC Hospitals
40
Medical ICU
Surgical ICU
Med-Surg Ward
Rehabilitation Ward
Rehabilitation Ward
Medical Ward
Medical-Surgical ICU
35
Prevalence (%)
30
The overall
prevalence of
CRE was
5.4%.
25
20
15
10
The average
monthly
prevalence
was 7.4%.
5
0
Calfee DP. Unpublished data.
68% of carriers were
identified by active
surveillance alone.
Frequency of and Risk Factors for
Acquisition of CRE
New Acquisitions of CRE
(n=104)
•
Independent predictors of CRE acquisition
included:
– Pulmonary disease (OR 11.53,
p=0.02)
– Mechanical ventilation (OR 5.19,
p=0.04)
– Days of antibiotic therapy (OR 1.04,
p=0.003)
– CRE colonization pressure (OR1.15,
p=0.01)
•
The odds of acquiring CRE increased by
4% for every day of antibiotic therapy
received and by 15% for every 1%
increase in the colonization pressure to
which a subject was exposed.
30
25
20
15
10
5
0
Calfee DP. Unpublished data.
Compliance with Infection Control Measures
Reduces Risk
• Compliance with infection
prevention policies can
reduce the association
between prevalence and
incidence of CRE.
Schwaber MJ. Clin Infect Dis 2011;52(7):1-8
Regional MDRO Control Initiatives
• Intervention included:
– Mandatory reporting of all
CRE patients
– Mandatory isolation of
hospitalized CRE carriers
• Contact precautions
(index and subsequent
admissions)
• Cohort nursing
– National Task Force with
authority to collect data and
intervene as needed.
National guidelines for active
surveillance and intervention
in LTCF issued
Schwaber MJ. Clin Infect Dis 2011;52(7):1-8
Antimicrobial Stewardship Programs
• Despite evidence of benefit, not all health care facilities have
introduced such programs.
– 79% of university hospitals
– 40% of community hospitals
– Almost unheard of in long-term care facilities
• Lack of funding and personnel are the most commonly reported
barriers.
Johannsson B. Infect Control Hosp Epidemiol 2011;32:367-74
Policy Statement on Antimicrobial
Stewardship: SHEA, IDSA, PIDS
• Antimicrobial stewardship programs should be required through
regulatory mechanisms.
• Antimicrobial stewardship should be monitored in ambulatory
healthcare settings.
• Education about antimicrobial resistance and antimicrobial
stewardship must be accomplished.
• Antimicrobial use data should be collected and readily available for
both inpatient and outpatient settings.
• Research on antimicrobial stewardship is needed.
SHEA, IDSA, PIDS. Infect Control Hosp Epidemiol 2012;33(4):322-7
CMS: Conditions of Participation for Infection
Control
• Facility has a multidisciplinary process to review antimicrobial utilization,
local susceptibility patterns, and antimicrobial agents in the formulary
and there is evidence that the process is followed.
• Systems are in place to prompt clinicians to use appropriate
antimicrobial agents (e.g., computerized physician order entry,
comments in microbiology susceptibility reports, notifications from
clinical pharmacist, formulary restrictions, evidenced based guidelines
and recommendations).
• Antibiotic orders include an indication for use.
• There is a mechanism in place to prompt clinicians to review antibiotic
courses of therapy after 72 hours of treatment.
• The facility has a system to identify patients currently receiving
intravenous antibiotics who might be eligible to receive oral antibiotic
treatment.
CMS. October 2011. https://www.cms.gov/Surveycertificationgeninfo/downloads/SCLetter12_01.pdf
HCW Influenza Vaccination
• In a CDC survey of the 2011-12 season, 66.9% of HCP reported
having received flu vaccine.
–
–
–
–
Physicians 85.6%
Nurses 77.9%
Others: 62.8%
Vaccination coverage was 76.9% among HCP in hospitals.
• Only 44% of HCW in NY received influenza vaccine.
• CMS-required reporting of healthcare worker influenza
vaccination (via NHSN) begins January 2013.
• Joint Commission requires hospitals to set incremental influenza
vaccination goals, achieving 90% by 2020.
• How will we get to >90%?
NYCDOHMH. Advisory #38. Influenza advisory. December 14 2012.
CDC. MMWR 2012;61(38):753-7
Greater New York Infection Prevention
Opportunities
New Appreciation for Healthcare-Associated
Infections
• HAIs are an important cause of morbidity and mortality among
patients in US hospitals.
• HAIs are not inevitable consequences of health care.
• HAIs are largely preventable.
– A “very low” rate of infection isn’t low enough for the patient that
develops the infection.
– Everyone shares the responsibility for preventing these infections.
Opportunities and Obligations
• Advocacy and engagement
– Professional societies: APIC, SHEA
– Organizations: healthcare facilities, GNYHA, HANYS
– Individual involvement: local, state, federal level
• Epidemiologic, clinical, and basic research
–
–
–
–
–
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Eliminate knowledge deficits
Optimize use of limited resources
Multicenter, high-quality studies
Develop new technology
Cost-effectiveness research
Utilize new sources of funding for research
• NIH, AHRQ, CDC, NYSDOH, foundations, industry
Opportunities and Obligations
• Innovative approaches to improving practice
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Implementation science
Systems engineering
Bundles and checklists
Behavioral science
Root cause analysis
Positive deviance
Collaboration
Opportunities and Obligations
• Take optimal advantage of the federal, state, and public interest
in HAIs
–
–
–
–
New York State Partnership for Patients
IPRO’s 10th Scope of Work Project
NYS HAI Reporting Program
DHHS/CMS initiatives
• HAI Action Plan, 2013 HAI Prevention Goals, VBP
– Joint Commission Standards
Acknowledgements
•
NewYork-Presbyterian Hospital
– Department of Infection Prevention and Control
•
•
Weill Cornell Medical College
•
•
Barbara Ross, Grimilda Augsburg, Hani Nasrallah,
Janett Pike, Jean-Marie Cannon, Jennifer Holohan,
Katie Albert, Kindra White, Lesley Covington, Lisa
Saiman, Liz DiPersia, Peggy Fracaro, Phil
Graham, Rich Vogel, Yoko Furuya
Michael Satlin, Matthew Simon, Kirsis Ham,
Stephen Jenkins, Jeannette Francois, Trip Gulick,
Marshall Glesby, Steve Wilson, Glenn Sturge, Luis
Lopez-Detres
•
–
•
•
–
Charlene Petrec, Elsa Santos-Cruz, Gene Kogan,
Lin Chen,Marianne Pavia, Mitch Reyes, Mona
Karam-Howlin, Sabine Jacques, Sandy Derevnuk,
Shelli Pickholz, Sonia Simpson-Morgan, Sophie
Labrecque, Steve Avalos-Bock, Teri Szulc, Dilcia
Ortega, Liz Coughlin, Lori Finkelstein-Blond
•
Gopi Patel, Mahesh Swaminathan, David Banach,
Stephanie Blash, Stephanie Factor, Meena Rana,
Mary Klotman
•
Michael Phillips, MD (NYU)
Saarika Sharma, MD (NYU)
Arjun Srinivasan, MD (CDC)
Brandon Kitchel (CDC)
Barry Kreiswirth, PhD (UMDNJ, PHRI)
Research funding
–
–
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Division of Infectious Diseases
Karline Roberts
Research collaborators
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•
Rachel Stricof, Kate Gase, Carol van Antwerpen
IPRO
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Hillary Jalon
New York State Department of Health
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•
Terri Straub, Maria Woods, Zeynep Sumer, Rafael
Ruiz, Gina Shin
United Hospital Fund
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Mount Sinai Medical Center
– Department of Infection Control
•
Greater New York Hospital Association
New York State Department of Health
Centers for Disease Control and Prevention
AHRQ
Greater New York Infection Prevention
Community
INFECTION
PREVENTION