Transcript Slide 1

Implementation of Texas
Healthcare-associated Infection
and Preventable Adverse Event
Reporting
Neil Pascoe RN BSN CIC
Epidemiologist
Today
• Federal Issues
• State Process
• Reporting (the who, what, when, and how)
Federal Healthcare Reform
Currently No Mandate for HAI
Reporting
Increasing Need for Public Health Approach
Across the Continuum of Care
Acute Care
Facility
Home
Care
Outpatient/
Ambulatory
Facility
Tranquil Gardens
Nursing Home
Long Term Care
Facility
Current Landscape of
HAI Surveillance - Policy
• Emphasis remains mandatory HAI
reporting and public reporting of hospitalspecific data
• possible federal mandate
• coupled with renewed interest in data
validation
• enabling greater public access to machine
readable data sets
Current Landscape of
HAI 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)
Current Landscape of
HAI 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
Healthcare-Associated Infections
(HAIs)
Problem
– Bloodstream infections, urinary tract infections,
pneumonia, surgical site infections
Annual Impact
– 1.7 million HAIs in hospitals—unknown 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
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
HHS Action Plan to Prevent
Healthcare-Associated Infections
Development and Implementation
See:
www.haitexas.org
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
Measuring Success
Metric
Data Target
Central line bloodstream infections
Adherence to CLIP
Hospitalizations with Clostridium difficile
Clostridium difficile infections
Catheter-associated urinary tract infections
MRSA incidence rate (healthcareassociated)
MRSA bacteremia (healthcare facility-wide)
Surgical site infections
Surgical Care Improvement Program
adherence
NHSN
NHSN
Admin
NHSN
NHSN
EIP
↓ 50%
100%
> ↓ 30%
> ↓ 30%
> ↓ 25%
> ↓ 50%
NHSN > ↓ 25%
NHSN > ↓ 25%
SCIP > 95%
Successful Implementation of Evidence-Based
Guidelines Prevents Bloodstream Infections
Successful Interventions

Sustained rates in Michigan
hospitals for 5 years
10
103 ICUs at
67 Michigan Hospitals
BSIs per 1,000 Catheter Days
8
6
4
2
0
0
Months
18
Pronovost P. New Engl J Med 2006;355:2725-32
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
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)
Background
• 78th legislative Session (2005) passed
study bill
– Advisory Panel
• White paper
– www.haitexas.org
Background
• 79th legislative Session (2007) passed
legislation (SB 288)
– Advisory Panel
– Reporting provisions
• No appropriation
• White paper
– www.haitexas.org
– www.texashai.org
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
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 didn’t 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)
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
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
Acute Care Reporting
• ..a health care facility…shall 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
CLABSI
• NHSN definitions
• Laboratory confirmed
– include the causative organism
– special care setting in hospital
– ICU/CCU/BurnICU
– Not NICU
Pediatric Reporting
• Cardiac procedures, excluding thoracic
cardiac procedures
• Ventriculoperitoneal shunt procedures <
• Spinal surgery with instrumentation
• Incidence of inpatient RSV
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
Approximate
number of reports
based on 2008 3rd
quarter
administrative
(hospital) data
53,676 x 4= 214,704
Chapter 98
• Confidentiality
– Same protections as notifiable conditions
• Legal protections
• Enforcement
– Regulatory/licensing
Who has to report
•
500+ general hospitals
– Includes LTAC
– Includes Pediatric and Adolescent
– Excludes long term rehab hospitals
• 350 ambulatory surgical centers
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**
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
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
Texas
Funded 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: (512) 458-7111, extension 6364
Fax: (512) 458-7616
[email protected]
www.haitexas.org
Summary of Activity:
Activity A
Texas has appointed a state healthcare-associated Infections (HAI) coordinator. This coordinator managed the convening of a multidisciplinary 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 B
By the end of Year 2, Texas will target the enrollment of all Texas acute care hospitals (n=517) 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 C
Texas 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.
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)
When to Report
• January 1, 2011
• April 1, 2011
• July 1, 2011
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.
Education and Training
GR funding will allow for contracted training
• State meeting in October 2010
– See www.haitexas.org
• CDC/NHSN training
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
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
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
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
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.
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
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)
– Veteran’s 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 facility’s chief executive
leadership (e.g., Chief Executive Officer).
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”?
Challenges of NHSN, cont’d
• 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…
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
Advantages of NHSN, cont’d
• 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
NHSN Change Control Process
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
Projected NHSN Data flows
State-Summary Report of HAI
Data Reported to NHSN
As a Method of Measuring Progress
Towards Elimination of HAIs
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
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/actionplan/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)
State-Summary Report of HAI Data
Reported to NHSN
Standardized Infection
Ratio:
No. expected / no. observed
State Obscured
•
•
•
Public report limited to states with mandate
Sharing summary data with state officials
Encouraging all facilities to work with state
officials
Data Tables in Report (DRAFT)
A
B
C
D
E
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
NHSN Performance and
Usability Improvements
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.
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
The DSHS Data Display
Data Display
Roles of Local and Regional HD
• Education and Training
• Information and Data Validation
• Outbreak investigation
• Other activities???
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
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
Thanks
• HAI and PAE AP (don’t you love acronyms?)
• Sharon Williamson, Patti Grant and NHSN
• HAI IPT
• TSICP
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/pu
blicReportingHAI.html
Questions or discussion?