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Principles of Epidemiology & Surveillance of Health care- Associated Infection Russ Olmsted

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1 Principles of Epidemiology & Surveillance of Health care- Associated Infection Russ Olmsted

2 Some “real world” definitions of Epidemiology “the worst taught course in medical school” “the worst taught course in medical school”  Medical student, U of M "the science of making the obvious obscure” "the science of making the obvious obscure”  Clinical Faculty, MSU “the science of long division” “the science of long division”  Statistician, Grand Valley State U "the study of skin diseases“ "the study of skin diseases“  New CDC Epidemic Intelligence Service Officer, Atlanta

3 The Real Definition epidemiology is "the study of the distribution and determinants of health- related states in specified populations, and the application of this study to control health problems." - smarty pants epidemiologist during a cocktail party epidemiology is "the study of the distribution and determinants of health- related states in specified populations, and the application of this study to control health problems." - smarty pants epidemiologist during a cocktail party

4 Goals of Infection Prevention/Control (IP/C) & Epidemiology Programs Surveillance : Surveillance :  systematic collection, analysis, & reporting of data from surveillance system to prevent disease & improve health Principal Goals: Principal Goals:  Protect the patient;  Protect health care personnel, visitors, & others  Accomplish these in a cost effective manner whenever possible Scheckler WE. AJIC 1998;26:47-60

5 Surveillance Definition: Definition: Function: noun Etymology: French, from surveiller to watch over, from Latin vigilare, from vigil watchful close watch kept over someone or something (as by a detective) close watch kept over someone or something (as by a detective) Application:... ongoing, systematic collection, analysis, interpretation, and dissemination of data regarding a health-related event... Purpose: to reduce morbidity and mortality and to improve health CDC. Surveillance system guideline. MMWR 2001;50(RR13)

6 Comparing & Contrasting Surveillance vs. Individual Patient Care Surveillance is: Population-based Population-based Incidence and prevalence rates versus raw numbers – trending Incidence and prevalence rates versus raw numbers – trending Risk stratification (age, disease, complexity of surgery, etc.) Risk stratification (age, disease, complexity of surgery, etc.) Systematic and improvement oriented Systematic and improvement oriented Measurement to improve patient safety. Measurement to improve patient safety. Surveillance is NOT: Clinical diagnosis of infection Clinical determination of antibiotic use Based on subjective criteria “Gut feeling” Based on definitions of from your facility’s medical director

7 Early Evidence of Efficacy of Surveillance; using data for patient safety  Power of performance measurement: feedback loop of surgeon-specific SSI rates, NY Roosevelt Hospital,  YearOverall SSI Rate % (baseline) (1 st yr. SSI data provided) Brewer GE. JAMA 1915

8 Keys for the Elimination of Healthcare-associated Infections Collect data and disseminate results Collect data and disseminate results  transparency with consumers  Engaging direct care providers Full adherence to best practices Full adherence to best practices Recognize excellence Recognize excellence Identify and respond to emerging threats Identify and respond to emerging threats Improve science for prevention through research Improve science for prevention through research  Cardo D, et al. ICHE 2010

9 Efficacy of Surveillance Data + Prevention Strategies at the Bedside

10 Using HAI Data for Comparing Performance Between Providers National Surgical Quality Improvement Program (NSQIP)

11 Uses of HAI Surveillance Data: Nationwide

12 Impact of C. difficile infection (CDI) Hospital-acquired, hospital-onset: 165,000 cases, $1.3 billion in excess costs, and 9,000 deaths annually Hospital-acquired, hospital-onset: 165,000 cases, $1.3 billion in excess costs, and 9,000 deaths annually Hospital-acquired, post-discharge (up to 4 weeks): 50,000 cases, $0.3 billion in excess costs, and 3,000 deaths annually Hospital-acquired, post-discharge (up to 4 weeks): 50,000 cases, $0.3 billion in excess costs, and 3,000 deaths annually Nursing home-onset: 263,000 cases, $2.2 billion in excess costs, and 16,500 deaths annually Nursing home-onset: 263,000 cases, $2.2 billion in excess costs, and 16,500 deaths annually Campbell et al. Infect Control Hosp Epidemiol. 2009:30: Dubberke et al. Emerg Infect Dis. 2008;14: Dubberke et al. Clin Infect Dis. 2008;46: Elixhauser et al. HCUP Statistical Brief #

13 Using HAI Data to Assess Efficacy of an Intervention; Preop Skin Prep Darouiche RO et al. N Engl J Med. 2010;362:18-26.

14 Snapshot of Relative Distribution of Health Care-Associated Infections (HAIs) in U.S. hospitals, 2002; 1.7 M/yr; 100,000 deaths HRN = high risk newborns WBN -= well-baby nurseries ICU = intensive care unit SSI = surgical site infections BSI – bloodstream infections UTI = urinary infections PNEU = pneumonia SSI 20% BSI 11% UTI 36% PNEU 11% Other 22% 133, , , , , , ,385 TOTAL HRN WBN Non-newborn ICU = SSI Klevens, et al. Pub Health Rep 2007;122:160-6 Comment: relative proportion of this Pie for UTI is less in 2012 = change to SUTI. SSI is #1

15 Updated Distribution of HAIs, U.S., 2012 SSIs are now most prevalent site of HAI SSIs are now most prevalent site of HAI Reason: Reason:  Change in criteria for UTI by NHSN, 2009  Complexity of Prevention of SSIs; multiple risk factors Magill SS, et al. ICHE 2012; 33: Magill SS, et al. ICHE 2012; 33: SSI -surgical site infection; Pneu -pneumonia; UTI –urinary tract infection; BSI –bloodstream infection; GI – gastrointestinal infection

16 Steps Involved in Managing Information Needs Assessment Planning & Design Capturing & Reporting Process & Analyze Storing & Retrieving Display & Disseminate Surveillance of HAIs Lee TB, et al. AJIC 2007;35: Assess Pt. Population Select Indicators Apply Surv. Definitions Collect Data Analyze Data Apply risk stratification Report & Use Findings JC. CAMH, 2007

17 How Much Time is Spent on Surveillance by Infection Preventionists (IPs) in NY? IPs surveyed from 222/224 acute care hospitals, NY Scope of responsibility for “average IP” 1.0 FTE:   151 pt. Beds   1.3 ICUs   21 LTCF beds   0.6 Dialysis ctrs   0.5 ASC   4.8 Amb. Care   1.3 PCP offices infrastructure capacity responsibilities In balance?

18 Conceptual Model for Performance Improvement: Have we created a culture of safety? Structure ProcessOutcome Have we reduced the likelihood of harm? How often do we do what we are supposed to? How often do we harm? Adapted from: Donabedian A. Evaluating the quality of medical care. Milbank Memorial Fund Quarterly 1966;44:166–206.

19 Using Process Data to Improve Antibiotic Stewardship Multidisciplinary team, IP+ID+Geriatrician visited and surveyed use of Abx to Prevent UTIs in all LTC units, Central Finland Multidisciplinary team, IP+ID+Geriatrician visited and surveyed use of Abx to Prevent UTIs in all LTC units, Central Finland Results: Results:  Most (80%) Abx use for UTI  Significant drop in Use overall 13 to 6%;acute+ LTC  59% of units used urine odor as reason for culture   Rummukainen ML, et al. AJIC 2012

20 Ensuring Quality of Surveillance Written Plan: risk assessment, goals, objectives, & elements Written Plan: risk assessment, goals, objectives, & elements Maintain thoroughness and intensity over time; e.g. what happens to rate of VAP if ICP leaves a position and it is not filled for 6 months? Maintain thoroughness and intensity over time; e.g. what happens to rate of VAP if ICP leaves a position and it is not filled for 6 months? Organization leaders need to provide adequate resources for surveillance program Organization leaders need to provide adequate resources for surveillance program Re-evaluate efficacy of surveillance program at least annually Re-evaluate efficacy of surveillance program at least annually

21 Validation of HAI Surveillance: Precision & Quality of the Information 20 ICUs, 4 Medical Centers Median CLABSI rates: IP = 3.3 Computer algorithm = 9.0 Medical Ctr C had the lowest rate by IP (2.4) however the highest rate by computer algorithm (12.6) Lin MY, et al. JAMA 2010

22 Step 1 – Assess population and environment Patient demographics (age, gender, socioeconomic status) Patient demographics (age, gender, socioeconomic status) Patient clinical characteristics (most frequent diagnoses and co-morbidities, most frequent and most rarely performed procedures, medical treatments) Patient clinical characteristics (most frequent diagnoses and co-morbidities, most frequent and most rarely performed procedures, medical treatments) Characteristics of HCP (knowledge and training) Characteristics of HCP (knowledge and training) Facility characteristics (physical size, age, condition, single or shared rooms, geographic location) Facility characteristics (physical size, age, condition, single or shared rooms, geographic location) Do you have existing surveillance data? Do you have existing surveillance data? Lee TB, et al. AJIC 2007

23 Step 2 – Select Indicators/Metrics to Measure: Process, Outcome… Use facility-specific risk assessment Use facility-specific risk assessment Search the literature for relevant studies that apply to your patient population Search the literature for relevant studies that apply to your patient population  What are most likely HAI issues? What are most likely HAI issues?  Frequency, cost, reg./accred. requirement, PI project Examples : Examples :  Process: % residents & HCP rec’d flu vax., CMS survey tool for ASC, % Abx use for ASB, Hand hygiene adherence  Outcome: CLABSI, CAUTI, SSI rates; incidence of CDI/10,000 patient days Lee TB, et al. AJIC 2007

24 Step 3 – Use Valid, Reproducible Surveillance Criteria Acute & Ambulatory Care: CDC’s National Healthcare Safety Network (NHSN); ww.cdc.gov/nhsn Acute & Ambulatory Care: CDC’s National Healthcare Safety Network (NHSN); ww.cdc.gov/nhsn Long Term Care: Revised McGeer;Stone ND, et al. Infect Control Hosp Epidemiol 2012;33: Long Term Care: Revised McGeer;Stone ND, et al. Infect Control Hosp Epidemiol 2012;33: Home Care & Hospice: APIC-HICPAC, Available from Home Care & Hospice: APIC-HICPAC, Available from Consider performing a “Point or period Prevalence” or even simple line listing to establish baseline frequency if existing data are not available Consider performing a “Point or period Prevalence” or even simple line listing to establish baseline frequency if existing data are not available Lee TB, et al. AJIC 2007

25 NHSN Surveillance Criteria HAI: localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that was not present on admission to the acute care facility HAI: localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s) that was not present on admission to the acute care facility …all elements of a CDC/NHSN site-specific infection criterion were first present together on or after the 3rd calendar day of admission to the facility (the day of hospital admission is day 1). …all elements of a CDC/NHSN site-specific infection criterion were first present together on or after the 3rd calendar day of admission to the facility (the day of hospital admission is day 1).

26 NHSN Surveillance Criteria: example of application

27 Present on Admission (POA) If all of the elements of an infection definition are present during the two calendar days before the day of admission, the first day of admission (day 1) and/or the day after admission (day 2) and are documented in the medical record, the infection would be considered POA If all of the elements of an infection definition are present during the two calendar days before the day of admission, the first day of admission (day 1) and/or the day after admission (day 2) and are documented in the medical record, the infection would be considered POA Fever = 102 F Urine Cx >10 5 E. coli This infection = POA

28 Location, Location, Location… key variable for NHSN surveillance

29 Key Terms & Concepts TermDefinition HAIAn infection is considered an HAI if all elements of a CDC/NHSN site-specific infection criterion were first present together on or after the 3rd hospital day (day of hospital admission is day 1). For an HAI, an element of the infection criterion may be present during the first 2 hospital days as long as it is also present on or after day 3. All elements used to meet the infection criterion must occur within a timeframe that does not exceed a gap of 1 calendar day between elements. Device- associated infection An infection meeting the HAI definition is considered a device- associated HAI if the device was in place for >2 calendar days when all elements of a CDC/NHSN site-specific infection criterion were first present together. HAIs occurring on the day of device discontinuation or the following calendar day are considered device-associated HAIs if the device had been in place already for >2 calendar days. Date of EventFor an HAI (excludes VAE), the date of event is the date when the last element used to meet the CDC/NHSN site-specific infection criterion occurred

30 Key Terms & Concepts TermDefinition Transfer RuleIf all elements of an HAI are present within 2 calendar days of transfer from one inpatient location to another in the same facility (i.e., on the day of transfer or the next day), the HAI is attributed to the transferring location. Likewise, if all elements of an HAI are present within 2 calendar days of transfer from one inpatient facility to another, the HAI is attributed to the transferring facility. Receiving facilities should share information about such HAIs with the transferring facility to enable reporting.

31 Step 4 – Collect HAI Data Run…don’t walk to your PC/Mac, fire up your browser, and take training on use of NHSN – AC & LTC Run…don’t walk to your PC/Mac, fire up your browser, and take training on use of NHSN – AC & LTC Lee TB AJIC 2007

32 New LTCF – specific Modules Now Available from NHSN. For Details see:

33 New HCP Vaccination Module Now Available at NHSN See:

34 Step 5 – Analyze HAI Data Line Listing CAUTI Rate Table Bar Graph & Pie Charts

35 Step 6 – Apply Risk Stratification to Data NHSN NHSN  Location: ICU, non-ICU, Hem-Onc  Standardized Infection Ratio (SIR)   Summary measure to compare HAI data among one or more groups of patients to that of a standard population’s (e.g. NHSN)   Accounts for differences in incidence of HAI by patient groups  SSI: ASA score, duration of surgery, wound class > 3  NICU: birthweight category Others: Others:  SSI rates; inpatients only vs inpt. + post-discharge  Fall injury risk scoring scheme  Stratify receipt of influenza vaccine by job class and department

36 Incorporate HAI data into health system monthly patient safety quality reporting dashboard Incorporate HAI data into health system monthly patient safety quality reporting dashboard Reporting data to MDCH Sharp Unit & CMS Reporting data to MDCH Sharp Unit & CMS  Permit access to MI-Specific HAI experience  Fulfills incentive-based reimbursement from CMS Be consistent in timelines for reporting to key personnel and other entities Be consistent in timelines for reporting to key personnel and other entities The most important step in the surveillance process – data for improvement at the local level is first step in improving care The most important step in the surveillance process – data for improvement at the local level is first step in improving care Step 7 – Reporting & Using HAI Surveillance Data

37 Keystone ICU Project: The Results 66% reduction in Central Line Bloodstream Infections (CLBSI) 66% reduction in Central Line Bloodstream Infections (CLBSI) Interventions: Interventions:  Hand hygiene  Max. barrier prec. during insertion  CHG antiseptic on insertion site  Avoid femoral CLs  Remove CL when not needed Pronovost P, et al. NEJM 2006;355: Pronovost P, et al. NEJM 2006;355: Rate Per 1,000 CL Days

38 Use of Surveillance Technology to Improve Efficiency of IPC Program M. Moyhla – Holy Cross Hospital

39 Improving Surveillance Skills: Case Studies in AJIC & Available online at cdc.gov/nhsn


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