Russ Olmsted olmstedr@trinity-health.org Principles of Epidemiology & Surveillance of Health care-Associated Infection Russ Olmsted olmstedr@trinity-health.org

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

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

Goals of Infection Prevention/Control (IP/C) & Epidemiology Programs Surveillance: systematic collection, analysis, & reporting of data from surveillance system to prevent disease & improve health 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

Surveillance 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) 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)

Comparing & Contrasting Surveillance vs. Individual Patient Care Surveillance is: Population-based Incidence and prevalence rates versus raw numbers – trending Risk stratification (age, disease, complexity of surgery, etc.) Systematic and improvement oriented 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

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, 1895-1914- Year Overall SSI Rate 1895 39.0 % (baseline) 1896 9.0 (1st yr. SSI data provided) 1899 3.2 1912 2.4 1914 1.2 Brewer GE. JAMA 1915

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

Efficacy of Surveillance Data + Prevention Strategies at the Bedside

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

Uses of HAI Surveillance Data: Nationwide http://www.cdc.gov/hai/statesummary.html

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, 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 Campbell et al. Infect Control Hosp Epidemiol. 2009:30:523-33. Dubberke et al. Emerg Infect Dis. 2008;14:1031-8. Dubberke et al. Clin Infect Dis. 2008;46:497-504. Elixhauser et al. HCUP Statistical Brief #50. 2008.

Using HAI Data to Assess Efficacy of an Intervention; Preop Skin Prep Table 2. Proportion of Patients with Surgical-Site Infection, According to Type of Infection (Intention-to-Treat Population). Reference: Darouiche RO et al. NEJM: 2010; 362:18-26. Darouiche RO et al. N Engl J Med. 2010;362:18-26.

Klevens, et al. Pub Health Rep 2007;122:160-6 Snapshot of Relative Distribution of Health Care-Associated Infections (HAIs) in U.S. hospitals, 2002; 1.7 M/yr; 100,000 deaths SSI 20% BSI 11% UTI 36% PNEU Other 22% 133,368 424,060 263,810 129,519 274,098 -967 -21 -28,725 244,385 TOTAL HRN WBN Non-newborn ICU = SSI Klevens, et al. Pub Health Rep 2007;122:160-6 HRN = high risk newborns WBN -= well-baby nurseries ICU = intensive care unit SSI = surgical site infections BSI – bloodstream infections UTI = urinary infections PNEU = pneumonia Comment: relative proportion of this Pie for UTI is less in 2012 = change to SUTI. SSI is #1 14

Updated Distribution of HAIs, U.S., 2012 SSIs are now most prevalent site of HAI Reason: Change in criteria for UTI by NHSN, 2009 Complexity of Prevention of SSIs; multiple risk factors Magill SS, et al. ICHE 2012; 33:283-91. SSI -surgical site infection; Pneu -pneumonia; UTI –urinary tract infection; BSI –bloodstream infection; GI – gastrointestinal infection

Steps Involved in Managing Information Surveillance of HAIs Lee TB, et al. AJIC 2007;35:427-40. Needs Assessment Assess Pt. Population Planning & Design Select Indicators Report & Use Findings Display & Disseminate Capturing & Reporting Apply Surv. Definitions Analyze Data Process & Analyze Storing & Retrieving Collect Data Apply risk stratification JC. CAMH, 2007

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 capacity responsibilities In balance? infrastructure

Conceptual Model for Performance Improvement: Have we created a culture of safety? Process Outcome Structure 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.

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 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

Ensuring Quality of Surveillance 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? Organization leaders need to provide adequate resources for surveillance program Re-evaluate efficacy of surveillance program at least annually

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

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

Step 2 – Select Indicators/Metrics to Measure: Process, Outcome… Use facility-specific risk assessment Search the literature for relevant studies that apply to your patient population http://www.ncbi.nlm.nih.gov/pubmed What are most likely HAI issues? Frequency, cost, reg./accred. requirement, PI project 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

Step 3 – Use Valid, Reproducible Surveillance Criteria 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;33:965-77 Home Care & Hospice: APIC-HICPAC, 2008. Available from http://www.apic.org 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

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 …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).

NHSN Surveillance Criteria: example of application

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 Urine Cx >105 E. coli Fever = 102 F This infection = POA

Location, Location, Location… key variable for NHSN surveillance

Key Terms & Concepts Term Definition HAI An 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 Event For 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

Key Terms & Concepts Term Definition Transfer Rule If 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.

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 Lee TB AJIC 2007

New LTCF – specific Modules Now Available from NHSN. For Details see: http://www.cdc.gov/nhsn/LTC/index.html

New HCP Vaccination Module Now Available at NHSN See: http://www.cdc.gov/nhsn/hps_Vacc.html

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

Step 6 – Apply Risk Stratification to Data 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: SSI rates; inpatients only vs inpt. + post-discharge Fall injury risk scoring scheme Stratify receipt of influenza vaccine by job class and department

Step 7 – Reporting & Using HAI Surveillance Data Incorporate HAI data into health system monthly patient safety quality reporting dashboard 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 The most important step in the surveillance process – data for improvement at the local level is first step in improving care

Keystone ICU Project: The Results 66% reduction in Central Line Bloodstream Infections (CLBSI) 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;355:2725-32. Rate Per 1,000 CL Days

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

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