1. HAI Program Update Meredith Kanago, MSPH TDH Statewide CEDEP Meeting 30 April 2014

2. Outline Background HAI Burden HAI Surveillance ▫ Tennessee ▫ National Public Reporting In Tennessee HAI Prevention Progress Antimicrobial Stewardship Recent HAI Outbreaks

3. Background For the purpose of surveillance, a healthcare- associated infection (HAI) is a 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 facility. HAIs occur in all types of care settings, including: ▫ Acute care within hospitals ▫ Same-day surgical centers ▫ Ambulatory outpatient care in health care clinics ▫ Long-term care facilities (e.g., nursing homes and rehabilitation facilities) http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=17

4. HAI Burden In 2011, there were ~722,000 HAIs in U.S. acute care hospitals ▫ Significant additional burden in other settings Nearly 75,000 deaths associated with HAIs ▫ 6th leading cause of death in the US $33 billion in added healthcare costs CDC, 2014

5. HAI Surveillance in TN

6. National HAI Surveillance Facilities are required to report HAIs and other events to CMS for payment incentives ▫ Examples:  Acute care hospitals: IPPS  Dialysis clinics: ESRD QIP Failure to report -> loss of 1% annual payment update Pay-for-reporting -> pay-for-performance ▫ Revenue neutral: bonus if in top 25%; money comes from bottom 25% TDH aligns requirements closely with CMS to minimize reporting burden while maximizing available data

7. National Healthcare Safety Network A secure, Internet-based surveillance system for collecting and utilizing data on HAIs Requires active, patient-based (or laboratory-based), prospective surveillance of events and corresponding denominator data Surveillance is conducted by infection preventionists (IPs) at healthcare facilities

8. NHSN for Regional Epidemiologists Good news – you don’t actually have to use (or know how to use) the NHSN application! What you do need to know: ▫ Which HAIs and MDROs are reportable in NHSN according to TN rules/regs ▫ Which MDROs are reportable in NBS ▫ What to do if you receive questions about NHSN  (HAI.health@tn.gov)HAI.health@tn.gov

11. Public Reporting in Tennessee Tennessee’s first public report on HAIs was published in December 2009 ▫ Included aggregate state data and facility-specific CLABSI data Published semi-annually, and includes facility- specific data on: ▫ CLABSI in adult/ped ICUS NICUS ▫ CAUTI in adult /ped ICUs ▫ SSI (COLO and HYST) ▫ LabID Events (MRSA and CDI) in acute care

12. ● To calculate O, sum the number of HAIs among a group ● To calculate P, requires the use of the appropriate aggregate data (risk-adjusted rates) (e.g., national NHSN data for 2006–2008) ● SIR > 1.0: # infections are HIGHER than predicted ▫ SIR= 1.5: # infections = 50% HIGHER than predicted ● SIR < 1.0: # infections are LOWER than predicted ▫ SIR= 0.4: # infections = 60% LOWER than predicted SIR = Observed (O) HAIs Predicted (P) HAIs Standardized Infection Ratio

13. CAUTI Standardized Infection Ratio (SIR) for Adult and Pediatric Intensive Care Units in Facilities with ≥1 Predicted CAUTI, Tennessee, 01/01/2013 - 06/30/2013 Data Reported from adult/pediatric ICUs as of January 30, 2014. N = number of types of intensive care units reporting OBS = observed number of CAUTI PRED = statistically 'predicted' number of CAUTI, based on NHSN baseline data SIR = standardized infection ratio (observed/predicted number of CAUTI) UCD = number of urinary catheter days NA = data not shown for hospitals with <50 urinary catheter days ** Significantly higher than national baseline Significantly lower than national baseline * Zero infections, but not statistically significant

17. Provisional Data CLABSI –Adult/Pediatric ICUs Over Time

18. CLABSI – NICU SIRs Over Time Provisional Data

19. CAUTI – A/P ICU SIRs Over Time Provisional Data

20. MRSA – ACH SIR Over Time Provisional Data

22. TN: 3 rd Highest Outpatient Antibiotic Use (TN: 1,159 Rx vs 801 Rx per 1,000 persons) http://www.cddep.org/resistancemap/use/all

23. Antimicrobial Stewardship Collaborative GOALS: ▫ Improve appropriate antibiotic use ▫ Reduce unnecessary antibiotic use ▫ Reduce emergence & spread of multidrug resistant organisms ▫ Reduce Clostridium difficile Prevalence of Antimicrobial Use in Hospitalized Patients (10 States (EIP), 2011)

24. Antimicrobial Stewardship (continued) Simplified monthly point prevalence survey Monthly webinar topics include: ▫ Assessing the Gaps and Identifying Champions for Antimicrobial Stewardship ▫ Multidisciplinary Efforts in Antimicrobial Stewardship ▫ Creating and Utilizing Antibiograms ▫ Dose Optimization and Kinetic Dosing ▫ Antimicrobial Stewardship in Small Hospitals ▫ De-Escalation ▫ Measurement in Stewardship Programs and Reporting Metrics to Stakeholders

25. Recent HAI Outbreak MSSA joint injections at an outpatient clinic ▫ September 9, 2013: TDH is notified of 3 joint infections among patients who received injections of triamcinolone acetate and lidocaine at a single outpatient clinic on the same day ▫ Triamcinolone was produced in out-of-state compounding pharmacy ▫ Medications were sequestered and injections were stopped

26. Recent HAI Outbreak MSSA joint infections (continued) ▫ Follow-up showed 4/5 pts receiving injections on 9/5 had evidence of a joint infection ▫ MSSA isolated from 3 cases (PFGE- indistinguishable strains); cultured meds negative ▫ Site visit revealed suboptimal med prep and hand hygiene; no separate clean area for med prep ▫ Recommendations provided, including avoiding use of multi-use vials

27. Questions? HAI.health@tn.gov