1. Healthcare-Associated Infection (HAI) Prevention
Jane Carmean, RN, BSN, CIC
Ohio Department of Health
Bureau of Disease Investigation and Surveillance
Outbreak Response Bioterrorism Investigation Team (ORBIT)
(614) (ORBIT phone)
(614) (desk phone)
In recent years, interest in healthcare-associated infections (HAIs) has grown steadily in the United States among consumers, legislators, providers, payers, regulatory/accreditation organizations, and organizations that focus on patient safety and performance improvement. HAIs are now a major clinical and public health problem across the spectrum of healthcare settings, not just acute-care hospitals, that results in high morbidity, mortality, and costs. Given their impact, there has been a rising chorus of calls for the elimination of HAIs.

2. How Do HAIs Impact Ohio?
Based on national estimates¹, HAIs affect 5 to 10 percent of hospitalized patients annually
For Ohio this translates into over 80 thousand infections
nearly 4 thousand deaths
adds $180 to $230 million to healthcare costs
¹ McKibben, L., et.al., AJIC 205:33:4,

3. CDC Statement: Public Reporting of Healthcare-Associated Infections
The Centers for Disease Control and Prevention (CDC) believes public reporting of healthcare-associated infections (HAIs) is an important component of national HAI elimination efforts
Research shows that when healthcare facilities are aware of their infection issues and implement concrete strategies to prevent them, rates of certain hospital infections can be decreased by more than 70%
Recently, several state health departments and Consumer Reports magazine released summaries of infection rates in healthcare facilities. As a follow-up, in early February of this year, CDC released a statement on public reporting of HAIs.

4. CDC Statement: Public Reporting of Healthcare-Associated Infections, cont
“Eliminating HAIs is a top priority for CDC.”
“The tracking and reporting of HAIs is an important step toward healthcare transparency.”
“Infection data can give healthcare facilities, patients and public health agencies the knowledge needed to design and implement prevention strategies that protect patients and save lives.”
Quotes of Denise Cardo, director of CDC’s Division of Healthcare Quality Promotion

5. HAIs—National Attention
US Department of Health and Human Services (HHS) developed an action plan to prevent healthcare-associated infections
Support for HAI prevention has been enhanced through the American Recovery and Reinvestment Act (ARRA)
In January, 2009, HHS released the HHS action plan to prevent HAIs
Within this plan, CDC is leading the implementation of recommendations on National Prevention Targets and Metrics and the implementation of prevention recommendations.
Three overarching goals in the HHS plan
National progress towards national prevention targets
Use and improve the metrics and supporting systems needed to assess progress towards meeting the targets
Prioritization and broad implementation of current evidence-based prevention guideline recommendations.

6. Congress Allocated $40 Million Through CDC
Support state health department efforts to prevent HAIs by enhancing state capacity for HAI prevention
Leverage the CDC’s National Health Care Safety Network (NHSN) to assess progress and support the dissemination of the HHS evidence-based practices within healthcare facilities
Pursue state-based collaborative implementation strategies
State health departments have traditionally had limited funding, or workforce directly targeted to HAI issues.
However, in recent years more than 28 states have passed laws requiring reporting of hospital-specific HAI data to state health departments with public disclosure of hospital infection rates (Ohio, as you know, is one of them).
In some states, long-term care facilities and ambulatory surgical clinics have also been included in the reporting requirements
In 21 states thus far, NHSN has been identified as the tool for reporting and NHSN participation has grown from 300 hospitals nationally to approximately 2100 hospitals in 2.5 years.
Despite the growing interest in HAI reporting and prevention, most state health departments have had little or no resources to use these data, the NHSN, or to develop healthcare facility interest in HAI prevention or to develop community and statewide prevention efforts.

7. How the Congress- Allocated Money Flows
American Recovery and Reinvestment Act, (ARRA)
U.S. Department of Health and Human Services (HHS),
Centers for Disease Control and Prevention (CDC)
To the State Health Departments by way of the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) grant
Healthcare-Associated Infections - Building and Sustaining State Programs to Prevent Healthcare-associated Infections
Note:
the purpose of the ELC cooperative agreement program is to assist state public health agencies improve surveillance for and response to, infectious disease by
Strengthening epidemiologic capacity
Enhancing laboratory practice
Improving information systems
Developing and implementing prevention and control strategies
The focus of the activities is on naturally occurring infectious diseases and drug-resistant infections
ELC aims
to enhance the ability of public health agencies to identify and monitor the occurrence of known infectious disease of public health importance
Detect new and emerging infectious disease threats
Identify and respond to disease outbreak
Use public health data for priority setting, policy development and for prevention and control.

8. Ohio’s Piece of the Pie
Ohio Department of Health submitted a letter of intent in May, 2009
The grant application was submitted the following month
The Ohio Department of Health (ODH) was awarded $373,868
To participate, each state health department, (plus Puerto Rico and Washington DC) was required to submit a “State HAI Prevention Plan” which covered the required activities outlined in the grant.

9. Three Activities Offered in the Grant
Activity A
Coordination and Reporting of Healthcare-Associated Infection (HAI) Prevention Efforts
Activity B
Detection and Reporting of Healthcare-Associated Infection Data - HAI Surveillance
Activity C (not funded in Ohio)
addressed the formation of a prevention collaborative among hospitals
Ohio applied for all 3 activities outlined in the grant.
Two of the three were partially funded amounting to a total of $373,868.
The bulk of the money will be spent on the development and improvement of electronic reporting systems of infectious diseases with the inclusion of selected healthcare-associated infections.

10. Activity “A”
ODH will compute Ohio’s baseline measurements for at least two HHS prevention measure targets
Measures were selected based on recommendations by the multidisciplinary ODH Director’s Advisory Committee on Emerging Infections

11. Activity “B”
ODH will create infrastructure for electronic laboratory reporting for up to 11 Ohio hospitals
Participating hospitals will map and successfully submit an acceptable standardized health level
(HL) 7 message to the ODH HL7 gateway
A “request for proposals” went out to all hospitals in Ohio. They will compete for the opportunity to enhance their electronic reporting systems, including applications for the reporting of select healthcare-associated infections. Once the groundwork is developed for HAI reporting, the way will be paved for other reporting. It is hoped that this information can then be exported into NHSN (CDC is working on their end to make this possible). This would allow the mandatory reporting of HAIs required by state mandates to be filtered into the national data base. A little more than half of the states have mandated their hospitals report selected HAIs to their state health departments. Greater than 20 of the states are utilizing NHSN now as their reporting tool.

12. Reporting HAIs in Ohio
The OAC C-3 was revised in 2008 to explicitly include healthcare-associated outbreaks effective January 1, 2009
This consequently strengthens the infrastructure of Ohio’s HAI prevention plan

13. Reporting HAIs in Ohio
The Ohio Department of Health Director’s Advisory Committee on Emerging Infections has assumed a leadership role in the statewide effort to reduce HAI in acute care facilities across Ohio.
This committee is a well established multidisciplinary group of individuals first brought together in the mid 1990s to address current and emerging infectious disease concerns.

14. Reporting HAIs in Ohio
Membership includes representatives from the Infectious Diseases Society of Ohio, five Ohio Association for Professionals in Infection Control and Epidemiology (APIC) chapters, local public health departments, academia, the Ohio Hospital Association and the Ohio Nurses Association.
For the purpose of developing a State healthcare-associated infection prevention plan, representation from KePRO, Ohio’s quality improvement organization, and additional stakeholders interested in the reduction of HAIs have joined the committee.

15. Four Top Concerns Facing Ohio Hospitals
A September 2009 survey of Ohio’s hospital infection preventionists identified:
Methicillin-resistant Staphylococcus aureus (MRSA)
Clostridium difficile (C. difficile) infections
Surgical site infections
Non-MRSA multi-drug resistant organisms (MDRO) as the

16. Measures Being Monitored
ODH will be implementing these activities for three of the HAI measures that are required for Ohio House Bill 197 compliance and outlined in Ohio Administrative Code :
Laboratory identified Hospital-acquired Clostridium difficile
Laboratory identified Hospital-acquired Methicillin Resistant Staphylococcus aureus bacteremia
Laboratory identified Hospital-acquired Methicillin Susceptible Staphylococcus aureus bacteremia
These three measures were selected by the directors advisory committee on emerging infections. In part, they were chosen because they are already required reporting through HB 197 and will require no additional data gathering.
The criteria for reporting these lab identified infections are identical to the criteria in NHSN MDRO module.
The hope would be that hospitals would participate by signing on to the NHSN MDRO module to track these metrics. Only then could Ohio determine Ohio’s progress related to national data.

17. Evaluation and Oversight
Program evaluation is an essential component of public health
Communicating the evaluation results allow for learning and ongoing improvement to occur
Evaluation activity of the prevention targets will be discussed and determined during future meetings of the Director’s Advisory Committee

18. CDC Surveillance for HAIs
Voluntary system for monitoring nosocomial infections ( )
Voluntary system for monitoring healthcare- associated events and processes ( )
Increasingly used to comply with State legislation that mandates reporting of HAI data ( )
Also being used as a tool for prevention collaboratives
Organization of talk

19. Why use NHSN for HAI Reporting?
Provides standard definitions, protocols and methodology
Not just a reporting tool, comparative rates used for performance improvement
Useful analysis tools are included
CDC provides training and user support
Use of the application is free
Ability to share data with a Group

20. Reporting to a National Data Base
Surveillance data collection must use
sound epidemiologic principles
scientifically credible and validated data
Surveillance systems must be able
to document the impact of HAIs
monitor trends
evaluate the effectiveness of prevention efforts
Surveillance systems must be able to document the impact of HAIs, monitor trends, and evaluate the effectiveness of prevention efforts. There are notable examples of reductions in HAIs through prevention and control efforts. These success stories are predicated on surveillance data collected using sound epidemiologic principles, are scientifically credible and validated. The predecessor of NHSN, the National Nosocomial Infections Surveillance (NNIS) System, was built on these attributes. DHQP developed NHSN on the same principles.

21. NHSN Demographics 125 “Groups” in NHSN 22 state health departments
45 QIOs and QIOSC
4 state hospital associations
22 hospital systems
1 Emerging Infections Program (EIP) site

22. Why Enroll with NHSN?
Enrolling in NHSN allows a facility to compare its data to national aggregated data, which helps drive the prevention process
Unlike facility-based systems, the maintenance and support for NHSN is conducted by CDC … so there is no additional cost for the facility

23. 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

24. What is a “Group” in NHSN?
A Group is a collection of facilities that have joined together within the NHSN framework to share some or all of their data at a single (group) level for a mutual purpose (e.g., performance improvement, state and/or public reporting)

25. Data Sharing in NHSN: Groups, cont
The group can analyze the data of its member facilities
Facilities within the group cannot see each other’s data
Facilities may join multiple groups

26. Steps to form a Group in NHSN
Complete required reading and training for the Group Administrator or Group User
An NHSN facility “nominates” the Group
The Group Administrator obtains a digital certificate

27. Steps to form a Group in NHSN, cont
4. The Group Administrator adds additional users to the group and sets a Group joining password.
5. The Group Administrator sends the Group ID and Group joining password to facilities and invites them to join the Group.
6. Facilities join the Group and confer some/all rights to data.

28. CDC Support for the Group-Level User
Consultation on experience from other States
Presentations to Advisory Groups
Collaboration with CSTE, SHEA, APIC, IDSA, other Federal agencies including CMS and AHRQ
Access to “test” facilities
NHSN State Users Group
Conference calls monthly
Web Board to share materials
Consultation on analysis, HAI comparison metrics
Many public reporting activities outside of NHSN, collab with CSTE 28

29. Summary of the NHSN Group Function
Any entity can form a Group in NHSN
An NHSN facility “nominates” the group
Facilities join the group and confer some/all rights to data
The group can analyze the data of its member facilities
Facilities within the Group cannot see each other’s data
Facilities can join as many Groups at they like

30. Components of NHSN 30

31. Components of NHSN 31

32. Patient Safety Component Modules
Device-associated
Procedure-associated
SSI
PPP
Medication-associated
AUR
MDRO/CDAD
Patient Influenza Immunization
CLABSI
CLIP
CAUTI
VAP DE
SSI
PPP
AUR Pharmacy
AUR Microbiology
For Ohio’s reporting needs at this time-related to the state’s HAI prevention plan, we are interested in the MDRO/CDAD module.
Specifically, the Lab ID module.
MDRO/CDAD Infection
Lab ID
Processes
Method A
Method B 32

33. Benefit of Reporting into the MRDO-lab identified event
Laboratory testing results can be used without clinical evaluation of the patient, allowing for a much less labor-intensive means to track MDROs.
When denominator data are available from electronic databases, these sources may be used as long as the counts are not substantially different (+ or – 5%) from manually collected counts.

34. Benefit of Reporting into the MRDO-lab identified event, cont
This method allows the facility to rely almost exclusively on easily obtained data from the clinical microbiology laboratory.
However, some data elements, such as date admitted to the facility would require other data sources.

35. How Data Are Used
In aggregate, CDC analyzes and publishes surveillance data to estimate and characterize the national burden of healthcare-associated infections
At the local level, the data analysis features of NHSN that are available to participating facilities range from rate tables and graphs to statistical analysis that compares the healthcare facility’s rates with the national aggregate metrics

36. Laboratory And Admission Data To Calculate Proxy Measures
admission prevalence rate
MDRO bloodstream infection incidence rate
Overall facility-wide: report only one denominator for the entire facility
This is an example of the valuable data that can be made available to the NHAN user.
admission prevalence rate and overall prevalence rate based on clinical testing (measures of exposure burden), MDRO bloodstream infection incidence rate (measure of infection burden), and overall MDRO infection/colonization incidence rate (measure of healthcare acquisition).

37. Data Analysis
NHSN will categorize LabID Events as healthcare facility-onset vs. community-onset
This is realized
by classifying positive cultures obtained on day 1 (admission date), day 2, and day 3 of admission as community-onset (CO) LabID Events
and positive cultures obtained on or after day 4 as healthcare facility-onset (HO) LabID Events.
each event can be categorized by NHSN to populate different measures. Of note,
NHSN will categorize LabID Events as healthcare facility-onset vs. community-onset to ensure that all healthcare facility-onset cases have been hospitalized at least a full 48 hours. Considering: 1) variable times of day that admissions occur and 2) the absence of clinical data to confirm if cultures represent infection incubating at the time of admission, this is operationalized by classifying positive cultures obtained on day 1 (admission date), day 2, and day 3 of admission as community-onset (CO) LabID Events and positive cultures obtained on or after day 4 as healthcare facility-onset (HO) LabID Events.

38. Laboratory-identified (LabID) Events reporting for CDI
Data collected without clinical evaluation
Limited admission date data required
Proxy measures of C. difficile provides
healthcare acquisition,
exposure burden,
and infection burden
is the second surveillance option and allows laboratory testing data to be used without clinical evaluation of the patient, allowing for a much less labor intensive method to track C. difficile. These provide proxy measures of C. difficile healthcare acquisition, exposure burden, and infection burden based solely on laboratory data and. Reporting of LabID Events for the entire facility (i.e., Overall facility-wide) can provide easily obtainable and valuable information for the facility. LabID Events can also be monitored for specific locations with unique denominator data required from each specific location

39. Question, Needs and Resources
Are Ohio IPs interested in face to face training in our State (CDC sponsored) for NHSN use?
ODH is requesting an NHSN facility to “nominate” ODH to form a “Group”
We will be asking the I Ps across the state if they have an interest in coming together in a central location for information about NHSN-all would be invited and it would be hoped that information could be shared about using NHSN. Most hospitals in Ohio are not signed up with NHSN, but during a survey, we were told that most IP s in Ohio use NHSN data and case definitions and they monitor the national trends related to their own hospital data.