Infection Prevention and Control Through the Ages

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Infection Prevention and Control Through the Ages

• Tammy Lundstrom, M.D., J.D.
• Chief Medical Officer
• Providence/Providence Park
• Asso. Prof. Medicine- Wayne State
• Adjunct Prof. of Law- Wayne State

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How far weve come and how far we have to go
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2008
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DODGE CHALLENGER
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In the News

Hospital Releases Details of Medical Error to
Staff
Medical Insurers Focus on 'Never Events'
Data on Number of Patients Injured in Serious
Medical Never Events'
When It's Surgery, Don't Get It Wrong
Infectious Dilemma

Blue Cross Wont Cover Costs Tied to Hospital
Errors
Medicare Says It Wont Cover Hospital Errors
When Surgeons Cut the Wrong Body Part
New York Medicaid Program Stops Paying
Hospitals for Preventable 'Never Events'
CMS Your Mistake, Your Problem
Medical Benchmarking Is Deadly
MedHeadlines
Medicare's no-pay events Coping with the
complications
100 Californians Injured By Hospitals Each Month
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Institute of Medicine - IIILeadership by Example
Coordinating Government Roles in Improving Health
Care Quality

• 20 areas of focus
• Immunization --
• Vaccine-preventable diseases kill 300 children
  and 70,000 adults ..target nursing-home
  residents, minorities, and low-income, inner-city
  children
• Nosocomial infections - -
• Wider implementation of the nosocomial infection
  guidelines from the CDC could save gt40,000 lives
  annually

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Broader implications of payment policies

• 36 states with event reporting
• 23 states where patients or plans cannot be
  billed for treatment of never events/HACs
• Private payers adopting such policies include
  Aetna, BCBS, Cigna, HealthNet, Kaiser, United
  Health.

SOURCE www.MSNBC.com
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What Should I Concentrate On?
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Overlap between AHRQ, CMS and NQF events

• AHRQ PSI Measures (27)
• Complications of anesthesia
• Death in low mortality DRGs
• Failure to rescue
• Selected infections due to medical care
• Unexpected post-operative events (e.g., sepsis)
• Birth and obstetric trauma
• Transfusion reaction
• Iatrogenic pneumothorax

• AHRQ and CMS
• Pulmonary Embolism

• AHRQ, CMS and NQF
• Object left in surgery
• Pressure ulcers

• NQF Never Events
• Surgery Events (4)
• Product or Device Events (2)
• Patient Protection Events (3)
• Criminal Events (4)
• Care Mgmt Events (6)
• Environmental Events (2)

• CMS Preventable Conditions
• Catheter-associated UTI
• Vascular catheter-associated infection
• Surgical site infection (mediastinitis, bariatric
  surgery for obesity, spinal fusion, other
  surgeries of shoulder and elbow)
• Glycemic control

• CMS and NQF
• Air embolism
• Blood incompatibility
• Hospital-acquired Conditions
• Glycemic control

Some codes in CMS policy are not part of NQF
policy Source CMS DRA, UAB Health System
http//www.uabhealth.org/33800/ , NQF, CMS DRA,
UAB Health System http//www.uabhealth.org/33800/
, AHRQ PSI
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Kissinger signing Vietnam Peace Treaty
US Troops in Iraq
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HAI Legislation as of June 09, 2006

• 11 states had mandated public reporting
• 22 states were considering legislative activity
• 5 states had legislated task forces/committees
• 3 states required use of NHSN and CDC
  definitions
• Tennessee, Virginia, Colorado

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HICPAC Guidance Document on Public Reporting

• Process measures
• Outcome measures
• CLA-BSI in ICU (NHSN definitions)
• SSI (NHSN definitions)

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Article Purpose

• To compare cases identified using CDC NHSN versus
  AHRQ Patient Safety Indicator 7 in elderly
  patients

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Methods

• CLA-BSI were identified utilizing CDC NHSN
  definitions as part of a multihospital study of
  patient safety in elderly ICU patients
• Medicare data were cross referenced with patient
  specific CLA BSI data
• AHRQ PSI 7 patients were identified by utilizing
  PSI version 2.1 software on Medicare data

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Cross Tabulation

• Performed to compare those identified as
  acquiring infection via PSI software versus CDC
  NHSN
• Sensitivity and specificity were calculated
• Patient demographics were compared between the
  two groups

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Results

• 14, 637 patients 4689 excluded due to not
  meeting denominator criteria for PSI-7
• 9948 patient evaluated from 41 ICUs in 24
  hospitals
• 89 patients were identified with CLA-BSI by CDC
  NHSN criteria
• 89 patients were identified with infection by
  PSI-7 criteria

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Assuming CDC NHSN as the Reference Group

• 8 (0.08) of cases were identified by both
  methods
• PSI specificity 99.18
• PSI sensitivity 8.99
• No differences in patient characteristics between
  the two groups
• Participating hospitals were larger than ave. US
  hospital and more likely to be academic
  institutions

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Conclusions

• PSI-7 indicator had poor sensitivity for
  identification of CLA-BSI
• PSI-7 indicator was not designed to detect
  central venous catheter infections
• If the goal of public reporting is to develop
  comparative data for public use, methodologies
  must be standardized

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Unit dose packaging of irrigating
solutions.Stach PE

• Am J Hosp Pharm. 1973 Sep30(9)809-10

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Occupationally Acquired HIVDecember 2002
www.cdc.gov/ncidod/hip/BLOOD/hivpersonnel.htm
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The infection unit. An attempt to control
infections in hospitals.Williams HB

• Clin Orthop Relat Res. 1973 Oct(96)36-41

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Study Purpose

• To evaluate the thoroughness of disinfection and
  cleaning in the patients immediate environment
• To identify opportunities for improvement in a
  diverse group of hospitals

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Methods

• 23 acute care hospitals in 10 states were
  evaluated (range 106-709 beds, mean 252)
• High touch objects were contaminated with
  fluorescing solution
• Evaluations were performed over 3-12 weeks
• Results collated according to type of high touch
  object, geographic areas within hospitals, and
  between institutions

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Results

• 13,369 High touch objects evaluated from 1119
  rooms and bathrooms
• Median of 12 HTO/room were evaluated
• Adequacy of room cleaning expressed as a
  percentage of objects evaluated
• Thoroughness 49 11 (35-81)

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HOWEVER

• Wide range of thoroughness of cleaning of certain
  high touch objects
• Toilet handholds (28 0-90)
• Bedpan cleaners (25 0-79)
• Room door knobs (23 2-73)
• Bathroom light switches (20 0-80)
• Telephones (49)
• Call lights (50)

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Thoroughness of cleaning DID NOT correlate with

• Total number of patient days
• Medicare case mix index
• Teaching versus non-teaching status
• Eastern hospitals versus Western hospitals

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Significant increase in thoroughness associated
with

• Low turnover rates among Environmental Services
  personnel
• Highly engaged administrative leaders
• 3 hospitals showed less thorough cleaning in ICUs
• Staffing issues in Environmental services
• High occupancy
• High tunrover

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Conclusions

• Although cleaning of high touch objects
  identified by CDC MDRO guidelines as critical to
  prevent transmission, thorough cleaning varied
  widely among and within hospitals
• CDC guidelines recommend monitoring the
  thoroughness of disinfection and cleaning in
  hospitals, especially high touch areas

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Public Health Reports / MarchApril 2007 / Volume
122
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PURPOSE

• To provide a national estimate of the number of
  healthcare associated infections and deaths in
  the United States

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Methods

• An HAI was defined as a localized or systemic
  condition that (1) results from an adverse
  reaction to the presence of an infectious
  agent(s) or its toxin(s), (2) that occurs during
  a hospital admission, (3) for which thereis no
  evidence the infection was present or incubating
  at admission, and (4) meets body site-specific
  criteria

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Methods

• 283 NNIS hospitals in 2002
• 2.3 million patient days
• 678 ICUs
• National Hospital Discharge Survey Data
• 445 hospitals participated in the survey and
  provided data on a weighted 37.5 million
  discharges. Of these discharges
• 90 (33,726,611) were among adults and children
  and
• 10 (3,789,310) were among newborns

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Methods

• AHA Survey
• 5,800 hospitals representing 34.9 million
  admissions and 236.4 million patient-days
• Federal hospitals accounted for 13.2 million
  (5.6) patient-days.

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Methods

• Four subpopulations
• newborns in high-risk nurseries
• newborns in well-baby nurseries
• adults and children in ICUs
• adults and children outside of ICUs)
• Grouped HAIs into five major sites
• surgical site infections
• bloodstream infections,
• Pneumonia
• urinary tract infections
• Other sites combined

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HAI- Location
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HAI DEATHS
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New tool to help control infection the
computer.Bolano CR

• Mod Hosp. 1973 Aug121(2)89-91

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Purpose

• To investigate the validity of ICD-9 codes for
  the identification of HAIs

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Methods

• gt1100 bed tertiary care facility
• Retrospective review of coded date from data mart
  from 01/01/05-12/31/05
• 5 ICUs performed prospective surveillance
  utilizing CDC NHSN definitions

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Methods

• BSI was identified by query for procedure code
  (ICD-9 38.93) followed by a positive blood
  culture obtained after catheter placement
• VAP was identified by query for ICD-9 ventilator
  procedure codes
• Secondary codes for BSI, SSI and VAP as utilized
  by Pennsylvania
• Looked for infection codes for select procedures
  that were coded after the procedure of interest

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Methods

• Then query patients with procedures of interest
  to determine if infections were coded after the
  procedure
• Cases were then sorted into four groups based on
  whether ICD-9 codes, traditional surveillance,
  both or neither identified HAI
• Discordant cases were reviewed by ICPs
• Assumed that previously identified CDC NHSN cases
  were true positives

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Results- Discordant cases
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Conclusion

• Classification of HAIs by ICD-9-CM secondary
  infection codes, when compared with
  classification of infections by standard
  infection surveillance methods using CDC/NHSN
  definitions and methods, is very imprecise with
  an aggregate PPV of only 0.23.
• 3 out of 4 HAIs as detected by coding data, on
  average, would not meet standard CDC/NHSN
  definitions and criteria.

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Conclusion

• There may be a role of ICD-9-CM codes as a part
  of surveillance algorithms combined with other
  data such as antimicrobial use data,
  microbiologic data, vital signs, or other
  clinical or laboratory data.
• Based on the results, coding data will over
  report HAIs, on aggregate, by 3-to 4-fold.

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Letter Germs under the nails.Hughes-Davies TH

• Lancet. 1973 Dec 12(7840)1268-9

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Purpose

• To determine whether improvement in hand hygiene
  associated with ABHR resulted in improved patient
  outcomes

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Methods

• 2 year controlled cross over trial
• Two 12-bed med/surg ICUs in a university teaching
  hospital
• Conducted from August 2001-Sept 2003
• 6 month pre-study period to establish baseline
  HAI and Hand Hygiene rates
• Hand hygiene education
• One year of ABHR then removed to the other unit

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Methods

• Hand hygiene compliance measured by trained
  surreptitious observers
• Hand Hygiene data was fed back to the units every
  two months

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Conclusions

• No change in HAI rates with improved hand hygiene
  BUT
• HAI rates were already low
• Study was underpowered
• Hand hygiene compliance rates were low (70)

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Smallpox vaccination of hospital personnel
urged.Shu CY

• Hospitals. 1973 Dec 147(23)94-6

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Purpose

• To develop surveillance definitions for C.
  difficile

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Methods

• Ad hoc working group
• Need highlighted by increasing incidence and
  severity
• Literature review and expert opinion

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Definition of a Case

• A case of diarrhea (ie, unformed stool that
  conforms to the shape of a specimen collection
  container)
• OR toxic megacolon (ie, abnormal dilation of the
  large intestine documented radiologically)
  without other known etiology that meets 1 or more
  of the following criteria
• the stool sample yields a positive result for a
  laboratory assay for C. difficile toxin A and/or
  B, or a toxin-producing C. difficile organism is
  detected in the stool sample by culture or other
  means
• (2) pseudomembranous colitis is seen during
  endoscopic examination or surgery
• (3) Pseudomembranous colitis is seen during
  histopathological examination.

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Recurrent CDAD

• An episode of CDAD (ie, one that meets the
  criteria for a CDAD case) that occurs 8 weeks or
  less after the onset of a previous episode,
  provided that CDAD symptoms from the earlier
  episode resolved with or without therapy.

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Healthcare Onset-Healthcare Associated (HCFA-HCFO)

• Patient with CDAD symptom onset more than 48
  hours after admission to an HCF.

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Community Onset- Healthcare Associated

• Patient with CDAD symptom onset in the community
  or 48 hours or less after admission to an HCF,
  provided that symptom onset was less than 4 weeks
  after the last discharge from an HCF.

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Community-Associated

• Patient with CDAD symptom onset in the community
  or 48 hours or less after admission to an HCF,
  provided that symptom onset was more than 12
  weeks after the last discharge from an HCF.

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Indeterminate

• Case patient who does not fit any of the above
  criteria for an exposure settingfor example, a
  patient who has CDAD symptom onset in the
  community but who was discharged from the same or
  another HCF 4-12 weeks before symptom onset.

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Unknown

• Case patient for whom the exposure setting cannot
  be determined because of lack of available
  datafor example, a patient who has CDAD symptom
  onset in the community or 48 hours or less after
  HCF admission and for whom available medical
  records are not sufficient to exclude discharge
  from an HCF 12 weeks or less before symptom onset.

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Usage

• Depending on the purposes of surveillance, all or
  only some of the above case definitions may be
  appropriate for use.
• If interfacility comparisons are to be made, they
  should be made using only the same definitions

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Denominators

• Rates of HCF-onset, HCF-associated cases and
  rates of community-onset, HCF-associated cases
  should be expressed, for feedback and comparative
  purposes, as case patients per reporting period
  (ie, per month, for most HCFs and surveillance
  systems) per 10,000 patient-days.
• The calculation of this rate is number of case
  patients per reporting period /number of
  inpatient days per reporting period 10,000
  prate per 10,000 inpatient-days.

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Resistance of the surgical wound to antimicrobial
prophylaxis and its mechanisms of
development.Edlich RF, Smith QT, Edgerton MT

• Am J Surg. 1973 Nov126(5)583-91

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www/hospitalcompare.hhs.gov Accessed Sept.
21,2008
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The more things change..

• The more things stay the same

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"This foreign policy stuff is a little
frustrating." as quoted by the New York Daily
News, April 23, 2002
Im not a crook Nixon Sworn in 1973