Title: Where the Rubber Meets the Road
1Where the Rubber Meets the Road
SB 739
- Jan 08 version (2) presented
- (insert your chapter, current date here)
- Sue Chen RN, MPH, CIC
- HAI Program Coordinator
- California Dept of Public Health
- Sue.Chen_at_cdph.ca.gov
2Objectives
- SB 739 in context
- History of mandatory reporting
- Making the business case
- Review of SB 739 requirements
- Your role in implementation of SB 739
(devil is in the details) - Introduction to NHSN
- Sequence of events/specific activities
- Updates from HAI-AC to CDPH
- Say amen and escape
3Number of nosocomial pathogens, according to
infection site, identified in the hospital-wide
component of the NNISprogram from January 1990
to March 1996
HAIs- The Big Four
- Urinary tract infections
- (catheter-associated)
- Surgical site
- Infections
- Bloodstream infections
- (central line-associated)
- Pneumonia
- (ventilator-associated)
4Healthcare-Associated Infections Numbers and
Costs
From Klevens et al..Public Health Rep.
2007122160-6 12 of U.S.
5Cost of HAI vs. Infection ControlDuke Infection
Control Outreach Network
- 28 community hospitals (30-616 beds)
- 25,072 for VAP 23,242 per CLA BSI
- 10,443 per SSI 758 per CAUTI
- Ave cost of infections 594,683/year
- Ave annual budget for IC 129,000
- Decreasing HAIs by 25 would save 148,667 per
hospital - Anderson et al. Underresourced Hospital Infection
Control and Prevention Programs Penny Wise,
Pound Foolish. Infect Control Hosp Epidemiol
2007 28767-773
6What Hospitals Dont Get
- Two economists are walking down the street. One
sees a dollar lying on the sidewalk, and says,
Look, there is a dollar lying on the ground!
Obviously not, says the other. If there were,
someone would have picked it up! - from Hollenbeak, APIC
2007
7Who Pays?
- Patients with HAI are disproportionally Medicare
but only 50 Medicare-paid
8Glimpse of the Future From Centers for Medicare
Medicaid Services
- Effective October 1, 2008, hospitals will no
longer receive higher payments for the additional
costs of treatment associated with following
HAIs - Catheter-associated urinary tract infections
- Vascular catheter-associated infections
- Surgical site infection mediastinitis after
coronary artery bypass graft surgery - Unless condition is present upon admission
9History of Reporting of HAIs
- Florence Nightengale descriptive epidemiology
during Crimean War documented causes of
mortality - National Nosocomial Infections Surveillance
(NNIS) - Epidemiology of HAIs, describe antimicrobial
resistance, enable inter-hospital comparisons - Study on the Efficacy of Nosocomial Infection
Control (SENIC) Study
1970s
Gill C, Gill G. Nightengale in Scutari Her
Legacy Reexamined. CID 200540.
10Public Reporting Background
- The quality and safety of healthcare in the U.S.
needs to improve - Public reporting is one of a number of quality
improvement methodologies adopted - Public reporting of health care performance
information is intended to - Provide information to enable consumers to obtain
safer care - Stimulate and provide basis for quality
improvement by reporting providers
11Public Reporting Slide 2
- Indicators for public reporting can be
- Outcomes (e.g. mortality, infections)
- Processes (e.g. aspirin for MI, antibiotic within
4 hours of admission for community-acquired
pneumonia, appropriate antibiotic prophylaxis
prior to surgery) - Public reporting for myocardial infarction,
coronary bypass graft surgery (CABG), and
community-acquired pneumonia has been in place
gt10 years - Reductions in the rate of death associated with
CABG in New York and Pennsylvania have been
attributed, in part, to public reporting
12Trend over time in bloodstream infections
associated w/ catheters in pediatric ICU
- Nov 1998 use of maximal barrier precautions
- July 1999 use of antibiotic-impregnated
catheters - March 2000 annual hand washing campaigns
- April 2003 move to new unit with private
rooms - May 2003 introduction of skin disinfection
with chlorhexidine
U Arkansas Childrens Hospital Bhutta et. al.,
BMJ 2007334362-5
13Leapfrog Report 9/18/07
- 87 hospitals (n1256) do not take all
recommended steps to prevent HAIs - 35.6 do not always follow hand hygiene practices
- 30.7 vaccinate staff against flu
- http//www.leapfroggroup.org/
14Consumers Union
- Focus on obtaining data on HAIs so consumer
can make an informed choice also - pressures hospitals to improve
- legislation for mandatory reporting
- active surveillance cultures for MRSA
- Rep. Tim Murphy (PA) is sponsoring the "Healthy
Hospitals Act of 2007" (HR1174). The bill will
make you safer during a hospital stay by
requiring public disclosure of hospital-acquired
infection rates. If hospitals must tell you about
their infections, they will work harder to reduce
them. - Please ask your representative to co-sponsor
this bill!
15Experience with Legislated Mandatory Public
Reporting
- Pennsylvania
- Have been reporting data since 2004
- Areas for improvement
- Use of administrative data
- Law of Unintended Consequences
- Pittsburg Regional Healthcare Initiative
Found error-prone systems that did not focus on
the patient at the point of care. Healthcare
must focus on delivering perfect healthcare to
every patient.
16Response to Public Reporting Consumers Dont
Seem to Care..
Source CHCF sponsored survey of Californians,
2004
17Quality of Care - Heart Attack
But Hospitals Do
Number of hospitals
18California Ancient History
- Little Hoover Commission report April 10, 2003
recommended increased capacity to fight HAIs - HAI-AWG met from July 05-Feb 07
- Recommendations for Reducing Morbidity and
Mortality in California Final Report to CDPH
December 31, 2005 - Result was SB 739 signed into law September 28,
2006
For those w/ attention deficit or CRS
19SB 739 Mandates
- Implement an HAI surveillance program
- Electronic database NHSN
- By July 1, 2007
- Appoint an HAI Advisory Committee
- Hospitals must implement respiratory
hygiene/cough etiquette program, employee flu
vaccine program, disaster plan w/ pandemic flu
component in conjunction w/ local health dept - Educate health facility evaluators in HAI
20Mandates contd
- On or after Jan 1, 2008
- Revise infection control-related portions of
Title 22 - GAC shall implement and annually report process
measures which are to be made public within 6
months - Central line insertion practices
- Influenza vaccination of HC personnel and high
risk patients - Surgical antimicrobial prophylaxis
21Current Tasks and Further Directions Slide 1
- Facilities must enroll in NHSN soft deadline Jan
31, 2008 - Be prepared to join CDPH group and give CDPH
permission to see appropriate data elements - Specific directions will be forthcoming from CDPH
with details and start dates for mandated
reporting.
22Slide 2
- Use CLIP practice module to get process in place
for data collection - Be prepared to report vaccination rates for
2007-08 flu season (model is TJC requirements) - Respond to SCIP questionnaire by Jan 15. SCIP
data will be required to be reported through
CMS/Lumetra
23Update on HAI_AC Recommendations
- Central Line Insertion Practice (CLIP)
- Influenza vaccine for
- Employees
- High risk patients
- Antimicrobial prophylaxis (SCIP)
- Legal
- Reporting of healthcare-associated MRSA infections
24HAI-AC Central Line Insertion Practices (CLIP)
- Option 1 fill out all asterisked data points on
CLIP form - In ICUs x 6 months
- Option 2 fill out 6 areas AND do outcome module
for those units - AND
- Documentation of daily assessment of line
necessity by a clinician.
25HAI-AC Influenza Vaccination for Employees
- Publicly report influenza vaccination/
declination rates for employees for 07-08
season - Differentiates between employees and healthcare
workers - Non-employee HCW should be offered vaccine a
rate for this not mandated at this time - Forms may only be obtained Sept-Mar
26HAI-AC Surgical Care Improvement Project (SCIP)
- Will be reported through CMS/Lumetra
- Facilities currently reporting data will not have
more work - Facilities not currently reporting must work w/
Lumetra to establish reporting pathway or - If facility does not perform surgeries, no
reporting will be required. - CDPH will begin downloading CMS data at a
to-be-announced date.
27HAI-AC Recommendations for Mandatory Reporting of
MRSA
- Report all laboratory-confirmed MRSA bloodstream
infections identified in hospitalized patients - Classify as community-onset (day 1-3) or Hospital
onset (day 4) - Publicly report as of July 1, 2008
- number of community-onset
- Rate of hospital-onset/1000 inpatient days
- No further characterization required at this time
28What is NHSN?
- CDC-sponsored voluntary, confidential system for
monitoring events associated with health care - Initial focus on infections in patients and
healthcare personnel - Expanding to include noninfectious events (such
as process measures) - Accessed through a secure, web-based interface
- Open to all US healthcare entities at no charge
29NHSN is a Partnership!
NHSN participation was never designed or intended
to be the sole responsibility of Infection
Control.
30Am J Infect Control 200735290-310
31- Device-associated
- Procedure-associated
- Medication-associated
modules
32Percentage of Hospitals in AHA Survey Enrolled
in NHSN
613 facilities
Status as of June 18, 2007
33National Healthcare Safety Network (NHSN)for
State Reporting
Heavily Plagiarized by CDPH from CSTE 2007
Annual Conference presentation June 2007
R. Monina Klevens, DDS, MPH Division for
Healthcare Quality Promotion National Center for
Infectious Diseases
Heavily is not an infestation
34Characteristics of NHSN Surveillance Methodology
- Active, patient-based, prospective,
priority-directed collection of data - Results in risk-adjusted incidence rates will
allow comparison between yourself or group
against national average. - Intended to be used as a quality improvement tool
to be of mutual benefit to facilities and NHSN
goal to eventually link processes with outcomes
35Authority and Confidentiality for NHSN
- Public Health Service Act (42 USC 242b, 242k, and
242m(d)) - Confidentiality Protection
- Sections 304, 306, and 308(d) of the PHS Act
The information contained in this surveillance
system that would permit identification of any
individual or institution is collected with a
guarantee that it will be held in strict
confidence, will be used only for the purposes
stated, and will not be disclosed or released
without the consent of the individual, or the
institution in accordance with Sections 304, 306,
and 308(d) of the Public Health Service Act (42
USC 242b, 242k, and 242m(d)).
36Strengths Built on NNIS Experience
- NNIS System is a model for patient safety1,2
- High quality data can be used for performance
improvement. Reductions in national infection
rates have been achieved. - Scientific credibility Definitions and methods
adopted internationally - Timely data can be immediately downloaded
- Aggregate comparisons by unit or procedure across
states ensure greater numbers
1Leape LL. Reporting of adverse events. NEJM
20023471633-8. 2Burke JP. Infection controla
problem for patient safety. NEJM 2003 348651-6.
37Registration ProcessFollow the Balloons and
Arrows
Accept Rules of Behavior
NHSN sends email w/ instructions for digital
certificate
You read and follow directions carefully
complete modules
NHSN sends further instructions
You read and follow directions carefully sign
away first born
Etc. Etc. Etc. (From Facility Administrator Enrol
lment Guide)
38Process for Hospitals to Register
- http//www.cdc.gov/ncidod/dhqp/nhsn_members.html
- Accept rules of behavior
- Part of registration is to complete 8 modules
(2 hrs each) - On R side of page NHSN Resources, click on
Training, then Archived Training, follow
stepwise directions - Name a facility administrator person with all
rights to all data for your facility
39Registration Process Contd
- Obtain (and dont lose) digital certificate
- If firewalls prevent access, own IT dept must
clear site - Fill out online form and survey
- Name group/groups
- Send to NHSN
- CDC will activate facility
- Facility must join CDPH group, give rights to see
mandated data
40Summary of NHSN Rules
- Every month, the facility must submit a
surveillance plan - Facility must report data to NHSN 6 of every 12
calendar months within 30 days of end of
reporting period - Failure to adhere to reporting can result in loss
of member status - Loss of member status puts facility at odds w/
mandates of SB 739 - All data fields marked w/ an asterisk must be
filled out for record to be counted if in plan
41I certify that I completed the required training
to participate in the National Healthcare
Safety Network
Registration Nirvana?
Name of participant
Name of facility
Dates of training
42How CDPH Accesses Data in NHSN
- Groups e.g., healthcare corporations, State
Health Departments - A facility nominates CDPH
- Facilities join the group and confer some/all
rights to data - Facilities within the group cannot see each
others data - Group sees data from all facilities as granted
- After joining, a facility can use any NHSN module
(ex outcome measure) they choose data not
visible to CDPH except w/ permission
43Limitations
- Primary experience with voluntary, confidential
reporting - Validation methods in development
- Labor intensive
- And deadlines for data reporting
- No special protocols for small hospitals
- Not tied to utilization or billing data directly
(DRGs, ICD9/10, etc.) - Must follow NHSN rules
44Support for States Users
- Collaboration with APIC/CACC, CSTE, SHEA, IDSA
- NHSN State Users Group
- Conference calls monthly/Webboard to share
materials, including users newsletter - Training for all members
- Webinars
- Interactive distance learning
- nhsn.cdc.gov
45What and When States Using NHSN are Reporting
PA CA
VA WA
SC
NY
CO
VT
OK
DE
TN
Jan 2007
2008
Undefined measures
46Anticipated Additions
- Process modules for CLIP and immunizations (for
both employees and patients) to be released Feb
08 - Introduction of 23 modules of interactive
computer training (20-30 min ea) Jan 08 - In addition to original modules
- Number required will depend on rights conferred
- Goal to set up CEUS for module completion
- Will contain post-test to document knowledge
minimal score of 80 to pass
47What CDPH would like to see
- Formulation of a model for reporting of never
events for nationwide use - Downloading capacity from 3rd party vendors
directly into NHSN - Discussion between CMS, CDPH, and NHSN for direct
download of SCIP data already reported to CMS - Disclaimer While willing, CDC lacks personnel
and monetary resources to develop these
capacities at this time.
48Challenges
- What are the evidence-based reporting best
practices? - Balance use of existing data with accuracy and
ownership - How to gain necessary resources for
implementation of reporting? - State and hospital levels
- More efficient methods
- How will reporting impact quality of care?
- Integrity of processes will drive decrease in
infection rates - Provider and consumer behavior
49Questions?
Answers Cheap
50Acknowledgements
- Jon Rosenberg
- Centers for Disease Prevention and Control
- New York State
- Audiences for
- refining the
- program
-
51- Infectious Diseases Experts Applaud Bill Against
"Bad Bugs" - With extensively drug-resistant tuberculosis,
life-threatening drug-resistant respiratory and
skin infections, and other bad bugs routinely
making headlines, infectious diseases physicians
are applauding Rep. Jim Matheson (D-UT) and Rep.
Michael Ferguson (R-NJ) for introducing H.R.
3697, Strategies To Address Antimicrobial
Resistance (STAAR) Act
52S.2278 Durbin Bill/H.R. 4214CHAI Reduction Act
of 2007
- Establish best practices guidelines for IC plans
to treat and control CHAI in GAC - Hospitals to begin reporting through NHSN within
90 days - CDC to be given authority to make rules
- Institute pay for performance
- Public awareness and education
- Ongoing interagency workgroup
Community-Associated and Healthcare-Associated
Infections
53H.R. 4352 Assistance to School Districts to
Combat MDRO (Towns)
- 30 million to Dept of Education for prevention,
outreach, educational activities in grades K-12
for qualifying pathogens - MRSA, CDC-identified life-threatening bacteria
- Money may cover personal hygiene supplies and
disinfectants if school district lacks a
sufficient budget.
Introduced Dec 11, 2007 D-NY
54H.R. 4451 MRSA Research and Study Act of 2007
(Stearns)
- Establish 6 year grant program under auspices of
Sec Health Human Services - Eligibility under university or u-affiliated
teaching hospital - Minimum 25 grants awarded during each 2 year
period 5 million ea
Introduction Dec 11, 2007 R-FL
55S. 2526 Worker Infection Protection Act
(Menendez, Durbin, Kennedy)
- Proposal covers HCW, first responders, other
workers _at_ risk against exposure to infectious
agents and drug-resistant infections avian
influenza, MRSA - Sec of Labor to develop temporary exposure
control plan w/ in 6 months permanent 6 mo later
OSHA - plan, PPE, training, medical surveillance,
immunization if available
Introduced Dec 19, 2007 D-NJ, IL, MA
56SB 1058 Medical Facility Infection Control
Prevention Act (Alquist)
- Health facilities and residential care facilities
for the elderly must implement procedures for
screening, prevention, and reporting of specified
infections - ASC for specified conditions
- Reporting
- Laboratory reporting of facility-acquired
positive cultures to CDPH - reporting of 2 or more cases MRSA within a 7 day
period - Facility must post that report on its website
- Cleaning of pt care equipment/environmental
surfaces - Adequate infection control staffing 1100
occupied inpatient beds, 1200 outpatient visits.
Same ratios of IC required for residential care
facilities. - Staff must be adequately trained
- Introduced Jan 8, 2008 by E Alquist, D-Santa
Clara
57Definition of Reportable CA Staph
- Severe staph infection resulting in death or ICU
admission in a previously healthy person - Covers both MRSA and MSSA
- Will be reported through local health dept via
CMR - Estimated burden of reporting 100-200 cases/year
in CA - Primary responsibility for reporting belongs to
local health departments - CDC definition of previously healthy
- Persons who have not been recently (within the
past year) hospitalized or had a medical
procedure (such as dialysis, surgery, catheters)