Reducing HealthcareAssociated Infections

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ReducingHealthcare-Associated Infections
Don Wright, MD, MPH L Clifford McDonald, MD,
FACP Barry M Straube, MD William B Munier, MD, MBA
OPHS CDC CMS AHRQ
AHRQ 2009 Annual Conference September 14, 2009
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Presentation Overview

• Introduction
• DHHS overview
• CDC initiatives
• CMS role in HAI reduction
• AHRQ HAI portfolio
• Discussion

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Participants

• Don Wright, MD, MPH
• Principal Deputy Assistant Secretary for Health,
  Office of Public Health Science
• L Clifford McDonald, MD
• Chief, Prevention and Response Branch, Division
  of Healthcare Quality Promotion, CDC

• Barry M Straube, MD
• CMS Chief Medical Officer, Director, Office of
  Clinical Standards Quality, CMS
• William B Munier, MD, MBA
• Director, Center for Quality Improvement
  Patient Safety, AHRQ

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DHHS Overview
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HHS Efforts to PreventHealthcare-Associated
Infections

• Don Wright, M.D. M.P.H.
• Principal Deputy Assistant Secretary
• for Health
• AHRQ Annual Conference
• Rockville, MD
• Monday, September 14, 2009

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Presentation Overview

• HHS Action Plan Development and Implementation
• State Action Plans States Adopt National Plan
• Recovery Act Funds Targeting HAIs
• Future Direction in Reducing HAIs Tier 2
• Healthy People 2020
• Questions

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Healthcare-Associated Infections (HAIs)

• What are they?
• Bloodstream infections, urinary tract infections,
  pneumonia, surgical site infections
• The Problem
• 1.7 million HAIs in hospitalsunknown burden in
  other healthcare settings
• 99,000 deaths per year
• 28-33 billion in added healthcare costs
• HAI Prevention
• Implementing what we know for prevention can lead
  to up to a 70 or more reduction in HAIs

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HHS Action Plan to Prevent Healthcare-Associated
Infections Development and Implementation
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GAO ReportRecommendations for HHS

• Improve central coordination of HHS-supported
  prevention and surveillance strategies
• Identify priorities among CDC guidelines to
• Promote implementation of high priority practices
• Establish greater consistency and compatibility
  of HAI-related data across HHS systems to
• Increase reliable national estimates of HAIs

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HHS Steering Committee for the Prevention of HAI

• Charge
• Develop an Action Plan to reduce, prevent, and
  ultimately eliminate HAIs
• Plan will
• Establish national goals for reducing HAIs
• Include short- and long-term benchmarks
• Outline opportunities for collaboration with
  external stakeholders
• Coordinate and leverage HHS resources to
  accelerate and maximize impact

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Tier One Priorities

• HAI Priority Areas
• Catheter-Associated Urinary Tract Infection
• Central Line-Associated Blood Stream Infection
• Surgical Site Infection
• Ventilator-Associated Pneumonia
• MRSA
• Clostridium difficile

• Implementation Focus
• Hospitals

Tier Two will address other types of healthcare
facilities
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Steering Committee Working Group Structure
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Stakeholder Public Engagement

• Hold five stakeholder/public engagement meetings
• Washington, DC Tuesday, June 30 (National
  Level)
• Denver, CO Saturday, July 25 (Regional/State
  Level)
• Chicago, IL Thursday, July 30 (Regional/State
  Level)
• Seattle, WA Thursday, Aug 27 (Regional/State
  Level)
• Chicago, IL Tuesday, Sept 22 (Regional/State
  Level)
• Engage professional and public stakeholders in
  the HHS Action Plan
• Request input on priorities and strategies

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State Action Plans
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State Action Plans

• State plans will
• Be consistent with the HHS Action Plan
• Contain measurable 5-year goals and interim
  milestones for preventing HAIs

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State Action Plans

• Fiscal Year 2009 Omnibus Appropriations Act
• Requires states receiving Preventive Health and
  Health Services (PHHS) Block Grant funds to
  certify that they will submit a plan to the
  Secretary of HHS not later than January 1, 2010
• Authorizes CDC to withhold 25 of states
  allocated funds until this certification is
  submitted
• All states have submitted a certification
• Be reviewed by the Secretary of HHS with a report
  submitted to Congress by June 1, 2010
• Technical assistance sessions and calls will be
  planned to assist states in plan development
• CDC has created a template to assist states in
  plan development

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American Reinvestment and Recovery Act Funds
Preventing Healthcare-Associated Infections
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Building State Programsto Prevent HAIs

• Project Description
• Create and expand state-based HAI prevention
  collaboratives
• Build a public health HAI workforce in states
• Enhance states abilities to assess where HAIs are
  occurring
• Agency Lead CDC
• Collaborating Agencies AHRQ and CMS
• Funds Source Amount American Reinvestment and
  Recovery Act Funds (40 million)
• CDC HAI Recovery Act Website
• www.cdc.gov/nhsn/ra

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New Ambulatory Surgery Center Infection Instrument

• Project Description
• Nationwide application of a new infection control
  survey instrument (designed by CMS CDC)
• Use of new tracer methodology
• Use of multiple-person teams for ASCs over a
  certain size or complexity
• Greater inspection frequency than the current
  10-year average inspection frequency (Goal 3
  years)
• Funds Source Amount 2-year funding with ARRA
  grant dollars of 1 million in FY09 and the
  remaining
• 9 million in FY10

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Future Direction
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HHS Commitment to Reducing Healthcare-Associated
Infections Tier 2
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Tier Two Priorities

• Ambulatory Surgical Centers
• Dialysis Centers

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Growth in Outpatient Care

• Shift in healthcare delivery from acute care
  settings to ambulatory care, long term care and
  free standing specialty care sites
• Infection control oversight often lacking
• Approximately 1.2 billion outpatient visits /
  year
• Number of Dialysis Centers
• 2008 4,950 (72 increase since 1996)
• Number of Ambulatory Surgical Centers
• 2008 5,100 (240 increase since 1996)
• 2007 more that 6 million surgeries performed in
  ASC and paid by Medicare

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Surgical Procedures Movingto Outpatient Setting
All Outpatient Settings
Procedures (millions)
Hospital Inpatient
Source Avalere Health analysis of Verispans
Diagnostic Imaging Center Profiling Solution,
2004, and American Hospital Association Annual
Survey data for community hospitals,
1981-2004. 2005 values are estimates.
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Healthy People 2020Defining the Nations Health
Objectives
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Healthy PeopleWhat is it Now?

• A comprehensive set of national ten-year health
  objectives
• A framework for public health priorities and
  actions
• Guided health policy decisions for 3 decades
• www.healthypeople.gov

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Healthy People 2020 Phase IINew Topic Areas

• Access to Health Services
• Adolescent Health
• Childrens Health
• Genomics
• Global Health
• Older Adults
• Healthcare-Associated Infections

• Quality of Life
• Social Determinants of Health
• Blood Disorders and Blood Safety
• Healthy Places
• Preparedness

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Points of Contact Links

• HHS Action Plan to
• Prevent Healthcare-Associated Infections
• Stakeholder Meeting Information
• www.hhs.gov/ophs/initiatives/hai

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CDC Initiatives
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CDC Approach to Eliminating Healthcare-associated
Infections

• L. Clifford McDonald, MD, FACP
• Chief, Prevention and Response Branch
• Division of Healthcare Quality Promotion
• Centers for Disease Control and Prevention

The findings and conclusions in this presentation
are those of the author and do not necessarily
represent the views of the Centers for Disease
Control and Prevention No Conflicts of Interest
to Disclose
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Patient Safety within CDCs Division of
Healthcare Quality Promotion (DHQP)
Healthcare Safety
Transfusion/Transplant Safety
Healthcare-associated Infections
Antimicrobial Resistance
Adverse Drug Events
Immunization Safety
Healthcare Preparedness

• Outbreak Investigations
• Surveillance
• Prevention Recommendations
• Intervention Implementation
• Extramural Research
• Laboratory Research and Support

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CDCs Role in HAI Elimination

• Provide technical support to states, local health
  agencies, and healthcare facilities
• Field investigations, consultations, training
• Define the scope of the problem and impact of
  interventions
• National Healthcare Safety Network (NHSN)
• Population-based surveillance systems
• Identify best practices
• Work with partners to promote prevention
• Complement other HHS agencies and support
  state/local health departments

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DHQP Field Investigations of Healthcare
Associated Outbreaks, United States, 2004-2009
PR
n 61, as of July 2009 DHQP
DVH DFBMD
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Epidemic Clostridium difficile InfectionsDetecti
on, Understanding, Surveillance, and Prevention
Emerg Infect Dis. 200612(3)409-15
Infect Control Hosp Epidemiol 2009 30264-272
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Nevada Field Investigation of Hepatitis C
Transmission in Ambulatory Surgery Centers

• Discovered reuse of syringes and single dose
  vials
• Resulted in massive patient notification risks
  of bloodborne viral infections due to unsafe
  injection practices

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• 33 outbreaks in 15 states
• Outpatient clinics, n12
• Dialysis centers, n6
• Long term care, n15

Thompson et al. Ann Intern Med. 200915033-39.
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Implementation Challenge ? Awareness and
Adherence
MMWR May 16, 2008 5719
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Injection Safety Campaign
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Collaboration with CMS

• Improve infection control in survey and
  certification process for ASCs
• Advise on the adoption of infectious Hospital
  Acquired Conditions for reduced reimbursement
• Part of the Deficit Reduction Act (DRA)
• Collaborate on HAI reduction through QIOs
• MRSA in the 9th Scope of Work
• Pilot for the 10th Scope of Work
• Hospital Compare
• Role for NHSN

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Surveillance
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National Healthcare Safety Network (NHSN)

• Voluntary, secure, internet-based surveillance
  system
• Includes information about infections,
  microorganisms, and practices for HAI prevention
• Over 2200 hospitals from 50 States currently
  report to NHSN 21 States mandate the use of NHSN
  for HAI reporting

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States Mandating NHSN for Reporting (as of August
2009)
WA
Jul-2008
VT
ME
Feb
-
2007
MT
ND
OR
MN
Jan-2009
ID
NH Jan-2009
NY
SD
WI
Jan-2007
MA Jul-2008
MI
WY
RI
PA
CT Jan-2008
IA
Feb-2008
NE
NJ Jan-2009
NV May 2009
OH
IL
IN
CA
UT
WV
DE Feb-2008
Sept-2008
CO
Jan-2008
Jul-2009
MD Jul-2008
VA
Jan-2008
DC
Jul-2008
MO
KS
KY
NC
TN
OK
Jan
-
2008
AZ
SC
AR
NM
Jul-2008
Jul-2007
GA
AL
MS
Mandates NHSN for public reporting
LA
TX Aug-2009
FL
AK
HI

6/30/2008
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NHSN eSurveillance Moving Towards the Future
NHSN
Component Biovigilance
Component Healthcare Personnel Safety
Component Patient Safety
Component Research and Development
Modules Hemovigilance

• Events Modules
• Device Associated
• Procedure Assoc.
• Medication Assoc.
• MDRO and CDAD
• High Risk Inpatient
• Influenza Vaccination

• eSurveillance
• HL7 CDA
• HL7 Messages
• Prevention research

HL7 Health Level Seven CDA Clinical Document
Architecture
Data Transmission Standards
- Structured documents for infection reports,
denominators, and process of care measures -
Messages for laboratory results,
admission/discharge/transfer, and pharmacy data
MDRO Multidrug-resistant
organism CDAD Clostridium difficile
associated disease
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NHSN Data for Action

• Data for local action
• Outcomes, adherence, analysis
• Compare trends and benchmark
• Data for regional/state action
• Data for national metrics from HHS plan

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HICPACThe Healthcare Infection Control
Practices Advisory Committee

• Guideline production
• Revised, systematic rapid-cycle evidence analysis
• Urgent infection prevention recommendations for
  emerging threats (e.g., SARS)
• June 2008, HHS Charge to HICPAC in response to
  findings of the GAO investigation
• Prioritization of recommendations from HICPAC
  guidelines
• Identification of major infection prevention
  strategies for Department-wide promotion

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From Guidelines to Checklist
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Following CDC Guidelines Reduces
Healthcare-associated Infections in
States-Examples of Success Pennsylvania, Michigan
ICUs at 103 Michigan hospitals, 18 months
BSIs/1,000 catheter days
Pronovost P. New Engl J Med 20063552725-32.
MMWR 2005541013-16
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Hospitals Participating in NHSN are Preventing
MRSA Bloodstream Infections
Trends in Bloodstream Infections by ICU Type,
NHSN hospitals, 1997-2007
9
8
7
6
5
Pooled Mean Annual CLABSI Rate per 1,000 Central
Line Days
4
3
2
1
0
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
Year
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Prevent Infection
Bundles (sets of infection control
recommendations) to prevent infection when
inserting devices or performing procedures.
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Prevent Transmission
Hand Hygiene, Isolation, Environmental Cleaning,
etc
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CDCs MRSA Prevention Initiatives
National
Region

• VA Pilot
• 17 hospitals,
  multiple states
• MarylandInitiative
• 15 hospitals

• National VA Initiative
• 150 hospitals
• nationwide
• CMS
• 9th Scope of Work

Facility
Unit
Hospital-wide VA Pittsburgh
ICUVA Pittsburgh

• RWJ Initiative
• 6 hospitals, 4 states

gt60 Reduction in MRSA
National
Local
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CDC and AHRQ collaborating to prevent MRSA/HAIs

• AHRQ receiving supplemental funds for MRSA/HAI
  research
• CDC and AHRQ are collaborating on MRSA/HAI
  prevention research in a healthcare system,
  including acute care hospitals and long-term
  facilities
• CDC provides technical expertise into what
  research questions need answering
• CDC will put research results into action, and
  use results to
• Update existing recommendations as appropriate
• Advise prevention implementation campaigns on how
  best to prevent HAIs

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CDC Works with Healthcare Facilities and States

• Technical and direct support (e.g. field
  investigations and consultation)
• Data for action (e.g., NHSN, emerging infections
  program)
• Training and tools
• Funding with accountability (e.g., epidemiology
  and laboratory capacity)

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CDC Successfully Collaborates with States to
Prevent Healthcare-associated Infections

• New York CDC guidelines basis for prevention
  implementation initiatives
• Greater New York Hospital Association prevention
  initiative
• Collaborative partnership with 46 hospitals

• Focused on incrementally building infrastructure
  needed for BSI and other future prevention
  initiatives (e.g. C. difficile)
• Communications to share best practices
• Culture of accountability
• CEO to support staff levels involved
• Site visits, monthly reporting
• Adopted bundles of practices

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Preventing Healthcare-associated Infections the
Time is NOW

• Problem is critical and costly but preventable
• Interventions can have an immediate national
  impact
• Interventions can be cost savings
• Ongoing efforts are needed to address changes in
  healthcare

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Keys for the Elimination of Healthcare-associated
Infections

• Collect data and disseminate results
• Communication with consumers
• Evaluate how were doing
• Full adherence to best practices
• Recognize excellence
• Identify and respond to emerging threats
• Improve science for prevention through research

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Public Health Continuum
Evaluate Impact Of Policy and Prevention

Translate Proven Strategies into Practice
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Increasing Needs for Public Health Approach
Across the Continuum of Care
Acute Care Facility
Home Care
Outpatient/ Ambulatory Facility
Long Term Care Facility
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INFECTION PREVENTION IS EVERYONES RESPONSIBILITY!

• http//www.cdc.gov/ncidod/dhqp/

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Save the DateFifth DecennialInternational
Conference onHealthcare AssociatedInfectionsMa
rch 18-22, 2010Hyatt Regency AtlantaAtlanta,
Georgiahttp//www.decennial2010.com
Co-organized by
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CMS Role in HAI Reduction
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Healthcare Acquired InfectionsCMS Driving
Improvement

• Barry M. Straube, M.D.
• CMS Chief Medical Officer
• Director, Office of Clinical Standards Quality
• Centers for Medicare Medicaid Services (CMS)

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Ensuring Quality ValueCMS Strategies

• Traditional Quality Improvement
• Transparency Public Reporting Data Sharing
• Incentives
• Financial Value-Based Purchasing
• Non-financial
• Regulatory vehicles
• Demonstrations, pilots, research
• Leveraging efforts with other HHS components,
  state/federal agencies private sector

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Traditional QI

• Prioritization of potential topics
• Evidence-based metrics and interventions
• Accountability Administrative financial
• Attribution of interventions to outcomes
• Scientific evaluation of outcomes as well as
  cost-benefit analysis of each initiative
• Continue, build, retire or new direction?

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Traditional QI

• QIO Program 9th SOW
• August 1, 2008 July 31, 2011
• Four themes
• Patient Safety
• Prevention
• Care Transitions
• Beneficiary Protection
• Cross-cutting issues
• HIT adoption and use
• Health Disparities
• Value in Healthcare

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Traditional QI

• QIO Program 9th SOW
• HAIs under patient safety theme
• Reduction of MRSA infections in 440 hospitals
  nationwide
• CDC National Healthcare Safety Network (NHSN)
• AHRQ TeamSTEPPS methodology
• Pilot programs ? 10th SOW inclusion
• C. difficile infection reduction
• Urinary tract catheter infection reduction

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Traditional QI

• ESRD Network Program QI activities
• Individual ESRD Networks have included activities
  to address infections in vascular access as well
  as other infection control issues, including
  facility-acquired infections (dialysis facilities
  and some hospitals)
• Collaboration with other HHS agencies, other
  state/federal agencies, private sector
  organizations

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Transparency

• Hospital Compare Website as prototype
• 27 quality process measures (all patients)
• 6 quality outcomes measures (Medicare only)
• HCAHPS survey for experience of care (all)
• Medicare payment and volume (Medicare only)
• Several infection-related quality measures
• Influenza and pneumonia vaccinations
• Therapeutic and prophylactic antibiotics
• Pre-op hair removal, blood cultures, etc.

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Transparency

• Additional reporting of HAI measures
• Considering for future Hospital Compare updates
• Requires NQF endorsement and Hospital Quality
  Alliance and other stakeholder input
• Expand to other provider sites, starting with
• Ambulatory surgery centers
• Dialysis facilities
• Link to transitions of care and episodes of care

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Transparency

• The White House, the Secretary and HHS have
  prioritized the concept of HHS making its data
  available to all healthcare stakeholders
• http//www.data.gov development and expansion
• CMS has now added the concept that as part of its
  public health agency role, collecting, reporting
  and making healthcare data available is a core
  competency/mission

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Incentives

• Value-based Purchasing (VBP)
• Hospital VBP Report to Congress (Nov 2007)
• Physician VBP RTC due May 2010
• ESRD Quality Incentive Program to be implemented
  by January 1, 2012
• All other settings with plans
• Healthcare Reform debate may define better
• HAI focus may be included in all

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Incentives Hospital Acquired Conditions

• DRA Section 5001(c) authorized this approach
• Beginning October 1, 2007, IPPS hospitals were
  required to submit data on their claims for
  payment indicating whether diagnoses were present
  on admission (POA)
• Beginning October 1, 2008, CMS stopped assigning
  a case to a higher DRG based on the occurrence of
  one of the selected conditions, if that condition
  was acquired during the hospitalization

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Incentives HACs

• By statute CMS had to select conditions that are
• High cost, high volume, or both
• Assigned to a higher paying DRG when present as a
  secondary diagnosis
• Reasonably preventable through the application of
  evidence-based guidelines
• CMS and CDC convened an internal workgroup to
  select the HACs

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Incentives HACs

• Almost all HACs might have indirect relationship
  to potential HAIs
• HACs clearly linked to HAIs
• Catheter-associated UTI
• Vascular catheter associated infection
• Surgical site infections
• Mediastinitis after CABG
• Certain orthopedic surgeries
• Bariatric surgery for obesity

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Incentives HACs

• HAC payment policies currently relate to outlier
  payments under Medicare Part A
• Could consider expansion of payment to more than
  the outlier portion
• In some cases can supplement payment policy
  restrictions with Coverage Policy via National
  Coverage Decisions (NCDs)
• Affects not only Part A (hospitals), but Part B
  (physicians, clinicians, suppliers, etc.)

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Conditions of Participation

• COPs are minimum health and safety standards set
  by CMS for facilities that may receive Medicare
  payments
• Current Infection Control COPs generally address
  reduction of HAIs
• Expansion possibilities for COPs
• Require facilities to incorporate specific
  standards of practice or guidelines set by the
  Secretary
• Require that infection control be part of the
  QAPI program

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Conditions of Participation

• Infection control regulations already
  strengthened
• Conditions for Coverage for ESRD facilities
  (April 15, 2008)
• CfC for Ambulatory Surgery Centers (ASCs)
  (November 18, 2008)
• Other current considerations
• Omnibus COP/CfC Rule for HAIs
• Individual setting strengthening of current regs

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Survey Certification

• All U.S. healthcare facilities certified by
  Medicare are expected to be in compliance with
  all current regulations, as well as applicable
  state laws
• SC process uses interpretive guidelines to
  assess compliance with regulations
• Focus on HAIs can be prioritized
• Surveyor training has included HAI emphasis
• Web-based training surveyor tools being
  developed
• Interpretive guidelines for 2010 to include QAPI
  opportunities for hospitals

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Other

• Demonstrations, pilots, research
• ARRA funding and other funding sources should
  also focus on HAIs as they fall under
• Comparative Effectiveness Research
• Prevention, Wellness, Patient Safety
• CMS will incorporate HAI topics into its demos,
  when appropriate
• Cross Agency HHS collaboration (a priority for
  all issues from the Secretary), as well as with
  other federal/state agencies, private sector

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Contact Information

• Barry M. Straube, M.D.
• CMS Chief Medical Officer,
• Director, Office of Clinical Standards Quality
• Centers for Medicare Medicaid Services
• 7500 Security Boulevard
• Baltimore, MD 21244
• Email Barry.Straube_at_cms.hhs.gov
• Phone [phone]

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AHRQ HAI Portfolio
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Overview

• Background
• Current Initiatives
• Future Directions

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Background

• General AHRQ approach
• Keystone ICU Project 2003
• First major AHRQ HAI project 454,000
• Enormously successful in reducing central line
  infections in ICUs in Michigan
• Barriers and Challenges for Preventing HAIs in 34
  Hospitals Initiative 2007
• 5 ACTION networks 2 million

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MRSA 2008

• 5 million in appropriated funds
• Coordinated with CDC CMS
• Funded 7 projects, e.g.,
• Implementation of MRSA-reducing practices
• Contribution of community LTC to rising
  occurrence of MRSA in hospital patients
• Rapid-cycle state and national estimates
• Understanding MRSA reservoirs

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MRSA CUSP 2009

• 17 million in appropriated funds
• 8 million for MRSA gt 7 MRSA projects
• 9 million for CUSP gt 6 CUSP projects
• Included projects also directed at
• C. difficile
• KPC-producing organisms
• Urinary tract infections
• Surgical site infections
• Antibiotic usage
• Hemodialysis

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AHRQ HAI Investments
CUSP Comprehensive Unit-based Safety
Program Includes other related infections
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Current Efforts

• Roll-out of CLABSI initiative in all 50 states,
  in cooperation with private sector
• Commencement of numerous new projects addressing
  effective implementation of known techniques
  research on better methods of prevention of HAIs
  by organism by infection site

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Future Plans

• Maintain alignment with DHHS
• Continue rollout of CLABSI nationwide
• Promote best practices research findings via
  proven techniques
• Align HAI efforts with those of Patient Safety
  Organizations (PSOs), which are collecting data
  on adverse events using AHRQs Common Formats

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Your questions?