TITLE OF PRESENTATION Subtitle of Presentation

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TITLE OF PRESENTATIONSubtitle of Presentation
Infection Prevention in New York City
Successes, Challenges Opportunities
David P. Calfee, MD, MS Associate Professor of
Medicine and Public Health Chief Hospital
Epidemiologist
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Outline

• A look-back at the past 10 years of infection
  prevention in the Greater New York area
• Successes
• Challenges
• Opportunities

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A Lot Can Happen in 10 Years
and did

• Outbreaks of old pathogens
• Mumps (2009)
• Measles (2011)
• Outbreaks of new pathogens
• SARS (2003)
• Pandemic influenza H1N1 (2009)
• Emergence and dissemination of new resistance
  patterns among healthcare-associated pathogens
• Multidrug-resistant Acinetobacter
• Carbapenem-resistant Enterobacteriaceae (e.g, K.
  pneumoniae)

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A Lot Can Happen in 10 Years

• Bioterrorism
• Anthrax (2001, and few days of panic in 2006)
• NYC small pox vaccination program (2003)
• Disasters
• Blackout (2003)
• Hurricanes (Irene 2011, Sandy 2012)

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A Lot Can Happen in 10 Years

• Public reporting of HAI in New York State
• Public health Law 2819 2005
• First year of hospital reporting 2007
• First public report of hospital-specific data
  2009
• Flu vaccine
• HCW vaccine mandate (and subsequent lawsuits)
  2009
• Pay-for-performance
• Core measures
• Hospital-acquired conditions
• Value-based purchasing
• National Patient Safety Goal 7
• Hand hygiene, CLABSI, CAUTI, SSI, MDROs

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Successes

• Greater New York Infection Prevention

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• Physicians cannot wait for operational
  excellence to justify their commitment they need
  to achieve excellence through influence, example,
  and leadership.
• Stephen C. Beeson, MD

Beeson SC. Practicing Excellence A Physicians
Manual to Exceptional Health Care. 2006
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GNYHA-UHF CLABs Collaborative

• 2005-2008
• 49 ICUs from 36 hospitals throughout the region
• This collaborative represented a paradigm shift
  in infection control practice and perception
  preventing infections is everyones
  responsibility.
• Interdisciplinary teams
• Regular team meetings
• Implementation of a central line bundle
• Plan-Do-Study-Act (PDSA) model

Koll BS, Straub TA, Jalon HS, Block R, Heller KS,
Ruiz RE. Jt Comm J Qual Patient Saf 34(12) 71323
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Outcomes of the CLABs Collaborative

• Mean rate decreased by 54.
• Some hospitals observed reductions as great as
  88.
• 56 of hospitals observed a reduction of at least
  50.
• The greatest reductions were seen in hospitals
  with the highest baseline rates.

Koll BS, Straub TA, Jalon HS, Block R, Heller KS,
Ruiz RE. Jt Comm J Qual Patient Saf 34(12) 71323
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CLABSI Rates in NYS ICUs Continue to Decline

• Comparing 2011 data to 2007 data
• Surgical ICUs 57 reduction
• Neurosurgical ICUs 48 reduction
• Cardiothoracic surgery ICUs 46 reduction
• Medical ICUs 45 reduction
• Medical-surgical ICUs 34 reduction
• Pediatric ICUs 31 reduction
• Coronary ICUs 25 reduction
• Neonatal ICUs
• Regional Perinatal Centers 49 reduction
• Level 3 and 2/3 ICUs 17 reduction

NYS DOH. Hospital-acquired infections, 2011.
September 2012. http//www.health.ny.gov/statistic
s/facilities/hospital/hospital_acquired_infections
/2011/docs/hospital_acquired_infection.pdf
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CLABSI Rates in NYS ICUs Continue to Decline

• NY State CLABSI SIR significantly decreased
  between 2009 and 2010.
• 2010 SIR was 0.858 (versus 1.029 in 2009)

CDC. National and state healthcare-associated
infections standardized infection ratio report,
2010. http//www.cdc.gov/hai/pdfs/SIR/national-SIR
-Report_03_29_2012.pdf
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GNYHA-UHF C. difficile Collaborative

• Goal to reduce C. difficile infection rates
  through standardized clinical infection
  prevention practices (a bundle) and
  environmental cleaning protocols
• Planning began in July 2007
• Collaborative began in 3/2008
• Data reporting ended in 12/2009

NYS DOH funded Phase I of Collaborative 7/2007
to 3/2009
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Interventions

• Assessment of baseline practices
• Use of standardized clinical case definitions
• Implementation of a clinical infection prevention
  bundle
• Development of a standardized environmental
  cleaning protocol
• Checklist
• Bleach
• Distribution of monthly data reports
• Educational and practice-sharing opportunities
• Site visits

Prior to availability of NHSN MDRO/C. difficile
module definitions
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The C. difficile Prevention Bundle

1. Contact precautions initiated at time of symptom
   onset
2. Contact precautions sign on door
3. Personal protective equipment (i.e., gowns and
   gloves) readily available
4. Hand hygiene
5. Strategy for optimal patient placement (e.g.,
   single room, cohorting with other CDI patient(s))
6. Dedicated thermometers for CDI patients if rectal
   thermometers are used.

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Outcomes C. difficile Infection Rates
20 reduction
plt0.001
CDC. MMWR 201261157-62
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Intrahospital Comparisons
Hospital Identification Number
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C. difficile Prevention Strategies
Strategy Strength of Recommendation and Quality of Evidence
Hand Hygiene Soap and water AII BIII
Gloves AI
Gowns BIII
Single room BIII
Environmental cleaning (bleach-containing/sporicidal agent) BII
Equipment cleaning BIII-CIII
Antimicrobial Stewardship AII
Cohen SH. Infect Control Hosp Epidemiol 2010
31431-55 Gerding DN. Infect Control Hosp
Epidemiol 200829(S1)S81-92
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GNYHA-UHF Antimicrobial Stewardship Project

• The overall objective was to develop and test
  strategies and tools that can be used by health
  care facilities to implement an effective and
  sustainable antimicrobial stewardship program.
• Specific objectives included
• To establish antibiotic stewardship programs
  (ASP) in acute care hospitals and LTCF using
  existing personnel and resources
• To establish acute care hospital-LTCF
  collaborations related to ASP
• To develop and pilot tools for ASP development
  and implementation in other health care
  facilities
• To identify best practices for and challenges
  associated with ASP implementation

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GNYHA-UHF Antimicrobial Stewardship Project

• 3 acute care hospitals were selected from among
  those participating in the C. difficile
  collaborative.
• Chosen hospitals were required to recruit a
  long-term care facility partner to participate in
  the project.
• October 2009-June 2010

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Interventions

• Develop a stewardship team.
• Participate in meetings and conference calls.
• Assess current practices and resources.
• Identify and prioritize ASP target areas.
• Select and implement interventions.

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Project Outcomes

• In a short period of time and without additional
  resources, hospitals and long-term care
  facilities were able to introduce antimicrobial
  stewardship programs into their facilities.
• Qualitative data suggest that the programs were
  beneficial.

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Outcomes Examples of Success

• Successful hospital interventions
• Expansion of activities to 3 new units
  (acceptance 100)
• Completion of an IRB-approved study of practices
  related to UTI diagnosis and treatment, involving
  students and residents, resulting in development
  and revision of guidelines
• Successful LTCF interventions
• Presentation of baseline data on inappropriate
  antimicrobial use for asymptomatic bacteriuria to
  Medical and Nursing Directors, leading to a
  facility-wide PI Project with development of a
  protocol for UTI diagnosis and treatment
• Development of a restricted antibiotic list
• Review of urine culture results with subsequent
  interaction with clinicians

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Outcomes Examples of Success

• Hospital-LTCF Collaborations
• At least one hospital-LTCF team began having
  joint ASP meetings that involved LTCF medical
  director.
• At one site, hospital pharmacists were granted
  access to LTCF resident drug profiles to assist
  with stewardship activities.

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• Educational materials
• Marketing materials
• Tools for stewardship teams

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Outcomes Lessons Learned

• Antimicrobial stewardship is complex there is
  not a one size fits all bundle.
• Keys to success
• A motivated team
• Support from administration and medical
  leadership
• Data
• Access to ready-made tools to assist ASP
  activities
• A forum to discuss challenges and best practices

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Challenges

• Greater New York Infection Prevention

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General Challenges

• Space constraints
• Hospital closures
• Permanent
• Temporary
• Infection Prevention staffing
• NYSDOH annual survey showed stable IP to bed
  ratio, but certainly no increase over past few
  years despite greater demands.
• How do we ensure that best practices are
  consistently applied?
• We are improving, but so is everyone else.

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Ongoing CLABSI Challenges

• The 2011 NYC CLABSI rate is significantly higher
  than the NYS average.
• SIR 1.15 (1.05-1.25)
• The New York State CLABSI rate is higher than the
  US average.
• 2010 NYS SIR was 25 higher than that of the US
  overall.
• In 2009, 17 states used NHSN to satisfy a
  state-specific CLABSI reporting mandate.
• New York had the fourth highest CLABSI SIR.
• The 5 states that had a data validation program
  had the 5 highest SIRs among the 17 states.
• CLABSI prevention efforts in non-ICU settings are
  lagging.

NYS DOH. Hospital-acquired infections, 2011.
September 2012. http//www.cdc.gov/hai/pdfs/SIR/n
ational-SIR-Report_03_29_2012.pdf http//www.cdc.g
ov/HAI/pdfs/stateplans/SIR_05_25_2010.pdf
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NYS DOH. Hospital-acquired infections, 2011.
September 2012.
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Multidrug-Resistant Organisms (MDROs)

• MRSA
• CMS will require reporting of MRSA bacteremias
  beginning January 2013.
• National target for MRSA bacteremia in hospitals
  25 reduction by 2013
• National data suggests that invasive MRSA
  infections are decreasing.

Kallen AJ. JAMA 2010304641-8
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US Targets for C. difficile Prevention, 2013

• U.S. data
• C. difficile hospitalizations
• Goal 30 reduction (vs 2008 rate of 11.7 per
  1,000 discharges)
• 2011 rate11.9 (1.7 increase from baseline)
• C. difficile infections
• Goal 30 reduction
• No progress report available

National Action Plan to Prevent
Healthcare-Associated Infections Roadmap to
Elimination. http//www.hhs.gov/ash/initiatives/ha
i/infection.html
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C. difficile Infection in US Hospitals, 2009
CDI stays per 100,000
Lucado, J. Clostridium difficile Infections (CDI)
in Hospital Stays, 2009. HCUP Statistical Brief
124. January 2012. Agency for Healthcare
Research and Quality, Rockville, MD.
http//www.hcup-us.ahrq.gov/reports/statbriefs/sb1
24.pdf
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Ongoing C. difficile Challenges

• NYC hospital-onset C. difficile SIR (compared to
  state average) was 1.01 (0.98-1.04).
• New York State hospital-onset C. difficile rates
• 2010 NYS rate of 8.2 per 10,000 patient-days was
  significantly higher than the national average of
  7.4.
• The 2011 rate was 8.48 cases per 10,000 patient
  days, a 3 increase compared to 2010.
• Note The percentage of hospitals using certain
  highly sensitive tests (i.e., PCR) increased from
  10 to 41.

NYS DOH. Hospital-acquired infections, 2011.
September 2012.
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MDR Gram-Negatives
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Outcomes Associated with MDR-GNR Infections
Invasive K. pneumoniae Infection
plt0.001
plt0.001
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48
CRKP carbapenem-resistant K. pneumoniae CSKP
carbapenem-susceptible K. pneumoniae
20
12
Patel G. Infect Control Hosp Epidemiol
2008291099-106
37
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Carbapenem Resistance among Health
Care-Associated K. pneumoniae Isolates

• Sporadic cases in the 1990s
• lt1 of all K. pneumoniae isolates reported to
  NNIS in 2000
• Rates of carbapenem-resistance among K.
  pneumoniae isolates reported to NHSN (2006-2007)
• All US states except NY 5
• New York 21

Hidron AI. Infect Control Hospital Epidemiol
2008 29(11)996-1011
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Prevalence of CRE Among Inpatients in Two NYC
Hospitals
The overall prevalence of CRE was 5.4. The
average monthly prevalence was 7.4.
68 of carriers were identified by active
surveillance alone.
Calfee DP. Unpublished data.
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Frequency of and Risk Factors for Acquisition of
CRE

• Independent predictors of CRE acquisition
  included
• Pulmonary disease (OR 11.53, p0.02)
• Mechanical ventilation (OR 5.19, p0.04)
• Days of antibiotic therapy (OR 1.04, p0.003)
• CRE colonization pressure (OR1.15, p0.01)
• The odds of acquiring CRE increased by 4 for
  every day of antibiotic therapy received and by
  15 for every 1 increase in the colonization
  pressure to which a subject was exposed.

Calfee DP. Unpublished data.
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Compliance with Infection Control Measures
Reduces Risk

• Compliance with infection prevention policies can
  reduce the association between prevalence and
  incidence of CRE.

Schwaber MJ. Clin Infect Dis 201152(7)1-8
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Regional MDRO Control Initiatives

• Intervention included
• Mandatory reporting of all CRE patients
• Mandatory isolation of hospitalized CRE carriers
• Contact precautions (index and subsequent
  admissions)
• Cohort nursing
• National Task Force with authority to collect
  data and intervene as needed.

National guidelines for active surveillance and
intervention in LTCF issued
Schwaber MJ. Clin Infect Dis 201152(7)1-8
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Antimicrobial Stewardship Programs

• Despite evidence of benefit, not all health care
  facilities have introduced such programs.
• 79 of university hospitals
• 40 of community hospitals
• Almost unheard of in long-term care facilities
• Lack of funding and personnel are the most
  commonly reported barriers.

Johannsson B. Infect Control Hosp Epidemiol
201132367-74
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Policy Statement on Antimicrobial Stewardship
SHEA, IDSA, PIDS

• Antimicrobial stewardship programs should be
  required through regulatory mechanisms.
• Antimicrobial stewardship should be monitored in
  ambulatory healthcare settings.
• Education about antimicrobial resistance and
  antimicrobial stewardship must be accomplished.
• Antimicrobial use data should be collected and
  readily available for both inpatient and
  outpatient settings.
• Research on antimicrobial stewardship is needed.

SHEA, IDSA, PIDS. Infect Control Hosp Epidemiol
201233(4)322-7
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CMS Conditions of Participation for Infection
Control

• Facility has a multidisciplinary process to
  review antimicrobial utilization, local
  susceptibility patterns, and antimicrobial agents
  in the formulary and there is evidence that the
  process is followed.
• Systems are in place to prompt clinicians to use
  appropriate antimicrobial agents (e.g.,
  computerized physician order entry, comments in
  microbiology susceptibility reports,
  notifications from clinical pharmacist, formulary
  restrictions, evidenced based guidelines and
  recommendations).
• Antibiotic orders include an indication for use.
  
• There is a mechanism in place to prompt
  clinicians to review antibiotic courses of
  therapy after 72 hours of treatment.
• The facility has a system to identify patients
  currently receiving intravenous antibiotics who
  might be eligible to receive oral antibiotic
  treatment.

Currently, deficiencies in these criteria will
NOT result in citation, but...
CMS. October 2011. https//www.cms.gov/Surveycerti
ficationgeninfo/downloads/SCLetter12_01.pdf
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HCW Influenza Vaccination

• In a CDC survey of the 2011-12 season, 66.9 of
  HCP reported having received flu vaccine.
• Physicians 85.6
• Nurses 77.9
• Others 62.8
• Vaccination coverage was 76.9 among HCP in
  hospitals.
• Only 44 of HCW in NY received influenza vaccine.
  
• CMS-required reporting of healthcare worker
  influenza vaccination (via NHSN) begins January
  2013.
• Joint Commission requires hospitals to set
  incremental influenza vaccination goals,
  achieving 90 by 2020.
• How will we get to gt90?

NYCDOHMH. Advisory 38. Influenza advisory.
December 14 2012. CDC. MMWR 201261(38)753-7
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Opportunities

• Greater New York Infection Prevention

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New Appreciation for Healthcare-Associated
Infections

• HAIs are an important cause of morbidity and
  mortality among patients in US hospitals.
• HAIs are not inevitable consequences of health
  care.
• HAIs are largely preventable.
• A very low rate of infection isnt low enough
  for the patient that develops the infection.
• Everyone shares the responsibility for preventing
  these infections.

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Opportunities and Obligations

• Advocacy and engagement
• Professional societies APIC, SHEA
• Organizations healthcare facilities, GNYHA,
  HANYS
• Individual involvement local, state, federal
  level
• Epidemiologic, clinical, and basic research
• Eliminate knowledge deficits
• Optimize use of limited resources
• Multicenter, high-quality studies
• Develop new technology
• Cost-effectiveness research
• Utilize new sources of funding for research
• NIH, AHRQ, CDC, NYSDOH, foundations, industry

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Opportunities and Obligations

• Innovative approaches to improving practice
• Implementation science
• Systems engineering
• Bundles and checklists
• Behavioral science
• Root cause analysis
• Positive deviance
• Collaboration

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Opportunities and Obligations

• Take optimal advantage of the federal, state, and
  public interest in HAIs
• New York State Partnership for Patients
• IPROs 10th Scope of Work Project
• NYS HAI Reporting Program
• DHHS/CMS initiatives
• HAI Action Plan, 2013 HAI Prevention Goals, VBP
• Joint Commission Standards

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Acknowledgements

• NewYork-Presbyterian Hospital
• Department of Infection Prevention and Control
• Barbara Ross, Grimilda Augsburg, Hani Nasrallah,
  Janett Pike, Jean-Marie Cannon, Jennifer Holohan,
  Katie Albert, Kindra White, Lesley Covington,
  Lisa Saiman, Liz DiPersia, Peggy Fracaro, Phil
  Graham, Rich Vogel, Yoko Furuya
• Weill Cornell Medical College
• Michael Satlin, Matthew Simon, Kirsis Ham,
  Stephen Jenkins, Jeannette Francois, Trip Gulick,
  Marshall Glesby, Steve Wilson, Glenn Sturge, Luis
  Lopez-Detres
• Mount Sinai Medical Center
• Department of Infection Control
• Charlene Petrec, Elsa Santos-Cruz, Gene Kogan,
  Lin Chen,Marianne Pavia, Mitch Reyes, Mona
  Karam-Howlin, Sabine Jacques, Sandy Derevnuk,
  Shelli Pickholz, Sonia Simpson-Morgan, Sophie
  Labrecque, Steve Avalos-Bock, Teri Szulc, Dilcia
  Ortega, Liz Coughlin, Lori Finkelstein-Blond
• Division of Infectious Diseases
• Gopi Patel, Mahesh Swaminathan, David Banach,
  Stephanie Blash, Stephanie Factor, Meena Rana,
  Mary Klotman

• Greater New York Hospital Association
• Terri Straub, Maria Woods, Zeynep Sumer, Rafael
  Ruiz, Gina Shin
• United Hospital Fund
• Hillary Jalon
• New York State Department of Health
• Rachel Stricof, Kate Gase, Carol van Antwerpen
• IPRO
• Karline Roberts
• Research collaborators
• Michael Phillips, MD (NYU)
• Saarika Sharma, MD (NYU)
• Arjun Srinivasan, MD (CDC)
• Brandon Kitchel (CDC)
• Barry Kreiswirth, PhD (UMDNJ, PHRI)
• Research funding
• New York State Department of Health
• Centers for Disease Control and Prevention
• AHRQ
• Greater New York Infection Prevention Community

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INFECTION PREVENTION