MQF HAI Subcommittee HAI Plan Update June 24

MQF HAI Subcommittee: HAI Plan Update June 24, 2013 Peg Shore, MT, MSPH, Ph. D. , CIC HAI Prevention Coordinator

Introduction to HAIs • Healthcare-Associated Infections • 99, 000 deaths/ year (more than breast cancer, prostate cancer and AIDs combined!) • 1. 7 million HAIs per year (2002) • Cost: total $36 billion to $45, 000, 000 (2007 dollars)/ year in U. S.

Types of HAIs • • • Central line infections (CLABSIs) SSIs: superficial and deep Catheter-associated UTIs Clostridium difficile MRSA-HAI

Deaths by HAIs, U. S. , 2002 • • • Pneumonia Bloodsteam infection UTI C. difficile** SSI 35, 000 31, 000 13, 000 9, 000 8, 000

CDC estimates • Could reduce between 33% to 50% of these infections, at a savings of $6. 6 to 8. 4 billion. • Could save 33, 000 lives/ year in U. S.

Changing Healthcare Landscape • Since 2002, shift in philosophy: Public demand for: • Accountability • Transparency • Financial reimbursement (Medicare & Maine. Care-Medicaid primarily)= no pay for HAIs

Maine State Reporting Mandates. All hospitals • 2007: Central line associated bloodstream infections (CLABSIs), central line bundles, central line insertion practice (CLIP), surgical care improvement program (SCIP), ventilator associated pneumonia (VAP) bundle. • 2011: Added MRSA-HAI and C. difficile (lab confirmed- inpatients only)

Current Medicare (CMS) Mandates: IPPS hospitals only (CAHs exempt) • • • Central line infections (CLABSIs) Catheter-associated UTIs (CAUTIs) SSIs: colons, abdominal hysterectomies MRSA bacteremias C. difficile- Lab ID event HCW influenza vaccination

Medicare Reimbursement: How Important is it? • For larger hospitals, Medicare is 50 percent of hospital’s payment for services. • Critical access hospitals, it is often 2/3 rds of hospital reimbursement. • Mandated reporting of HAIs (CMS): if miss deadline, reduce payment by 2%. (5. 5 months lag)

Public Health & HAI Prevention: ARRA funding • As 5 th cause of death in the US, it has become a public health issue. • 2009, American Recovery and Rehabilitation Act (ARRA) funded 49 states to build programs. • HAI Prevention Programs: 1) infrastructure, 2) prevention & surveillance, 3) communication.

Maine HAI Prevention Program • Initially, focus on hospitals with Maine Infection Prevention Collaborative as the advisory group. • Expanded into LTC. Worked with QIO. Offered 10 day long seminars all over the state. • Working on antibiotic stewardship to reduce C. difficile and resistant organisms (multiple drug resistant organisms-MDRO).

Data validation • How do we know if the numbers reported are accurate? • Must validate the data • State law: Maine CDC must validate C. difficile and MRSA-HAI • Maine Quality Forum: validating CLABSI. Being done by John Snow Institute (JSI)Boston, MA.

Maine HAI Plan • Create infrastructure • Surveillance & Prevention • Communication • After 3 years of work, we are in a NEW place. We have created program in Maine CDc, gathered & validated data, are analyzing, and communicating with hospitals.

State of Maine HAI Plan • We have accomplished all that was in the grant, and more: – LTC – ASP – Outbreak reporting and assistance – Distributed educational materials for patients – Surveillance and feedback to hospitals – Self-sustaining model for HH compliance – NHSN used by all hospitals/ validation of data

ASP • Maine CDC is analyzing Maine. General antibiogram and creating pocket reference guide for outpatient prescribing. • Working with MMA- Maine Independent Clinical Information Service to do academic detailing of antibiotics. Rollout is scheduled for November, 2013.

CLABSI validation • JSI plans to do a 2 day visit to Peer Group A hospitals. • Will do a 1 day visit to 2 of largest hospitals in Peer Group B (St. Mary’s and Mercy). Other B hospitals will be done by sharing data remotely.

Types of Communication • Facility-specific dashboard reports to hospital • Hand hygiene compliance every 6 months • Influenza vaccination of HCW comparing all hospitals, yearly. • Meet with MIPC monthly= all hospitals IP • Maine Quality Council: HAI subcommittee

State of Infection Control & Prevention (Maine CDC/ MQF Annual Report) • CLABSI- adult and NICU: • CLABSI: high mortality rate 14%-25% – majority of infections are in the 3 largest hospitals/ more complicated patient/ more CLs – Device utilization statewide is low – MMC made huge progress in past 5 years but is still above the national average for CLABSIs.

Statewide analysis: CAUTI • CAUTI for IPPS hospitals: Mandated reporting by CMS/ Most common type of HAI. – A few larger hospitals had higher CAUTI rates, sometimes in a single unit. – Most hospitals had decreasing urinary catheterization utilization rates. Again, some units had high DU rates. Often these units also had high CAUTI rates.

SSI • Very limited data, CMS requires only colon and abdominal hysterectomy data from IPPS hospitals. • Critical Access Hospitals do not report any SSI data.

MRSA-HAI • Rates varied widely between hospitals. • 50% in ICU and 50% in non-ICU • Highest type of MRSA-HAI – SSI 42% (47) – Pneumonia 22% (25) – BSI 19% (22)

MRSA-HAI 2011, All Maine Hospitals 4%(4) 4%(5) 2%(2) 1%(1) SSI PNU/LRI 4%(5) BSI 42%(47) Intraabdominal UTI with symptoms 19%(22) SKIN Bone/jt Intracranial disseminated 22%(25)

C. difficile • Every peer group had one or more hospitals with higher than average rates. • Rates varied from 0 to 19/10, 000 patient days. • State average is 6. 6/ 10, 000 days. This will become threshold by which to measure progress. • Rates included healthcare facility onset and community onset/ healthcare facility associated.

C difficile categories in NHSN • Healthcare facility onset (HO: ) Patient had positive specimen on day four or later. • Community onset Healthcare Facility associated (CO-HCFA): specimen from patient who was discharged from the facility 4 weeks or less. • Community Onset (CO): specimen occurs

MQF Annual Report Three new pages (see handout or pages 33, 35, 36 of the report): • MRSA-HAI for 2011 (validated data) by hospital/ by peer group. • C. difficile Lab. ID rates (2011 Q 4 -2012 Q 3, all validated data). Does include both HO and CO -HCFA data. Is a proxy measure. When viewing all 3 (HO, CO-HCFA, CO) it shows the hospital burden of C. difficile.

Percentage C. difficile by Category 10/1/2011 to 9/30/2012 256; 33% community onset CO-HCFacility Associated 384; 49% 142; 18% Hospital Onset

C. difficile Results 10/1/2011 - 9/30/2012 • Total Inpatient positive labs (whole state): 780 • Total hospital-related C. difficile (HO & CO-HCFA): 397 • 397 C. difficile compared to 119 MRSA-HAI Summary: C. diff bigger problem than MRSA

Prevention: Statewide Efforts • HH: All hospitals doing internal and external audits. Slowly improving with each external audit. Median: 63% in Fall of 2011 to 81% in December of 2012.

Statewide analysis Influenza vaccination of HCWs: • State average last year was 77%. • 2012 -13 state average improved to 84%. • (New Hampshire: hospitals w/o a policy=78%, hospitals with a policy=93%, hospitals that terminate unvaccinated HCW w/o an exemption=98% vaccination rate. )

MQF Annual Report – HAI 3: Central line bundle: improved from 71% (2007 -08) to 94%(2011 -12) – CLABSI rates: improved from 2. 5/ 1, 000 CL days (07 -08) to 1. 7/1, 000 (2011 -2012). National avg=1. 2 in 2010. – NICU CLABSI rates: improved from 3. 8/ 1, 000 CL days (07 -08) to 2. 5 (11 -12). National average=1. 6 in 2010.

Are we seeing improvement in Maine? • CLABSIs: Yes, although a few hospitals still above national average. Huge improvement since 2007 (66) to 2011 (47)= 19 less, 5 persons who didn’t die in 2011. • MRSA and C. difficile: too early to tell, but we now have baseline. • SSIs: not enough data, only following 2 surgeries. • CAUTI: only collected since 2012, but device utilization is low in most hospitals and very good in nursing homes.

HAI program work continues • Validation of NHSN MRSA-HAI • Validation of NHSN C. difficile lab ID • Continue working with hospitals to audit hand hygiene. • Continue to analyze data, communicate analysis to hospitals. • Increase efforts to LTC and physician offices.

New Efforts • Collaboration with QIO to reduce C. difficile in the Augusta area: early diagnosis, contact precautions, environmental cleaning, antibiotic stewardship. • ASP: Educating several hospitals, working with MICIS, developing physician pocket reference. • CRE: include as a reportable, ASP as prevention. Develop state lab as reference to confirm. • Outbreak assistance for LTC C. difficile outbreaks.

HAI Network • Maine CDC collaborates with: • Maine Infection Prevention Collaborative and MIPC-CC • MHDO & MQF • UNE School of Pharmacy • Maine Medical Association- MICIS • Maine Healthcare Association (LTC) • QIO/Maine. General Med. Ctr. / 5 area NHs • Maine Health • Legislature/ rule making process.