noreen mollon, ms infection prevention consultant multi-drug resistant organisms (mdros) in michigan
TRANSCRIPT
NOREEN MOLLON, MSINFECTION PREVENTION CONSULTANT
Multi-Drug Resistant Organisms (MDROs) in
Michigan
www.michigan.gov/hai
Objectives
Describe MDROsMDRO surveillance and reporting
SHARP Prevention Initiatives Recent MDRO investigationsIP practices for MDROs
Describing MDROs
What is a MDRO?
Multidrug-Resistant Organisms (MDROs) are defined as microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents (HICPAC)
Deserve special attention in healthcare facilities– Healthcare-Associated Infections (HAIs)
Clinically significantAssociated with increased lengths of stay,
costs, and mortality
Types of MDROs
MRSAVISAVRSAVREC. DiffMDR GNB
Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii
ESBLs CRE
What is MRSA?
• MRSA:o Methicillino Resistanto Staphylococcuso aureus
• Staphylococcus aureus are Gram positive bacteria that can be transmitted from person-to-person in a healthcare facility or in the community
• MRSA is a staph infection that is resistant to β-lactam antibiotics (like methicillin, penicillin, and amoxicillin)
Methicillin-Resistant Staphylococcus aureus (MRSA)
MRSA >40% of US hospital-associated S. aureus
infections >50% of ICU-associated S. aureus infections
Increasing reports in non-healthcare settings Prisons Schools Day-care Workplace Other
Approximately 1% of the general population is colonized with MRSA
VISA
Vancomycin-intermediate Staphylococcus aureus
Vancomycin minimum inhibitory concentration (MIC) =4–8 µg/mL
Isolate must be confirmed at MDCH laboratory
Resistance mechanism is not transferrable to susceptible strains and is usually associated with vancomycin exposure
VRSA
Vancomycin-resistant Staphylococcus aureusVancomycin minimum inhibitory
concentration (MIC) 16 µg/mLIsolate must be confirmed at MDCH
laboratoryResistance is acquired from VRE and is
transferrable
VRE
Vancomycin-resistant Enterococcus
Can colonize the intestines and female genital tract
Can cause infections of the urinary tract, the bloodstream, or of wounds associated with catheters or surgical procedures
Clostridium difficile (C. diff)
Background Accounts for 15-25% antibiotic-associated
diarrhea 80% Clostridium difficile infection (CDI)
associated with healthcare Elderly and patients on antibiotics at highest
riskCurrent epidemiology
Increased rates nationwide Increased severity and mortality
Reasons Widespread use of antibiotics Changes in infection control practices New strain: NAP-1
MDR GNB
Multidrug-resistant gram-negative bacilliCan refer to various organisms:
Escherichia coli, Klebsiella pneumoniae,Pseudomonas aeruginosa, Acinetobacter baumannii, Stenotrophomonas maltophilia, Burkholderia cepacia,and Ralstonia pickettii
MDR GNB
Grouped according to resistance Extended-spectrum β-Lactamases (ESBLs) Carbapenem-resistant Enterobacteriaceae (CREs)
Carbapenemase-producers (such as Klebsiella pneumoniae carbapenemase or KPC)
Metallo-beta-lactamase (MBL)-producers
Difficult to lab confirmWorrisome public health threat
What is a HAI?
Healthcare-Associated Infections (HAIs) are infections that patients acquire during the course of receiving healthcare treatment for other conditions that were not present at admission
HAIs are often MDROsAre frequently device-associated
HAIs
Approximately 1 out of every 20 hospitalized patients will contract an HAI
CDC estimated that 1.7 million HAIs occurred in US hospitals in 2002
HAIs are responsible for about 100,000 deaths in the US annually
The medical costs associated with these infections are approximated to be between $36-45 billion
Types of HAIs
Central Line-Associated Blood Stream Infections (CLABSI)
Catheter-Associated Urinary Tract Infections (CAUTI)
Ventilator-Associated Events (VAE)
Surgical Site Infections (SSI)
Clostridium difficile (C.diff) Infection
Methicillin-Resistant Staphylococcus aureus (MRSA)
Multidrug-Resistant Organisms (MDROs) – Acinetobacter, Klebsiella, Pseudomonas, Enterobacter, E.coli, etc.
Types of HAIs
Staphylococcus aureus
Subclavian central venous line
Mechanical ventilator
Surgical incision showing signs of infection
Clostridium difficile
Foley catheter insertion kit
SSI
CLABSI
VAE
CAUTI
CDI LabID
MRSA LabID
Costs of HAIs*
Meta-analysis results of top 5 HAIs
Infection Cost/Infection Attributed LOS(Days)
Total annual cost
($, billions)
Total annual cases
CLABSI $45,814 10.4 1.85 40,411
SSI $20,785 11.2 3.30 158.369
VAP $40,144 13.1 3.09 31,130
C. Diff $11,285 3.3 1.51 133,657
CAUTI $896 -- 0.28 77,079
* source: JAMAInternalMedicine, 9/2/2013
MDRO Surveillance and Reporting
33 states have laws requiring HAIs to be reported to state health departments, the majority of which publically release hospital HAI rates
Surveillance and Reportingwww.michigan.gov/hai
National Reporting Requirements
The Centers for Medicare and Medicaid Services (CMS) requires hospitals to report: CLABSI (effective January 2011) CAUTI (effective January 2012) SSI for Colon Surgeries and Abdominal
Hysterectomies (effective January 2012) MRSA Bacteremia LabID (effective January 2013) C. difficile LabID (effective January 2013)
Bureau of Disease Prevention, Control and Epidemiologywww.michigan.gov/epi
Division of Communicable Diseasewww.michigan.gov/mdch/0,1607,7-132-2945_5104-12219--,00.html
Surveillance and Infectious Disease Epidemiology Section (SIDE)
www.michigan.gov/cdinfo
Surveillance for Healthcare-Associated and Resistant Pathogens (SHARP) Unit www.michigan.gov/hai
Education and Outbreak Response
SurveillancePrevention Initiatives
Carbapenem-Resistant Enterobacteriaceae (CRE) Prevention Collaborative
MRSA/CDI Prevention Collaborative
Collect HAI data from Michigan hospitals through the CDC’s web-based National Healthcare Safety Network (NHSN)
Provide general education and recommendations based on current best-practice, evidence-based guidelines
Authority of State and Local HDs
• Michigan is a “home rule” state, meaning local HDs have autonomy within their jurisdiction
• The MDCH operates independently from the local HDs
• The primary role of the MDCH in communicable disease control is to provide:\o Expert consultationo Reference level diagnostics laboratory serviceso Childhood vaccineso Support local HDs upon their requesto Maintenance and administration of the MDSS
• All communicable disease reports should be reported to your local HDs
Public Health Investigative Authority
State and local HD personnel are authorized to investigate reported diseases, including: Contacting health providers Conducting additional case-finding Conducting epidemiological studies Conducting specimen collection Gathering information on medical history, lab results,
diagnostic procedures, treatment, and health outcomes
The MDCH works collaboratively with the local HDs and participates in investigations when requested
Confidentiality, HIPAA, and PHI
Disclosure of protected health information (PHI) to health authorities without individual consent or authorization is permitted when disclosure is required by law or is authorized by law for a public health purpose (www.hhs.gov/ocr/hipaa/)
All information provided to public health authorities is kept confidential
Map of Michigan Local HDs
Communicable Disease Surveillance
Communicable disease reporting is required by Michigan law: Michigan Public Health Act No. 368 Communicable
Disease Rules: R 325.171-3, 333.5111 Rule revision allows the State the right to
periodically update the list of reportable diseases This reporting is expressly allowed under HIPAA
Hepatitis C Virus Neisseria meningitidis Histoplasma capsulatum Bordetella pertussis
Why Communicable Disease Surveillance is Important
To identify outbreaksTo assure treatment, preventive treatment
and/or educationTo evaluate prevention and control
programsTo help target prevention resourcesTo facilitate epidemiologic researchTo assist national and global surveillance
efforts
Salmonella sp.Influenza VirusChlamydia trachomatis Mycobacterium tuberculosis
Communicable Disease Reporting Entities
• Physicians*• Laboratories*• Hospital ICP• Private citizens• School systems*• Pharmacists• Veterinarians• Medical
Examiners
• Hospitals*• Child care
facilities• Long-term care
facilities*• Pre-hospital
emergency serviceso Policeo Fireo EMS
*Required to report
Communicable Disease “Brick Book”
The current 2012 version (electric crimson), provides a good summary of the communicable disease rules, requirements, and responsibilities
Michigan Reportable Diseases
~90 disease/conditions are reportable in Michigan
Also reportable are ‘unusual occurrences’, outbreaks and epidemics of any disease or condition (including healthcare-associated infections)
Specific reporting rules and definitions can be found at www.michigan.gov/cdinfo
Michigan Reportable MDROs and HAIs
Vancomycin-Intermediate Staphylococcus aureus (VISA) and Vancomycin-Resistant Staphylococcus aureus (VRSA) are required to be reported according to the communicable disease rules
Unusual occurrences and outbreaks of HAIs are also mandated by law to be reported
However, individual HAIs (like a CLABSI), are not required to be reported to state or local health departments
Surveillance of Healthcare Associated and Resistant Pathogens(SHARP) Activities
Surveillance and ReportingMDRO Prevention Initiatives Consulting/EducationOutbreak Response
Staphylococcus aureus
Clostridium difficileKlebsiella pneumoniae
www.michigan.gov/hai
www.michigan.gov/hai
SHARP Unit
Objectives of the SHARP Unit: Coordinate activities related to HAI surveillance
and prevention in Michigan Improve surveillance and detection of
antimicrobial-resistant pathogens and HAIs Identify and respond to disease outbreaks Use collected data to monitor trends Educate healthcare providers, state and local public
health partners, and the public on HAIs
In Michigan, hospitals can voluntarily report HAIs to MDCH SHARP via the National Healthcare Safety Network (NHSN)
NHSN is a web-based surveillance program designed by CDC: Uses standardized HAI surveillance definitions Users can enter and analyze HAI data
The data sent to SHARP from Michigan hospitals are de-identified and the numbers aggregated for the purposes of producing state-wide HAI surveillance reports
NHSN Surveillance Initiative
www.michigan.gov/hai
HAIs tracked by MDCH SHARP surveillance: Central Line-Associated Blood Stream Infection
(CLABSI) Surgical Site Infection (SSI) Catheter-Associated Urinary Tract Infection (CAUTI) Ventilator-Associated Pneumonia (VAP) Clostridium difficile LabID surveillance MRSA LabID surveillance Antimicrobial resistance in select pathogens
NHSN Surveillancewww.michigan.gov/hai
SHARP releases state-wide HAI reports quarterly, semiannually, and annually which are posted at www.michigan.gov/hai All hospital data is de-identified and aggregated Individual hospital data is not made public
SHARP also compiles hospital specific HAI reports which are only shared with those individual hospitals
SHARP Surveillance Reportswww.michigan.gov/hai
SHARP Surveillance
Currently there are 83 Michigan hospitals sharing HAI data with SHARP, 82 hospitals releasing their data to the Michigan Health and Hospital Association MHA Keystone Center, and 13 hospitals releasing their NICU data to the Vermont Oxford Network (9/26/13).
www.michigan.gov/hai
0
10
20
30
40
50
60
70
80
90
Number of Acute Care Hospitals that have Signed a Data Use Agreement with MDCH SHARP
Master Agreement
MHA Data Release
VON Data Release
Nu
mber
of
Hosp
itals
SHARP HAI Data: MRSA Lab IDwww.michigan.gov/hai
2011 Q1 2011 Q2 2011 Q3 2011 Q4 2012 Q1 2012 Q2 2012 Q3 2012 Q40
1
2
3
4
5
6
MRSA LabID Rates
MR
SA
LabID
Rate
per
1,0
00 P
ati
ent
Days
SHARP HAI Data: CDI LabIDwww.michigan.gov/hai
2011 Q1 2011 Q2 2011 Q3 2011 Q4 2012 Q1 2012 Q2 2012 Q3 2012 Q40
5
10
15
20
25
C. diff LabID Rates
C.
diff
LabID
Rate
per
10,0
00 P
ati
ent
Days
SHARP HAI Data: SIRStandardized Infection Ratios (SIR)
2012 Quarter 4
Type of Infection
Number of Hospitals
Procedures Done
Device Days Observed1 Predicted2 MI SIR3
MI p-value
MI 95% CI4
CAUTI5 75 N/A 99,581 232 215.972 1.074 0.1456 0.940, 1.222CLABSI6 73 N/A 89,342 86 179.784 0.478 <0.0001 0.383, 0.591SSI7 72 11,954 N/A 233 267.056 0.872 0.0184 0.762, 0.994SSI COLO8 69 2,111 N/A 91 122.292 0.744 0.0019 0.596, 0.917SSI HYST9 67 2,109 N/A 35 39.824 0.879 0.2509 0.607, 1.230 MI Data US Data
Green Font: SIR demonstrates statistically significantly fewer infections than expectedRed Font: SIR demonstrates statistically significantly more infections than expected
1Observed: Number of infections (CAUTI, CLABSIs or SSIs) reported during the time frame.2Predicted: The number of CAUTIs or CLABSIs predicted based on the type of hospital unit(s) under surveillance, or the number of SSIs predicted based upon 2009 national SSI rates by procedure type. 3SIR: Standardized Infection Ratio: Ratio of observed events compared to the number of predicted events, accounting for unit type or procedure. An SIR of 1 can be interpreted as having the same number of events that were predicted. An SIR that is between 0 and 1 represents fewer events than predicted, while an SIR of greater than 1 represents more events than expected. 495% CI: 95% confidence interval around the SIR estimate. A 95% CI indicates that 95% of the time, the actual SIR will fall within this interval.5CAUTI: Catheter-Associated Urinary Tract Infection. CAUTIs are defined using symptomatic urinary tract infection (SUTI) criteria or Asymptomatic Bacteremic UTI (ABUTI) criteria. UTIs must be catheter-associated (i.e. patient had an indwelling urinary catheter at the time of or within 48 hours before onset of the event).6CLABSI: Central Line-Associated Blood Stream Infection. CLABSIs are laboratory-confirmed bloodstream infections (LCBI) that are not secondary to a community-acquired infection, or an HAI meeting CDC/NHSN criteria at another body site. BSIs must be central line associated (i.e., a central line or umbilical catheter was in place at the time of, or within 48 hours before, onset of the event).7SSI: Surgical Site Infection. Includes any superficial incisional, deep incisional, or organ/space SSI.8SSI COLO: Colon surgeries9SSI HYST: Abdominal Hysterectomies17.
www.michigan.gov/hai
2009-2010 Annual Report 2010-2011 Semi-Annual Report0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
CLABSI Rates from Data Shared with MDCH SHARP through NHSN (MI vs. US)
MI CLABSI
US CLABSI
Time Period
CL
AB
SI R
ate
SHARP HAI Data: CLABSIwww.michigan.gov/hai
SHARP HAI Data: CAUTIwww.michigan.gov/hai
2011Q1 2011Q2 2011Q3 2011Q4 2012Q1 2012Q2 2012Q3 2012Q4 2013Q10
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
Michigan Overall CAUTI SIR
SIR
2011Q1 2011Q2 2011Q3 2011Q4 2012Q1 2012Q2 2012Q3 2012Q4 2013Q10
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
Michigan Original 25 Hospitals CAUTI SIR
SIR
SHARP HAI Data: CAUTIwww.michigan.gov/hai
MRSA/C. DIFFCRE
MDCH Prevention Initiatives
MDRO Prevention Initiatives
SHARP also has started two prevention initiatives aimed to reduce the incidence and prevalence of MDROs in healthcare facilities in Michigan:
Methicillin-Resistant Staphylococcus aureus (MRSA) and Clostridium difficile (CDI) prevention initiative
Carbapenem-Resistant Enterobacteriaceae (CRE) surveillance and prevention initiative
Enterobacter cloacaeCitrobacter freundii Klebsiella pneumoniaeEscherichia coli
Staphylococcus aureus
SHARP recruited facilities into the two initiatives
Both will measure the baseline prevalence and incidence of their respective organisms
Then there will be a period of measurement during which facilities are encouraged to begin implementing infection prevention interventions to reduce the transmission of these organisms
MDRO Prevention Initiatives
Planning Stage Baseline Stage
Intervention Stage
www.michigan.gov/hai
MDRO Prevention Initiativeswww.michigan.gov/hai
MRSA/CDI Contact- Gail Denkins [email protected]
CRE Contact- Brenda Brennan [email protected]
MRSA/CDI Prevention Collaborative
Established September 28, 2011 and includes representation from:• MDCH • Michigan Society for Infection Prevention and
Control (MSIPC)• Michigan Health and Hospital
Association(MHA) Keystone Center for Patient Safety and Quality
• MPRO (Michigan's Quality Improvement Organization)
• Long Term Care• Michigan Association of Local Public Health
(MALPH)
MRSA/CDI Prevention Collaborative
The Collaborative works to integrate evidence based best practices along the continuum of care to reduce and eliminate the occurrence of MRSA and CDI among Michigan citizens
The Initiative Focus
• Acute care and skilled nursing care facilities can work together to reduce MRSA and CDI among patients that share the health care services provided within their regions
• Recognize the benefits of improving transfer of care communication
• Build collaborative community relationships with focus on sharing best practices to prevent and reduce MRSA and CDI infections
MRSA/CDI Prevention Initiative
• Design of the program was formed by the MRSA/CDI Collaborative
• Facilities submitted formal applications• 13 hospital and 12 skilled nursing facilities
were chosen by the MRSA/CDI Collaborative committee
• Facilities were provided MSIPC scholarships to attend conferences and training
• Facilities are required to submit a formal action plan, submit monthly MRSA/CDI event data
Cost Analysis
• Healthcare-associated infections (HAIs) in acute care hospitals and long term care facilities impose significant economic consequences on the healthcare system.
• The overall annual direct medical cost of HAIs to U.S. hospitals ranges from $35.7 to $45 billion (in 2007 dollars).
• This report utilizes published results from medical and epidemiological literature to provide a healthcare cost estimate for treating methicillin-resistant Staphylococcus aureus and Clostridium difficile Infection (MRSA/CDI) in Michigan.
MRSA Results
Facility Type Healthcare Onset Cost
Total Cost
Acute Care $ 9,245,800 $ 24,627,400
Skilled Nursing Facility
$ 381,900 $ 445,300
* Data represents 14 months of data collection at enrolled facilities
C.Diff Results
Facility Type Healthcare Onset Cost
Total Cost
Acute Care $ 7,595,100 $ 17,878,500
Skilled Nursing Facility
$ 452,400 $ 522,000
* Data represents 14 months of data collection at enrolled facilities
CRE Surveillance and Prevention Initiative
Develop a practical reporting mechanism for CRE, enroll acute care and LTAC facilities to participate, and identify best-practice recommendations that can be applied across the healthcare continuum. The overall goal is to build a regional, public health model to
reduce the spread of CRE in Michigan. Twenty one facilities (17 acute care and 4 long-term acute care
facilities) enrolled into the Initiative. Facilities are distributed across the state, with the greatest
concentration in SE and West Michigan. Facilities voluntarily report cases of CRE (per our surveillance
definition) and submit monthly denominator reports. Facilities developed CRE Prevention Plans designed for the specific
needs of their facility. These plans were implemented in March 2013.
More information about the CRE Surveillance and Prevention Initiative is available online at www.michigan.gov/hai under MDCH Prevention Initiatives.
Data HighlightsSeptember 2012 – September 2013
CRE Patient Demographics
• Total of 191 cases reported• Age
– Median: 66 y/o– Range: 21-96 y/o
• Sex– 50% Female
• Patient Type– Inpatient ICU: 40%– Inpatient Non-ICU: 50%– Outpatient: 9%– Referral patient: 1%
CRE Incidence in Michigan
CRE Laboratory Testing and Micro
Organism Klebsiella pneumoniae: 88% Escherichia coli: 12%
Specimen Type Clinical culture: 98% Surveillance Culture or screen: 2%
CRE Contact Precautions
Time from Antimicrobial Susceptibility Results to placing the patient into isolation/contact precautions: Paired dates for 133 (of 191) acute care patients
130 (98%) of patients were placed in CP within 24 hours Range: 0-11 days, Mean: 3.6 hours
The MDCH SHARP staff are available to offer our services and expertise in healthcare-associated outbreak investigations
MDCH can help facilities coordinate molecular testing with the MDCH Bureau of Laboratories to identify genetic-relatedness between patient isolates (at no cost)
Outbreak Response
Acinetobacter baumannii
www.michigan.gov/hai
Recent MDRO Investigations
VRSA in the United States
Case No. State Date1 Michigan June 2002
2 Pennsylvania September 2002
3 New York March 2004
4–6 Michigan February, October & December 2005
7 Michigan October 2006
8, 9 Michigan October & December 2007
10 Michigan December 2009
11, 12 Delaware April & August 2010
Most have had a history of:
Underlying health conditions including: diabetes, hemodialysis, heart disease, obesity, osteomyelitis
Recurrent MRSA infections and non-healing wounds
Catheters and indwelling medical devices
Recent hospitalizations or stays in LTC/rehab facilities
Recent and frequent exposure to vancomycin and other antimicrobials
VISA/VRSA Cases
CRE- Early 2013
BOL received a short-term grant from APHL to perform confirmatory testing of CRE isolates
This testing yielded Increased communications with hospitals improvements in communications between lab and IP
One facility implemented pre-emptive isolation of patients from a particular LTC after identifying a high rate of CRE positivity among those patients
Fungal Infections Associated with Contaminated Methylprednisolone Acetate in
Michigan, 2012-2013
September 26th, 2012 – NECC voluntarily recalls three lots of MPA (05212012, 06292012, and 08102012)
September 28th, 2012 – Growing evidence of connection between meningitis cases and NECC MPA shared on multi-state call with CDC
October 1st, 2012 –NECC customer invoice list shared with the Michigan Department of Community Health (MDCH) Bureau of Epidemiology
October 2nd, 2012 – MDCH begins contacting Michigan clinics who were recipients of recalled lots of NECC MPA
68
Case Count (as of June 3rd, 2013 - http://
www.cdc.gov/hai/outbreaks/meningitis-map-large.html)
Contributions from MDCH
MDCH dedicated ~4,000 hours during the first three months of the outbreak (equivalent of two FTEs)
Case report form completion – over 10,000 pages of hospitalization information from fungal cases abstracted from medical records sent to CDC: 264 case report forms, each a minimum of 27 pages
in length – totaling ~7,128 pages 277 additional admission case report forms, each a
minimum of 12 pages in length – totaling ~3,324 pages
Sharing information to help inform national guidelines and recommendations
IP Practices
Preventing Transmission of MDROs
Who is responsible for infection prevention?
All of us!We are each responsible for maintaining a safe
environment for our patients, staff, visitors, everyone!
We are each responsible for our own hands
Standard Precautions
All blood, body fluids, secretions (except sweat), nonintact skin, and mucus membranes assumed infectious
Includes hand hygiene, appropriate gloves/gown/mask/face shield when necessary, and safe injection practices
Because colonization with MDROs is often unrecognized, standard precautions have an ESSENTIAL role in preventing MDRO transmission in ALL healthcare settings
Preventing Transmission of MDROs
Promote compliance with CDC hand hygiene recommendations
Use Contact Precautions for all MDRO patients (colonized and infected)
Ensure cleaning and disinfection of both equipment and environment
Educate HCWs about MDROsEducate and engage patients and families
about MDROsMonitor compliance-personal accountability
Contact Precautions
Contact Precautions are intended to prevent transmission of organisms (MDROs) that are spread by direct or indirect contact with a patient or a patient's environment
A single patient room is preferred for patients who require Contact Precautions When a single-patient room is not available,
consultation with infection prevention personnel is recommended to assess the various risks associated with other patient placement options (e.g., cohorting, keeping the patient with an existing roommate)
Contact Precautions
Requires putting on gown and gloves Perform hand hygiene before putting on gloves Gown must be tied at the waist and neck
Remove gown and gloves before leaving the room
Perform hand hygiene immediately after removing gown and gloves
Acknowledgements
SHARP Unit Jennie Finks Brenda Brennan Bryan Buckley Gail Denkins Allie Murad Judy Weber
Viral Hepatitis Unit Joe Coyle
Resources
www.cdc.gov/haiwww.michigan.gov/hai
Surveillance Initiative Prevention Initiatives
MRSA/CDI TTT
www.michigan.gov/cdinfohttp://www.apic.org/For-Consumers/Materials
-for-healthcare-facilities
Thank you
www.michigan.gov/hai