Patient Safety and Health Care Associated Infections

Infectious Disease Epidemiology Workgroup

Jan. 4, 2008 Austin, Texas

Gary Heseltine MD MPH

Infectious Disease Control Unit

“When speculation has done its worst, two and two still make four.” Samuel Johnson, The Idler

Outline• Big picture – patient safety

– Harm unintentional or not, preventable or not– The many players

• Health care-associated infections (HAI)– Surgical care improvement project (SCIP)– The burden of morbidity and mortality– What the evidence says

• SB 288 Public Reporting of HAI– Where are we and where are we going in Texas?

• Changing practices – adopting protocols– Barriers and incentives– Direction for the future

Patient Safety• Hippocrates, Epidemics

"Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things — to help, or at least to do no harm."

• The Joint Commission defines patient safety solutions:"Any system design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from the processes of health care.“

• Institute for Healthcare Improvement defines medical harm:“Unintended physical injury resulting from or contributed to by medical care (including the

absence of indicated medical treatment), that requires additional monitoring, treatment or hospitalization, or that results in death.

Such injury is considered harm whether or not it is considered preventable, whether or not it resulted from a medical error, and whether or not it occurred within a hospital.”

• Safe - free from hurt, injury, danger or risk • Harm – injury; damage; hurt• Safety - state of being safe

Institute for Healthcare Improvement

37 Million AdmissionsX

40 Injuries per 100 Admissions=

15 Million Injuries per Year

Proportion of Adverse EventsMost Frequent Categories

0%

5%

10%

15%

20%

25%

Drug-related

Woundinfect.

Tech.comp.

Latecomp.

Diag.mishap

Therap.mishap

Nontech.comp.

Proc.related

Brennan. N Engl J Med. 1991;324 (6):377-384.

Non-surgicalSurgical

3.7% of patients experience serious adverse events related to medical management.

58% of these events were preventable mistakes – now called medical errors or patient safety failuresTechnical complication – e.g. injury to adjacent structures, gas emboli, anastomostic leakNon-technical complication – e.g. development of cardiac arrhythmias, vascular emboli

Burden of Healthcare-Associated Infections in the United States, 2002

• 1.7 million infections in hospitals– Most (1.3 million) were outside of ICUs– 9.3 infections per 1,000 patient-days– 4.5 per 100 admissions

• 99,000 deaths associated with infections– 36,000 – pneumonia– 31,000 – bloodstream infections

Klevens, et al. Pub Health Rep 2007;122:160-6

Impact of Surgical Site Infections (SSI)

Infected Uninfected

Mortality (in-hospital)

7.8% 3.5%

ICU admission 29% 18%

Readmission 41% 7%

Median initial LOS 11d 6d

Median total LOS 18d 7d

Initial excess cost +$3,644 (median)

Total excess cost +$5,038 (median)

*Pairs matched for procedure, NNIS index, age*General inpatient surgical population; 22, 742 procedures included

Kirkland. Infect Control Hosp Epidemiol. 1999;20:725.

An estimated 40-60% of SSIs are preventable.

• Centers for Medicare & Medicaid Services (CMS)

• Centers for Disease Control and Prevention (CDC)

• Department of Veteran’s Affairs

• Institute for Healthcare Improvement (IHI)

• Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

• American College of Surgeons (ACS)

• American Hospital Association (AHA)

• American Society of Anesthesiologists (ASA)

• Association of peri- Operative Registered Nurses (AORN)

• Agency for Healthcare Research and Quality (AHRQ)

Surgical Care Improvement Project (SCIP)

2010 National GoalReduce preventable surgical morbidity and mortality by 25%

Surgical Infection Prevention (SIP): previous CMS initiative focusing appropriate selection, administration and discontinuation of surgical antibiotic prophylaxis.

SCIP Has Four Modules

Infection• 7 Infection Prevention Process Measures

Venous Thromboembolus (VTE)• 2 VTE Prevention Process Measures

Cardiac Prevention Module• 1 Cardiovascular Prevention Measure

Respiratory (Post-operative ventilator associated pneumonia)

• Delayed implementation to use these measures in expanding the ICU Core Measure Set

SCIP Infection Module• SCIP INF 1:

– Prophylactic antibiotic received within one hour prior to surgical incision

• SCIP INF 2:– Prophylactic antibiotic selection for surgical patients

• SCIP INF 3:– Prophylactic antibiotics discontinued within 24 hours after

surgery end time (48 hours for cardiac patients)• SCIP INF 4:

– Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose

• SCIP INF 6:– Surgery patients with appropriate hair removal

• SCIP INF 7: – Colorectal surgery patients with immediate postoperative

normothermia

Effective with discharges beginning July 1, 2006

0

1

2

3

4

≤-3 -2 -1 0 1 2 3 4 ≥5

Classen. NEJM. 1992;328:281.

Prophylactic AntibioticsTiming Administration of Pre-op

DoseIn

fect

ion

s (%

)

Hours From IncisionNote: only 40% received antibiotics within two hours of incision

14/369

5/699

5/1009

2/180

1/81

1/411/47

15/441

Diabetes, Glucose Control, and SSIsAfter Median Sternotomy

0

5

10

15

20

<200 200-249 250-299 >300

% In

fect

ion

s

Increased risk:Diagnosed diabetesUndiagnosed diabetesPost-op glucose > 200 mg% within 48h

Latham. Inf Contr Hosp Epidemiol. 2001;22:607.Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604.

Cleveland Regional Medical Center

Central Line Infections:Incidence & Risk

• 48% of ICU patients have central venous catheters, accounting for 15 million central venous catheter-days per year in ICUs.

• The case fatality rate for catheter-related blood stream infections approaches 20%.

• Attributable mortality ranges from 12-25% but was 3% in one meta-analysis.

Mermel LA. Ann Int Med 2000;132: 391-402Soufir L et al. Infect Control Hosp Epidemiol 1999 Jun;20(6):396-401.

Central Line Insertion Checklist

Prevention of Central Line-Associated Bloodstream Infections

Bundle: standard pack or cart for line insertion with all needed supplies

Do Central Line Bundles Work?• 12 month Baseline average CA-BSI rate 2.84• 12 month Project Average CA-BSI rate .73 = 74% Reduction• 10 out of 12 months with zero CA-BSI

CA-BSI Process/ Outcome

0%

20%

40%

60%

80%

100%

Co

mp

lian

ce

0.002.004.006.008.0010.0012.0014.00

CA

-BS

I R

ate

CL Bundle Compliance 0% 0% 0% 0% 0% 0% 0% 0% 82% 67% 74% 70% 94% 91% 91% 94% 100 100 92% 86% 91%

CA-BSI Rate 0.00 0.00 0.00 4.00 11.8 3.13 3.47 3.46 0.00 0.00 0.00 5.68 3.02 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0

CA-BSI Cases 0 0 0 1 4 1 1 1 0 0 0 2 1 0 0 0 0 0 0 0 0

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04

D-

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J-

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F-

05

M-

05

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05

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05

J-

05

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05

A-

05

S-

05

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05

Started PI

Spread to all providers

Overlake Hospital Medical Center - Seattle IHI Collaborative

IOM Report 2002

“Disparities in the health care delivered to racial and ethnic minorities are real and are associated with worse outcomes in many cases, which is unacceptable.”

Alan Nelson, committee chair

Unequal Treatment: Confronting Racial and Disparities in Health Care

Protocol driven interventions for HAIs are one step in addressing this larger issue.

SB 288 Mandatory Public Reporting of Healthcare-associated Infections

80th Regular Legislative Session 2007

• Hospitals, Ambulatory Surgical Centers (ASCs) to report specific HAIs to DSHS using CDC case definitions

• Must begin no later than 6/1/08• Minimum once per year, maximum each quarter• Must contain sufficient patient ID data

– avoid duplication– verify accuracy and completeness– allow for risk adjustment

• DSHS will review data for validity and “unusual data patterns or trends”

SB 288 Advisory Panel

• Two certified ICPs, one from a rural hospital• Two ICP certified and licensed nurses• Three MDs one with Pedi ID and Pedi epi, SHEA

members with expertise in IC• Two QA professionals-one ASC & one acute care• One officer of a general hospital• One officer of an ASC• Three nonvoting DSHS members• Two members representing the public as consumers

No lobbyists or healthcare trade association representatives Reimbursement is allowed

Sixteen member Advisory Panel– two year term

Adult Reportable SSI Infections• colon surgeries• hip and knee arthroplasties• abdominal and vaginal hysterectomies• CABG and vascular procedures

Pediatric Reportable SSI Infections

• Cardiac procedures excluding thoracic cardiac• VP shunt procedures• Spinal surgery with instrumentation• And (non-SSI) respiratory syncitial virus infection

Reportable Central Line InfectionsLab confirmed from a patient in any “special care setting

in the hospital”

Alternative Reporting

Report SSIs related to the 3 most frequently performed procedures from the National Healthcare Safety Network (NHSN) procedure list

For facilities with an average < 50 procedures/monthly

Reporting Mechanism• Plan A: Missouri Healthcare-Associated Infection

Reporting System- large IT project• Plan B: NHSN- complex and burdensome to ICP

– CDC proposal: vendors send HL7 messages to NHSN

• Plan C: Use Texas Hospital Discharge Data Network– Already reaches statewide except rural hospitals and will be

expanded to all ASCs under existing legislation– Claims file is called ANSI 837I, carries ICD9 claims data – ICP generated data attached to the ANSI 837

Common network carrying two data sets, claims and ICP-HAI.Both data sets can be used jointly to evaluate quality of care.

• Plan D – as needed• Option for public to report suspected SSIs to DSHS

– Poses significant challenges, particularly validation

HAI Report• Public summary for each reporting facility• Risk adjusted with a comparison of the risk- adjusted rates

for each reporting facility• Easy to read (consumer friendly)• Concise facility comments on report will be allowed• Posted on internet

Reporting Protections

• Confidential and privileged data• May not be used in a civil action to establish standard of

care• Enforcement- general hospital under Health and Safety

Code chapter 241, ASC under chapter 243

Potential Adverse Consequences of Reporting

• Diversion of resources from patient care to forms

• Creation of disincentives to treat higher risk patients• Misleading stakeholders through data manipulation

SB 288 Funding

• For FY 2008 DSHS requested $4.5M, 36 FTEs• LBB calculated $1.1M and 5 FTEs• FY 2009 DSHS requested $3.7M LBB calculated

$1.2M and 8 more FTEs• Other scenarios presented

Current status = not funded

• Safe, nurturing place

• Place of sanctuary

• Place of healing

Images of a Hospital

In one location• Lots of colonized and/or infected persons• Lots of vulnerable/susceptible persons• Lots of traffic between infected and vulnerable

persons Add in lots of antibiotic use

Reality of a Hospital

Design a system to facilitate the spread of infection. What would it look like?– A Hospital

Design a system to select for antimicrobial resistance.

What would it look like?– A Hospital

Reality of a Hospital

Adopting Change

Transformational Change

• Transformation (1) alters the culture of the institution by changing select underlying assumptions and institutional behaviors, processes and products; (2) is deep and pervasive, affecting the whole institution; (3) is intentional; and (4) occurs over time.

• Incremental improvement is not enough

• The pace of improvement is not fast enough

Resources

•Institute for Healthcare Improvement www.ihi.org•Texas legislature www.legis.state.tx.us•Association of Professionals in Infection Control

•www.apic.org•DSHS HAI website www.texasdisease.org