SC ACA Implementation Committee – Quality and Outcomes Work Group Jerry Gibson DHEC ‐ State Epidemiologist 6/3/2011
HIDA � Hospital Infections Disclosure Act � Passed in May 2006, requiring inpatient acute care hospitals to report to the SC DHEC selected hospital acquired infections and selected infection prevention processes
HIDA (cont) � Since 2007, inpatient rehabilitation and long ‐ term acute care (LTAC) facilities have been added. � Currently, 79 facilities report on central line associated bloodstream infections (CLABSIs) and certain surgical site infections (SSIs)
Timeline for Activities Required for Compliance with Hospital Infections Disclosure Law Aug 06 1 st Advisory Nov 07 Committee DHEC meeting Feb 07 accesses DHEC July 07 6-month Aug 06 Feb 08 Feb 09 DHEC of data in 1/31/08 6/29/06 CDC begins DHEC DHEC DHEC Training pilot gets NHSN to DHEC begins submits 1 st internal for analysis funding begin publishes QA of Report to 1 st report meeting DHEC of data ??? analysis data legislature May 06 Nov 06 Jan 07 May 07 Law Begin ICPs ICPs passed Training begin to begin formal for ICPs pilot at APIC NHSN entry of data into NHSN
National Healthcare Safety Network � A secure, internet based surveillance system through which facilities can report their data on hospital associated infections
What is a Standardized Infection Ratio (SIR)? � The SIR is a summary measure used to track HAIs at a national, state, and local level over time. � Method of calculating is similar to the Standardized Mortality Ratio � The SIR compares the actual number of HAIs reported to the baseline experience � Adjusted for several risk factors that have been found to be significantly associated with differences in infection incidence. � An SIR greater than 1.0 indicates that more HAIs were observed than predicted; an SIR less than 1.0 means fewer HAIs were observed than predicted
Mandatory Reporting of Healthcare ‐ associated Infection Rates ‐ 2009 * www.APIC.org
Central lines access large veins, catheter tip is near heart, may remain in place for weeks or months Central line ‐ associated bloodstream infection = CLABSI
CLABSI � Crude mortality 10 ‐ 40% � Attributable mortality 2 ‐ 15% � Prolongation of hospitalization 5 ‐ 20 days � Attributable cost $34,000 ‐ $56,000
Central Line # Hospitals Total # Total # % Lower % Not % Comments Locations monitoring Central Infection SIR Different Higher Locations Line s SIR SIR Days SIRs for CLABSI, All Adult 62 247,473 329 4.84% (3) 82.26% 1.61% (1) Seven all SC hospitals Inpatient (51) hospitals Units (11.29%) had too calendar year few central line days to calculate 2010, by patient a statistical care unit percentage Adult 52 134,929 228 7.69% (4) 84.62% 5.77% (3) One hospital Critical (44) (1.92%) had too Care Units few central line days Pediatric 16 9833 10 6.25% (1) 56.25% 0% Six hospitals Inpatient (9) (37.5%) had too few central line days Pediatric 5 7371 11 20% (1) 80% 0% N/A Critical (4) Care Unit Inpatient 16 12,804 14 0% 87.5% 6.25% (1) One hospital Rehab Unit (14) (6.25%) had too few central line days LTAC 7 50,279 77 0% 100% 0% N/A Heme/Onc 8 35,566 53 25% 75% 0% N/A Unit (2) (6) Pediatric 3 6378 15 0% 100% 0% N/A Heme/Onc Unit Bone 1 810 0 0% 100% 0% N/A Marrow Transplant Unit
SC CLABSI DATA � **Although not from 2010 data, it should be noted that in March 2011, the CDC released data showing that, of 17 states with a mandate for reporting CLABSIs to NHSN, South Carolina was the only state to demonstrate a significant decrease in CLABSI SIRs. South Carolina’s CLABSI rate dropped 30% July to December 2009 when compared to January to June 2009, in continuously reporting facilities. (www.cdc.gov/vital signs)
PICU CLABSI SIR Trend Graph (Only Includes Medical and Medical/Surgival PICUs) 5 ?? CI 4.5 SIR O=E 4 3.5 Standardized Infection Ratio 3 3 2.5 2 1.61 1.5 1.18 1.01 1 0.53 0.5 Source: DHEC, Bureau of Disease Control - HAI Section 0 Jan 08 - Jun 08 Jul 08 - Dec 08 Jan 09 - Jun 09 Jul 09 - Dec 09 Jan 10 - Dec 10 Trend Point
Continuation of Hospital Report
Surgical Site Infections � In SC, we monitor SSIs from: � Coronary Artery Bypass Graft (CABG) � Hip Replacements � Knee Replacements � Abdominal Hysterectomies � Colectomies (in facilities with <200 beds) � Previously collected cholecystectomies, but site dropped because very low infection rates
SIR � SIR= observed expected � For SSIs, calculated using logistical regression model � Risk factors vary by procedure, but include patient age, ASA score, surgery duration, medical school affiliation, gender, type of anesthesia used, hospital bed size, wound class, trauma and others
Surgical site infections, six sites, all SC hospitals, calendar year 2010 Surgical # Hospitals Total # Total # % Lower % Not % Higher Comments* Procedures performing Procedures Infections SIR Different SIR procedure SIR Coronary 16 3930 29 0% 93.75% (15) 6.25% N/A Artery Bypass (1) Graft (Chest and Donor Incision) Coronary 12 293 1 0% 33.33% (4) 0% * Eight Artery Bypass Hospitals (66.67%) had too Graft (Chest few procedures to calculate Incision) statistical percentage Hysterectomy 49 5337 44 0% 75.51% 2.04% Eleven (Abdominal) (37) (1) hospitals (22.45%) had too few procedures Hip Prosthesis - 53 6684 81 0% 73.58% (39) 5.66% Eleven -Replacement (3) hospitals (20.75%) had too few procedures Knee Prosthesis 50 10,394 69 0% 82% 6% Six --Replacement (41) (3) hospitals (12%) had too few procedures Colon Surgery 34 1,246 36 0% 58.82% (20) 5.88% Twelve hospitals (35.29%) (2) had too few procedures
Example of an Individual Hospital Report SC was one of only 5 states that validated all Reports. Rates were significantly higher in those states, due to better reporting.
Microorganisms Number Percent Isolates Candida species and other yeasts 147 17.8 Enterococcus species (includes VRE) 143 17.3 Vancomycin resistant enterococcus (VRE only - % of total isolates) 41 (5.0) Coagulase negative Staphylococcus species 140 16.9 Staphylococcus aureus (includes MRSA) 104 12.6 Methicillin resistant Staphylococcus aureus (MRSA) only - % of total positive 66 (8.0) isolates) Klebsiella species 77 9.3 Enterobacter species 39 4.7 Escherichia coli 33 4.0 Pseudomonas species 25 3.0 Serratia species 22 2.7 Streptococcus species 18 2.2 Acinetobacter species 15 1.8 Stenotrophomonas maltophilia 7 0.8 Citrobacter species 7 0.8 Proteus species 6 0.7 Bacteroides species 5 0.6 Other anaerobes 5 0.6 Providencia species 4 0.5 Morganella species 4 0.5 Burkholderia species 3 0.4 Clostridium species 3 0.4
Validation � SC is one of few states that validates data entered into NHSN by facilities � One of only five states that perform actual chart reviews � Especially important to identify “system” errors � Also helps DHEC to establish and maintain good relationships with IPs � In 2009 CDC report on infection rates from 10 states with “mature” reporting, CDC concluded that the states doing validation had significantly better reporting completeness(including SC and NY).
� Provides framework to ensure progress towards five ‐ year national prevention targets as described in the HHS Action Plan in the following areas: � Develop or Enhance Public Health HAI Program Infrastructure � Surveillance, Detection, Reporting, and Response � Prevention � Evaluation, Oversight, and Communication
Hospital Infections Disclosure Act (HIDA) Web Sites � DHEC Public Reports � www.scdhec.gov/hai � Information for Hospitals � www.scdhec.gov/hidainfo
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