Implementation of Texas Healthcare-associated Infection Reporting Neil Pascoe RN BSN CIC Epidemiologist TPHA 4/22/10

Today Federal Issues State Process Reporting ( who, what, when, and how) Possible LHD and HSR roles

Increasing Need for Public Health Approach Across the Continuum of Care Outpatient/ Ambulatory Facility Tranquil Gardens Nursing Home Home Care Acute Care Long Term Care

Current Landscape of HAI Surveillance - Policy Emphasis remains mandatory HAI reporting and public reporting of hospital-specific data possible federal mandate coupled with renewed interest in data validation enabling greater public access to machine readable data sets

Current Landscape of HAI Surveillance - Scientific Increasing interest in MDRO Clostridium difficile-associated disease HAIs in non-hospital settings LTCF and ASC Algorithmic detection of HAIs Risk modeling Use of observed-to-predicted (expected) ratios as summary statistics for comparative purposes (SIR)

Current Landscape of HAI Surveillance -Technical Renewed calls for system simplification Increasing demand for technical solutions that make use of healthcare data in electronic form Harmonizing data and reporting Unprecedented federal support for healthcare information technology

Healthcare-Associated Infections (HAIs) Problem Bloodstream infections, urinary tract infections, pneumonia, surgical site infections Annual Impact 1.7 million HAIs in hospitals—unknown burden in other healthcare settings 99,000 deaths and $28-33 billion in added costs Solution Implementing what we know for prevention can lead to up to a 70% or more reduction in HAIs 7

National Initiatives TJC- Patient Safety/NPSG/EOC CMS- PAO/Reimbursement and Standards AHRQ: improve the quality, safety, efficiency, and effectiveness of health care NQF: setting priorities and goals for PI (SRE ≠ PAE) PSO: The Patient Safety and Quality Improvement Act of 2005 Consumer Advocates- Consumers Union- others CDC: lead agency for many initiatives and coordination AHRQ is the lead Federal agency charged with improving the quality, safety, efficiency, and effectiveness of health care NQF Setting national priorities and goals for performance improvement; Endorsing national consensus standards for measuring and publicly reporting on performance; and Promoting the attainment of national goals through education and outreach programs. PSOs are organizations that share the goal of improving the quality and safety of health care delivery

Caveats There are some discrepancies in the legislation There are staffing and funding issues “RULES HAVE NOT BEEN WRITTEN” Composition of the AP will change We do not have all of the answers (or for that matter the questions)

Background 78th legislative Session (2005) passed study bill Advisory Panel 79th session passed SB 288 created chapter 98, expanded AP, no $ 80th session passed SB 203 expanded AP, PAE, 4 FTE and $$ www.haitexas.org

Who has to report >350 ambulatory surgical centers Includes LTAC 500+ general hospitals Includes LTAC Includes Pediatric and Adolescent Excludes long term rehab hospitals >350 ambulatory surgical centers

What has to be reported Bloodstream infections associated with central lines Surgical Site Infections 3 pediatric 7 adult Preventable Adverse Events National Quality Forum (SRE) Non-reimbursed Medicare event or condition

Healthcare-associated Infections Patient and procedure information for each reportable surgery More than 10 reportable surgeries Each reportable surgery regardless of associated infections Over 72,000 knee replacement surgeries performed annually in Texas Over 38,000 hip replacement surgeries performed annually in Texas Infections occur with 1-2% of these surgeries

Approximate number of reports based on 2008 3rd quarter administrative (hospital) data

What does DSHS need to do? Establish a reporting system Provide education and training Prepare a summary by health care facility Succinct facility comments Publish a summary at least annually Make summary available on a website Accept reports from the public Perform data validations--validation tools Functionality to conduct and track audits at hospitals and ASCs**

HAI - Funding $710,872 to build surveillance infrastructure General appropriation $2,173,452 for the biennium and four new FTEs American Recovery and Reinvestment Act (ARRA) $1,234,000 total $710,872 to build surveillance infrastructure funds for two FTEs

How will Facilities Report? (The Reporting System) National Healthcare Safety Network Used by over 2,000 healthcare facilities in 50 states (2456 as of 1/18/10) Healthcare facilities may enter data on: Device-associated adverse events Procedure-associated adverse events Medication-associated adverse events

What is NHSN? National voluntary, confidential system for monitoring events associated with health care Initial focus on infections in patients and healthcare personnel (NNISS) Expanding to include noninfectious events (such as process measures) Accessed through a secure, web-based interface Open to all US healthcare entities at no charge

NHSN Managed by the Division of Healthcare Quality Promotion (DHQP) at CDC. Open to all types of healthcare facilities in the United States, including acute care hospitals, long term acute care hospitals, psychiatric hospitals, rehabilitation hospitals, outpatient dialysis centers, ambulatory surgery centers, and long term care facilities.

NHSN Eligibility Criteria US healthcare facility listed in or associated with a facility that is listed in one of the following national databases: American Hospital Association (AHA) Centers for Medicare and Medicaid Services (CMS) Veteran’s Affairs (VA). high-speed Internet access digital certificate on computers willing to follow the selected NHSN component protocols exactly report complete and accurate data in a timely manner during months when reporting data for use by CDC willing to share such data with CDC for the purposes stated above. provide written consent from facility’s chief executive leadership (e.g., Chief Executive Officer).

Texas - State HAI Plan Technical Review From HHS 4/14/10 1) Continue developing infrastructure and partnerships across the healthcare continuum to improve the detection, reporting, and investigation of HAI outbreaks in both inpatient and outpatient facilities. 2) It would be beneficial to work with your advisory committee to monitor the effectiveness of your prevention initiatives activities and time it takes for full implementation. 3) Develop methods of communication to share best practices among the participating healthcare facilities. 4) Continue working on assessing how to use NHSN for statewide standardized reporting of HAI data. 5) Ensure engagement of local health departments in HAI activities.

Roles of Local and Regional HD Education and training Information transfer and data validation Outbreak investigation Other activities???

Preventable Adverse Events NQF Serious Reportable Events and CMS non-reimbursable event program will not provide additional payment to the facility under a policy adopted by the federal Centers for Medicare and Medicaid Services Different method for reporting How many reports? Separate rules almost a certainty

Summary SB 203 went into effect 9/1/09 There will be more legislation Be watching in Texas Register for proposed and then adopted RULES to provide the ‘how to’ of these new laws

Thanks HAI and PAE AP (don’t you love acronyms?) Sharon Williamson, Patti Grant and NHSN HAI IPT TSICP

HAI Resources DSHS : www.haitexas.org Consumers ww.stophospitalinfections.org/ NHSN website: http://www.cdc.gov/nhsn National Quality Forum: www.qualityforum.org/ AHRQ: http://www.ahrq.gov/ Centers for Medicare and Medicaid Services http://www.cms.gov/ HICPAC Guidance on Reporting HAIs http://www.cdc.gov/hicpac/pubReportGuide/publicReportingHAI.html