HAI Surveillance and Investigations in California CACDC Annual Meeting Oakland, California HAI Surveillance and Investigations in California CACDC Annual Meeting November 1, 2012 Oakland, California Kavita K. Trivedi, MD Public Health Medical Officer California Department of Public Health

Agenda Burden of Healthcare Associated Infections (HAIs) Role of Public Health CDPH HAI Program Federal HAI Requirements and Messages HAI Outbreak and Infection Control Management Collaboration with LHDs

Burden of Healthcare Associated Infections (HAIs)

Historically hospitals were not the safest places

The Current Problem Annual U.S. Total HAIs*1.7 million Deaths*99,000 Average additional direct cost to hospital $13.6 billion Overall net hospital cost $8.5 billion * From Klevens et al..Public Health Rep. 2007;122:160-6

Major HAIs 75% are accounted by four categories HHS National Action Plan for the Prevention of HAIs

Major HAIs Most are procedure related

Old Paradigm Many HAIs cannot be prevented because patients –Older –Immunocompromised –Multiple comorbidities and acute illnesses –One or more indwelling devices Low number of HAIs in any one institution renders prevention efforts not cost effective

New Paradigm HAIs can be prevented –Contamination of many devices can be prevented at time of placement and during maintenance –Devices can be removed as soon as they are no longer needed –Systems can be implemented to ensure that these steps are taken and if patient safety culture develops –Saves lives and money

New Paradigm? If you can’t measure it, you can’t prevent it If you measure and report it, it will decrease

MSNBC article June 27, 2012: 14 Worst Hospital Mistakes to Avoid 1.If you have a choice of hospitals, ask if your doctor knows your options' infection rates, which are measured using "catheter days," meaning every 24 hours that a tube is inserted in a patient's blood vessels. "The best hospitals' rates have been zero in one thousand catheter days for a year or more," says Dr. Pronovost. "If it's risen above three, I'd be worried."

Stakeholders in HAI Prevention Patients/residents Family members Community members Healthcare personnel Public health providers

Role of Public Health

Role of Public Health in HAI Surveillance and Prevention Abides by core functions of public health: –Monitor and detect HAIs in all healthcare settings; in some states report findings –Educate healthcare systems, providers and public on HAI prevention measures –Partner with healthcare providers and CDC to support HAI prevention efforts –Identify best practices and share across healthcare systems

Role of Public Health in HAI Surveillance and Prevention Abides by core functions of public health: –Interpret laws and regulations to improve public health by preventing HAIs –Ensure competent healthcare systems in HAI prevention and state surveyors –Evaluate and improve Infection Prevention programs including antimicrobial stewardship –Research innovative solutions through prevention collaboratives with stakeholders

California Department of Public Health HAI Program

Authorized by California Senate Bill 739 (2006) to provide HAI surveillance, prevention and annual reporting from all general acute care hospitals Established December 2009 Mission is to improve care quality and patient safety through the prevention of infections in licensed California healthcare facilities –Assist with surveillance and prevention activities –Develop and disseminate infection prevention recommendations and guidelines –Implement mandatory public reporting of HAI data CDPH HAI Program

Enforcement (L&C) is separated from all HAI Program functions HAI Program does not share information from healthcare facilities with L&C unless there is an imminent threat that is not being addressed HAI Program informs facility of need to report outbreaks and breeches to L&C (and LHD) Licensing and Certification (L&C) and HAI Program Relationship

A close working relationship between oversight and prevention programs enhances the effectiveness of each. It is helpful to have a structure that facilitates the relationship. Enforcement and Prevention

HAI Program Consultation and Guidance Provide infection prevention, outbreak management and antimicrobial stewardship recommendations with education at facility and county level per request of LHD and in partnership with CDPH Division of Communicable Disease Control Provide coordination with other state agencies Develop infection prevention guidance Provide onsite assistance when/if possible Educate L&C surveyors

Mandatory HAI Public Reporting in California Since April 1, 2010, CDPH only accepts data entered through CDC’s National Healthcare Safety Network (NHSN) for: Central line-associated bloodstream infections (CLABSIs), MRSA and VRE bloodstream infections, Clostridium difficile infection – public 2011 –Must be risk-adjusted using methodology “consistent with NHSN” 29 surgical site infections (SSIs) – public 2012 Healthcare personnel influenza vaccination, central line insertion practices (CLIP), and surgical antimicrobial prophylaxis (SCIP measures 1-3) – within 6 months of receipt beginning in

434 general acute care hospitals with 390 reporting entities –Law applies to licensed general acute care hospitals –No exemptions (size, nature, etc) Mandatory HAI Public Reporting in California

Reports are available at: –Unclear how these are being used by LHDs to target prevention activities –HAI Program has offered at CCLHO meetings to generate LHD specific reports if requested –To date, none have been requested other than Los Angeles in 2010 –All hospitals in Los Angeles County have joined their NHSN group Mandatory Public Reporting in California

Federal HAI Requirements and Messages

Health and Human Services HAI Action Plan - Strategy Prevention and Implementation –Prioritize recommended practices to facilitate implementation Research –Identify gaps and develop coordinated research agenda Incentive and Oversight –Evaluate compliance with infection control practices in hospitals through required certification processes –Identify additional options for use of payment policies and financial incentives to motivate organizations to provide better, more efficient care Information Systems and Technology –Make varied HHS data systems interoperable Outreach and Messaging

26 American Recovery and Reinvestment Act (ARRA) $40 million over 2 years to increase state capacity and supplement existing programs –49/50 states with HAI Programs –Through CDC Expanded Epidemiology and Laboratory Capacity (ELC) Cooperative Agreement Tied to Federal HHS National Action Plan for the Prevention of HAIs –Required submission of state plan –Expand use of NHSN –Develop prevention collaboratives

27 American Recovery and Reinvestment Act (ARRA) CDPH Funding $2.6 million over 2 years –Contract with Public Health Foundation Enterprises Supported up to 8 FTE infection preventionists Regionally placed to facilitate onsite services –LHDs including LA, San Diego, Stanislaus Onsite consultation to most California hospitals Prevention collaboratives –Small/rural hospitals, LTACs, prison hospitals Courses, trainings

Affordable Care Act (ACA) Jan 2011-July 2012 –With additional funding supported 7 IP FTEs –Project oriented, across spectrum of care (e.g. CDI in Imperial County) August 2012-July 2013 –Funding for 6 IP FTEs –Restricted to across spectrum projects except for 50 hospital SSI data validation

Current Center for Medicare and Medicaid Services (CMS) Requirements CMS IPPS Rule – CMS-1498-P: Changes to FY2011 Rates for acute care hospitals –National public reporting of HAIs through NHSN CLABSI and SSI initially (hip and CABG) Implementation of HHS HAI Action Plan over time –6% of Medicare payments to hospitals contingent on reporting errors and provision of safety care, focus on HAIs and readmissions 9% by 2015, $70 billion Links reduction of HAIs to federal payment De facto national mandate

Upcoming CMS Requirements CMS Reporting ProgramHAI EventReporting Specifications Reporting Start Date Long Term Care Hospital Quality Reporting (LTCHQR) Program CLABSI Long Term Care Hospitals *: Adult and Pediatric LTAC ICUs and Wards October 2012 Long Term Care Hospital Quality Reporting (LTCHQR) Program CAUTI Long Term Care Hospitals *: Adult and Pediatric LTAC ICUs and Wards October 2012 Inpatient Rehabilitation Facility Quality Reporting Program CAUTI Inpatient Rehabilitation Facilities: Adult and Pediatric IRF Wards October 2012 Hospital Inpatient Quality Reporting (IQR) Program MRSA Bacteremia LabID Event Acute Care Hospitals: FacWideIN January 2013 Hospital Inpatient Quality Reporting (IQR) Program C. difficile LabID Event Acute Care Hospitals: FacWideIN January 2013 Hospital Inpatient Quality Reporting (IQR) Program HCW Influenza VaccinationAcute Care HospitalsJanuary 2013 Long Term Care Hospital Quality Reporting (LTCHQR) Program HCW Influenza Vaccination (proposed) Long Term Care Hospitals*TBD Ambulatory Surgery Centers Quality Reporting Program HCW Influenza VaccinationAmbulatory Surgery CentersOctober 2014 Ambulatory Surgery Centers Quality Reporting Program TBD (future proposal) Hospital Outpatient Departments and Ambulatory Surgery Centers TBD * Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN

Medi-Cal Non-reimbursement As of July 1, 2012 providers must report Provider-Preventable Conditions (PPCs) Documents/LNC-AFL pdfhttp:// Documents/LNC-AFL pdf

HAI Outbreak and Infection Control Management

HAI Outbreak and Infection Control Breech Investigations Major detriment to patient care and patient safety –Can be devastating for healthcare workers Can have massive financial and public relations impacts on healthcare facilities Sentinel events that help us understand and confront emerging challenges in healthcare Can play an important role in making recommendations that improve overall patient care and provide important opportunities for education

HAI Program and Outbreak Investigations Led the investigation of: –MDR Acinetobacter baumannii in LTCF (2010) –Candida spp. CLABSIs in acute care hospital (2011) –Vascular-associated bloodstream infections in hemodialysis (HD) patients from one company providing outpatient HD services ( ) –Clostridium difficile infections in LTCF (2012) –Hepatitis B virus exposure in an ambulatory surgical center (2012) –National fungal meningitis outbreak due to contaminated epidural/joint steroid injections

HAI Program and Telephone Consultations Invasive Group A Streptococcus in postpartum women Salmonella Newport in NICU Norovirus, scabies, influenza management in LTCFs MDRO (CRE and ESBLs) management HBV and HCV exposures associated with licensed healthcare facility Hospital realized they had been using wrong % gluteraldehyde for endoscope disinfection for approximately 7 years

CDPH Outbreak and Infection Control Management Contact LHD Encourage LHD/facility to report to L&C –If unusual occurrence Rely on our experience (Jon Rosenberg, Infection Preventionists) Conduct literature review Contact CDC subject matter expert –Other state clusters/outbreaks –Management expertise –FDA involvement

Worldwide HAI Outbreak Resource

Investigation Management Case Finding –Microbiology data –Infection control or surveillance records –Discussions with clinicians Linelist –Signs and symptoms- is this an outbreak? –Medications –Procedures –Consults –Location –Staff contact? –Host factors?

Caveat emptor! A limited line list can be misleading Not every case might be exposed to the source Many cases may be exposed to something that is only an associated factor

Observations Who and what to observe is generally driven by the line list Initial observations and review of procedures can be very informative and can help with the creation of a standard observation tool, if needed

Implementing Control Measures Ultimately, primary goal is to stop transmission, not necessarily find source It’s OK to implement a variety of control measures targeting various possibilities based on initial observations

Other Important Issues in HAI Outbreaks Aside from the patients, there will be other “interested parties” –Hospital administration –Media –Lawyers

Collaboration with LHDs

HAI Surveillance, Public Reporting and LHDs Important for LHDs to be aware of HAI prevention activity given reporting requirements and federal reimbursement policies HAI Program strives to improve utility of HAI public reports to LHDs by: –Providing dedicated education on how to use reports –Assisting in targeting prevention activities at local level

HAI Surveillance, Public Reporting and LHDs Prevention component is extremely important and not been main focus of HAI Program LHDs can assist with leading these efforts at the local level

HAI Outbreak and Infection Control Management and LHDs Important for LHDs to continue to be notified and manage these at the local level HAI Program will continue to provide telephone consultations and active involvement –First points of contact: Kavita K. Trivedi, MD and Rebecca Siiteri, RN, MPH

HAI Outbreak and Infection Control Management and LHDs No distinction between LTCF and acute care Acute care – safety net of hospital epidemiologist and infection preventionist –If outbreak or breech, may consider quickly contacting HAI Program LTCF – limited safety net and LHDs have much experience –Contact HAI Program if something unusual

HAI Outbreak and Infection Control Management and LHDs Important to remember that CDPH can only issue guidance if they are notified about infection control issues in LTCFs and acute care Even if LHD is able to manage, consider notifying HAI Program of investigation

HAI Outbreak and Infection Control Management and LHDs If observation or onsite assessment is requested of the HAI Program: –HAI Program will assess resources Note: Current travel of state employees is limited; 1 furlough day per month –Assistance will be provided only if member of LHD is able to accompany HAI Program staff for education System should be sustainable so that if another similar infection control problem arises at same LHD, they are able to better manage

Discussion What is the role of LHDs in HAI investigations? Should a triage process be developed for HAI investigations and when CDPH is involved? Should a distinction be made between licensed and unlicensed facilities for investigation purposes?

Discussion Should an assessment of LHDs HAI resources and capabilities be done? Should we focus on HAIs with the greatest threat to public health? –Communicability vs. severity of illness

Questions/Comments? Kavita K. Trivedi, MD Rebecca Siiteri, RN, MPH CDPH HAI Program