HealthCare Associated Infections in Acute Care Hospitals Data from July 1, 2009 – June 30, 2011 Public Health Council

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH Reporting Philosophy To catalyze hospital-specific and statewide initiatives to address the most prevalent preventable infections through surveillance and dissemination of best practices To validate that the extensive work conducted across the health system often reduces the rate of preventable adverse health events, and to refocus interventions where such reduction is not seen To further inform consumers, policy-makers, and providers on the frequency and setting of adverse events To report the occurrence of HAIs as a means to inform improvement as a core measure of hospital quality and safety; these measures are not intended to be punitive Not all HAIs may be averted. However, our goal remains elimination of all those adverse events which are preventable. The long-term goal of HAI reporting is to minimize the number of these occurrences through increased awareness and development of robust systems for error trapping and prevention. Therefore, we seek to gain a greater understanding of how preventable infections happen and how they can be prevented in the future

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH A New Philosophy To increase accessibility to consumers, policy-makers, and technical experts alike To develop data feedback loops to focus high-yield interventions “Not letting the perfect get in the way of the good”

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH HAI Background HAI recognized as a critical challenge to patient safety and public health Increased attention due to role in escalating healthcare costs, patient and family impact and recognition many are preventable Aggressive national and local efforts to address HAI Targeted by HHS and CMS for nonpayment

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH HAI Data Overview The public presentation of quality and safety data is essential to the DPH commitment to transparency and accountability Consumers need reliable data to help make informed healthcare decisions Providers need standardized performance measures to support improvement efforts Policy makers require access to data to target prevention efforts, promote alignment of incentives and reinvestment in successful strategies.

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH Statutory & Regulatory Framework Massachusetts law provides DPH with legal authority to conduct surveillance and to investigate and control spread of communicable and infectious diseases MGL c.111, sections 6 & 7 HAI regulatory language can be found in 105 CMR

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH Acknowledgements Deb Wachenheim (Health Care for All) Paula Griswold (MA Coalition for the Prevention of Medical Errors) Deb Yokoe (Brigham & Women’s Hospital) Ken Sands & Sharon Wright (Beth Israel Deaconess Medical Center) John Snow Inc. data validation team Charles Deutsch, Richard Platt, Michael Klompas, Ken Kleinman, Karen Kieser (Harvard Catalyst) Al DeMaria, Shauna Onofrey, Johanna Vostok, Nora McElroy, Will Lapsley (DPH HAI Epidemiology Team) Eileen McHale (DPH HAI Coordinator) Karen Boudreau (Institute for Health Care Improvement) MDPH Healthcare Associated Infection Technical Advisory Group NHSN staff Commissioner Auerbach

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH 2012 Reporting Goals Present objective data using national standardized definitions and scientifically sound analysis Provide reports that are useful, accessible and understandable for consumers, providers and policy makers Use data to inform policy, drive innovation and quality improvement

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH Process for Improvement MDPH leadership commitment to creating change and driving improvement Collaboration with a diverse group of stakeholders Evaluated multiple options for depiction of data graphics intended to improve understanding of data Includes hospital specific summary to be used by facilities as an improvement tool

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH History

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH ASTHO Framework Cardo D, Dennehy PH, Halverson P, et al., Moving toward Elimination of Healthcare-Associated Infections: A Call to Action ICHE 2010, 31:

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH How to Use this Report “…every member of the health care team, from the doctor to patients and their families, has a role in prevention and elimination of HAIs…” Key risk factors – shared responsibility Encourages candid communication with providers “…many factors contribute to a hospital’s quality of care. The overall quality and safety of a hospital is not determined only by HAI rates…” Resources for patients and their families

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH Why HAI? Among the leading causes of preventable death in U.S. 1 in 20 hospitalized patients affected 1.7 million infections/99,000 deaths 2007, the annual economic burden of HAI in Massachusetts ranged from $200 to $400 million CDC estimated the U.S. direct medical cost of treating HAI ranges from $35.7 billion to $45 billion annually. Adherence to evidence based practices can reduce certain HAIs by as much as 70 percent.

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH Surveillance systematic collection, analysis, and interpretation of data on the occurrence of infectious diseases or events all healthcare facilities reporting data must use the same definitions National Healthcare Safety Network. Extensive data validation (JSI)

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH Data Flow

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH CLABSI Central Line Associated Blood Stream Infections “The CDC defines a CLABSI as recovery of a pathogen from a blood culture (a single blood culture for organisms not commonly present on the skin and two or more blood cultures for organisms commonly present on the skin) in a patient who had a central line at the time of infection or within the 48-hour period before development of infection” 12,000 to 28,000 per year. Each episode costs ~$16,550 Use of central lines directly correlated to infections rates

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH SSI Surgical Site Infections: hysterectomy (abdominal and vaginal), knee and hip arthroplasty, coronary artery bypass graft more than half of SSIs are not identified until patients are discharged from the hospital and patients with infection do not always return to the same hospital where the original surgery was performed.

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH Risk Adjustment & Stats Many factors may contribute to infections, including prior health history, age, complications of a procedure, smoking, obesity, and others. Models used attempt a correction for some degree of risk, they likely do not entirely eliminate differences between facilities that may result from this risk. CLABSI: state and national baselines SSI: national baseline only (smaller sample size)

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH Flu Vaccination

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH Data Highlights Summarizes HAI rates in acute care hospitals for the reporting period of July 1, 2009 – June 30, 2011 New - Hospital specific “Summary Sheets” (handout) Describes prevention activities and initiatives Improved graphics and readability

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH CLABSI Data Massachusetts acute care hospitals reported 199 CLABSIs during FY11, an overall decrease in SIR of 24% from FY10 SIR in all ICU types was statistically the same or lower than predicted compared with both state and national baselines. Compared with state baseline, SIR of medical ICUs in major teaching hospitals and SIR of NICUs for babies g were statistically significantly improved FY10  FY11. Central line utilization only modestly decreased.

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH CLABSI Data cont.

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH CLABSI Data Cont.

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH CLABSI Data Cont.

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH Central Line Utilization

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH CLABSI Pathogens

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH Surgical Site Infections Hip arthroplasty statistically significantly lower than predicted Vaginal hysterectomy statistically significantly higher than predicted Knee arthroplasty, abdominal hysterectomy, and CABG as predicted Primary barrier to good data is high variability of post- discharge surveillance capacity; reliance on admin data provides limited insights.

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH SSI Data

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH Vaginal Hysterectomy Statistical high-outlier in FY10 and FY11 Further investigation is needed to determine causes though it may in part be due to coding inconsistencies by which hysterectomies with an abdominal incision but a vaginal extraction are counted as vaginal hysterectomies. Not mandated nationwide therefore smaller pool for national baseline DPH is assembling a small working group of key stakeholders/outliers to assess etiology and disseminate best practices

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH SSI Pathogens

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH SSI Outliers (high and Low)

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH One-Pagers Caution Page (description of statistical limitations) Overview Page (explanation of how to read hospital-specific one pagers)

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH One-Pager Template

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH HAI Activities: Infection Prevention Surveys Infection Prevention Unit within Division of Health Care Quality MDPH nurse-surveyors conduct unannounced, on-site assessments of infection control programs, encouraging innovative programs and guiding best practices, as well as addressing deficiencies or concerns

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH ARRA Funding Coordination and Reporting of State HAI Prevention Efforts Detection and Reporting of HAI Surveillance Data Establishing a Prevention Collaborative (C. difficile)

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH Collaboratives : CDC, MDPH, MA Coalition, Masspro C. difficile Infection Prevention in Hospitals July 2012: CDC, MDPH, MA Coalition, Mass Senior Care, Masspro C. difficile Infection Prevention Partnerships in Hospitals and Skilled Nursing Facilities Expansion of HAI prevention to additional settings of care – Long Term Care. 17 acute care hospital teams and 74 long term care facilities participating Evidence based CDI prevention recommendations Expanding professional social networks Teaching and encouraging use of QI methods, focusing especially on small tests of change Teaching and encouraging use of adaptive strategies for front line staff engagement : CDC, MDPH, MA Coalition, Masspro C. difficile Infection Prevention in Hospitals July 2012: CDC, MDPH, MA Coalition, Mass Senior Care, Masspro C. difficile Infection Prevention Partnerships in Hospitals and Skilled Nursing Facilities Expansion of HAI prevention to additional settings of care – Long Term Care. 17 acute care hospital teams and 74 long term care facilities participating Evidence based CDI prevention recommendations Expanding professional social networks Teaching and encouraging use of QI methods, focusing especially on small tests of change Teaching and encouraging use of adaptive strategies for front line staff engagement.

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH Report Dissemination PLan This report is an important step in promoting transparency for healthcare consumers and motivation for hospitals to continue to prioritize HAI prevention but much remains to be done to accelerate progress towards the goal of HAI elimination MDPH has contacted CQOs (or CMOs) in high and low outliers prior to public release Over time MDPH will continue to refine and enhance data presentation MDPH will continue to work with hospitals and additional state and national organizations in a comprehensive effort to address these largely preventable infections. Text report will be posted online today. Hospital-specific fact sheets will be posted by Friday

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH Facilitating continuous QI. Moving towards consumer self-assessment of risk to inform decision making. Make the reported HAI data easily actionable & readily available so that reports may be used to more rapidly drive improvements. Developing thresholds for action and recommended next steps if these thresholds are reached. Benchmarking our state not against national averages, but against high- performers in the 80th percentile and higher. Dual focus on clinical and surveillance data. Looking to the Future

M ASSACHUSETTS D EPARTMENT OF P UBLIC H EALTH Thank you Massachusetts Department of Public Health Bureau of Health Care Safety & Quality Office of Emergency Medical Services 99 Chauncy Street, 11 th Floor Boston, MA For Further Information, Please Contact Iyah Romm, Special Assistant to the Director