1. MQF HAI Subcommittee: HAI Plan Update June 24, 2013 Peg Shore, MT, MSPH, Ph.D., CIC HAI Prevention Coordinator

2. Introduction to HAIs Healthcare-Associated Infections 99,000 deaths/ year (more than breast cancer, prostate cancer and AIDs combined!) 1.7 million HAIs per year (2002) Cost: total $36 billion to $45,000,000,000 (2007 dollars)/ year in U.S.

3. Types of HAIs Central line infections (CLABSIs) SSIs: superficial and deep Catheter-associated UTIs Clostridium difficile MRSA-HAI

4. Deaths by HAIs, U.S., 2002 Pneumonia35,000 Bloodsteam infection 31,000 UTI13,000 C. difficile** 9,000 SSI 8,000

5. CDC estimates Could reduce between 33% to 50% of these infections, at a savings of $6.6 to 8.4 billion. Could save 33,000 lives/ year in U.S.

6. Changing Healthcare Landscape Since 2002, shift in philosophy: Public demand for: Accountability Transparency Financial reimbursement (Medicare & MaineCare-Medicaid primarily)= no pay for HAIs

7. Maine State Reporting Mandates- All hospitals 2007: Central line associated bloodstream infections (CLABSIs), central line bundles, central line insertion practice (CLIP), surgical care improvement program (SCIP), ventilator associated pneumonia (VAP) bundle. 2011: Added MRSA-HAI and C. difficile (lab confirmed- inpatients only)

8. Current Medicare (CMS) Mandates: IPPS hospitals only (CAHs exempt) Central line infections (CLABSIs) Catheter-associated UTIs (CAUTIs) SSIs: colons, abdominal hysterectomies MRSA bacteremias C. difficile- Lab ID event HCW influenza vaccination

9. Medicare Reimbursement: How Important is it? For larger hospitals, Medicare is 50 percent of hospital’s payment for services. Critical access hospitals, it is often 2/3rds of hospital reimbursement. Mandated reporting of HAIs (CMS): if miss deadline, reduce payment by 2%. (5.5 months lag)

10. Public Health & HAI Prevention: ARRA funding As 5 th cause of death in the US, it has become a public health issue. 2009, American Recovery and Rehabilitation Act (ARRA) funded 49 states to build programs. HAI Prevention Programs: 1) infrastructure, 2) prevention & surveillance, 3) communication.

11. Maine HAI Prevention Program Initially, focus on hospitals with Maine Infection Prevention Collaborative as the advisory group. Expanded into LTC. Worked with QIO. Offered 10 day long seminars all over the state. Working on antibiotic stewardship to reduce C. difficile and resistant organisms (multiple drug resistant organisms-MDRO).

12. Data validation How do we know if the numbers reported are accurate? Must validate the data State law: Maine CDC must validate C. difficile and MRSA-HAI Maine Quality Forum: validating CLABSI. Being done by John Snow Institute (JSI)- Boston, MA.

13. Maine HAI Plan Create infrastructure Surveillance & Prevention Communication After 3 years of work, we are in a NEW place. We have created program in Maine CDc, gathered & validated data, are analyzing, and communicating with hospitals.

14. State of Maine HAI Plan We have accomplished all that was in the grant, and more: – LTC – ASP – Outbreak reporting and assistance – Distributed educational materials for patients – Surveillance and feedback to hospitals – Self-sustaining model for HH compliance – NHSN used by all hospitals/ validation of data

15. ASP Maine CDC is analyzing MaineGeneral antibiogram and creating pocket reference guide for outpatient prescribing. Working with MMA- Maine Independent Clinical Information Service to do academic detailing of antibiotics. Rollout is scheduled for November, 2013.

16. CLABSI validation JSI plans to do a 2 day visit to Peer Group A hospitals. Will do a 1 day visit to 2 of largest hospitals in Peer Group B (St. Mary’s and Mercy). Other B hospitals will be done by sharing data remotely.

17. Types of Communication Facility-specific dashboard reports to hospital Hand hygiene compliance every 6 months Influenza vaccination of HCW comparing all hospitals, yearly. Meet with MIPC monthly= all hospitals IP Maine Quality Council: HAI subcommittee

18. State of Infection Control & Prevention (Maine CDC/ MQF Annual Report) CLABSI- adult and NICU: CLABSI: high mortality rate 14%-25% – majority of infections are in the 3 largest hospitals/ more complicated patient/ more CLs – Device utilization statewide is low – MMC made huge progress in past 5 years but is still above the national average for CLABSIs.

19. Statewide analysis: CAUTI CAUTI for IPPS hospitals: Mandated reporting by CMS/ Most common type of HAI. – A few larger hospitals had higher CAUTI rates, sometimes in a single unit. – Most hospitals had decreasing urinary catheterization utilization rates. Again, some units had high DU rates. Often these units also had high CAUTI rates.

20. SSI Very limited data, CMS requires only colon and abdominal hysterectomy data from IPPS hospitals. Critical Access Hospitals do not report any SSI data.

21. MRSA-HAI Rates varied widely between hospitals. 50% in ICU and 50% in non-ICU Highest type of MRSA-HAI – SSI 42% (47) – Pneumonia22% (25) – BSI19% (22)

24. C. difficile Every peer group had one or more hospitals with higher than average rates. Rates varied from 0 to 19/10,000 patient days. State average is 6.6/ 10,000 days. This will become the threshold by which to measure progress. Rates included healthcare facility onset and community onset/ healthcare facility associated.

25. C difficile categories in NHSN Healthcare facility onset (HO:) Patient had positive specimen on day four or later. Community onset Healthcare Facility associated (CO-HCFA): specimen from patient who was discharged from the facility 4 weeks or less. Community Onset (CO): specimen occurs

26. MQF Annual Report Three new pages (see handout or pages 33,35,36 of the report): MRSA-HAI for 2011 (validated data) by hospital/ by peer group. C. difficile LabID rates (2011Q4-2012Q3, all validated data). Does include both HO and CO-HCFA data. Is a proxy measure. When viewing all 3 (HO, CO-HCFA, CO) it shows the hospital burden of C. difficile.

29. C. difficile Results 10/1/2011- 9/30/2012 Total Inpatient positive labs (whole state):780 Total hospital-related C. difficile (HO & CO-HCFA): 397 397 C. difficile compared to 119 MRSA-HAI Summary: C. diff bigger problem than MRSA

32. Prevention: Statewide Efforts HH: All hospitals doing internal and external audits. Slowly improving with each external audit. Median: 63% in Fall of 2011 to 81% in December of 2012.

33. Statewide analysis Influenza vaccination of HCWs: State average last year was 77%. 2012-13 state average improved to 84%. (New Hampshire: hospitals w/o a policy=78%, hospitals with a policy=93%, hospitals that terminate unvaccinated HCW w/o an exemption=98% vaccination rate.)

34. MQF Annual Report – HAI 3: Central line bundle: improved from 71% (2007-08) to 94%(2011-12) – CLABSI rates: improved from 2.5/ 1,000 CL days (07-08) to 1.7/1,000 (2011-2012). National avg=1.2in 2010. – NICU CLABSI rates: improved from 3.8/ 1,000 CL days (07-08) to 2.5 (11-12). National average=1.6 in 2010.

35. Are we seeing improvement in Maine? CLABSIs: Yes, although a few hospitals still above national average. Huge improvement since 2007 (66) to 2011 (47)= 19 less, 5 persons who didn’t die in 2011. MRSA and C. difficile: too early to tell, but we now have baseline. SSIs: not enough data, only following 2 surgeries. CAUTI: only collected since 2012, but device utilization is low in most hospitals and very good in nursing homes.

36. HAI program work continues Validation of NHSN MRSA-HAI Validation of NHSN C. difficile lab ID Continue working with hospitals to audit hand hygiene. Continue to analyze data, communicate analysis to hospitals. Increase efforts to LTC and physician offices.

37. New Efforts Collaboration with QIO to reduce C. difficile in the Augusta area: early diagnosis, contact precautions, environmental cleaning, antibiotic stewardship. ASP: Educating several hospitals, working with MICIS, developing physician pocket reference. CRE: include as a reportable, ASP as prevention. Develop state lab as reference to confirm. Outbreak assistance for LTC C. difficile outbreaks.

38. HAI Network Maine CDC collaborates with: Maine Infection Prevention Collaborative and MIPC-CC MHDO & MQF UNE School of Pharmacy Maine Medical Association- MICIS Maine Healthcare Association (LTC) QIO/MaineGeneral Med. Ctr./ 5 area NHs Maine Health Legislature/ rule making process.