1. Public Reporting of Healthcare- associated Infections in Texas Neil Pascoe RN BSN CIC (aka “the Messenger”) Epidemiologist Infectious Disease Control Unit

2. Outline A brief history of issue International overview National perspective Texas legislative session SB 288 Public Reporting of HAI Where it is going and who is taking us

3. History of Issue HAI/Nosocomial infections are not recent issue Semmelweis in 19 th century Hospital penicillin resistance MRSA, UTI, VAP, BSI, SSI Contaminated products and devices Invasive procedures Population changes

4. Are acquired as a result of a hospital stay 5-15% of all hospital patients acquire HAI Healthcare-associated Infections

5. Why HAI May Increase Sicker patients, older population More invasive procedures for longer duration Increasing immuno-incompetent population Staffing shortages –Nursing –Pharmacists –Pharmacy Techs –Radiology Techs

6. Why HAI May Increase Resistant Organisms –1990’sP. aeruginosa –1990’sVRE/MRSA –2002 VRSA/MDRO’s Emerging Infectious Disease –1980’sHIV –1990’shantavirus/HCV –2000’sWNV/SARS/Pandemic Flu C. diff, GNRs

7. Calculation of estimates of healthcare-associated infections in U.S. hospitals among adults and children outside of intensive care units, 2002 HRN = high risk newborns WBN -= well-baby nurseries ICU = intensive care unit SSI = surgical site infections BSI – bloodstream infections UTI = urinary infections PNEU = pneumonia SSI 20% BSI 11% UTI 36% PNEU 11% Other 22% 133,368 424,060 263,810 129,519 274,098 -967 -21 -28,725 244,385 TOTAL HRN WBN Non-newborn ICU = SSI Klevens, et al. Pub Health Rep 2007;122:160-6

8. Rates of Healthcare-Associated Infections in Newborns, Adults, and Children by Site of Infection, National Nosocomial Infections Surveillance (NNIS) System Well-baby nursery a High-risk nursery b Intensive care unit b (adults and children) Patient-days c 7,436,5204,835,70230,236,811 Major site of infectionRate of infection per 1,000 patient-days Urinary tract0.190.5 3.38 Bloodstream0.76 3.06 2.71 Pneumonia0.24 0.91 3.33 Surgical site 0.0030.2 0.95 Other1.37 2.21 2.67 Total2.56 6.8813.04 a From NNIS hospital-wide surveillance, 1990-1995 b From NNIS surveillance 2002, high-risk nursery and ICU component c From the National Hospital Discharge Survey (NHDS) for the U.S. population in non- federal hospitals

9. Consequences 2 million HAI annually 90,000 deaths $4.5-5.7 billion/ year 25% in Intensive Care Units 70% involve organisms with resistance to one or more antibiotics J. Burke. NEJM 2003; 348: 7 Emerging Infect Dis 1998; 4: 416-20 Infect Control Hosp Epi 2001; 22: 708-14

10. The International Overview

15. The National Overview

16. Infection Control in the Headlines “Lax Procedures put Infants at High Risk; Simple Actions by Hospital Workers, Such as Diligent Hand-washing, Could Cut the Number of Fatal Infections.” Chicago Tribune 2002

20. As of 5/14/07

26. Texas The State Perspective

27. Texas Travis County Capitol You are here

29. 80 th Legislature Regular Session 4 bills introduced on HAI Only SB 288 passed related to HAI HB 1082 More Patients Suffering Infections At Hospitals POSTED: 3:10 pm PDT May 10, 2007 UPDATED: 4:43 pm PDT May 10, 2007 -- Hospitals aren't supposed to make you sicker.

30. Setting the Stage for HAI

32. SB 872 (HAI portion) 79 th Legislative session 2005 Unfunded mandate directing the DSHS to: Solicit persons to fill an advisory panel that will report back to the legislature by 11/1/06 with Recommendations on the public reporting of HAI 14 positions on the advisory panel First meeting November 2, 2005

33. The Advisory Panel 2 ICPs, certified, 1 rural & 1 urban 2 ICPs, certified and both nurses 3 MDs, SHEA members, IC experts in a healthcare facility CEO of an acute care facility CEO of an ASC 2 consumer representatives 3 nonvoting department members

34. The Members of the Advisory Panel Susan Jones, Betsy Colvin Greg Bond/Lynda Watkins, Patti Grant Robert Haley, Luis Ostrosky-Zeichner, Jan Patterson Dan Schultz, Marilyn Christian Lisa McGiffert, Raquel Sanchez Neil Pascoe, Tom Betz, Nance Stearman

35. HAI Ethical issues Legislation has potential to divert infection control staff away from disease prevention and control activities at patient level and have them focus on health care-associated infection reporting at administrative level. Reporting adjustments need to be made so that hospitals with higher risk patients or patients undergoing procedures placing them at higher risk for infection are not unduly penalized.

36. HAI Ethical issues (cont.) Health care facilities that under-report may appear superior in infection control to others. Checks and balances need to be in place. Sample sizes of procedures reported need to be sufficiently robust to permit valid comparisons between institutions within reasonable limits of confidence. This is a serious potential problem.

37. HAI Ethical issues (cont.) Health care institutions that in good faith report infections in an open and honest manner should not suffer undue medical-legal consequences for such openness. Increased perceived risk of litigation will seriously undermine reporting efforts. Potential patients who use the reporting information for selecting institutions need to understand the limits of such information.

38. HAI Ethical Issues (cont.) –System failure versus Personal Accountability- The Case for Clean Hands “…the hospital and its leaders are accountable for establishing a system in which caregivers have the knowledge, competence, time, and tools to practice perfect hygiene.” “But each caregiver has the duty to perform hand hygiene- perfectly and everytime.” “When this widely accepted, straightforward standard of care is violated, we cannot continue to blame the system.” Goldmann D. System failure versus personal accountability. N Engl J Med 2006; 355; 2: 121-2

39. SB 288 Mandatory Public Reporting of Healthcare-associated Infections 80 th Regular Session 2007 http://www.capitol.state.tx.us/tlodocs/80R/billtext/pdf/SB00288H.pdf

41. “The statement, ‘It’s worth it if it saves just one life is dangerously false if the same resources, used in a different manner, can save more than one life.’” Wm. Haddon Jr. Medical Ethics 101

42. SB 288 Requires a 16 member Advisory Panel within the DSHS infectious disease epi and surveillance division to guide the implementation, development, maintenance and evaluation of the reporting system Hospitals, Ambulatory Surgical Centers (ASCs) to report specific HAI to DSHS

43. SB 288 Advisory Panel 2 year term 2 ICPs certified and one from a rural hospital 2 ICPs certified and licensed nurses 3 MDs one with Pedi ID and Pedi epi exp. are SHEA members with expertise in IC 2 QA professionals-1 ASC & 1 acute care

44. SB 288 Advisory Panel 1 officer of a general hospital 1 officer of an ASC 3 nonvoting department members 2 members representing the public as consumers No lobbyists or HC trade association Reimbursement is allowed!

45. SB 288 Requires DSHS To adopt rules that do not duplicate or conflict with federal reporting HAI rules Establish Texas Healthcare-associated Infection Reporting System to: –receive HAI reports –publish HAI reporting to the public –educate and train ICPs on the THIRS

46. SB 288 Reporting Must begin no later than 6/1/08 Quarterly or less frequent Must contain sufficient patient ID data –avoid duplication –verify accuracy and completeness –allow for risk adjustment DSHS will review data for validity and “unusual data patterns or trends”

47. SB 288 Reportable SSI Infections Acute care other than pediatric shall report SSI on 7 surgical procedures -colon surgeries -hip and knee arthroplasties -abdominal and vaginal hysterectomies -CABG and vascular procedures

48. SB 288 Reportable SSI Infections Pediatric facilities will report SSI associated with Cardiac procedures excluding thoracic cardiac VP shunt procedures Spinal surgery with instrumentation And Pediatric HA RSV

49. SB 288 Reportable CLABSI Lab confirmed from a patient in any “special care setting in the hospital” All Texas definitions from CDC case definitions

50. SB 288- Alternative Reporting For facilities with an average of less than 50 procedures/monthly Instead--report SSI related to the 3 most frequently performed procedures from the NHSN procedure list

51. SB 288 DSHS Summary Public summary for each reporting facility Risk adjusted with a comparison of the risk- adjusted rates for each reporting facility Easy to read (consumer friendly) Annual summary minimum Concise facility comments on report will be allowed Posted on internet Option for public to report suspected infections to DSHS

52. SB 288 Protections Confidential, de-identified, protected MAY NOT BE USED IN A CIVIL ACTION TO ESTABLISH A STANDARD OF CARE

53. SB 288 Enforcement General Hospital under Chapter 241 ASC under Chapter 243

54. Funding For FY 2008 DSHS requested $4.5M 36 FTEs LBB calculated $1.1M and 5 FTE FY 2009 DSHS requested $3.7M LBB calculated $1.2M and 8 more FTE Status = not currently funded

56. Reporting Missouri Healthcare-Associated Infection Reporting System (MHIRS) Perseus NHSN Plan D

59. Reminder What Don’t You Do to the Messenger?

60. American National Standards Institute, Accredited Standards Committee X12N, 837 Health Care Institutional Claim Implementation Guide (version 004010X096A1). Most people call it the ANSI 837I or ANSI 837 Institutional version 4010. DSHS has modified this HIPAA compliant version by adding in Race code to the DMG05 data field, thus we are HIPAA compatible. Plan D- Reporting

61. Reporting continued ICP generated attachment to the ANSI 4010 Details should be in place by November 1, 2007 Testing by January 2008 Implementation….?

63. Resources http://www.legis.state.tx.us/ http://www.apic.org http://www.dshs.state.tx.us/idcu/disease/HAI/ Gary Heseltine 512 458-7111 x6352 Gary.heseltine@dshs.state.tx.us Neil Pascoe 512 458-7111 x2358 neil.pascoe@dshs.state.tx.us