1. Piloting HAI Data Collection in Maryland Long Term Care Facilities: Successes and Challenges Elisabeth Vaeth, MPH Epidemiologist, Emerging Infections Program Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration

2. MISSION AND VISION MISSION The mission of the Prevention and Health Promotion Administration is to protect, promote and improve the health and well-being of all Marylanders and their families through provision of public health leadership and through community-based public health efforts in partnership with local health departments, providers, community based organizations, and public and private sector agencies, giving special attention to at-risk and vulnerable populations. VISION The Prevention and Health Promotion Administration envisions a future in which all Marylanders and their families enjoy optimal health and well- being. Prevention and Health Promotion Administration June 10, 2013 2

3. EIP PISToL Project Pilot of Infection Surveillance Tools for Long Term Care Facilities 2012 EIP project to pilot new NHSN component Prevention and Health Promotion Administration June 10, 2013 3

4. EIP PISToL Project Designed for LTC UTI and Lab-ID CDI Voluntary recruitment Never been done before… Prevention and Health Promotion Administration June 10, 2013 4

5. Recruited from: –Local LTC APIC chapter meeting –Networking with LTC corporate contacts 8 willing facilities –6 agree to both modules –1 UTI only, 1 CDI only MD’s Guinea Pig LTCFs Prevention and Health Promotion Administration June 10, 2013 5

6. MD LTCF Facility Characteristics All for-profit, chain LTCFs Sizes: 62 beds to 192 beds Two with vent units Baseline hours devoted to infection prevention/control: 10-24* All send out lab tests* Two with EMR* * For 5 facilities completing facility surveys Prevention and Health Promotion Administration June 10, 2013 6

7. Identify surveillance coordinator (S.C.) Facility Survey CDC training webinars Standardized surveillance: UTI events and Lab-ID CDI events Denominator data –Resident-Days, Urinary Catheter-Days, and New Admissions PISToL Activities Prevention and Health Promotion Administration June 10, 2013 7

8. Time Logs Monthly data submission Post-pilot survey Post-pilot feedback conference call PISToL Activities Prevention and Health Promotion Administration June 10, 2013 8

9. Case Definitions: UTI SUTI (Symptomatic Urinary Tract Infection) Either of the following 1.Acute dysuria 2.Acute pain, swelling or tenderness of the testes, epididymis or prostate 1.Fever or Leukocytosis AND Any ONE of the following:  Costovertebral angle pain or tenderness  Suprapubic pain  Gross hematuria  New or marked increase in incontinence  New or marked increase in urgency  New or marked increase in frequency Any TWO of the following:  Costovertebral angle pain or tenderness  Suprapubic pain  Gross hematuria  New or marked increase in incontinence  New or marked increase in urgency  New or marked increase in frequency A voided urine culture with  10 5 cfu/ml of no more than 2 species of microorganisms or a specimen collected by in and out catheter specimen with  10 2 cfu/ml of any number of organisms SUTI – Criteria 1aSUTI – Criteria 2aSUTI – Criteria 3a SUTI Prevention and Health Promotion Administration June 10, 2013 9

10. Case Definitions: UTI CA-SUTI (Catheter-Associated Symptomatic UTI) At least ONE of the following with no alternate source:  Fever or rigors OR new onset hypotension, with no alternate site of infection.  Any acute functional decline or mental status change AND leukocytosis  New costovertebral angle pain or tenderness  New suprapubic pain  Acute pain, swelling or tenderness of the testes, epididymis or prostate  Purulent discharge from around the catheter A urine culture with  10 5 cfu/ml of any organism(s), collected following placement of a new catheter if current catheter has been in place >14 days SUTI – Criteria 1b CA-SUTI Prevention and Health Promotion Administration June 10, 2013 10

11. Case Definitions: UTI ABUTI (Asymptomatic Bacteremic UTI) Resident has no localizing urinary signs or symptoms (i.e., no urgency, frequency, acute dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness). If no catheter is in place, fever alone would not exclude ABUTI if other criteria are met. A positive urine culture with  10 5 cfu/ml of no more than 2 species of microorganisms, or a specimen collected by in and out catheter specimen with  10 2 cfu/ml of any number of organisms AND ABUTI AND A positive blood culture with at least 1 matching uropathogen microorganism to the urine culture. Prevention and Health Promotion Administration June 10, 2013 11

12. Case Definitions: Lab-ID CDI CDI-positive laboratory assay: A positive result for a laboratory assay for C. difficile toxin A and/or B, OR a toxin-producing C. difficile organism detected in the stool sample by culture or other laboratory means –Incident CDI Assay: Any LabID Event from a specimen obtained > 8 weeks after the most recent LabID Event (or with no previous LabID Event documented). –Recurrent CDI Assay: Any LabID Event from a specimen obtained > 2 weeks and ≤ 8 weeks after the most recent LabID Event for that resident. Prevention and Health Promotion Administration June 10, 2013 12

13. Surveillance Forms Forms also collect –Demographic info on patient –Infection risk factors –Catheter status (UTI only) –Associated hospitalization (UTI only) –30-day outcome (UTI only) –Antibiotic susceptibilities (UTI only) Prevention and Health Promotion Administration June 10, 2013 13

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16. Great, begin on March 1, 2012! Simple enough…? Prevention and Health Promotion Administration June 10, 2013 16

17. Not everyone completes training webinars… –But recorded versions distributed Emails seem to enter a black hole… –But after repeat phone calls, everyone says they’re ready to start A few early challenges… Prevention and Health Promotion Administration June 10, 2013 17

18. Month 1: March Submits forms in April MD001 Drops Out MD002 Submits forms in April MD003 Will submit soon!! MD004 Drops out MD005 Delays start date MD006 Submits forms in May MD007 Delays start date MD008 Prevention and Health Promotion Administration June 10, 2013 18

19. Definition confusion –Paper forms offer ALL possible UTI signs and symptoms –Surveillance coordinators over-identify UTI events –BUT, Lab-ID CDI event identification is a success March Madness Prevention and Health Promotion Administration June 10, 2013 19

20. Month 2: April Submits forms in May MD001 Drops out MD003 Will submit March and April forms soon!! MD004 Submits forms in May MD006 Submits form in May MD007 Submits form in May MD008 Prevention and Health Promotion Administration June 10, 2013 20

21. Month 3: May Submits forms in June, completes 3 months surveillance MD001 Will submit March and April and May forms soon!! MD004 Submits forms in July MD006 Submits forms in July, completes 3 months surveillance MD007 Submits forms in July MD008 Prevention and Health Promotion Administration June 10, 2013 21

22. Month 4: June Never submits any forms… MD004 Submits forms in July and completes 3 months of surveillance MD006 Submits form in August and completes 3 months of surveillance MD008 Prevention and Health Promotion Administration June 10, 2013 22

23. Final Tally Four facilities complete three months of surveillance –Three UTI & CDI –One UTI only One facility completes one month of surveillance –UTI & CDI Prevention and Health Promotion Administration June 10, 2013 23

24. March (n=2) April (n=4) May (n=4) June (n=2) Total Total UTI events reported 1520262081 Total UTI events that met surveillance definitions 141012642 Total SUTI 1168328 Total CA-SUTI 344314 Total ABUTI 00000 Summary Stats: Event Breakdown by Month *Data from 4 facilities completing 3 months of surveillance Prevention and Health Promotion Administration June 10, 2013 24

25. March (n=2) April (n=3) May (n=3) June (n=2) Total Total Lab-ID CDI events reported 524213 Total Lab-ID CDI events that met surveillance definition 524213 Summary Stats: CDI Event Breakdown by Month *Data from 4 facilities completing 3 months of surveillance Prevention and Health Promotion Administration June 10, 2013 25

26. Summary Stats Reported Events vs. Events Meeting Surveillance Definition *Data from 4 facilities completing 3 months of surveillance Prevention and Health Promotion Administration June 10, 2013 26

27. Denominators Not collected as instructed in protocol (daily counts) Monthly resident-days –Ranged from 1,750 (62 bed-facility) to 5,272 (192 bed-facility) Monthly urinary catheter-days –Ranged from 30* (150 bed-facility) to 525 (192 bed-facility) Monthly resident admissions –Ranged from 0 (155 bed-facility) to 60 (152 bed- facility) * Possible data collection error Prevention and Health Promotion Administration June 10, 2013 27

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29. Time Spent on Surveillance Logs sporadically completed (received 7 total over course of surveillance period) Reports for combined UTI/CDI surveillance time per month ranged from 4 hours to 18 hours When completed, showed that surveillance not occurring daily –Often mostly on one day near end of month Prevention and Health Promotion Administration June 10, 2013 29

30. Validation: Activities and Goals Five main validation activities –UTI event chart reviews –Stool culture reviews –Urine culture reviews –Review of CDI antibiotic starts –Review of UTI antibiotic starts Interview S.C.’s on denominator collection practices Completed at 3 facilities Prevention and Health Promotion Administration June 10, 2013 30

31. Validation: Process and Conclusions Challenging chart reviews –Signs and symptoms not always noted in chart –Many discrepancies Challenging lab and pharmacy reviews –Matching cultures to starts –Lack of indications Take home: Data sources available but not as useful as hoped Prevention and Health Promotion Administration June 10, 2013 31

32. PISToL: Lessons Learned Infection prevention in LTCF –Not like acute care! –Often one IP who wears many hats Long protocols will not be read –Very wide range of knowledge/experience –Standardized surveillance not the routine –Computer access and know-how not a given Prevention and Health Promotion Administration June 10, 2013 32

33. PISToL: Lessons Learned However… –NHSN LTC component launched September 14, 2012 will guide event identification –CMS may require HAI reporting in LTCFs in the future… Administrators will have to hire more and better-skilled IP staff Standardized surveillance will hopefully become routine Prevention and Health Promotion Administration June 10, 2013 33

34. Thank you! Katie Richards, DHMH Lucy Wilson, DHMH David Blythe, DHMH Pat Ryan, DHMH Brenda Roup, DHMH Ruth Belflower, CDC Nicola Thompson, CDC Nimalie Stone, CDC Anonymous Maryland PISToL S.C.’s! Prevention and Health Promotion Administration June 10, 2013 34

35. Prevention and Health Promotion Administration Questions? Prevention and Health Promotion Administration June 10, 2013 35