1. Principles of Epidemiology & Surveillance of Health care- Associated Infection Russ Olmsted Trinity Health olmstedr@trinity-health.org

2. Some “real world” definitions of Epidemiology “the worst taught course in medical school” “the worst taught course in medical school”  Medical student, U of M "the science of making the obvious obscure” "the science of making the obvious obscure”  Clinical Faculty, MSU “the science of long division” “the science of long division”  Statistician, Grand Valley State U "the study of skin diseases“ "the study of skin diseases“  New CDC Epidemic Intelligence Service Officer, Atlanta

3. The Real Definition epidemiology is "the study of the distribution and determinants of health- related states in specified populations, and the application of this study to control health problems." - smarty pants epidemiologist during a cocktail party epidemiology is "the study of the distribution and determinants of health- related states in specified populations, and the application of this study to control health problems." - smarty pants epidemiologist during a cocktail party

4. Comparison of Definitions; Epidemiology vs Population Health CDC: Epidemiology – CDC: Epidemiology – “the study of the distribution and determinants of health- related states or events in specified populations, and the application of this study to the control of health problems” “the study of the distribution and determinants of health- related states or events in specified populations, and the application of this study to the control of health problems” Institute of Medicine: Population Health - “the health outcomes of a group of individuals, including the distribution of such outcomes within the group” (Kindig and Stoddart, 2003).

5. Goals of Infection Prevention/Control (IP/C) & Epidemiology Programs Surveillance : Surveillance :  systematic collection, analysis, & reporting of data from surveillance system to prevent disease & improve health Principal Goals: Principal Goals:  Protect the patient;  Protect health care personnel, visitors, & others  Accomplish these in a cost effective manner whenever possible Scheckler WE. AJIC 1998;26:47-60

6. Surveillance Definition: Definition: Function: noun Etymology: French, from surveiller to watch over, from Latin vigilare, from vigil watchful close watch kept over someone or something (as by a detective) close watch kept over someone or something (as by a detective) Application:... ongoing, systematic collection, analysis, interpretation, and dissemination of data regarding a health-related event... Purpose: to reduce morbidity and mortality and to improve health CDC. Surveillance system guideline. MMWR 2001;50(RR13)

7. Comparing & Contrasting Surveillance vs. Individual Patient Care Surveillance is: Population-based Population-based Incidence and prevalence rates versus raw numbers – trending Incidence and prevalence rates versus raw numbers – trending Risk stratification (age, disease, complexity of surgery, etc.) Risk stratification (age, disease, complexity of surgery, etc.) Systematic and improvement oriented Systematic and improvement oriented Measurement to improve patient safety. Measurement to improve patient safety. Surveillance is NOT: Clinical diagnosis of infection Clinical determination of antibiotic use Based on subjective criteria “Gut feeling” Based on definitions of from your facility’s medical director

8. Early Evidence of Efficacy of Surveillance; using data for patient safety  Power of performance measurement: feedback loop of surgeon-specific SSI rates, NY Roosevelt Hospital, 1895- 1914-  YearOverall SSI Rate 189539.0 % (baseline) 18969.0 (1 st yr. SSI data provided) 18993.2 19122.4 19141.2 Brewer GE. JAMA 1915

9. Keys for the Elimination of Healthcare-associated Infections Collect data and disseminate results  transparency with consumers  Engaging direct care providers Full adherence to best practices Full adherence to best practices Recognize excellence Recognize excellence Identify and respond to emerging threats Identify and respond to emerging threats Improve science for prevention through research Improve science for prevention through research  Cardo D, et al. ICHE 2010

10. How Big of a Problem are Healthcare Associated Infections (HAIs)? Point Prevalence Survey; National Healthcare Safety Network (NHSN) N=183 hospitals, 2011 Point Prevalence Survey; National Healthcare Safety Network (NHSN) N=183 hospitals, 2011 Patients at risk = 11,282 Patients at risk = 11,282  452 (4.0%) with > one HAI  Distribution by site – see pie chart  C. difficile = 70% of GI infections Nationwide estimates: Nationwide estimates:  648,000 patients with 721,800 HAIs/year Magill SS et al. NEJM 2014;370:1198-208

11. Efficacy of Surveillance Data + Prevention Strategies at the Bedside

12. Who Gets HAIs? 1/25 on any given day in U.S. hospitals; many are older adults McGill SS, et al

13. HAIs in Long Term Care Setting Schweon S, LTC Safety Project, HRET, Cohort 5, 9/2015

14. Impact of C. difficile infection (CDI) Hospital-acquired, hospital- onset: 165,000 cases, $1.3 billion in excess costs, and 9,000 deaths annually Hospital-acquired, hospital- onset: 165,000 cases, $1.3 billion in excess costs, and 9,000 deaths annually Hospital-acquired, post- discharge (up to 4 weeks): 50,000 cases, $0.3 billion in excess costs, and 3,000 deaths annually Hospital-acquired, post- discharge (up to 4 weeks): 50,000 cases, $0.3 billion in excess costs, and 3,000 deaths annually Nursing home-onset: 263,000 cases, $2.2 billion in excess costs, and 16,500 deaths annually Nursing home-onset: 263,000 cases, $2.2 billion in excess costs, and 16,500 deaths annually Campbell et al. Infect Control Hosp Epidemiol. 2009:30:523-33.; Dubberke et al. Emerg Infect Dis. 2008;14:1031-8. ; Dubberke et al. Clin Infect Dis. 2008;46:497-504.; Elixhauser et al. HCUP Statistical Brief #50. 2008.

15. Steps Involved in Managing Information Needs Assessment Planning & Design Capturing & Reporting Process & Analyze Storing & Retrieving Display & Disseminate Surveillance of HAIs Lee TB, et al. AJIC 2007;35:427-40. Assess Pt. Population Select Indicators Apply Surv. Definitions Collect Data Analyze Data Apply risk stratification Report & Use Findings JC. CAMH, 2007

16. Conceptual Model for Performance Improvement: Have we created a culture of safety? Structure ProcessOutcome Have we reduced the likelihood of harm? How often do we do what we are supposed to? How often do we harm? Adapted from: Donabedian A. Evaluating the quality of medical care. Milbank Memorial Fund Quarterly 1966;44:166–206.

17. Ensuring Quality of Surveillance Written Plan: risk assessment, goals, objectives, & elements Written Plan: risk assessment, goals, objectives, & elements Maintain thoroughness and intensity over time; e.g. what happens to rate of VAP if ICP leaves a position and it is not filled for 6 months? Maintain thoroughness and intensity over time; e.g. what happens to rate of VAP if ICP leaves a position and it is not filled for 6 months? Organization leaders need to provide adequate resources for surveillance program Organization leaders need to provide adequate resources for surveillance program Re-evaluate efficacy of surveillance program at least annually Re-evaluate efficacy of surveillance program at least annually

18. “In response to anecdotal reports of intentional non- reporting of infection data, CDC and CMS are jointly issuing a reminder that addresses concerns about healthcare facility non–reporting of healthcare- associated infections events. While there is no evidence of a widespread issue, CDC and CMS want to emphasize that accurate reporting to NHSN through strict adherence to the NHSN definitions is critical… “ Issued: 10/7/2015

19. How Much Time is Spent on Surveillance by Infection Preventionists (IPs) in NY? IPs surveyed from 222/224 acute care hospitals, NY Scope of responsibility for “average IP” 1.0 FTE:   151 pt. Beds   1.3 ICUs   21 LTCF beds   0.6 Dialysis ctrs   0.5 ASC   4.8 Amb. Care   1.3 PCP offices infrastructure capacity responsibilities In balance?

20. Validation of HAI Surveillance: Precision & Quality of the Information 20 ICUs, 4 Medical Centers Median CLABSI rates: IP = 3.3 Computer algorithm = 9.0 Medical Ctr C had the lowest rate by IP (2.4) however the highest rate by computer algorithm (12.6)! Lin MY, et al. JAMA 2010

21. Step 1 – Assess population and environment Patient demographics (age, gender, socioeconomic status) Patient demographics (age, gender, socioeconomic status) Patient clinical characteristics (most frequent diagnoses and co-morbidities, most frequent and most rarely performed procedures, medical treatments) Patient clinical characteristics (most frequent diagnoses and co-morbidities, most frequent and most rarely performed procedures, medical treatments) Characteristics of HCP (knowledge and training) Characteristics of HCP (knowledge and training) Facility characteristics (physical size, age, condition, single or shared rooms, geographic location) Facility characteristics (physical size, age, condition, single or shared rooms, geographic location) Do you have existing surveillance data? Do you have existing surveillance data? Lee TB, et al. AJIC 2007

22. Step 2 – Select Indicators/Metrics to Measure: Process, Outcome… Use facility-specific risk assessment Use facility-specific risk assessment Search the literature for relevant studies that apply to your patient population Search the literature for relevant studies that apply to your patient population  http://www.ncbi.nlm.nih.gov/pubmed http://www.ncbi.nlm.nih.gov/pubmed What are most likely HAI issues? What are most likely HAI issues?  Frequency, cost, reg./accred. requirement, PI project Examples : Examples :  : % residents & HCP rec’d flu vax., CMS survey tool for ASC, % Abx use for ASB, Hand hygiene adherence  Process: % residents & HCP rec’d flu vax., CMS survey tool for ASC, % Abx use for ASB, Hand hygiene adherence  : CLABSI, CAUTI, SSI rates; incidence of CDI/10,000 patient days  Outcome: CLABSI, CAUTI, SSI rates; incidence of CDI/10,000 patient days Lee TB, et al. AJIC 2007

23. Step 3 – Use Valid, Reproducible Surveillance Criteria Acute & Ambulatory Care: CDC’s National Healthcare Safety Network (NHSN); ww.cdc.gov/nhsn Acute & Ambulatory Care: CDC’s National Healthcare Safety Network (NHSN); ww.cdc.gov/nhsn Long Term Care: Stone ND, et al. Infect Control Hosp Epidemiol 2012;33:965-77 Long Term Care: Stone ND, et al. Infect Control Hosp Epidemiol 2012;33:965-77 Home Care & Hospice: APIC-HICPAC, 2008. Available from http://www.apic.org Home Care & Hospice: APIC-HICPAC, 2008. Available from http://www.apic.orghttp://www.apic.org Consider performing a “Point or period Prevalence” or even simple line listing to establish baseline frequency if existing data are not available Consider performing a “Point or period Prevalence” or even simple line listing to establish baseline frequency if existing data are not available Lee TB, et al. AJIC 2007

24. www.cdc.gov/nhsn

25. NHSN Surveillance Concepts Healthcare-associated Infection (HAI); if the date of event of the NHSN site-specific infection criterion occurs on or after the 3rd calendar day of admission to an inpatient location where day of admission is calendar day 1. Present on Admission (POA); if the date of event of the NHSN site-specific infection criterion occurs during the POA time period, which is defined as the day of admission to an inpatient location (calendar day 1), the 2 days before admission, and the calendar day after admission

26. Guide for Classification of Infection Symptomatic UTI criteria 1a, CAUTI: 1.Indwelling urinary catheter in place >2 d 2.fever (>38.0°C), suprapubic tenderness, costovertebral angle pain, urgency, frequency, or dysuria & 3.Urine culture detects ≥10 5 CFU/ml.

27. NHSN Key Concepts, cont.

29. Application of Key Concepts IWP, RIT, and secondary bloodstream infection attribution period do apply to other sites, e.g. CAUTI, CLABSI

30. NHSN Surveillance Criteria: Let’s Practice Ms. Jones admitted to 5 West on 1/15/2015 Ms. Jones admitted to 5 West on 1/15/2015  New medical resident orders urine culture on admission because he wants to know what’s in her bladder but Ms. Jones shares she has no symptoms or fever.  Indwelling urinary catheter inserted  Culture reveals > 100,000 CFU/ml of E. coli Day 9 of admission, 1/23/2015 Day 9 of admission, 1/23/2015  New temperature = 39°C (102.2 F)  Repeat urine culture ordered and finds > 100,000 CFU/ml of E. coli. Is this a UTI that was POA? Is this a UTI that was POA? Should this be reported to NHSN as a SUTI (CAUTI)? Should this be reported to NHSN as a SUTI (CAUTI)?

31. Locations & Transfers Location:. Location: inpatient location (unit) where the patient was assigned on the date of the HAI event, i.e. date when the first element used to meet the event criterion occurred. Transfer rule: Transfer rule: if date of event for a HAI is the day of transfer or discharge, or the next day, the infection is attributed to the transferring location. Day of admission, 3/20/15 3/23/153/24/15Tranfer rule Result Unit A; MICU Central line inserted Transfer to Unit B; progressive care unit Unit C, medical ward New fever, blood cx = S. aureus CLABSI attribute to Unit B

32. Key Terms & Concepts TermDefinition HAIAn infection is considered an HAI if all elements of a CDC/NHSN site-specific infection criterion were first present together on or after the 3rd hospital day (day of hospital admission is day 1). For an HAI, an element of the infection criterion may be present during the first 2 hospital days as long as it is also present on or after day 3. All elements used to meet the infection criterion must occur within a timeframe that does not exceed a gap of 1 calendar day between elements. Device- associated infection An infection meeting the HAI definition is considered a device- associated HAI if the device was in place for >2 calendar days when all elements of a CDC/NHSN site-specific infection criterion were first present together. HAIs occurring on the day of device discontinuation or the following calendar day are considered device-associated HAIs if the device had been in place already for >2 calendar days.

33. Step 4 – Collect HAI Data Run…don’t walk to your PC/Mac, fire up your browser, and take training on use of NHSN – AC & LTC Run…don’t walk to your PC/Mac, fire up your browser, and take training on use of NHSN – AC & LTC Lee TB AJIC 2007

34. Surveillance Modules available for Acute & Long Term Care For Details on LTC see: http://www.cdc.gov/nhsn/LTC/index.html

35. LabID C. difficile event

36. Community-onset (CO) LabID Event: Date specimen collected ≤ 3 calendar days after current admission to the facility (i.e., days 1, 2, or 3 of admission) Community-onset (CO) LabID Event: Date specimen collected ≤ 3 calendar days after current admission to the facility (i.e., days 1, 2, or 3 of admission) Long-term Care Facility-onset (LO) LabID Event : Date specimen collected > 3 calendar days after current admission to the facility (i.e., on or after day 4) Long-term Care Facility-onset (LO) LabID Event : Date specimen collected > 3 calendar days after current admission to the facility (i.e., on or after day 4)  sub-classified futher into:  Acute Care Transfer-Long-term Care Facility-onset (ACT- LO): LTCF-onset (LO) LabID event with specimen collection date ≤ 4 weeks following date of last transfer from an Acute Care Facility (Hospital, Long-term acute care hospital, or Acute inpatient rehabilitation facility only)

37. New HCP Vaccination Module Now Available at NHSN See: http://www.cdc.gov/nhsn/hps_Vacc.html

38. Step 5 – Analyze HAI Data Line Listing CAUTI Rate Table Bar Graph & Pie Charts

39. Step 5 – Analyze HAI Data Standardized Infection Ratio (SIR)

40. Step 6 – Apply Risk Stratification to Data NHSN NHSN  Location: ICU, non-ICU, Hem-Onc  Standardized Infection Ratio (SIR)   Summary measure to compare HAI data among one or more groups of patients to that of a standard population’s (e.g. NHSN)   Accounts for differences in incidence of HAI by patient groups  SSI: ASA score, duration of surgery, wound class > 3  NICU: birthweight category Others: Others:  SSI rates; inpatients only vs inpt. + post-discharge  Fall injury risk scoring scheme  Stratify receipt of influenza vaccine by job class and department

41. Incorporate HAI data into health system monthly patient safety quality reporting dashboard Incorporate HAI data into health system monthly patient safety quality reporting dashboard Reporting data to MDCH Sharp Unit & CMS Reporting data to MDCH Sharp Unit & CMS  Permit access to MI-Specific HAI experience  Fulfills incentive-based reimbursement from CMS Be consistent in timelines for reporting to key personnel and other entities Be consistent in timelines for reporting to key personnel and other entities The most important step in the surveillance process – data for improvement at the local level is first step in improving care The most important step in the surveillance process – data for improvement at the local level is first step in improving care Step 7 – Reporting & Using HAI Surveillance Data

42. Uses of HAI Data; CMS Hospital Compare CY 2014

43. Uses of HAI Data, Hospital Compare, continued.

44. Using HAI Data for Comparing Performance Between Providers National Surgical Quality Improvement Program (NSQIP)

45. Uses of HAI Data; Keystone ICU Project 66% reduction in Central Line Bloodstream Infections (CLBSI) 66% reduction in Central Line Bloodstream Infections (CLBSI) Interventions: Interventions:  Hand hygiene  Max. barrier prec. during insertion  CHG antiseptic on insertion site  Avoid femoral CLs  Remove CL when not needed Pronovost P, et al. NEJM 2006;355:2725-32. Pronovost P, et al. NEJM 2006;355:2725-32. Rate Per 1,000 CL Days

46. Use of Surveillance Technology to Improve Efficiency of IPC Program M. Moyhla – Holy Cross Hospital

47. Using HAI Data to Assess Efficacy of an Intervention; Preop Skin Prep Darouiche RO et al. N Engl J Med. 2010;362:18-26.

48. Using Process Data to Improve Antibiotic Stewardship Multidisciplinary team, IP+ID+Geriatrician visited and surveyed use of Abx to Prevent UTIs in all LTC units, Central Finland Multidisciplinary team, IP+ID+Geriatrician visited and surveyed use of Abx to Prevent UTIs in all LTC units, Central Finland Results: Results:  Most (80%) Abx use for UTI  Significant drop in Use overall 13 to 6%;acute+ LTC  59% of units used urine odor as reason for culture   Rummukainen ML, et al. AJIC 2012