Presentation On The CUSP Stop HAI

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					                        On The CUSP of Elimination
                        of HAIs: The Role of APIC &
                        the Infection Preventionist in
                        Spreading the belief in zero
                        Central Line-Associated
                        Bloodstream Infections
                        (CLABSIs), 11/16/2010
Russ Olmsted, MPH, CIC - President-Elect, APIC, 2010
Peter J. Pronovost, MD, PhD, FCCM – Professor & Director,
Adult Critical Care Medicine & Quality and Safety Research
Group, Johns Hopkins
           Today’s Objectives:
• Understand the On the CUSP Initiative
• List select, updated recommendations in the
  upcoming 2010 CDC/HICPAC Guideline for the
  Prevention of Intravascular Catheter-Related
  Bloodstream Infection
• Describe the experience of the IP in CLABSI
  Prevention Collaborative.
• List an example that illustrates the importance
  of validation of CLABSI Detection
           On The CUSP: HAI Prevention

• Coordinated by AHA’s Health Research &
  Educational Trust [HRET] under contract from
  Agency for Healthcare Research & Quality
• Nationwide initiative using Comprehensive Unit-
  based Safety Program (CUSP) to prevent HAIs
• HAIs of focus:
  – Catheter associated UTIs (CAUTIs)
                  On The CUSP: HAI Prevention

Partnering Organizations:

                                       Ann Arbor VA Medical Center /
                                       University of MI Patient Safety
                                       Enhancement Program
Hospital Recruitment:
Deborah Bohr, 646-678-4280,
Project Management:
Marchelle Djordjevic, 312-422-2614,
General Inquires:
            On The CUSP: HAI Prevention

Core Elements of CUSP:
1.   Educate Staff on the Science of Safety
2.   Identify Defects
3.   Engage Executives
4.   Learn from Defects
5.   Implement Teamwork Tool
            On The CUSP: HAI Prevention

The Stimulus for Prevention:
   State Hospital Association Survey on CLABSI
    Prevention Initiatives; all 50 responded
   42 (84%) agreed CLABSI Prevention is a
   11 (22%) provided statewide CLABSI rates
   Active collaboratives in 6 (12%); 7 (14%)
   Need: national collaborative ; build capacity
        Murphy DJ, et al. Am J Med Qual 2010;25(4):255-60.
• No reimbursement for certain Hospital
  acquired conditions (HACs):
  1) Serious preventable events: Object left in during
    surgery; air embolism; Delivering ABO-incompatible
    blood or blood products
  2) Catheter-associated urinary tract infections
  3) pressure ulcers (stages III & IV)
  4) Vascular catheter-associated infection
  5) SSI: mediastinitis after CABG; certain orthopedic
    procedures, bariatric surgery
  6) Patient falls
  7) Manifestations of poor glycemic control
  8) DVT/PE after total knee or hip replacement
• Hospital Inpatient Quality Reporting
  Program – for 2011:
• Requires providers to report outcome
  metrics to CMS using NHSN –
   – CLABSI events beginning in January 2011 for
     FY 2013 Medicare Payment Determination
• Pay 4 Reporting: 2% reduction in
  reimbursement for Medicare beneficiaries if
  providers fail to report.
• For details on NHSN see:
Action Plan to Prevent HAIs, June 2009

Tier 1: See Targets/Metrics

Tier 2: Ambulatory Surgery Clinics, Dialysis Centers,
Influenza vaccine for Healthcare Personnel

                                        American Recovery and
                                        Reinvestment Act (ARRA), 2009.
                                        Public Law 111-5
                                            HAI Prevention Plan 5 yr. Targets;
                                                           A Progress Report
TOPIC                             METRIC & TARGET                     Progress Report

Central line-assoc. bloodstream   CLABSI Std Infection Ratio (SIR);   18% drop in 2009 – on target!
infection (CLABSI)                50% reduction
CLABSI Insert. Bundle             Proportion of insertions using      Sample of Hospitals = 92% - on
                                  bundle; 100% adherence              target
C. difficile Infection (CDI)      Rate/1000 discharges; 30%           8.9 in 2009; 9.4 in 2010 – not
                                  reduction                           likely to meet target
Catheter-assoc. UTI (CAUTI)       CAUTI rate ; 25% reduction          Estimate in ’08 = 5% reduction
                                                                      but new def. in ’09 - unsure
MRSA                              Rate invasive MRSA/100k pop.;       22.72 in 2009 = 13.4% drop
                                  50% reduction                       compared to ’07-’08 – on target
SSI                               SIR; 25% reduction                  5% fewer SSIs in 2009 – on
SSI                               Proportion SCIP measures; 95%       > 92% in 2009 – on target
    National Patient Safety Goals (NPSG),
               Hospital, 2010
• NPSG.07.01.01: Hand Hygiene
• NPSG.07.03.01: Prevent HAIs caused by
  multidrug-resistant organisms (MDROs)
• NPSG.07.04.01: CLABSI prevention
• NPSG.07.05.01: SSI prevention
Coming attractions: CAUTI focused NPSG?
                     Other Successful CLABSI Prevention
New York: CDC guidelines basis for prevention implementation
    –   Greater New York Hospital Association prevention initiative
    –   Collaborative partnership with 46 hospitals
                                                         •    Focused on
                                                              incrementally building
                                                              infrastructure needed for
                                                              BSI and other future
                                                              prevention initiatives
                                                              (e.g. C. difficile)
                                                         •    Communications to
                                                              share best practices
                                                         •    Culture of accountability
                                                               –      CEO to support
                                                                      staff levels
                                                               –      Site visits,
                                                                      monthly reporting
                                                         •    Adopted bundles of
                            CLABSI Prevention
                                                             More Common Mechanisms
                            Personnel Hand                   1. Pathogen migration along external
                                                                    - more common early
                                                                    (< 7days)
   Contamination                             Contaminated
   of insertion site                           Infusate      2. Hub contamination with
                                                             intraluminal colonization
                                                                    -more common >10 days
                                                             Less Common Mechanisms
    Extraluminal       Hematogenous                          1. Hematogenous
   Contamination          spread
                                                             seeding from another source
                                                             2. Contaminated infusates

HICPAC. Guideline for Prevention of
Intravascular Device-Related Infections. 2002
       Select Highlights, CDC/HICPAC CRBSI
        Prevention Guideline, 2010 – in press
• Section: Catheter Site Dressing Regimens
  – Use a chlorhexidine-impregnated sponge dressing for
    temporary short-term catheters in patients older than 2
    months of age if the CABSI rate has not been
    substantially reduced despite adherence to basic
    prevention measures, including education and training,
    use of chlorhexidine for skin antisepsis, and MSB.
    Category IB
      Select Highlights, CDC/HICPAC CRBSI
       Prevention Guideline, 2010 – in press
Section: Needleless Intravascular Catheter
  – When needleless systems are used, a split septum valve may be
    preferred over a mechanical valve due to increased risk of infection
    with some mechanical valves. Category II

  – Minimize contamination risk by scrubbing the access port with an
    appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor,
    or 70% alcohol) and accessing the port only with sterile devices.
    Category IA
      Select Highlights, CDC/HICPAC CRBSI
       Prevention Guideline, 2010 – in press

Section: Skin Preparation
• Prepare clean skin with a > 0.5% alcohol-based
  chlorhexidine preparation before central venous
  catheter insertion and during dressing changes. If
  there is a contraindication to chlorhexidine,
  tincture of iodine, an iodophor, or 70% alcohol can
  be used as alternatives. Category IA
A Model

Saint S, et al ICHE 2010
 Overcoming barriers: The Golytely
• How active resisters and organizational
  constipatorsapproach? care-acquired
               affect health
 infection prevention efforts. Jt Comm J Qual
 Patient Saf 2009
  – Resisters: Benchmarking, champions, &
  – Constipators: use golytely!
18 %

May 25,
        The Importance of Validation of
                                          Lin MY, Hota B, Khan YM, et al.
                                          JAMA 2010; 304 (Nov.10):2035-41.

Compared CLABSI identified by IP vs computer algorithm, 4 medical ctrs,
         20 ICUs

Findings: Median CLABSI 3.3 (2.0-4.5) by IP vs 9.0 (6.3-11.3) by algorithm
          Significant variation in detection by IP vs algorithm by facility
         The Importance of Validation of

Niedner NF & 2008 NACHRI PICU Focus Group [N=16 PICUs / 14 facilities]
Findings: Substantial variation in CLABSI Surveillance Practices
           Units with more aggressive surveillance program = higher CLABSI r
            Summary Thoughts
• Let’s Sustain the Momentum from Launch of “I believe in
  zero BSIs” at APIC 2010
• Use the On the CUSP tools and resources & encourage
  enrollment of your affiliate
• Ingredients of the “secret sauce” of prevention
   – individual accountability, teamwork and behavioral change
• Validation of identification of CLABSI is critical
   – Being built into ARRA fund HAI prevention initiatives
   – APIC education & training
   – Complete HAI Studies Project Modules: see Wright MO, et al. Am
     J Infect Control 2010; 38:416-8
   – Practice, practice, practice….

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