Hospital-Acquired Infection Reporting by 87qxFj6


									Hospital-Acquired Infection Reporting

 Rachel L. Stricof
Chapter Laws 284 & 239

 Enacted in 2005
 “Hospital-acquired infection” = any
 localized or systemic condition that
   (a) resulted from the presence of an infectious
    agent(s)/toxin(s) as determined by clinical
    examination or by lab testing; and
   (b) was not found to be present or incubating at
    admission unless related to a previous admission
    to the same setting
 Who Has To Report?

 “General hospitals” – not residential
  facilities, not public health centers, not
  diagnostic and treatment centers
 General hospitals must have programs
  for identifying and tracking HAI for
  reporting purposes under this law and
  also for quality improvement (QI)
Hospital Responsibilities
  The program must have capacity to
    Specific infectious agents/toxins;
    The site of infection;
    Location where patient became infected;
    Patient diagnoses;
    Any relevant surgical, medical and diagnostic
     procedures during current stay
  The hospital must identify and regularly
   report HAIs to NYSDOH [or designated
   agent (e.g., CDC/NHSN)] as directed by
NYSDOH Responsibilities
  Establish guidelines, definitions, criteria,
   standards and coding for hospital identification,
   tracking and reporting of HAIs;
       Consistent with NHSN or other recognized center of
  Establish data collection and analytical
   methodologies that meet accepted standards for
   validity and reliability
  Initially require reporting of central line
   associated blood stream infections and surgical
   site infections associated with critical care units
  Subsequently, may require tracking and reporting
   of other HAIs in consultation with technical
NYSDOH Requirements
 Report annually to governor, legislature & the public
  (on the web)
      Pilot project and data (Year 1 – hospitals de-identified)
      Annually thereafter, hospital risk-adjusted rates
      Quality improvement efforts
 Prior to release, department will consult with various
  groups to ensure summary tables are easily
  understandable and accurately reflect HAI rates.
 Audit hospitals for completeness and accuracy of
 Department may award grants (if funding is made
Hospital Reporting

  NYS cannot require reporting more
   often than once every six months.
  Reporting must occur within 60 days
   of the end of the reporting period.
What is to be Done With Information?

 The data will          The aggregate data will
  support quality         be made available to the
  improvement and         public, providers &
  prevention efforts.     insurers for their use.
When is this Going to Happen?

 7/1/06–DOH must have a reporting system
 1/1/07-Hospitals must begin collecting
  data for reporting
 1/1/07-12/31/07- Pilot Year
   DOH  will publish report but will not identify
   Only DOH will know the identity of hospitals
What About Patient Privacy?

  Patient identifying information
   governed by PHL 206(1)(j)
  - The most stringent assurance of
   confidentiality in the PHL.
  - Hospital identifying information is not
   protected after the pilot year.

 PHL 206(1)(j):              PHL 206(1)(j):
 a) information must be      b) information when
  kept confidential and        received by Commissioner/
  used solely for research     designee is “not admissible
  or QI through medical        as evidence in any action of
  audits                       any kind in any court or
                               before any other tribunal,
                               board, agency or person.”

Patient information submitted by hospitals
 under PHL 2819 to the DOH or designee
 (NHSN) is not reachable by subpoena or
 court order.
NYS Public Health Law 2819

  Critical care/intensive care units
    Central line associated blood stream
    Surgical site infections

  DOH may require reporting of other
  types of HAIs
Selection of Indicators

 Central-line associated blood stream
  infections in ICUs
 Surgical Site Infections – Which Procedures ?
     • Frequency
     • Severity
     • Preventability
     • Likelihood that they can be detected and reported
     • Cardiac
     • Colon
Reporting System

  CDC’s National Healthcare Safety
  Network (NHSN)
    Standard  definitions, surveillance, risk
    Protocols in place

  Post-discharge Surveillance
    Sub-workgroup established
Regulatory – Historical Perspective
  Adverse event reporting system [PHL 2805-l, October
   1, 1985]

  Definition of occurrences:
       patients' deaths or impairments of bodily
        functions in circumstances other than those related
        to the natural course of illness, disease or proper
        treatment in accordance with generally accepted
        medical standards

  Confidentiality prevents disclosure of incident reports
   under the Freedom of Information Law [PHL 2805-m ]
New York Patient Occurrence Reporting
and Tracking System (NYPORTS)

  Electronic internet-based system
     Created to simplify reporting and coding
     Coordinated with other reporting systems to
      reduce duplication
     Designed to provide feedback on reporting
      patterns and compare facilities in the region and
      the State
     Initiated in 1995 – implemented statewide April,
Health Care Reform Act - 1996
  Hospital Report Cards
  Infection indicators sought
  Limited to existing data sources only
       Discharge database not valid for HAI indicators
         • Studies revealed poor sensitivity and specificity
         • Not able to distinguish between community, nosocomial or
           other healthcare facility-related events
         • No evidence in record to support diagnosis
         • Post-discharge events not detected
       No other existing data source

  Let’s investigate……….conduct a study
Iroquois Project
  Iroquois Healthcare Consortium
    57 hospitals, 31 counties
    NYSDOH funded project 4-1-99 to 3-31-03

  Goal
      Identify appropriate nosocomial infection
       indicators for potential public reporting
        • Feasible and useful
      Design, develop, implement and evaluate
        • Hospital-associated infection indicators
        • Antimicrobial-resistant organism indicator
Bed Size

            NYS         Iroquois
 Bed Size   Hospitals   Project
 <100       32%         31%
 100-299    40%         46%

 >300       28%         23%
Surgical Site Indicators

  Ideal: high volume and high risk procedures
    Difficulty identifying common surgical procedures
    Hysterectomy
       • Sufficient volume
       • Performed across spectrum of hospitals
       • Relatively low infection risk
  Required adopting standardized definitions
   and surveillance methods, including post-
   discharge surveillance
  Needed to control for type (vaginal, laparoscopic
   vs. abdominal), complexity (single vs. multiple
   procedures, risk index), and conditions (elective
   vs. emergency)
  2949 procedures in 1 year
  Vaginal hysterectomy – 1.0% infection rate
       75% not cultured
  Abdominal hysterectomy – 3.0% infection rate
       42% not cultured
  82% of infections identified post-discharge
     2/3 via physician survey
     1/3 upon readmission
Lessons Learned
  Cannot compare unless:
    Standardized definitions
    Standardized surveillance methods
    Comparing same procedures
    Adjusted for risk

  Existing data could not be used
    Administrative (SPARCS) database would not
     detect post-discharge events
    Laboratory-based surveillance not adequate

  Highly resource dependent
      Not sustainable without additional resources
Infection Control Resources Survey

New York State Department of Health
       Analysis, December 2004
Response Rate

  167/234 (71.4%)
  148 Infection control professionals
   (ICPs) responded
  Representing 167 acute care facilities
    ICPs    may cover more than one acute care
    Survey only sent to acute care facilities
Professional Resources

  218 full-time equivalent (FTE) ICPs
    158 were dedicated to routine surveillance
    11% of infection control programs cover more than
     one acute care facility
  Less than ½ of the facilities (45.8%) had
   a hospital epidemiologist (HE)
      For those facilities with a hospital epidemiologist,
       the individual devoted an average of .35 FTE to
       HE activities.
Organizational Placement

                      Number   Percent
 Quality Assurance    48       32%
 Nursing              43       29%
 Administration       20       14%
 Infectious Disease   8        5%
 Internal Medicine    6        4%
 Laboratory           3        1%
 Other/Unknown        20       14%
ICP-Surveillance Responsibilities

                    1 FTE ICP to:   1 Surveillance FTE to:

 ACH Beds                  150.5           208.1
 ICUs                        1.3             1.9
 ICU Beds                   14.4            20.0
 LTC Beds                   24.4            33.7
 Dialysis Centers            0.6             0.8
 Amb Surg Ctrs               0.5             0.6
 Outpt Clinics               5.0             7.0
Routine Surveillance Activities

                  Total House     Targeted
Bloodstream        57%              40%
Surgical Site      51%              44%
Pneumonia          36%              57%
Urinary Tract      28%              41%
ICPs Responsibilities*

 Employee/Occupational Health      68%
 Central Supply/Sterile Processing 52%
 Staff Education                   73%
 Risk Management                   45%
 Emergency/BT preparedness         70%
 Quality assurance                 55%

    * At least partial responsibility
Support and Services for IC Program

 Some Secretarial Support                           57%
       FTE, if secretarial support      0.7 FTE
   Computer for ICP                                 96%
   Internet Access                                  99%
   Fax                                              86%
   Computerized Medical Records, incl. partial      53%
   Computerized Laboratory Records                  93%
   Computerized Radiology Reports                   86%

                              No  Part Yes Unk
Inhouse Clin Micro            20% 11% 69%
Inhouse Mycobacteriol (TB)    45% 20% 34% 1%
Inhouse Viral Culture         68% 11% 20% 1%
Inhouse Rapid Viral Testing   29% 26% 45% 1%
Inhouse Fungal Testing        51% 15% 32% 2%

Most Recent Antibiogram prior to 2003: 7%
Hope to continue to monitor resources

 Why Infection Control Resources?
Julian et al. Hershey Medical Center SHEA 2005
ICD-9 vs. Active Surveillance –
Validation Study, PA

  Reason                 CL-         SSI        UTI      Total
  Community- acquired    6           0          0          6 (10%)

  No Exposure            6           14         4         24 (39%)
  No Device/Surgery
  Other HC Facility      0           1          2          3 ( 5%)

  No Infection           8           14         6         28 (46%)
      Total              20          29         12        61

 Sherman et al Children’s Hospital of Philadelphia - SHEA 2005
NYSDOH Goals and Objectives
   Develop and implement meaningful and useful HAI
    reporting system for Department, Facilities & Public

   The ultimate goal is the prevention of the HAI indicators
   The system will be used to evaluate potential
    interventions, risk factors, and risk adjustment strategies
    for those factors that are not amenable to change.
   The NYSDOH may, in the future, consider supporting
    regional research efforts in the area of infection prevention
    and control.
   The HAI reporting system will be used to evaluate impact
    of quality initiatives.

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