State of the State Address on HAI Prevention Activities

Disclaimer/Conflict of Interest I have no disclaimers or conflicts of interest to report

Objectives Identify priority action areas and components outlined in the Illinois HAI Prevention Plan Discuss current HAI Prevention initiatives lead by IDPH Division of Patient Safety and Quality

IDPH HAI Prevention Program Housed in the Office of Policy, Planning, and Statistics, Division of Patient Safety & Quality Expanded with ARRA funding in 2009, continued with ACA funds 5 year State HAI plan http://www.cdc.gov/hai/state-based/ Address Illinois priorities, & align with National Priorities HAI Roadmap to Elimination http://www.hhs.gov/ash/initiatives/hai/actionplan/

IDPH HAI Prevention Program 1) Collect, evaluate, interpret and report HAI data Illinois Hospital Report Card & Consumer Guide to Healthcare http://www.healthcarereportcard.illinois.gov/ 2) Use the data for action Lead and assist healthcare organizations with improving the quality & safety of services

HAI Prevention Team Illinois IDPH Division of Patient Safety & Quality Division Chief Mary Driscoll, RN, MPH HAI Prevention Coordinator Erica Runningdeer, MSN, MPH, RN Epidemiologist Anh-Thu Runez, MPH CDC Public Health Prevention Service Fellow Robynn Leidig, MPH Project Director, CDI collaborative Kelly Fugate, ND, RN, HSMI Project Director, Antimicrobial Stewardship collaborative Chinyere Alu, MPH DPSQ Staff Barbara Fischer, RN & Jessica Ledesma, M. Ed, MPH IDPH Division of Infectious Diseases, Communicable Disease Section CDC Subject matter experts and research methods *HAI projects primarily funded with ACA awards through the CDC

HAI Prevention Team HAI Advisory Council Stakeholders & Subject Matter Experts Chicago CDC Prevention EpiCenter State QIO (Telligen) Local Health Departments APIC Infection Preventionists from various facility types/settings Trade Organizations Payers/Insurance Patient advocates

HAI Prevention Team National Partners Subject matter expertise Resources CDC CSTE ASTHO NACCHO Other states HAI programs Share lessons learned

HAI Prevention Team XDRO Registry collaborators IDPH Division of Patient Safety & Quality Division of Infectious Diseases, Communicable Disease Control Section Judy Kauerauf & Judy Conway Chicago CDC Prevention Epicenter Mike Lin, MD, MPH William Trick, MD Mary Hayden, MD Bala Hota, MD Robert Weinstein, MD CDC Alex Kallen, MD

IDPH HAI Prevention Program Major topics of focus: NHSN Reporting & Validation Clostridium difficile Antimicrobial Stewardship CRE & XDROs Practice Areas: Initial focus on acute care facilities, now expanding initiatives to Long Term Care settings and beyond

IDPH HAI Prevention Program Mandated NHSN reporting publicly posted to the Illinois Hospital Report Card NHSN measure mandated by IDPH CLABSIs in ICU settings Date reporting started -adult ICUs (medical, surgical, med/surg): January 2009 -pediatric & neonatal ICUs: January 2010 -all other adult ICUs: July 2010 SSI knee arthroplasty (KPRO) April 2010 SSI coronary artery bypass graft (CABG) MRSA blood specimen Lab ID event April 2010 -acute care hospitals: January 2012 -LTACHs & IRFs: October 2012 C. difficile Lab ID event -acute care hospitals: January 2012 -LTACHs & IRFs: October 2012

The Institute for Healthcare Improvement (IHI) Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Shared goal Measures to track progress/success Process Outcome Bundle Interventions & Innovations Multidisciplinary teams Act Plan Study Do The Breakthrough Series: IHI s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003. (Available on www.ihi.org)

The Institute for Healthcare Improvement (IHI) Model for Improvement Start with a small test of change Then, build on and expand your efforts. Act Plan Study Do

How do we start the process of improvement? Build on past successes HAI prevention efforts often grow as an extension of a previous prevention efforts Expansion from acute to long term care settings C. diff antimicrobial stewardship CRE Do what s feasible Many small steps still get you closer to achieving your goals Sustainability Build changes into the workflow Engagement of partners & coordination of efforts

IDPH HAI Prevention Program Clostridium difficile CDI Prevention Collaborative (2010-2011) 20 acute care hospitals focused on bundle of CDI prevention interventions Illinois Campaign to Eliminate Clostridium difficile ICE C. diff (2011-2012) http://www.idph.state.il.us/patientsafety/ice_home.htm CDI Prevention Across the Continuum of Care PACC Collaborative (2013-2014)

23 campaign sponsors Representing hospital groups, long term care trade associations, local health departments, and infection prevention groups 254 facilities signed up for the campaign 46% hospitals, 54% long term care facilities 8 webinars on 5 topics were held March through September 2012 Average of 270 phone lines used for each topic 3 regional workshops with 457 attendees 56% hospitals, 38% Long Term Care Facilities, 6% other

IL CDI Prevention Across the Care Continuum (PACC) Collaborative 4 clusters of facilities 4 acute care hospitals 11 long term care facilities Goals: Address issues specific to LTC Improve transitions of care Reduce readmissions

IDPH HAI Prevention Program Antimicrobial Stewardship (AMS) AMS Collaborative (2011-2012) 5 acute care hospitals Illinois Summit on AMS (June 2013) Hospitals, Long Term Care facilities, and other stakeholders 250 participants AMS Webinars (co-hosted with Telligen) November 25th, December 20th, January 15th Assessment of AMS in LTC - web-based survey & site interviews Illinois Collaborative for Antimicrobial Stewardship Enhancement ICHASE (2013-2014) Acute care hospitals reporting antibiotic use to NHSN Focus on evaluating the implementation of guidelines

Why stewardship? Address the root cause, the prevention of infections and resistance rather than controlling transmission of infection Not addressed by CDI prevention bundle Involves different multidisciplinary team members Involves complex systems, physician prescribing

Rationale for Antimicrobial Stewardship Mitigate the unintended consequences of antimicrobial use Direct/immediate harms to patients C. difficile Adverse drug events Indirect/delayed harms effectiveness of antimicrobials in future costs Regulatory burden & public perceptions Mandatory NHSN reporting & hospital report card CMS measures & potential mandates for AMS programs

Operational Goals of Antimicrobial Stewardship* right Diagnosis: Does this patient have an infection or something else? right Drug selection: for the diagnosis, the institution, AND for the patient right Dose: adjusted for size & renal function right Duration: harms minimized by shortest effective duration right De-escalation: narrowest spectrum, least invasive, lowest cost *Developed by Ramesh Patel, PharmD & David Schwartz, MD

Assessment of Antimicrobial Stewardship in Skilled & Intermediate Nursing Facilities Learn about challenges to improving antibiotic use in LTC Findings will be used to develop action steps on how to improve antibiotic use in LTCFs Two pronged approach: Online survey (August September 2013) >60% targeted facilities responded On site focus groups and individual (phone) interviews with 12 sites in progress Multidisciplinary, multi-stakeholder project team HAI Capacity Building Project: Funded by ASTHO (Association for State and Territorial Health Officials) through support from the CDC

CRE carbapenem-resistant Enterobacteriaceae Mandatory reporting to the ex tensively D rug R esistant O rganism registry began November 1, 2013 Amendment to the Control of Communicable Diseases Code (77 Ill. Adm. Code 690) Rules

CRE carbapenem-resistant Enterobacteriaceae Why?... When the reporting burden is already high

CRE carbapenem-resistant Enterobacteriaceae NIGHTMARE BACTERIA Few treatment options (if any) High mortality rate Spreading quickly http://www.cdc.gov/drugresistance/threat-report-2013/ cdc.gov

Enterobacteriaceae Family of bacteria that include: Escherichia coli Klebsiella species Enterobacter species Citrobacter species Cause healthcare and communityassociated infections Example: urinary tract infections cdc.gov

Geographical Distribution of Klebsiella pneumonia carbapenemase (KPC) Infections

Emergence and Rapid Regional Spread of KPC Social Network of Resistant Pathogens Won, Munoz-Price, Lolans, Hota, Weinstein, Hayden (2011). Emergence and Rapid Regional Spread of KPC Producing enterobacteriaceae. Clinical Infectious Diseases, 53(6), 532-540.

Illinois Situation Update Chicago area facilities (REALM project), 2010-2011 Facility type Short stay acute care hospitals (adult ICUs) Long term acute care hospitals (LTACHs) CRE colonization prevalence 3% 30% Lin MY et al. CID, 2013 CRE are relatively common in some Chicago healthcare facilities, particularly LTACHs Few prevalence data exist for hospital non-icu wards, nursing homes, and regions outside of Chicago

Regional Spread of CRE Long term acute care hospitals (LTACHs) Inter-facility transmission Short stay acute care hospitals Skilled nursing facility Lin MY CID 2013, 57:1246 Thurlow CJ ICHE 2013, 34:56 Prabaker K ICHE 2012, 33:1193 Won SY CID 2011; 53:532 (Slide courtesy M Hayden)

Slide courtesy of Michael Lin, MD

CDC CRE toolkit Detect and protect 1. Find CRE-carrying patients 2. Maintain them in contact precautions http://www.cdc.gov/hai/organisms/cre/cre-toolkit

Regional collaboration is critical Israeli CRE detect and protect strategy with communication between healthcare facilities across the country Intervention Before After Adapted from Schwaber M J et al. Clin Infect Dis. 2011;52:848-855

XDRO Registry Goals Improve detection and surveillance of patience with CRE Improve communication among facilities as patients transfer within the healthcare system

CRE identified Report XDRO registry Query Patient admit (Unknown CRE status) Isolation Precautions (Y/N)

XDRO registry intended participants All Illinois hospitals (including LTACHs): 142 All Illinois nursing homes: 784 All Illinois laboratories

CRE surveillance definition: Enterobacteriaceae with one of the following test results: 1. Molecular test (e.g., PCR) specific for carbapenemase OR 2. Phenotypic test (e.g., Modified Hodge) specific for carbapenemase production OR 3. For E. coli and Klebsiella species only: non-susceptible to ONE of the carbapenems (doripenem, meropenem, or imipenem) AND resistant to ALL third generation cephalosporins tested (ceftriaxone, cefotaxime, and ceftazidime). Report 1 st CRE event per patient per encounter

Reporting Example A patient is admitted to your hospital. On hospital day 2, a urine culture grows Klebsiella pneumoniae, resistant to all cephalosporins and imipenem. (On day 3, the same organism grows from blood) Action: The patient has CRE. Report the first isolate (urine culture) to the registry

www.xdro.org www.xdro.org DPH.XDROregistry@illinois.gov

Future vision

System Maturation CRE Registry Automated admission feed IP notification Healthcare Facility

System Maturation Healthcare Facility ELR feed CRE Registry Automated admission feed IP notification Healthcare Facility

System Maturation Healthcare Facility ELR feed CRE Registry Automated admission feed IP notification Healthcare Facility I-NEDSS

Illinois CRE campaign coming soon!

http://www.cdc.gov/vitalsigns/pdf/2013-03-vitalsigns.pdf

CRE task force Chicago Department of Public Health convened CRE Task force to coordinate regional approach to CRE control and prevention. The aim is to clearly define actionable steps to address various aspects of CRE control and prevention. Task force is multi-jurisdictional and multidisciplinary: Representation includes: ACH, LTACH, ICP, laboratorians, local and state public health epidemiologists and infectious disease practitioners.

CRE task force Priority areas include: Surveillance. Laboratory detection. Reporting and inter-facility communication. Infection Control measures. Deliverables: Describe regional epidemiology. Distribute Alert for emerging NDM in region. Develop and disseminate recommendations for CRE laboratory testing. Identify Infection control measures and develop a team of experts to assist in implementation with facility-specific education.

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