Healthcare Associated Infections (HAI) Texas Reporting Updates

Healthcare Associated Infections (HAI) Texas Reporting Updates

Objectives Briefly review Texas HAI reporting requirements Describe updates and changes for Health Care Safety Group & Reporting Review findings from 2016 Annual Report 1. 2016 Validation Findings 2. Discuss common data reporting errors and how to avoid them. And I ll pose some FAQs along the way! 3/19/2018 HAI Updates 2

Raise of Hands How many years have you been in Infection Prevention? A. <1 year B. 1-5 years C. 5-10 years D. 10+ How many of you are eligible to take the CIC exam? Of those eligible, how many of you are Certified in Infection Control & Prevention? 3/19/2018 HAI Updates 3

Texas Requirements Central line-associated bloodstream infections (CLABSI) in the following special care settings: adult, pediatric and/or adolescent ICUs & NICUs (Level II/III & Level III Nurseries). Catheter associated urinary tract infections (CAUTI) in the following special care settings: adult, pediatric and/or adolescent ICUs. Surgical site infections (SSI) CHILDREN S HOSPITALS: Cardiac procedures, heart transplants, spinal surgery with instrumentation, and VP shunt procedures ALL OTHER GENERAL HOSPITALS & ASCs: Colon surgeries, hip & knee arthroplasties, abdominal & vaginal hysterectomies, vascular procedures, and coronary artery bypass grafts 3/19/2018 HAI Updates 4

Centers for Medicaid and Medicare Services (CMS) Reporting Requirements 3/19/2018 HAI Updates 5

Reporting Overview Alerts regarding data & reports View reports & make comments 3/19/2018 HAI Updates 6

Facility-Specific Reports 3/19/2018 HAI Updates 7

Facility-Specific Reports 3/19/2018 HAI Updates 8

Raise of Hands How many of you have looked at your own facility s reports on the public website before? How many of you have looked at COMPETING facility s reports on the public website before? How many of you had no idea this was out there? 3/19/2018 HAI Updates 9

Updates State of the State 2017 Data Suspension Future of Reporting Program Updates 3/19/2018 HAI Updates 10

2017 Data Suspended 1. 2017 data reporting suspended 2. Hurricane Harvey hit right before H1 2017 deadline a. DSHS and hospital resources taxed in regions where >50% of reporting hospitals are located 3. TxHSN updates related to the 2015 Re-Baseline need to be performed on TxHSN before those data can be imported from NHSN. 3/19/2018 HAI Updates 11

Future of Reporting Changes to Facility-Specific Report due to converting to new Standardized Infection Ratio (SIR) data Inpatient/Outpatient SSI data will change to Pediatric and Adult SSI data New Oncology Intensive Care Unit (ICU) row for CAUTI and CLABSI 3/19/2018 HAI Updates 12

Future of Reporting Alignment with CMS reporting requirements On hold until next legislative session TAP report review by Regional HAI Epidemiologists Remote Audit option ONLY for HAI data validation starting with 2018 data (next audit round starts in Sept 2018) 3/19/2018 HAI Updates 13

Frequent Questions QUESTION: TRUE OR FALSE. Surgeries that were closed Primarily and by Other means will BOTH be included in new 2015 SIR. 3/19/2018 HAI Updates 14

Frequent Questions QUESTION: TRUE OR FALSE. Surgeries that were closed Primarily and by Other means will BOTH be included in the new 2015 SIR. True. The old baseline used to exclude surgeries that were not primarily closed. The new 2015 baseline will include both CLOSURE = PRIMARY and CLOSURE = OTHER. 3/19/2018 HAI Updates 15

Recent Changes Sunset Commission recommended consolidating DSHS HHS DSHS Logo changed in Spring 2017 New Regional HAI Epidemiologists Subject Matter Experts for Infection Prevention All are CIC Certified!! New Antimicrobial Resistance Expert: Dr. Michael Fisher 3/19/2018 HAI Updates 16

Regional HAI Epidemiologists Gillian Blackwell HSR 1 Thi Dang HSR 2/3 Annie Nutt HSR 4/5 N Sandi Arnold HSR 7 Susana Baumann HSR 9/10 Gretchen Rodriguez HSR 8 Bobbiejean Garcia HSR 6/5 S Melba Zambrano HSR 11 17

Regional HAI Job Duties 1. Outbreak Response 2. Infection Prevention Consultations 3. Infection Control Assessments for Acute care and long term care facilities 4. Targeted Assessments for Prevention of HAIs 5. Multi-drug Resistant Organism Reporting (MDRO) CRE E. coli and Klebsiella MDR Acinetobacter 3/19/2018 HAI Updates 18

Raise of Hands How many of you DID NOT know you had a Regional HAI Epidemiologist at your disposal? Of those that didn t know How many of you would have contacted your Regional HAI Epidemiologists recently if you had known you had one? 3/19/2018 HAI Updates 19

2016 Annual Report Summary Where to find it Overview of SIRs/Trends Top Pathogens MDROs 3/19/2018 HAI Updates 20

HCS Annual Report HAITexas.org 3/19/2018 HAI Updates 21

2016 Annual Report Overview 994 CLABSIs, 953 CAUTIs and 2,841 SSIs Texas CLABSI SIR = 0.496 (95% CI: 0.466, 0.528) 39 (5.2%) fewer infections than 2015, but this change was not statistically significant. Texas CAUTI SIR = 0.551 (95% CI 0.517, 0.587) 74 (6%) fewer infections than 2015, but was not statistically significant. Texas SSI SIR = 0.72 (95% CI: 0.694, 0.747) 72 (4.6%) fewer infections than 2015, however, this was not statistically significant. 3/19/2018 HAI Updates 22

Top 10 Pathogens 3/19/2018 HAI Updates 23

2016 MDROs 3/19/2018 HAI Updates 24

Frequent Questions QUESTION: If you have more then one diagnostic test used to meet criteria on different dates, which do you use to determine the Infection Window Period? 3/19/2018 HAI Updates 25

Frequent Questions QUESTION: If you have more then one diagnostic test used to meet criteria on different dates, which do you use to determine the Infection Window Period? Use the most localized test. Example: If you have a lab specimen and an imaging test, you would use the lab specimen. 3/19/2018 HAI Updates 26

CLABSI SIR Trends 3/19/2018 HAI Updates 27

CLABSI SIR Trends 3/19/2018 HAI Updates 28

CAUTI SIR Trends 3/19/2018 HAI Updates 29

CAUTI SIR Trends 3/19/2018 HAI Updates 30

SSI SIR Trends 3/19/2018 HAI Updates 31

SSI SIR Trends 3/19/2018 HAI Updates 32

Frequent Questions QUESTION: TRUE OR FALSE. If there was an infection present at the time of surgery (PATOS), then I do not have to report it in NHSN. 3/19/2018 HAI Updates 33

Frequent Questions QUESTION: TRUE OR FALSE. If there was an infection present at the time of surgery (PATOS), then I do not have to report it in NHSN. FALSE. You will still report these infections as PATOS = YES. But they will not be included in the 2015 SIR calculation. 3/19/2018 HAI Updates 34

HAI Data Validation Overview Current Process for Validation CLABSI/CAUTI SSI Targeted Assessment and Prevention Reports Validation Results Future of Texas HAI validation 3/19/2018 HAI Updates 35

HAI Data Validation 3/19/2018 HAI Updates 36

Historically Prior to current validation methods, only reported events were reviewed and validated by DSHS. 97-99% of events were reported accurately. Those responsible for reporting, mostly Infection Preventionists, had a good grasp of requirements and definitions. Facilities that were audited had very robust IP programs that were good at finding and identifying HAIs. 3/19/2018 HAI Updates 37

CLABSI/CAUTI Validation Facility selection process modeled after the NHSN CLABSI Validation Protocol CDC recommends targeted validation in order to investigate and correct potential deficiencies in an efficient manner. NHSN recommends 21 facilities be chosen via targeted selection and 5% of the remaining facilities selected randomly. For Texas, this is approximately 35-40 facilities per HAI. 3/19/2018 HAI Updates 38

Facility Selection: Details 21 in the top 33% of facilities with highest number of expected/predicted infections are selected. Top 7 facilities with SIRs above the median Top 7 with SIRs at or below the median, but above 0 Top 7 with SIRs = 0 5% of all remaining facilities are randomly selected (~10-15). 3/19/2018 HAI Updates 39

Record Selection Selected facilities are required to submit a line list of all positive cultures from the given audit period (6 months). From the line list, DSHS will select: a. Up to 20 patient records of NHSN reported b. Up to 40 patient records of unreported candidate events NOTE: the entire patient s medical record will be reviewed, not just the data around a single positive culture. 3/19/2018 HAI Updates 40

Summary of Validation Process 1. Facility notified and line list requested 2. DSHS selects medical records for review and sends to facility 3. Select site visit date and send Facility Audit Survey for completion by facility prior to site visit. 4. Notify CEO/Administrator, DSHS Regulatory and Regional/Local Health Departments about upcoming visit 5. Review Facility Audit Survey and perform site visit Introductions/Entrance Interview Partially Blind Chart Review Debriefing/Conclusions 6. Send Validation Summary Report to IPs, CEO/Admin and other staff as needed. 3/19/2018 HAI Updates 41

Frequent Questions QUESTION: Can you use non-definitive chest x-rays (e.g. opacities/infiltrates noted but pneumonia not specified as cause) to meet pneumonia criteria? 3/19/2018 HAI Updates 42

Frequent Questions QUESTION: Can you use non-definitive chest x-rays (e.g. opacities/infiltrates noted but pneumonia not specified as cause) to meet pneumonia criteria? If there is any documentation in the medical record that correlates the nondefinitive findings on imaging with what is clinically happening with the patient and that documentation suggests it is pneumonia and there is treatment for pneumonia then the imaging tests would be eligible for use in meeting the imaging portion of the PNEU definitions. 3/19/2018 43

Surgical Site Infection (SSI) Validation SSI: Identify facilities based on Standardized Infection Ratio (SIR): If Statistically Significantly High 2 Audit Tiers: First Time High SIR no high SIR for same HAI for previous time period) Subsequent High SIR high SIR for same HAI for two reporting periods in a row 3/19/2018 HAI Updates 44

SSI Validation First Time High SSI SIR Purpose: To ensure facility is applying the CDC definitions correctly and to verify the number of infections reported to DSHS. Audits for those facilities with significantly high SIRs to verify data reported meet NHSN HAI criteria Review of reported SSI events only Record Review & IP/Administration staff Interview 3/19/2018 HAI Updates 45

SSI Validation Subsequent High SIR Investigations: Purpose: DSHS will aid facilities in prevention efforts and provide consultation/support as needed. Conducted by Epidemiologists with Certification in Infection Control and Prevention (CIC certification) Phone consultation to review interventions taken and action plans in place at facility to determine if site visit is warranted If site visit needed, CIC HAI Epidemiologist will come to facility and may perform environmental rounds, interview floor staff, observe procedures/patient care activities, review policies and patient records. 3/19/2018 46

Validation Results For validation of data reported between Jan 2016 Dec 2016: Overall, approximately 1.4% of cases were identified as discrepant (either overor under-reported). These cases tended to represent the most complex cases. 3/19/2018 HAI Updates 47

CAUTI Common Errors Date of Event: IP uses date of positive culture instead of date of first sign/symptom Foley wasn t in place for > 2 days Infection attributed to wrong unit Facility didn t look for symptoms that can be used with catheter is not in place (e.g. urgency, frequency) after foley was removed. 3/19/2018 HAI Updates 48

CLABSI Common Errors #1: Inappropriately attributing as secondary to pneumonia (PNEU) or intra abdominal infection (IAB). Used non-definitive imaging without clinical correlation NOTE: clinical correlation is physician documentation of treatment for primary infection Documentation of central line or symptom missed initially or unable to be found at validation Definition of hypotension if no policy will default to electronic flags/alert thresholds. 3/19/2018 HAI Updates 49

SSI Common Errors Wrong depth of SSI reported EX: Superficial reported when it should have been Deep Subsequent SSI for same patient not reported Remember, SSIs do not have repeat infection timeframes. Joint (JNT) Infection reported instead of Periprosthetic Joint Infection (PJI) for SSIs following knee or hip replacements. 3/19/2018 HAI Updates 50

Validation Updates For 2018 data audits, DSHS will only be conducting GoToMeeting remote audits To mitigate validation fatigue only facilities with > 10% discrepancies will be re-audited within 2 years 3/19/2018 HAI Updates 51

Current Audit Team Candace Campbell, MPH DSHS Epidemiologist Candace.Campbell@dshs.texas.gov Office Phone: 512.776.6488 Nesreen Gusbi, MPH(c) DSHS HAI/PAE Specialist Nesreen.Gusbi@dshs.texas.gov Office Phone: 940.689.5087 3/19/2018 HAI Updates 52

Regional HAI Epi Contact Info Region 1: Gillian Blackwell, BSN, RN, CIC Gillian.Blackwell@dshs.texas.gov (806) 783-6418 Region 7: Sandi Arnold, RN, CIC Sandi.Arnold@dshs.texas.gov (254) 292-2130 Region 2/3: Thi Dang, MPH, CHES, CIC Thi.Dang@dshs.texas.gov (817) 264-4585 Region 8: Gretchen Rodriguez, MPH, CIC Gretchen.Rodriguez@dshs.texas.gov (210) 949-2025 Region 4/5N: Annie Nutt, MPH, CIC Anna.Nutt@dshs.texas.gov (903) 533-5317 Region 6/5S: Bobbiejean Garcia, MPH, CIC Bobbiejean.Garcia@dshs.texas.gov (713) 767-3404 Region 9/10: Susana Baumann, MPH, CIC Susana.Baumann@dshs.texas.gov (512) 776-6545 Region 11: Melba Zambrano, MSN, RN, CIC Melba.Zambrano@dshs.texas.gov (956) 444-3208 3/19/2018 HAI Updates 53

Thank you Jennifer Vinyard, MPH, CIC Email: Jennifer.Vinyard@dshs.texas.gov Office: 512-776-3773 3/19/2018 HAI Updates 54