Kate Arnold MD, GA Division of Public Health, kearnold@dhr.state.ga.uswith many thanks to Nancy White, NHSN Coordinator, GA EIP

State HAI Prevention Planning

Presented to:

APIC Greater Atlanta

January 13, 2010

What is Driving HAI Prevention Planning in Public Health?

• Government Accountability Office (GAO) recommended to Health & Human Services (HHS) to improve the coordination and support of infection prevention and surveillance.

• January 2009 HHS Action Plan to reduce HAIs (HHS response to GAO): Public Health to become involved in the prevention of healthcare associated infections across the continuum of care.

State HAI Plan Legislation

Fiscal Year 2009 Omnibus Bill: • States receiving Preventive Health Services (PHHS) Block

Grant funds required to submit a plan to the Secretary of HHS by January 1, 2010. – Consistent with HHS Action Plan to Prevent HAIs – Blueprint” for state HAI activities going forward

HHS Action Plan

• Develop specific metrics and national targets to prevent HAIs

• Develop approach to reduce disease transmission• Prioritize and facilitate rapid implementation of

recommended prevention practices• Support research to address gaps in the science of

HAI prevention

Take Home Message

• Prevention of HAIs is cost effective, saves lives and reduces disability for healthcare consumers

• The time to act on HAIs is now and HHS is working closely with its partners to help accomplish the established targets to prevent HAIs.

http://www.hhs.gov/ophs/initiatives/hai

HHS Phase 1

• Focus on Acute Care Facilities– (Phase II will expand to include LTC facilities)

• 6 HHS Priority Areas are associated with devices and procedures:

– Central line associated blood stream infection (CLABSIs)– Catheter Associated Urinary Tract Infections (CAUTIs)– Ventilator Associated Pneumonia (VAP)– Surgical Site Infections (SSIs)– MRSA– Clostridium difficile

HHS Standardized Metric

The standardized infection ratio (SIR) is proposed as the next generation in epidemiological approaches for monitoring and feeding back risk adjusted infection rate

Observed Number (your facility)Expected Number (benchmark data)

SIR (con’t)• Like the standardized mortality ratio, the advantage is one

generalizable quality index regardless of the mix of operations performed

• 95% confidence interval describes the variability around the estimate or the range in which the true value should fall

• The standardized population comes from the historical NHSN data

• Ideally, one would want a facility SIR of less than one to demonstrate a ratio that is lower than the standard population

State and Local Programs

• Funding Source:• American Reinvestment and Recovery Act (ARRA) • CDC given $50 M to build programs to prevent HAIs

– $10 M to CMS to address ambulatory surgery centers– $40 M to divide among 50 states based on an application

process– State of Georgia got minimal funding: $242k (only enough to fund one

employee salary and benefits for 2 years)…no operational budget for program

– Additional funds to Georgia EIP are helping establish infrastructure and will eventually be used for special projects

Georgia’s Plan

• States submitted plans to HHS before January 1– Georgia plan to establish infrastructure to achieve measurable

5 year goals, with milestones toward the prevention of HAIs– Requires us to

– Establish advisory committee– Establish centralized surveillance system– Choose metrics and goals for surveillance baseline– Take periodic or longitudinal measurements– Build reductions on facility efforts and prevention collaboratives

– Progress report to Congress due by June 1, 2010

Existing HAI Reduction Collaboratives in GA

• Comprehensive Unit-based Safety Program (CUSP): STOP BSI Project

• GA initiative led by Denise Flook, GHA• 23 GA Hospitals enrolled • Encouraging additional hospitals to join www.safercare.net

• AHRQ’s Team Strategies and Tools to Enhance Performance and Patient Safety (Team STEPPS) MRSA reduction program

• 8 GA Hospitals participating through GMCF (CMS-QIO)• Requires NHSN enrollment• http://teamstepps.ahrq.gov/index.htm

GA State Plan

– Use of NHSN infrastructure previously agreed upon– No mandate in GA for participation or public reporting

• Though this may occur at some point

– Stakeholders Meeting on Dec 2 at State Offices:• Required to select 2 priority prevention targets in support of the HHS HAI

Action Plan• Chosen based on importance to patient safety, reliable data, and proven

preventability, and existing infrastructure and collaboratives. • Use of NHSN system, definitions and parameters

– Stakeholders choices for prevention metrics: • CLABSI, and SSI for at least one of [hip, knee, abdominal

hysterectomy]

HHS Metrics and 5 Year Targetsfor CLABSIs

• Decrease CLABSIs per 1,000 device days by 50%, using NHSN definitions and a metric which benchmarks against expected rates

• 100 % Compliance with Process Measures:• NHSN Central Line Insertion Practices (CLIP)

HHS Metrics and 5 Year Targetsfor SSIs

• Reduce SSIs by 25% for deep incision and organ space infections, using NHSN definitions and a metric which benchmarks against expected rates

• Expect at least 95% compliance rate to SCIP/NQF infection prevention process measures

You’re Invited !!!

• In January 2010, all acute care facilities with at least 25 beds will be invited to:– Begin reporting to CDC’s NHSN

• CLABSI• At least one of [hip, knee, abdominal hysterectomy]

– Join G-SNUG (Georgia State NHSN Users’ Group)• To begin contributing information for establishing baseline

rates of HAIs

What is G-SNUG ?

• A group within NHSN established by the state health department and the GA EIP (agents of the state) to allow statewide surveillance for HAIs– To establish G-SNUG infrastructure, state and EIP will work hand-in-

hand to recruit and support reporting facilities– G-SNUG permits state epis and EIP to view and analyze aggregate

or facility-level information, but not patient information, as agreed to by the reporting facility.

• State’s purpose: conduct surveillance toward HHS goals and assist facilities with HAI problems

• EIP purpose: conduct special studies (needs assessment and evaluations of prevention practices)

Why Would We Join G-SNUG??

• Look GOOD just in case!– Proactively take control of our facility’s infection prevention

practices/discipline before a PUBLIC reporting mandate is issued by federal and/or state legislation

• Avoid a “bad” mandate!– Demonstrate that infection prevention is improving in GA,

just like other states required to deal with difficult reporting mandates

Why Would We Join G-SNUG??

• Raise the bar!– Collaborate with colleagues to identify new best

practices• Get on the moving train!

– Ensure that our facility and all of GA achieves HHS five year HAI prevention goals

• Strut our stuff together!– Demonstrate the Great Teamwork and Collaboration

among GA IPs

What if I’m Worried about Joining G-SNUG?

• Facilities NOT joining G-SNUG may appear to have “something to hide” or to be unwilling to embrace transparency about their quality of care

• This is a PROBLEM in the current era of transparency

Other Advantages To Joining G-SNUG

• Standardized definitions and gold-standard NHSN methodology

• Provides risk-adjusted comparisons to national data• Assists in the development of data analysis skills to

recognize trends in patient safety issues • Additional training for IPs• Conduct collaborative research initiatives

How to Join the G-SNUG

• NHSN Enrollment• Complete Application and C-Suite Approval

• Training for start up and modules in use• Digital Certificate – need IT Administrator rights or

IT support to install • Establish ‘location’ codes in NHSN and input

monthly surveillance plan• Input your Facility’s surveillance data

What to Do NOW??

• Enroll Your Facility/Health System in NHSN• Once joined, Facility Administrator confers rights to

the GA State NHSN Users Group (G-SNUG) to access data based on the data use agreement

G-SNUG Goal :– January begin recruitment – March 1 = 10 Facilities enrolled– May 1 = 20 Facilities enrolled

WHAT’S COMING in Georgia?

• Additional training for Infection Preventionists

• CDC’s commitment to simplify data collection and data entry methodology

Coming Soon: Improvements to NHSN

• Collection of CL device days outside of the ICU

• Software vendors establishing an HL7 standard for importing data from EMRs to NHSN

Theradoc Premiere Medmind vigilant AICE Pharmacy I epiquest

• Additionally, CDC speaking w McKesson, Cerner and Sunquest

CDC Piloting electronic transfer of data into NHSN modules

• First two NHSN modules working well• BSI (summary and ICU location)• SSI (denominator, procedure)

• 3 additional modules go live, hopefully, in March• UTI• Pneumonia• MDRO labID events

Unresolved Issue

• Protection of facility ID and the Open Records Act– How big is this problem, and shouldn’t we be more positive

and proactive? Don’t we WANT people to know how well we are/ strive to be doing?

• GA DHR exploring possible solutions – No simple answers per our lawyers…even those used by

other states• Need to hear from facility decision-makers where this is

a road-block…organize meeting with legal team and public health leadership

2010

• Let’s meet the challenges of Infection Preventionists collectively and collaboratively rather than individually

Comments and Questions ???