Tapping Into Strategies to Reduce Infections Strategy - Kainer.pdf · Tapping Into Strategies to...

Tapping Into Strategies to Reduce Infections

Marion Kainer MD, MPH Pamela Talley MD, MPH

Director Deputy Director

Healthcare Associated Infections

and Antimicrobial Infections

TCPS Regional Networking Meetings April 2018

Objectives

• Review CAD metric for targeted HAI reduction

• Describe current efforts to reduce CLABSI, CAUTI and

CDI using TAP strategy

• Provide TAP resources for other interested facilities

• Describe MDRO containment experience in Tennessee

• Update findings and next steps for invasive MRSA

prevention

• Other HOT TOPICS

Targeted Assessment

for Prevention

Standardized Infection Ratio (SIR)

SIR = 1 Same # of HAIs as predicted by US baseline data

SIR > 1 More HAIs than predicted

SIR < 1 Fewer HAIs than predicted

SIR = Observed O HAIs

Predicted P HAIs

CAUTI 25% SIR = 0.75

SSI 30% SIR = 0.70

CDI LabID 30% SIR = 0.70

MRSA LabID 50% SIR = 0.50

HHS 2020 Goals

CLABSI 50% SIR = 0.50

nEW

CLABSI SIR in Adult/Pediatric ICUs

0.75

0.39

CLABSI in Acute Care Hospitals

Unit Year

No.

of

Facs

TN SIR

No. of Facs

with Sig.

LOW SIR

No. of Facs

with Sig.

HIGH SIR

Adult/Pediatric

ICUs

2015 82 0.88 3 5

2016 82 0.85 3 2

2017 83 0.87 2 0

Adult/Pediatric

Wards

2015 100 0.80 7 1

2016 100 0.75 6 1

2017 99 0.69 7 1

Neonatal ICUs 2015 25 0.92 0 0

2016 25 0.63 2 0

2017 25 0.73 1 0

CLABSI HHS 2020 Goal: SIR = 0.5

CAUTI SIR in Adult/Pediatric ICUs

1.05

0.68

CAUTI in Acute Care Hospitals

Unit Year

No.

of

Facs

TN SIR

No. of Facs

with Sig.

LOW SIR

No. of Facs

with Sig.

HIGH SIR

Adult/Pediatric

ICUs

2015 82 1.06 3 5

2016 82 0.96 5 5

2017 83 0.72 9 2

Adult/Pediatric

Wards

2015 100 0.70 4 1

2016 100 0.73 5 2

2017 99 0.76 6 1

CAUTI HHS 2020 Goal: SIR = 0.75

Healthcare-Onset CDI SIR

CDI in Acute Care Hospitals

Year No. of

Facs TN SIR

No. of Facs with

Sig. LOW SIR

No. of Facs with

Sig. HIGH SIR

2015 108 0.97 11 8

2016 108 0.88 23 11

2017 106 0.84 29 6

CDI HHS 2020 Goal: SIR = 0.7

How do we get there?

A New Metric…

Cumulative Attributable Difference (CAD)

CAD =

Observed− (Predicted x SIRgoal)

+ CAD (Number need to prevent)

number of infections in a location or facility in a defined

period of time that must be prevented to reach HAI reduction

goal

TAP Strategy

Targeted Assessment for Prevention: Using Data for Action

www.cdc.gov/hai/prevent/tap.htm

❶ Target ❷ Assess ❸ Prevent

• Generate TAP Reports using the

National Healthcare Safety

Network (NHSN)

• Identify facilities/units with

excess HAIs using the

Cumulative Attributable

Difference (CAD) metric

• Engage targeted facilities/units

to participate in focused

prevention efforts

Tools

• NHSN TAP Reports

• TAP ‘How To’ Guide

Tools

• TAP Facility Assessment Tools

• TAP Excel Databases and

User Guide

Tools

• TAP Feedback Report

• TAP Implementation Guide -

Links to Resources

• Assess targeted facilities/units

for potential gaps in infection

control using the TAP Facility

Assessment Tools

• Summarize responses and

calculate scores across units,

facilities, and groups to identify

gaps

• Present identified gaps and

data to facility using TAP

Feedback Report

• Utilize the Implementation

Guide to access Resources to

aid in addressing identified

gaps

• Implement proven prevention

strategies in the targeted

facilities/units to reduce

infection rates

CAD and HAI Reduction Goal: CLABSI

• SIR goal is “HAI Reduction Goal

– HHS 2020 goal for CLABSI = 50% reduction SIR 0.50

_________________________________________________________

Facility A Observed=30, Predicted=30 SIR=1.0 in 2016

_________________________________________________________

HHS Reduction Goal SIR CAD Formula CAD

(Reduction in reported) O- (P x SIR goal)

0% 1.0 30- (30 x 1.0) 0

50% 0.50 30- (30 x 0.50) 15

75% 0.25 30- (30 x 0.25) 22.5

CAD at the Location Level

17

Observed # HAIs – (Predicted # HAIs x SIR goal) = CAD

Facility

A

Observed Predicted SIR SIR goal CAD

Ward 30 20 1.5 0.50 20

ICU 0 10 0 0.50 -5

Facility 30 30 1.0 0.50 15

CAD Report Types

• TAP reports available in NHSN starting in January 2015

• As of 3/2017

– ACH & LTAC TAP reports: CAUTI, CLABSI, CDI

– IRF and IRF units reports: CAUTI and CDI

18

Helpful Hints

• Ensure that locations are mapped correctly https://www.cdc.gov/nhsn/pdfs/pscmanual/15locationsdescriptions_current.pdf

• Generate up-to-date data set

• Use time periods of at least 1 quarter

• Default NHSN goals based on HHS 2020 SIR goals

– CAUTI 0.75

– CLABSI 0.50

– CDI 0.70

• Custom SIR goals must be <1

19

Limitations

• Influenced by risk exposure volume (i.e., larger hospitals

may be preferentially targeted

• Should not be used as a comparative metric

• Facility-level CAD is summary measure that may mask

prevention needs at the location level because of

cancelling effect among positive and negative CAD

values in different locations. Therefore, facilities should

run location specific CAD for internal use.

TAP Strategy

Targeted Assessment for Prevention: Using Data for Action

www.cdc.gov/hai/prevent/tap.htm

❶ Target ❷ Assess ❸ Prevent

• Generate TAP Reports using the

National Healthcare Safety

Network (NHSN)

• Identify facilities/units with

excess HAIs using the

Cumulative Attributable

Difference (CAD) metric

• Engage targeted facilities/units

to participate in focused

prevention efforts

Tools

• NHSN TAP Reports

• TAP ‘How To’ Guide

Tools

• TAP Facility Assessment Tools

• TAP Excel Databases and

User Guide

Tools

• TAP Feedback Report

• TAP Implementation Guide -

Links to Resources

• Assess targeted facilities/units

for potential gaps in infection

control using the TAP Facility

Assessment Tools

• Summarize responses and

calculate scores across units,

facilities, and groups to identify

gaps

• Present identified gaps and

data to facility using TAP

Feedback Report

• Utilize the Implementation

Guide to access Resources to

aid in addressing identified

gaps

• Implement proven prevention

strategies in the targeted

facilities/units to reduce

infection rates

Assessment Tools

Sample Feedback Report

TAP Strategy

Targeted Assessment for Prevention: Using Data for Action

www.cdc.gov/hai/prevent/tap.htm

❶ Target ❷ Assess ❸ Prevent

• Generate TAP Reports using the

National Healthcare Safety

Network (NHSN)

• Identify facilities/units with

excess HAIs using the

Cumulative Attributable

Difference (CAD) metric

• Engage targeted facilities/units

to participate in focused

prevention efforts

Tools

• NHSN TAP Reports

• TAP ‘How To’ Guide

Tools

• TAP Facility Assessment Tools

• TAP Excel Databases and

User Guide

Tools

• TAP Feedback Report

• TAP Implementation Guide -

Links to Resources

• Assess targeted facilities/units

for potential gaps in infection

control using the TAP Facility

Assessment Tools

• Summarize responses and

calculate scores across units,

facilities, and groups to identify

gaps

• Present identified gaps and

data to facility using TAP

Feedback Report

• Utilize the Implementation

Guide to access Resources to

aid in addressing identified

gaps

• Implement proven prevention

strategies in the targeted

facilities/units to reduce

infection rates

Timeline for TAP Collaborative

TDH/THA Webinar

Jan 2018

Invitation Letters

Feb 2018

Self-assessment

On-site visits

April-Oct 2018

Interventions

Track Progress

2018-2019

Wrap-up Webinar

June 2019

Other Resources

• Detailed “how-to” guidance & FAQs https://www.cdc.gov/nhsn/ps-analysis-resources/reference-guides.html

• TAP tools

https://www.cdc.gov/hai/prevent/tap.html

26

STRIVE Resources

Antibiotic stewardship

Building a Business case for

Infection Prevention

CAUTI Prevention

CLABSI Prevention

CDI Prevention

Environmental Cleaning

Hand Hygiene

MRSA Bacteremia Prevention

Patient and Family Engagement

Personal Protective Equipment

Providing Feedback

http://www.hret.org/quality/projects/strive-community.shtml

Containment Strategy:

“Be on guard

to contain the first spark”

https://www.cdc.gov/vitalsigns/containing-unusual-resistance/infographic.html#infographic

https://www.cdc.gov/vitalsigns/containing-unusual-resistance/infographic.html#infographic

https://www.cdc.gov/vitalsigns/containing-unusual-resistance/infographic.html#infographic

https://www.cdc.gov/vitalsigns/containing-unusual-resistance/infographic.html#infographic

https://www.cdc.gov/vitalsigns/containing-unusual-resistance/infographic.html#infographic

https://www.cdc.gov/vitalsigns/containing-unusual-resistance/infographic.html#infographic

Vital Signs Report: Containment

https://www.cdc.gov/mmwr/volumes/67/wr/mm6713e1.htm?s_cid=mm6713e1_w

Percentage Reduction of Proportion of

ESBL vs CRE E. coli and K. pneumoniae 2006-2015

ESBL E. coli and K. pneumoniae

NHSN: CAUTI, CLABSI

~2% decrease per year

CRE E. coli and K. pneumoniae

NHSN: CAUTI, CLABSI

~ 15% decrease per year

Epidemic stages (modified from Grundmann et al.)

0 – No cases reported

1 – Sporadic occurrence – single cases not epi-related

2 - Single facility outbreaks - ≥2 epi-linked cases in 1 facility

3 – Regional spread - >1 facility cluster within 1 referral network

4 – Interregional spread – multiple clusters occurring within different referral networks

5 – Endemic – most facilities are repeatedly seeing cases admitted from unrelated

sources

Containment

INTERVENTIONS:

DETECTION INFECTION CONTROL CONTACT SCREENING

ARLN Regional Laboratories

Rapid Containment

Response in Tennessee

Day 1: Identification and Next Steps

“Dr. X: we have identified NDM in one of

your patients. This is a Tier 2 organism.

We will be following CDC’s guidance

document. Would like to have

conference call to discuss.”

Conference Call Joint Risk Assessment

NDM +

Klebsiella

pneumoniae

(CP-CRE)

30 minutes:

2 hours after

identification of

NDM:

Tier

1

Tier

2

Tier

3

Infection Control Assessment

Laboratory lookback

Prospective surveillance

Healthcare roommate screening

Broader healthcare contact

screening

Household contact screening

Environmental sampling

Healthcare personnel screening

https://www.cdc.gov/hai/outbreaks/mdro/

NDM= New Dehli Metallo-betalactamase

CP-CRE Carbapenemase producing Carbapenem resistant

Enterobacteriaceae 40

Day 1: Joint Risk Assessment

Hospital Day 20

41

Recommendations:

Based on CDC’s Containment Guidance

Tier

1

Tier

2

Tier

3

Infection Control

Assessment

Lab Lookback

Prospective Surveillance

Healthcare Roommate

screening

Broader Healthcare

Contact Screening

Household Contact

Screening

Environmental Sampling

Healthcare Personnel

Screening

Yes Sometimes Nohttps://www.cdc.gov/hai/outbreaks/mdro/

42

Day 1 continued; Day 2: Collect Swabs

Hospital Leadership Logistics

• Confirm best address for shipment of

swabs

• Point of contact for swabs

• Email: Document packet, including

instructions, FAQ, sample assent,

specimen requisition form

Assent

Next Day…

https://www.cdc.gov/hai/outbreaks/mdro/

Regional Laboratory Collect Swabs

43

Day 3: Regional Laboratory: Testing

Dr. X notified of results

< 48 hours after initial NDM

notification

12/12 swabs negative • 11 patients on unit >3 days

• 5 patients on unit before contact

precautions initiated

Next Day…

44

Keys to Rapid Response

• Advance protocol knowledge

• Effective communications:

– Healthcare staff

– Hospital leadership

– Laboratory

– Health department

• Logistics

• ARLabNetwork:

– Report out results within 2 working days of specimen receipt

• CRE reportable, isolate submission required in Tennessee

45

ARLN Admission Screening

• Patients with hospitalization outside the U.S. in past

6 months

– Screen patient

– Place in Contact Precautions pending screening

result

– ARLN now can process these admission

colonization swabs

Day 1

CDCHAN 00341-02-14-2013

Distributed Feb. 14, 2013

How to operationalize? • Protocol for direct admissions

• Travel question (time interval)

46

MRSA

2016 TN “Rankings”

Acute Care Hospitals

• LabID – HO MRSA Bacteremia

US: 0.93 (0.92, 0.96)

TN: 1.33 (1.19, 1.47) (#49/50)

2015 TN: 1.24 (#46/52)

2014 TN: 1.01 (#41/51)

2013 TN: 1.13 (#42/51)

2012 TN: 1.44 (#33/39)

Q1 Q2 Q3 Q4

TN Acute Care Hospital SIRs, 2016

No. of Infections

Standardized

Infection Ratio (SIR) and 95% CI

Distribution of Facility-specific SIRs

HAI Unit/Type No. of Facilities

Obs. Pred. SIR Lower Upper No. of Facs with ≥1 Pred.

Infection

Facs

with

Sig.

Low SIR

Facs

with

Sig.

High SIR

CLABSI Adult/Pediatric ICUs

86 206 245 0.84 0.73 0.96 42 3 2

Adult/Pediatric Wards

104 175 232 0.75 0.65 0.87 44 6 2

Neonatal ICUs 25 37 59 0.63 0.45 0.86 12 2 0

CAUTI Adult/Pediatric ICUs 86 375 392 0.96 0.86 1.06 51 4 5

Adult/Pediatric Wards

104 174 240 0.72 0.62 0.84 51 5 2

SSI Colon Surgery 99 195 212 0.92 0.80 1.06 44 2 4

Abdominal Hysterectomy

99 62 59 1.04 0.81 1.33 16 0 1

MRSA Acute Care Hospitals

110 347 261 1.33 1.19 1.47 44 2 7

CDI Acute Care Hospitals

110 2,266 2,570 0.88 0.85 0.92 91 24 11

Data reported as of September 18, 2017

Adult/Pediatric ICUs exclude burn and trauma units for CLABSI

Adult Complex Admission/Readmission SIRs are presented for surgical site infections (SSI)

Green highlighting indicates an SIR significantly LOWER than the 2015 national baseline

Red highlighting indicates an SIR significantly HIGHER than the 2015 national baseline

Hospital Onset MRSA BSI in TN Hospitals, 2016

2016 SIR: 1.33

Standardized Infection Ratio:

Observed

Predicted

Hospital Onset MRSA BSI in TN Hospitals, 2016

2016 SIR: 1.33

2020 Goal: 0.50

Hospital Onset MRSA BSI in TN Hospitals, 2016

2016 SIR: 1.33

10% 25% 50% 75% 90%

0.28 0.77 1.08 1.72 2.98

Percentile Distribution of SIR in 2016

2020 Goal: 0.50

MRSA BSI Burden in TN

ED: 1586, 55% CO: 935, 33%

HO: 347, 12% 2,868 MRSA-

BSI LabID events

reported in 2016 in

TN hospitals

12%= HO HO= Hospital-onset; CO= Community-onset;

ED= Emergency Department

All HO-MRSA BSI LabID Events by Location-2016

54

CDC Location Observed Percent

ICU - Other Adult/Ped 159 28.3

Ward - Med/Surg 97 17.3

Ward - Medical 79 14.1

Stepdown 72 12.8

Ward - Other Adult/Ped 51 9.1

Hematology/Oncology 29 5.2

Ward - Surgical 24 4.3

NICU 21 3.7

ICU - Trauma 12 2.1

Mixed Acuity 11 2.0

ICU - Burn 7 1.3

MRSA Deep Dive Recommendations

Overall:

1. Leadership support for a culture of safety

2. Focused clinical interventions with compliance audits

depending on institutional MRSA performance using

the 2014 Compendium of Strategies to Prevent

Healthcare- Associated Infections in Acute Care

Hospitals (SHEA)

55

1. Leadership Support for a Culture of Safety

• Demonstrate a visible culture of safety within the

organization through safety huddles, safety briefings,

and executive rounding in which preventing the spread

of MRSA is emphasized.

• Designate infection prevention and control as a

focused priority of the organization.

56

Leadership Support for a culture of safety

• Provide ample resources for practice audits to measure the true

level of compliance with infection control practices related to

MRSA spread.

• Adopt accountability standards for all staff and physicians for

compliance with infection prevention practices.

• Allocate resources to assess overall infection control program

and increase infection prevention staff as needed to address

the added scope of work.

57

2. Monitor Compliance

2A. All hospitals should implement and monitor

compliance with basic infection prevention practices to

broadly address infections including MRSA.

– Hand hygiene

– Environmental cleaning

– Isolation precautions

– Correct use of personal protective equipment (PPE)

58

Require Training

2.B. Require training on the practices in 2.A. to any

healthcare providers involved in the specific action,

including staff, physicians and physician extenders.

e.g., all personnel involved with room cleaning (including preparation)

should be trained on proper practices. All personnel who enter isolation

rooms should be trained on use of the PPE. All personnel who have contact

with the patient and/or their environment should be trained on proper hand

hygiene practice.

59

Competency-based Training Programs for Acute

Care Hospitals (N=12)

60

17%

25%

50%

0% 20% 40% 60% 80% 100%

Hand Hygiene

PPE

Environmental Cleaning

Compliance Audits/ Isolation Rounds

2.C. Conduct isolation rounds and compliance audits with regular reporting to leadership on the following:

• Appropriate use of isolation precautions (i.e. appropriate patient placement)

• Donning/doffing of personal protective equipment (PPE) used for patients placed in Contact Precautions

• Environmental cleaning using objective assessments in a standardized fashion

• Safety huddles or other feedback methods to share audit data results to drive improvement

61

Medical Record Flags and Chlorhexidine

2.D. Use Information Technology to alert clinical staff of newly diagnosed

MRSA patients and readmission of prior MRSA patients

2.E. Special approaches should be considered- e.g., Chlorhexidine (CHG)

daily bathing of patients

• If utilized, consider targeting high-risk populations (i.e. based on review of

institutional MRSA data and may include ICU patients, patients with

vascular devices, patients with a history of MRSA, dialysis patients, etc.)

• If utilized, carefully train personnel administering the CHG bathing and

monitor compliance with correct practices

62

Hospital Onset MRSA BSI in TN Hospitals, 2016

2016 SIR: 1.33

2020 Goal: 0.50

Must

prevent

217

Hospital Onset MRSA BSI in TN Hospitals, 2017

2017 SIR: 1.10

2020 Goal: 0.50

Must

prevent

157

Excess* HO-MRSA BSI

65

52%

74%

0% 50% 100%

Top 5

Top 10

Excess = observed- (predicted *goal SIR)

62% (‘17)

42% (‘17)

HO-MRSA in

Tennessee and Kentucky

Conclusions: Summary

• Case-patients had long lengths of stay, multiple co-morbidities,

and high mortality

– Almost half with ICU admissions prior to BSI

• Most frequent locations of attribution for BSIs were ICUs and

Step Down Units

• Most common sources of infection were CVCs, Wounds, SSIs,

and Pneumonia

Conclusions

• Preventing infections caused by CVCs, CAUTIs, SSIs, and VAPs could substantially decrease MRSA BSI burden in these facilities

– Infections caused by CVCs appear more frequently related to maintenance, however many likely related to insertion

• Potential at risk populations include: surgical patients, patients with wounds, acute dialysis patients, those with indwelling devices, and those in ICUs and Step Down units

• Areas for improved prevention interventions

– Non-VAP Pneumonia (early ambulation post-op?)

– Wounds (i.e. burn wound care)

NHSN Surveillance Recommendations

(1) Surveillance of CLABSI in Step Down Units

(2) Capture presence of hemodialysis catheter

UP Campaign

70

http://www.hret-hiin.org/engage/up-campaign.shtml

Thank You!

Contact

Hai.health@tn.gov

TDH: (615) 741-7247

Report all Outbreaks