Download Neil Pascoe RN BSN CIC

Public Reporting of Healthcareassociated Infections in Texas
Neil Pascoe RN BSN CIC
(aka “the Messenger”)
Epidemiologist
Infectious Disease Control Unit
Outline
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A brief history of issue
International overview
National perspective
Texas legislative session
SB 288 Public Reporting of HAI
Where it is going and who is taking us
History of Issue
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HAI/Nosocomial infections are not recent issue
Semmelweis in 19th century
Hospital penicillin resistance
MRSA, UTI, VAP, BSI, SSI
Contaminated products and devices
Invasive procedures
Population changes
Healthcare-associated Infections
• Are acquired as a result of a hospital stay
• 5-15% of all hospital patients acquire HAI
Why HAI May Increase
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Sicker patients, older population
More invasive procedures for longer duration
Increasing immuno-incompetent population
Staffing shortages
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Nursing
Pharmacists
Pharmacy Techs
Radiology Techs
Why HAI May Increase
• Resistant Organisms
– 1990’s
– 1990’s
– 2002
P. aeruginosa
VRE/MRSA
VRSA/MDRO’s
• Emerging Infectious Disease
– 1980’s
– 1990’s
– 2000’s
HIV
hantavirus/HCV
WNV/SARS/Pandemic Flu
C. diff, GNRs
Calculation of estimates of healthcare-associated
infections in U.S. hospitals among adults and children
outside of intensive care units, 2002
263,810
274,098
-967
-21
-28,725
244,385
TOTAL
HRN
WBN
Non-newborn ICU
= SSI
Other
22%
BSI
11%
SSI
20%
PNEU
11%
129,519
Klevens, et al. Pub Health Rep
2007;122:160-6
133,368
HRN = high risk newborns
WBN -= well-baby nurseries
ICU = intensive care unit
SSI = surgical site infections
BSI – bloodstream infections
UTI = urinary infections
PNEU = pneumonia
UTI
36%
424,060
Rates of Healthcare-Associated Infections in
Newborns, Adults, and Children by Site of Infection,
National Nosocomial Infections Surveillance (NNIS)
System
Well-baby nurserya High-risk nurseryb Intensive care unitb
(adults and children)
Patient-daysc
7,436,520
Major site of infection
Urinary tract
Bloodstream
Pneumonia
Surgical site
Other
Total
aFrom
4,835,702
30,236,811
Rate of infection per 1,000 patient-days
0.19
0.76
0.24
0.003
1.37
2.56
0.5
3.06
0.91
0.2
2.21
6.88
3.38
2.71
3.33
0.95
2.67
13.04
NNIS hospital-wide surveillance, 1990-1995
bFrom NNIS surveillance 2002, high-risk nursery and ICU component
cFrom the National Hospital Discharge Survey (NHDS) for the U.S. population in nonfederal hospitals
Consequences
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2 million HAI annually
90,000 deaths
$4.5-5.7 billion/ year
25% in Intensive Care Units
70% involve organisms with resistance to
one or more antibiotics
J. Burke. NEJM 2003; 348: 7
Emerging Infect Dis 1998; 4: 416-20
Infect Control Hosp Epi 2001; 22: 708-14
The International Overview
The National Overview
Infection Control in the
Headlines
“Lax Procedures put Infants at High Risk;
Simple Actions by Hospital Workers, Such
as Diligent Hand-washing, Could Cut the
Number of Fatal Infections.”
Chicago Tribune 2002
As of 5/14/07
Texas
The State Perspective
Texas
Travis County
Capitol
You are here
th
80
Legislature Regular Session
• 4 bills introduced on HAI
• Only SB 288 passed related to HAI
• HB 1082
More Patients Suffering Infections At Hospitals
POSTED: 3:10 pm PDT May 10, 2007
UPDATED: 4:43 pm PDT May 10, 2007
-- Hospitals aren't supposed to make you sicker.
Setting the Stage for HAI
SB 872 (HAI portion)
• 79th Legislative session 2005
• Unfunded mandate directing the DSHS to:
• Solicit persons to fill an advisory panel that
will
• report back to the legislature by 11/1/06 with
• Recommendations on the public reporting of
HAI
• 14 positions on the advisory panel
• First meeting November 2, 2005
The Advisory Panel
• 2 ICPs, certified, 1 rural & 1 urban
• 2 ICPs, certified and both nurses
• 3 MDs, SHEA members, IC experts in a
healthcare facility
• CEO of an acute care facility
• CEO of an ASC
• 2 consumer representatives
• 3 nonvoting department members
The Members of the Advisory Panel
• Susan Jones, Betsy Colvin
• Greg Bond/Lynda Watkins, Patti Grant
• Robert Haley, Luis Ostrosky-Zeichner, Jan
Patterson
• Dan Schultz, Marilyn Christian
• Lisa McGiffert, Raquel Sanchez
• Neil Pascoe, Tom Betz, Nance Stearman
HAI Ethical issues
• Legislation has potential to divert infection control
staff away from disease prevention and control
activities at patient level and have them focus on
health care-associated infection reporting at
administrative level.
• Reporting adjustments need to be made so that
hospitals with higher risk patients or patients
undergoing procedures placing them at higher risk
for infection are not unduly penalized.
HAI Ethical issues (cont.)
• Health care facilities that under-report may
appear superior in infection control to
others. Checks and balances need to be in
place.
• Sample sizes of procedures reported need to
be sufficiently robust to permit valid
comparisons between institutions within
reasonable limits of confidence. This is a
serious potential problem.
HAI Ethical issues (cont.)
• Health care institutions that in good faith report
infections in an open and honest manner should
not suffer undue medical-legal consequences for
such openness.
• Increased perceived risk of litigation will seriously
undermine reporting efforts.
• Potential patients who use the reporting
information for selecting institutions need to
understand the limits of such information.
HAI Ethical Issues (cont.)
– System failure versus Personal Accountability- The Case
for Clean Hands
• “…the hospital and its leaders are accountable for
establishing a system in which caregivers have the
knowledge, competence, time, and tools to practice
perfect hygiene.”
• “But each caregiver has the duty to perform hand
hygiene- perfectly and everytime.”
• “When this widely accepted, straightforward standard of
care is violated, we cannot continue to blame the
system.”
Goldmann D. System failure versus personal accountability. N
Engl J Med 2006; 355; 2: 121-2
SB 288
Mandatory Public Reporting of
Healthcare-associated Infections
80th Regular Session 2007
http://www.capitol.state.tx.us/tlodocs/80R/billtext/pdf/SB00288H.pdf
Medical Ethics 101
“The statement, ‘It’s worth it if it saves
just one life is dangerously false if the
same resources, used in a different
manner, can save more than one life.’”
Wm. Haddon Jr.
SB 288 Requires
• a 16 member Advisory Panel within the
DSHS infectious disease epi and
surveillance division to guide the
implementation, development, maintenance
and evaluation of the reporting system
• Hospitals, Ambulatory Surgical Centers
(ASCs) to report specific HAI to DSHS
SB 288 Advisory Panel
• 2 year term
• 2 ICPs certified and one from a rural
hospital
• 2 ICPs certified and licensed nurses
• 3 MDs one with Pedi ID and Pedi epi exp.
are SHEA members with expertise in IC
• 2 QA professionals-1 ASC & 1 acute care
SB 288 Advisory Panel
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1 officer of a general hospital
1 officer of an ASC
3 nonvoting department members
2 members representing the public as
consumers
• No lobbyists or HC trade association
• Reimbursement is allowed!
SB 288 Requires DSHS
• To adopt rules that do not duplicate or
conflict with federal reporting HAI rules
• Establish Texas Healthcare-associated
Infection Reporting System to:
– receive HAI reports
– publish HAI reporting to the public
– educate and train ICPs on the THIRS
SB 288 Reporting
• Must begin no later than 6/1/08
• Quarterly or less frequent
• Must contain sufficient patient ID data
– avoid duplication
– verify accuracy and completeness
– allow for risk adjustment
• DSHS will review data for validity and
“unusual data patterns or trends”
SB 288 Reportable SSI Infections
• Acute care other than pediatric shall report
SSI on 7 surgical procedures
-colon surgeries
-hip and knee arthroplasties
-abdominal and vaginal hysterectomies
-CABG and vascular procedures
SB 288 Reportable SSI Infections
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Pediatric facilities will report SSI associated with
Cardiac procedures excluding thoracic cardiac
VP shunt procedures
Spinal surgery with instrumentation
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• Pediatric HA RSV
SB 288 Reportable CLABSI
• Lab confirmed from a patient in any
“special care setting in the hospital”
• All Texas definitions from CDC case
definitions
SB 288- Alternative Reporting
• For facilities with an average of less than 50
procedures/monthly
• Instead--report SSI related to the 3 most
frequently performed procedures from the
NHSN procedure list
SB 288 DSHS Summary
• Public summary for each reporting facility
• Risk adjusted with a comparison of the riskadjusted rates for each reporting facility
• Easy to read (consumer friendly)
• Annual summary minimum
• Concise facility comments on report will be
allowed
• Posted on internet
• Option for public to report suspected infections to
DSHS
SB 288 Protections
• Confidential, de-identified, protected
• MAY NOT BE USED IN A CIVIL
ACTION TO ESTABLISH A STANDARD
OF CARE
SB 288 Enforcement
• General Hospital under Chapter 241
• ASC under Chapter 243
Funding
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For FY 2008 DSHS requested $4.5M
36 FTEs
LBB calculated $1.1M and 5 FTE
FY 2009 DSHS requested $3.7M LBB
calculated $1.2M and 8 more FTE
• Status = not currently funded
Reporting
• Missouri Healthcare-Associated Infection
Reporting System (MHIRS)
• Perseus
• NHSN
• Plan D
Reminder
What Don’t You Do to the Messenger?
Plan D- Reporting
American National Standards Institute, Accredited Standards
Committee X12N, 837 Health Care Institutional Claim
Implementation Guide (version 004010X096A1).
Most people call it the ANSI 837I or ANSI 837 Institutional
version 4010.
DSHS has modified this HIPAA compliant version by adding
in Race code to the DMG05 data field, thus we are HIPAA
compatible.
Reporting continued
• ICP generated attachment to the ANSI 4010
• Details should be in place by November 1,
2007
• Testing by January 2008
• Implementation….?
Resources
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http://www.legis.state.tx.us/
http://www.apic.org
http://www.dshs.state.tx.us/idcu/disease/HAI/
Gary Heseltine 512 458-7111 x6352
[email protected]
Neil Pascoe 512 458-7111 x2358
[email protected]