Transcript Patient Safety and Health Care Associated Infections

Patient Safety and Health Care
Associated Infections
Infectious Disease Epidemiology Workgroup
Jan. 4, 2008 Austin, Texas
Gary Heseltine MD MPH
Infectious Disease Control Unit
“When speculation has done its worst, two and two
still make four.” Samuel Johnson, The Idler
Outline
• Big picture – patient safety
– Harm unintentional or not, preventable or not
– The many players
• Health care-associated infections (HAI)
– Surgical care improvement project (SCIP)
– The burden of morbidity and mortality
– What the evidence says
• SB 288 Public Reporting of HAI
– Where are we and where are we going in Texas?
• Changing practices – adopting protocols
– Barriers and incentives
– Direction for the future
Patient Safety
• Hippocrates, Epidemics
"Declare the past, diagnose the present, foretell the future; practice these acts. As to
diseases, make a habit of two things — to help, or at least to do no harm."
• The Joint Commission defines patient safety solutions:
"Any system design or intervention that has demonstrated the ability to prevent or
mitigate patient harm stemming from the processes of health care.“
• Institute for Healthcare Improvement defines medical harm:
“Unintended physical injury resulting from or contributed to by medical care (including the
absence of indicated medical treatment), that requires additional monitoring, treatment
or hospitalization, or that results in death.
Such injury is considered harm whether or not it is considered preventable, whether or
not it resulted from a medical error, and whether or not it occurred within a hospital.”
• Safe - free from hurt, injury, danger or risk
• Harm – injury; damage; hurt
• Safety - state of being safe
Institute for Healthcare Improvement
37 Million Admissions
X
40 Injuries per 100 Admissions
=
15 Million Injuries per Year
Proportion of Adverse Events
Most Frequent Categories
3.7% of patients experience serious adverse events related to medical management.
25%
Non-surgical
Surgical
20%
15%
10%
5%
0%
Drugrelated
Wound
infect.
Tech.
comp.
Late
comp.
Diag.
mishap
Therap. Nontech.
mishap
comp.
Proc.
related
58% of these events were preventable mistakes – now called medical errors or patient safety failures
Technical complication – e.g. injury to adjacent structures, gas emboli, anastomostic leak
Non-technical complication – e.g. development of cardiac arrhythmias, vascular emboli
Brennan. N Engl J Med. 1991;324 (6):377-384.
Burden of Healthcare-Associated
Infections in the United States, 2002
• 1.7 million infections in hospitals
– Most (1.3 million) were outside of ICUs
– 9.3 infections per 1,000 patient-days
– 4.5 per 100 admissions
• 99,000 deaths associated with infections
– 36,000 – pneumonia
– 31,000 – bloodstream infections
Klevens, et al. Pub Health Rep 2007;122:160-6
Impact of Surgical Site Infections (SSI)
An estimated 40-60% of SSIs are preventable.
Infected
Uninfected
Mortality (inhospital)
7.8%
3.5%
ICU admission
29%
18%
Readmission
41%
7%
Median initial LOS
11d
6d
Median total LOS
18d
7d
Initial excess cost
+$3,644 (median)
Total excess cost
+$5,038 (median)
*Pairs matched for procedure, NNIS index, age
*General inpatient surgical population; 22, 742 procedures included
Kirkland. Infect Control Hosp Epidemiol. 1999;20:725.
Surgical Care Improvement Project (SCIP)
2010 National Goal
Reduce preventable surgical morbidity and mortality by 25%
•
•
•
•
•
American College of Surgeons
(ACS)
American Hospital Association
(AHA)
American Society of
Anesthesiologists (ASA)
Association of peri- Operative
Registered Nurses (AORN)
Agency for Healthcare
Research and Quality (AHRQ)
•
•
•
•
•
Centers for Medicare & Medicaid
Services (CMS)
Centers for Disease Control and
Prevention (CDC)
Department of Veteran’s Affairs
Institute for Healthcare
Improvement (IHI)
Joint Commission on Accreditation
of Healthcare Organizations
(JCAHO)
Surgical Infection Prevention (SIP): previous CMS initiative focusing appropriate
selection, administration and discontinuation of surgical antibiotic prophylaxis.
SCIP Has Four Modules
Infection
• 7 Infection Prevention Process Measures
Venous Thromboembolus (VTE)
• 2 VTE Prevention Process Measures
Cardiac Prevention Module
• 1 Cardiovascular Prevention Measure
Respiratory (Post-operative ventilator associated pneumonia)
• Delayed implementation to use these measures in
expanding the ICU Core Measure Set
SCIP Infection Module
• SCIP INF 1:
– Prophylactic antibiotic received within one hour prior to
surgical incision
• SCIP INF 2:
– Prophylactic antibiotic selection for surgical patients
• SCIP INF 3:
– Prophylactic antibiotics discontinued within 24 hours after
surgery end time (48 hours for cardiac patients)
• SCIP INF 4:
– Cardiac surgery patients with controlled 6 a.m.
postoperative serum glucose
• SCIP INF 6:
– Surgery patients with appropriate hair removal
• SCIP INF 7:
– Colorectal surgery patients with immediate postoperative
normothermia
Effective with discharges beginning July 1, 2006
Prophylactic Antibiotics
Timing Administration of Pre-op Dose
14/369
4
15/441
Infections (%)
3
1/41
1/47
1/81
2
2/180
5/699
5/1009
1
0
≤-3
-2
-1
0
1
2
3
4
≥5
Hours From Incision
Note: only 40% received antibiotics within two hours of incision
Classen. NEJM. 1992;328:281.
Diabetes, Glucose Control, and SSIs
After Median Sternotomy
% Infections
20
15
10
5
0
<200
200-249
250-299
>300
Increased risk:
Diagnosed diabetes
Undiagnosed diabetes
Post-op glucose > 200 mg% within 48h
Latham. Inf Contr Hosp Epidemiol. 2001;22:607.
Dellinger. Inf Contr Hosp Epidemiol. 2001;22:604.
Cleveland Regional Medical Center
Central Line Infections:
Incidence & Risk
•
•
•
48% of ICU patients have central venous catheters,
accounting for 15 million central venous catheter-days
per year in ICUs.
The case fatality rate for catheter-related blood stream
infections approaches 20%.
Attributable mortality ranges from 12-25% but was 3%
in one meta-analysis.
Mermel LA. Ann Int Med 2000;132: 391-402
Soufir L et al. Infect Control Hosp Epidemiol 1999 Jun;20(6):396-401.
Prevention of Central
Line-Associated
Bloodstream Infections
Bundle: standard pack or
cart for line insertion with
all needed supplies
Central Line
Insertion Checklist
Do Central Line Bundles Work?
• 12 month Baseline average CA-BSI rate 2.84
• 12 month Project Average CA-BSI rate .73 = 74% Reduction
• 10 out of 12 months with zero CA-BSI
100%
Compliance
80%
Spread to all
providers
60%
Started PI
40%
20%
0%
F- M-
A- M-
J-
J-
A- S- O- N- D- J-
F- M- A- M-
J-
J-
A-
S- O-
04 04 04 04 04 04 04 04 04 04 04 05 05 05 05 05 05 05 05 05 05
CL Bundle Compliance 0% 0% 0% 0% 0% 0% 0% 0% 82% 67% 74% 70% 94% 91% 91% 94% 100 100 92% 86% 91%
CA-BSI Rate
CA-BSI Cases
0.00 0.00 0.00 4.00 11.8 3.13 3.47 3.46 0.00 0.00 0.00 5.68 3.02 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0
0
0
0
1
4
1
1
1
0
0
Overlake Hospital Medical Center - Seattle
0
2
1
0
0
0
0
0
0
IHI Collaborative
0
0
14.00
12.00
10.00
8.00
6.00
4.00
2.00
0.00
CA-BSI Rate
CA-BSI Process/ Outcome
Unequal Treatment: Confronting Racial and
Disparities in Health Care
IOM Report 2002
“Disparities in the health care
delivered to racial and ethnic
minorities are real and are
associated with worse outcomes
in many cases, which is
unacceptable.”
Alan Nelson, committee chair
Protocol driven interventions for HAIs are
one step in addressing this larger issue.
SB 288 Mandatory Public Reporting of
Healthcare-associated Infections
80th Regular Legislative Session 2007
• Hospitals, Ambulatory Surgical Centers (ASCs) to report
specific HAIs to DSHS using CDC case definitions
• Must begin no later than 6/1/08
• Minimum once per year, maximum each quarter
• 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 Advisory Panel
Sixteen member Advisory Panel– two year term
• Two certified ICPs, one from a rural hospital
• Two ICP certified and licensed nurses
• Three MDs one with Pedi ID and Pedi epi, SHEA
members with expertise in IC
• Two QA professionals-one ASC & one acute care
• One officer of a general hospital
• One officer of an ASC
• Three nonvoting DSHS members
• Two members representing the public as consumers
No lobbyists or healthcare trade association representatives
Reimbursement is allowed
Adult Reportable SSI Infections
•
•
•
•
colon surgeries
hip and knee arthroplasties
abdominal and vaginal hysterectomies
CABG and vascular procedures
Pediatric Reportable SSI Infections
•
•
•
•
Cardiac procedures excluding thoracic cardiac
VP shunt procedures
Spinal surgery with instrumentation
And (non-SSI) respiratory syncitial virus infection
Reportable Central Line Infections
Lab confirmed from a patient in any “special care setting
in the hospital”
Alternative Reporting
For facilities with an average < 50 procedures/monthly
Report SSIs related to the 3 most frequently performed
procedures from the National Healthcare Safety Network
(NHSN) procedure list
Reporting Mechanism
• Plan A: Missouri Healthcare-Associated Infection
Reporting System- large IT project
• Plan B: NHSN- complex and burdensome to ICP
– CDC proposal: vendors send HL7 messages to NHSN
• Plan C: Use Texas Hospital Discharge Data Network
– Already reaches statewide except rural hospitals and will be expanded
to all ASCs under existing legislation
– Claims file is called ANSI 837I, carries ICD9 claims data
– ICP generated data attached to the ANSI 837
Common network carrying two data sets, claims and ICP-HAI.
Both data sets can be used jointly to evaluate quality of care.
• Plan D – as needed
• Option for public to report suspected SSIs to DSHS
– Poses significant challenges, particularly validation
HAI Report
• Public summary for each reporting facility
• Risk adjusted with a comparison of the risk- adjusted rates
for each reporting facility
• Easy to read (consumer friendly)
• Concise facility comments on report will be allowed
• Posted on internet
Reporting Protections
• Confidential and privileged data
• May not be used in a civil action to establish standard of
care
• Enforcement- general hospital under Health and Safety
Code chapter 241, ASC under chapter 243
Potential Adverse Consequences of Reporting
•
•
•
Diversion of resources from patient care to forms
Creation of disincentives to treat higher risk patients
Misleading stakeholders through data manipulation
SB 288 Funding
• For FY 2008 DSHS requested $4.5M, 36 FTEs
• LBB calculated $1.1M and 5 FTEs
• FY 2009 DSHS requested $3.7M LBB calculated
$1.2M and 8 more FTEs
• Other scenarios presented
Current status = not funded
Images of a Hospital
• Safe, nurturing place
• Place of sanctuary
• Place of healing
Reality of a Hospital
In one location
• Lots of colonized and/or infected persons
• Lots of vulnerable/susceptible persons
• Lots of traffic between infected and vulnerable
persons
Add in lots of antibiotic use
Reality of a Hospital
Design a system to facilitate the spread of infection.
What would it look like?
– A Hospital
Design a system to select for antimicrobial resistance.
What would it look like?
– A Hospital
Adopting Change
Transformational Change
• Transformation (1) alters the culture of the
institution by changing select underlying assumptions
and institutional behaviors, processes and products; (2)
is deep and pervasive, affecting the whole institution; (3)
is intentional; and (4) occurs over time.
• Incremental improvement is not enough
• The pace of improvement is not fast enough
Resources
•Institute for Healthcare Improvement www.ihi.org
•Texas legislature www.legis.state.tx.us
•Association of Professionals in Infection Control
•www.apic.org
•DSHS HAI website www.texasdisease.org