State of the State Address on HAIs

Erica Runningdeer, MSN, MPH RN HAI Prevention Coordinator

November 21, 2014

Disclosure/Conflict of Interest

I have no disclaimers or conflicts of interest to report

IDPH Healthcare Associated Infection (HAI) Prevention Program

• Housed in the Office of Health Policy and Planning, Division of Patient Safety & Quality

• Funding is primarily provided through cooperative agreements with the Centers for Disease Control and Prevention (CDC)

IDPH Division of Patient Safety & Quality Division Chief – Mary Driscoll, RN, MPH

HAI Prevention Coordinator – Erica Runningdeer, MSN, MPH, RN

Program Director, Antimicrobial Stewardship & CDI – Chinyere Alu, MPH

CDC Public Health Prevention Service Fellow – Robynn Cheng Leidig, MPH

Project Director, CRE – Angela Tang, MPH

Project Director, CDI – Jessica Ledesma, M. Ed, MPH

Epidemiologist – Anh-Thu Runez, MPH

Program Assistant – Jennifer Polk, BS

Section Chief, Public Reporting – Barbara Fischer, RN

HAI Prevention “Team Illinois” WHO WE ARE

IDPH Division of Infectious Diseases, Communicable Disease Section

HAI Advisory Council Stakeholders & Subject

Matter Experts

Chicago CDC Prevention EpiCenter

Telligen (State QIO)

Local Health Departments

APIC & Infection Preventionists from various facility types/settings

Trade Organizations

Payers/Insurance

Patient advocates

National Partners

CDC

CSTE

ASTHO

NACCHO

Other states’ HAI programs

Share “lessons learned”

HAI Prevention “Team Illinois” WHO WE ARE

• Surveillance and reporting of HAI data

– NHSN Illinois Hospital Report Card & Consumer Guide to Healthcare http://www.healthcarereportcard.illinois.gov/

– XDRO registry not publicly reported

• Use the data for action

– Lead and assist healthcare organizations with improving the quality and safety of services

• Develop a state plan to prevent HAIs

– Align state priorities with national HAI Roadmap to Elimination http://www.hhs.gov/ash/initiatives/hai/actionplan/

HAI Prevention “Team Illinois” WHAT WE DO

HAI Prevention Initiatives 2014-2015

HAI Prevention Landscape

Evaluation Project: Data for Action

HAI Prevention Plan

Antimicrobial Stewardship

C. difficile prevention collaborative

CRE detect & protect

Inpatient Collaborative Outpatient Campaign

XDRO Registry

Shared Goals: the Triple Aim

• framework to optimize health system performance Integration of public health

and clinical medicine

Align priorities • Federal

• State

• County

• Community

• Facility Improve

Patient

Care

Improve

Population

Health

Reduce

Cost

Developed by the Institute for Healthcare Improvement (IHI)

Central component of ACA, National Quality Strategy, and many National action plans to improve health & healthcare

HAI Prevention Landscape

• State-wide assessment to inform the revised HAI Prevention State Plan – Evaluate trends in infection rates

– Identify gaps in data

– Identify potential new sources of data

– Survey current and/or ongoing prevention activities by organizations and facilities

– Identify gaps/needs for prevention efforts

– Find areas for enhancement of coordination among partners

HAI Prevention Plan

• Establish (SMART) goals for HAI Prevention

• Align state goals/priorities with National priorities (HHS Action Plan to Prevent Health Care Associated Infections: Road Map to Elimination)

• Recommend strategies and future projects to achieve goals

• Antimicrobial stewardship to be key component/strategy for addressing HAIs

HAI Progress Report

http://www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report.pdf

HAI Progress in Illinois % change

2013 vs 2012 Illinois

% difference IL vs national

2013

% difference 2013 IL

vs national baseline

CLABSI 17%↓ 13%↓ 53%↓ CAUTI 7%↓ = 9%↓ 3%↓ = MRSA 17%↓ 23%↓ 29%↓ C. DIFF 2%↓ = < 1%↑ = 9%↓ =

SSI HYST 36%↓ 33%↓ 42%↓ SSI COLON 32%↑ 12%↓ 19%↓ SSI KPRO** 36%↓ 24%*↓ 64%↓ SSI CABG** 14%↓ 21%*↓ 52%↓ SSI combined 21%*↓ 37%*↓

*data is for 2012; data for 2013 not yet available **SSI KPRO & SSI CABG measures for IL analyzed by state fiscal year: 2012 = 7/2011-6/2012; 2013=7/2012-6/2013

HAI Progress in Illinois

2013 IL SIR

% difference 2013 IL

vs national baseline

HHS 2013 Prevention

TARGET % reduction

Target Met?

CLABSI 0.47 53%↓ 50%↓ YES CAUTI 0.97 3%↓ 25%↓ NO MRSA 0.72 29%↓ 50%↓ NO C. DIFF 0.91 9%↓ 30%↓ NO

SSI HYST 0.58 42%↓ SSI COLON 0.81 19%↓ SSI KPRO** 0.36 64%↓ SSI CABG** 0.48 52%↓ SSI combined 0.63* 37%*↓ 25%↓ YES

*data is for 2012; data for 2013 not yet available **SSI KPRO & SSI CABG measures for IL analyzed by state fiscal year: 2012 = 7/2011-6/2012; 2013=7/2012-6/2013

• How many infections would we need to have prevented to meet our target?

Targeted Assessment for Prevention (TAP) Strategy

• The TAP strategy allows for the ranking of facilities (or locations) in order to identify and target those areas with the greatest need for improvement.

• New output options, referred to as “TAP Reports”, will be available for facilities and groups and will be generated for CLABSI, CAUTI, and CDI LabID data.

• http://www.cdc.gov/nhsn/PDFs/Newsletters/vol9-3-eNL-Sept-2014.pdf

Cumulative Attributable Difference (CAD)

• A measure to help focus prevention efforts toward areas (facilities/units) with the highest burden of excess infections.

CAD = OBSERVED – (PREDICTED * SIRtarget)

FAC

RANK

ORG

ID

MED TYPE

BEDS PT. DAYS CO HCFA

PREV. RATE

HO CDI EVENTS

PREDICTED EVENTS

CAD SIR SIR

TEST

1 001 M >600 141,000 0.21 195 141.97 95.60 1.37 SIG

2 003 M >600 160,000 0.40 192 156.37 82.50 1.23 SIG

3 004 U 246 49,000 0.38 110 43.60 79.50 2.52 SIG

4 010 M >600 159,500 0.19 176 144.25 75.00 1.22 SIG

5 050 M 552 116,000 0.36 148 110.37 70.70 1.34 SIG

6 020 M 675 194,602 0.23 189 182.08 61.50 1.04

7 070 G 298 57,675 0.23 97 55.82 57.90 1.74 SIG

Sample CDI TAP Report

Ranked by CAD in descending order

http://health.state.tn.us/ceds/HAI/calculator.shtml

Tennessee example: the CAD Calculator

18

TAP REPORT: CDI (2013Q1 - 2013Q4) Statewide and Chicago-wide CAD 'Cummulative

Attributable Difference')

REGION

HOSPITAL

ONSET CDI

EVENTS

PREDICTED

EVENTS CAD SIR LLIMIT ULIMIT

ILLINOIS 4465 4926.13 1016.70 0.91 0.8801 0.9333

CHICAGO 1132 1380.65 165.50 0.82 0.7732 0.8687

How many infections would we need to have prevented to meet our target?

A national security priority

Antimicrobial Stewardship

2010 2011 2012 2013 2014 2015

1st AMS Collaborative (5 acute care hospitals)

AMS Summit (250 attendees)

Assess AMS practices (466 LTCFs)

AMS webinar series (6 webinars)

Antimicrobial use reporting to NHSN (21 acute care hospitals)

1st CDI Collaborative (20 acute care hospitals)

2nd CDI Collaborative (20 acute care hospitals)

ICE C. diff Campaign (254 acute care hospitals, LTACHs, & LTCFs)

2nd AMS Collaborative (6 acute care hospitals)

AMS: -2nd Summit; Campaign -Assessments -Strategic plan

3rd CDI Collaborative

IDPH Antimicrobial Stewardship (AMS) and CDI Prevention Initiatives

ANTIMICROBIAL STEWARDSHIP ACTIVITIES (2014-2015)

1. Illinois Collaborative for Hospital Antimicrobial Stewardship Enhancement (ICHASE)

2. Illinois Summit on Antimicrobial Stewardship

3. Precious Drugs & Scary Bugs campaign • Get Smart Week 2014

4. State Strategic Plan for Antimicrobial Stewardship

(1) ICHASE

• Setting: Inpatient

• Participation: Six acute care hospitals submitting data to the NHSN Antimicrobial Use Option

• Goals: – Evaluate impact of implementing institutional guidelines on

antimicrobial prescribing

– Identify and develop other interventions to improve antimicrobial use

– Collaborate with CDC to assess correlation between use of specific broad spectrum antibiotics and appropriateness of use

• Setting: Inpatient, outpatient, long term care

• Participation: Healthcare professionals and providers

• Thursday, March 5, 2015 in Chicago

• Collaborating with Northwestern and Telligen

(2) 2nd Illinois Summit on Antimicrobial Stewardship

(3) Precious Drugs & Scary Bugs campaign

• Setting: Outpatient

• Participation: Primary care and ED providers in year 1

• Goals:

– Improve provider knowledge and attitudes related to antibiotic resistance and antibiotic use

– Increase provider adherence to appropriate antibiotic prescribing for outpatient visits (for upper respiratory infections*)

– Improve coordination and exchange among stakeholders around antibiotic stewardship

*Focus URIs: Otitis media, sinusitis, pharyngitis, bronchitis,

and the common cold

(3) Precious Drugs & Scary Bugs campaign

• Core intervention: public commitment letters

– Achieved 19.7% reduction in inappropriate prescribing for ARIs, compared to control group in Meeker et al study

• Implement tiered approach to engage providers

– Level 1: Providers enroll in initiative + complete baseline survey

– Level 2: Level 1 + participate in webinars

– Level 3: Level 2 + customize and utilize public poster-sized commitment letters* + complete post-survey

– Level 4: Level 3 + collect and submit data on antibiotic prescribing using template provided

*Meeker D, et al Nudging Guideline-Concordant Antibiotic Prescribing: A Randomized Clinical Trial. JAMA Intern Med. 2014 ; 174(2):425-431.

Activities

November 17 – 23, 2014

• Quick-learn webinars – Collaborate with Telligen to host mini-webinar series

– Topics: Immunization, CDI, antibiotic use

• Social media – CDC twitter chat on November 18

• Signage on BCBSIL building (under exploration)

• Op-ed piece

• Part of Illinois HAI Prevention Plan

• Informed by:

– Assessment of long term care facility antimicrobial prescribing

– Assessment of acute care hospital AMS practices

– Gaps and needs identified from HAI landscape study

– Lessons learned from previous & ongoing initiatives

– Stakeholder feedback

(4) State Strategic Plan for Antimicrobial Stewardship

CDI Transitions of Care (CDITOC) Prevention Collaborative

Statewide multi-year initiative with regional approach

Pilot in Chicago (2014-2015)

4 to 8 acute care hospitals

8 to 16 skilled nursing facilities (SNFs) or long term acute care hospitals (LTACHs)

Partner with Chicago Department of Health

Establish a state level workgroup to guide planning and implementation

Goals

Enhance communication about CDI events between transferring and receiving healthcare facilities Improve care coordination to maintain appropriate

infection control precautions for patients with CDI upon transfer to receiving facility Improve surveillance through rapid identification of

patients with CDI Improve implementation of CDI prevention strategies

within LTACHs and SNFs

Develop a model that can be spread regionally

across Illinois

Reduce rates of healthcare facility onset CDI

Activities

Refine and test communication processes for CDI patient transfers

Facilitate SNF enrollment and reporting to NHSNs

Multidrug-Resistant Organism & Clostridium difficile Infection Module Perform monthly review of NHSN input/results

Facilitate sharing and learning through cross-organizational meetings and webinars

XDRO registry

www.idph.state.il.us/patientsafety/cre www.xdro.org

Carbapenem-resistant Enterobacteriaceae (CRE) Activities

Activity 1: CRE Task Force

Purpose

• Gather key CRE experts and stakeholders statewide

• Develop a coordinated regional approach to CRE surveillance and prevention

• Promote CRE guidelines at healthcare facilities and local health departments

CRE Activities

Activity 2: Three regional training workshops

• Purpose

– Bring together acute and long-term care facilities, labs, and health departments to work out a coordinated approach to CRE surveillance and response

• Selected suggested topics

– Role of local health departments

– Infection control (esp. case studies and LTC)

– Antimicrobial stewardship

– Rectal swab screening tests

CRE Activities

Activity 3: Laboratory validation of CRE reported to the Extensively Drug-Resistant Organism

(XDRO) registry

CRE +

Validation Testing

Send isolates

Report

CRE

Not CRE

CRE Activities

Activity 4: XDRO registry development

•Automatic alert pilot • Cluster detection using SaTScan

Graphics courtesy of Chicago CDC Prevention Epicenter Note: cluster data are fictitious

Unique CRE patients reported to XDRO registry

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Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct

2013 2014

Pat

ien

ts (

n)

1083 patients reported since Nov. 2013 (avg. 2-3 pts reported/day) Data as of Nov. 5, 2014

XDRO registry: usage trends

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4500

5000

Nov Dec Jan Feb Mar Apr May Jun Jul Aug

2013 2014

Patient queries Webpage views

112 facilities have searched for patients 1487 times Data as of Sept. 15, 2014

Start of CRE Campaign Webinars

Thank You!

Erica.Runningdeer@illinois.gov

dph.XDROregistry@illiniois.gov