Quantitative validation of central line- associated bloodstream infections (CLABSI) in Oregon intensive care units (ICU) 2009 Zintars Beldavs Manager HAI.
Post on 18-Dec-2015
218 Views
Preview:
Transcript
Quantitative validation of central line-associated bloodstream infections
(CLABSI) in Oregon intensive care units (ICU) 2009
Zintars BeldavsManager HAI Program, Acute and Communicable Disease Section,
Oregon Public Health Division, Oregon Health AuthorityJune, 2012
Central Line-Associated Bloodstream Infection (CLABSI)
Deadly: 18% mortality14,000 deaths/ year in ICU patientsProlong hospitalization by mean of 7 days
Expensive: $3,700 - $29,000/episode
Preventable: hand hygiene, barrier precautions, skin antisepsis, catheter site selection
Pittet D, Tarara D, Wenzel RP. Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs, and attributable mortality. JAMA. 1994;271:1598-1601.Soufir L et al. Infect Control Hosp Epidemiol 1999 Jun;20(6):396-401.
Mandated Reporting in Oregon
Reportable as of 1/1/2009
• CLABSIs in ICU
• SSI knee prostheses and coronary artery bypass grafts
More reportable surgical site infections as of 1/1/11• Colon surgery• Hip prosthesis• Laminectomy• Abdominal hysterectomy
2009 Oregon CLABSI Pathogens
Candida albicans14%
Candida non-albicans15%
Yeast NOS2%
Enterococcus spp.13%Gram-neg bacilli
15%
Staphylococcus aureus15%
Coagulase-neg Staphy-lococcus spp.
22%
Other bacteria 5%
2009
-01
2009
-02
2009
-03
2009
-04
2009
-05
2009
-06
2009
-07
2009
-08
2009
-09
2009
-10
2009
-11
2009
-12
2010
-01
2010
-02
2010
-03
2010
-04
2010
-05
2010
-06
2010
-07
2010
-08
2010
-09
2010
-10
2010
-11
2010
-12
2011
-01
2011
-02
2011
-03
2011
-04
2011
-05
2011
-06
2011
-07
2011
-08
2011
-09
2011
-10
2011
-11
2011
-12
0
0.5
1
1.5
2
2.5
ICU CLABSI per 1,000 central line-daysAll reporting Oregon hospitals (Note only 2009 data
validated)
CLABSI Rate 2009-2011
Rate increased by 1.01 or more*2%
Rate increased by 0.01-1.0
9%
No change in rate (no CLABSI in 2009 or in
2011)53%
Rate decreased by 0.01- 1
15%
Rate decreased by 1.01 or more**
21%
*The only Oregon hospital with a rate increase of more than 1 CLABSI per 1000 central line-days reported one CLABSI in 2011 (vs. zero in 2009).**Six of the ten hospirals reporting decreases of more than 1 CLABSI per 1000 central line-days reported zero CLABSI for 2011.
CLABSI Rate Change 2009-2011
CLABSI Count by Hospital Size
2009 2010 2011
1 30
3 3 1
20
7 5
62
34
40
Number of beds<=25 26-100 101-200 >200
Validation for Accurate Data
• Concern: surveillance definitions applied inconsistently by IPs
• Poor inter-rater reliability: kappas .30 to .58
• Previous validation studies: potentially > half of cases not reported (Connecticut)
Objectives
• Evaluate quality of reported data
– Assess under- and over-reporting
– Gauge the reliability and consistency of surveillance case definitions
• Provide feedback to facilities on surveillance case definitions and reporting methods
Methods
• Study period: 2009• Included: 44 acute care
hospitals– 28 with < 50 beds– 10 with > 200 beds– Median central line days
210, range 4-4956
• OPHD validation team:– HAI Program Manager– Epidemiologist– EIS Officer/Physician– 3 public health nurses
Map: Oregon Association of Hospitals and Healthcare Systems, oahhs.org
Methods
All blood culture (+)
Drawn in ICU or up to 48 hours after and
Organism not isolated in 14 days before admit
Methods
Unit of analysis:
Single bacteremia episode
More than one CLABSI/patient possible
Methods
All (+) culture reviewe
d
All reported CLABSI and random sample 60 (+) culture
not reported as CLABSI
37 Hospitals
7 Hospitals
Reviewers blind as to reported CLABSI status
Methods
Hospital Determinati
on
ValidatorDeterminati
on
Adjudication Discussion
NHSN
Methods
1926 (+) cultures received on line lists
1204 from 7 highest volume facilities
722 from 41 facilities < than 60 (+) cultures
Methods
1199 medical records reviewed
477 sampled at 7 highest-volume facilities
722 at small- and medium- volume facilities
Results
817 included in final analysis
382 of 1199 reviewed censored
Hospitals included cultures not requested:
(+) blood cultures obtained prior admit or > 48 hours after discharge from ICU
ResultsDiscordant Cases
• 35 records with disagreement– 18 (51%) adjudicated as CLABSI– 17 (49%) adjudicated as not CLABSI– Hospital correct in 13 (37%)– OPHD correct in 22 (63%)– 4 required NHSN consult (2 CLABSI)
Reasons for discrepancies
For CLABSI “just missed”: at some facilities, IP staff had changed since 2009 and current staff unaware of rationale for previous reporting decisions.
Reason for discrepancy for under-reported CLABSI No. episodes %
No clearly discernible reason determined 7 44
Misattributed CLABSI to other infection 7 44
Recognized CLABSI failed to attribute ICU 1 6
Misclassified CLABSI as present on admit 1 6
Total 44 100
Reason for discrepancy for over-reported CLABSI No. episodes %
Infection attributable to other site 2 33
Infection not attributable to ICU 2 33
Single blood culture for probable contaminant 1 16.5
Unknown why reported CLABSI 1 16.5
Total 6 100
ResultsValidation outcome, unadjusted
CLABSIs among All ICU Patients with Positive Blood Cultures, by Initial Hospital Report — Oregon, 2009
CLABSIFinal determination
Present Absent Total
Hospital
report
Present 70 (TP) 6 (FP) 76
Absent 16 (FN) 725(TN) 741
Total 86 731 817
Example Calculation to Adjust for Sampling Fraction• 60 Records sampled at hospital• 142 Total BSI• 2 BSI reported as CLABSI• Sampling fraction: 60/140=.43• True positive and false positive remain (all reported CLABSI
reviewed)• False negative and true negative results divided by sampling
fraction Final DeterminationCLABSI Present
Final DeterminationCLABSI Absent
HospitalCLABSI Present
1True Positive
1False Positive“Overreport”
Hospital CLABSI Absent
2 (Estimate: 2/.43=4.7)
False Negative“Underreport”
42 (Estimate: 42/.43=98)
True Negative
Results Estimated # of CLABSI adjusted for sampling fraction
Estimated CLABSIs among All ICU Patients with Positive Blood Cultures, by Initial Hospital Report — Oregon, 2009
CLABSIFinal determination
Present Absent Total
Hospital
report
Present 70 (TP) 6 (FP) 76
Absent 27a (FN) 1089a (TN) 1116
Total 97 1095 1192
72% of true CLABSIs had been reported (Sensitivity = 0.72)99% of true non-CLABSI were correctly not reported (Specificity = 0.99)92% of CLABSIs reported were true CLABSI (Positive predictive value = 0.92)98% of cases not reported CLABSI were not CLABSI (Negative predictive value = 0.98)8% of positive cultures were CLABSIs (Prevalence = 0.08 )
Change after validation in CLABSI rate No. hospitals %
Rate decreased 0.70 1 2
No change 33a 75
0.01–0.50 higher 2 5
0.51–1.00 higher 2 5
>1.00 higher 6b 14
Total 44 100
a 23/33 had no CLABSI identified either before or after the validation.b 3/6 had no CLABSI before the validation.
Validation increased the statewide ICU CLABSI rate from 1.21 (95% CI: 0.95–1.51) to 1.54 (95% CI: 1.25–
1.88) CLABSI per 1,000 central-line days
Validation Impact on CLABSI Rate
Importance of Inter-Agency Follow-up Discussion
• Of 27 unreported cases identified as CLABSI by OPHD, 16 (59%) true CLABSI
• Sensitivity of reporting:– 72% based on follow-up adjudication– vs. 60% based on OPHD review alone
(P= 0.07), closer to some previous validation efforts
Limitations
• Denominator data not rigorously assessed
• Did not adjudicate cases when reviews concordant with reported data
• Unbiased 3rd party not involved in adjudication discussions
Conclusions
• Validating hospital CLABSI reporting improves accuracy of hospital-based CLABSI surveillance
• Discussing discordant findings improves the quality of validation
Future Work
• Currently completing coronary artery bypass graft validation of all 14 hospitals– Similar adjudication procedure– Sampling higher duration procedures
• Given funding: comprehensive baseline and yearly sampled validation other HAIs
Acknowledgments
OPHD HAI program staff and others assisting• Paul Cieslak – Public Health Physician• Ann Thomas – Public Health Physician• Margaret Cunningham – HAI Epidemiologist• Diane Roy – HAI Administrative Assistant• John Oh – EIS Officer• Steve Moore – Public Health Nurse• Jennifer Tujo – Infection Preventionist• Valerie Ocampo – HAI Public Health Nurse
Oregon Patient Safety Commission
Office for Oregon Health Policy and Research
Association of Professionals in Infection Control, Oregon-SW Washington Chapter
Questions?971-673-1111zintars.g.beldavs@state.or.us
Questions?
top related