Challenges in HAI Surveillance SHEA 04_12

8/2/2019 Challenges in HAI Surveillance SHEA 04_12

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Michael Edmond, MD, MPH, MPA

Richard P. Wenzel Professor of Internal MedicineChair, Division of Infectious DiseasesHospital Epidemiologist

Challenges in Surveillance for

Healthcare Associated Infections


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Surveillance Challenges

Goal of this presentation: to have you look beyondthe infection rate to appreciate the complexity of itsderivation


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Shifting Paradigms

Many infections areinevitable, although

some can beprevented

Each infection ispotentially

preventable unlessproven otherwise

Little attentiongiven to HAI rates

given lack ofconsequences

High visibility issuewith high stakes

Patients Consumers


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Genesis of External Pressures onInfection Prevention Programs

Higher accountability

Increasedtransparency

Rapid solutionsto highly

complexproblems

Edmond MB, Eickhoff T. Clin Infect Dis 2008;46:1746-50.


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EdmondMB,Eickhoff T.Clin InfectDis 2008;46:1746-50.

InfectionControl

Programs

Governmentagencies

Legislativebodies

Payers

Consumer

advocacygroups

Mainstreammedia

Accreditationbodies

Nonprofits

Industry

Professionalsocieties


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Mandatory Reporting for HAIs

Source: APIC, July 2011.

Mandates public reporting Passed a bill to study the issue


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Rationale for HAI surveillance

To establish endemic rates of HAIs

To identify outbreaks

To allow prioritization of problems & thedevelopment of interventions to reduceinfections

To determine the impact of interventions toimprove the quality of care

Public reporting: to assist consumers inassessing quality of care across hospitals


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Characteristics of the ideal HAIsurveillance system

Unambiguous definitions

Minimizes surveyor time input

Maximally sensitive

Maximally specific

Low inter-observer variability

Clinically relevant output

Validated

Useful output for consumers


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Whats 2 + 2?

Count von Count


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Whats 2 + 2?

The mathematician says:

I believe its 4, but Ill haveto prove it.


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Whats 2 + 2?

The engineer says:

The answer is 4, but Ill

have to add a safety factor

so well call it 5.


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Whats 2 +2?

The biostatistician says:

The sample is too small togive a precise answer, but

based on the data set,there is a high probability itis somewhere between 3and 5.


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Whats 2 + 2?

The clinical microbiologistsays:

We dont deal with

numbers that small.


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Whats 2 + 2?

The infection preventionistsays:

I think its 4, but Ill have to

ask the hospitalepidemiologist.


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Whats 2 + 2?

The hospital epidemiologistssay:

What do you want it to be?


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The journey from definition to rate

HAIdefinition

HAIrate


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Resources

ValidityBias

Local effects

Ethicalissues

SurveillanceChallenges


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HAI Definitions

National Healthcare Safety Network

NHSN HAI definitions have become the

national standard An increasing number of states mandating

that hospitals join NHSN

NHSN definitions initially created in adifferent era; erred on the side ofsensitivity rather than specificity


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CDC CLABSI Definition

Central line is present Must meet 1 of the following criteria:

Criterion 1: Patient has a recognized pathogen cultured from 1 ormore blood cultures and organism cultured from blood is notrelated to an infection at another site.

Criterion 2: Patient has at least 1 of the following signs or symptoms: fever

(>38C), chills, or hypotension and

Signs and symptoms and positive laboratory results are not related toan infection at another site and

Common commensal (i.e., diphtheroids, Bacillusspp [not B. anthracis],Propionibacteriumspp, coagulase-negative staphylococci, viridansgroup streptococci, Aerococcusspp, and Micrococcusspp) is culturedfrom 2 or more blood cultures drawn on separate occasions.

http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf

CDC CLABSI definition, January 2012. Accessed 3/5/12.
http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdfhttp://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdfhttp://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf


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CLABSIx 1,000 = CLABSI rateCentral line

days


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Epidemiologist Clinician

Clinical Validity

Surveillance definitions Disease concepts

Does the patient who meets the definition of CLABSI, really have a

CLABSI? Increasingly important as front line clinicians face pressure to reduce

HAIS


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Surveillance

Efficacy: how well do the case definitionsidentify HAIs in the ideal world (i.e., thedefinitions are applied perfectly)

Measures the validity of the definition purely

Effectiveness: how well do the case

definitions identify HAIs in the real world Measures the validity of the definition + the

ability of IP surveyors to apply the definition


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HAIdefinition

HAIrate

Patient populations


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Special patient populations

Patient populations at high risk forbloodstream infections being misclassifiedas central-line associated

Hematologic malignancies Short bowel syndrome

Solid organ transplant

Critically ill patients undergoing abdominalsurgery

Cardiac surgery patients with vasoplegicshock and small bowel ischemia

Fraser TG, Gordon SM. Clin Infect Dis 2011;52:1446-1450.


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Impact of special populations

0

2

4

6

8

10

12

Q1 Q2 Q3 Q4

NHSN

Modified

Modified definitionexcludes:

Viridans strep BSI in ptswith neutropenia &

mucositis Gram-negative bacilli,

Candidaspp, &enterococci in patientswith neutropenia fromdose-intensivechemotherapy or BMTpatients with graft vs hostdisease of the gut

Fraser TG, Gordon SM. Clin Infect Dis 2011;52:1446-1450.

CLABSI/1,000 line days

Cleveland Clinic Medical ICU


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Changes in CLABSI rates by pathogenNHSN, 2001 vs 2009

-73

-37

-55

-46

-80

-70

-60

-50

-40

-30

-20

-10

0S. aureus GNR Enterococci Candida%

Srinivasan A. MMWR 2011;60:243-248.


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HAIdefinition

HAIrate

Patient populations

Deviceutilization


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Impact of device utilization onCAUTI rates

Hospital A Hospital B

8.0/1,000 catheter days 10.0/1,000 catheter days

80 UTIs 50 UTIs

10,000 catheter days 5,000 catheter days

8.0/10,000 patient days 5.0/10,000 patient days

Assume:2 similar hospitalsSame number of bedsSame number of patient days (100,000/year)

Same case mix indexNo differences in surveillance


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No good deed goes unpunished

Most catheter sparing interventions removecatheter days from relatively less ill patients,

who likely have a lower risk of infection

Remaining patients with catheters are athigher risk for UTI

CA-UTI rate will increase

Trick WE, Samore M. Infect Control Hosp Epidemiol 2011;32:641-643.


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Not all catheter days are created equal

Hospital A Hospital B

1,000 urinary catheter days:50 pts have devices for 10 days (last 5 days are unnecessary250 unnecessary days)

500 pts have devices for 1 day (half unnecessary250 unnecessary days)

Intervention:Eliminate unnecessary post-insertion

catheter daysIntervention:Eliminate unnecessary insertions

Outcome:250 catheter days eliminated

Outcome:250 catheter days eliminated

CA-UTI rate decreases(eliminated relatively high-risk catheterdays & retained relatively low-risk days)

CA-UTI rate increases(eliminated relatively low-risk days, retained

relatively high-risk days)

Trick WE, Samore M. Infect Control Hosp Epidemiol 2011;32:641-643.


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1 + 1 + 1 = 1

NHSN allows only 1 central line to be countedper day

Number of central lines may be a crude markerfor severity of illness

Impact of allowing all central lines to be counted:

Cleveland Clinic: 30% decrease in CLABSI rate

Johns Hopkins: 36% decrease in CLABSI rate

VCU Medical Center: 20% decrease in CLABSI rate

Fraser TG, Gordon SM. Clin Infect Dis 2011;52:1446-1450.Aslakson RA et al. Infect Control Hosp Epidemiol 2011;32:121-124.

Nalepa M, Bearman G, Edmond M. SHEA 2010.


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HAIdefinition

HAIrate

Patient populations

Bed management

Deviceutilization


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Bed management impacts HAI rates

How hospitals utilize ICU beds will impactICU HAI rates:

Hospitals with easy access to LTACHs are ableto transfer out high-risk patients (long-term

device patients) from their ICUs, reducing theirICU infection rates

Hospitals with a relative shortage of ICU beds

will concentrate the sickest, highest riskpatients in their ICUs, likely increasing ICU HAIrates

Providing critical care services in non-ICU

settings


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HAIdefinition

HAIrate

Patient populations

Microbiologyculture

practices

Bed management

Deviceutilization


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Practices affecting the blood culturepositivity

CLABSI requires a positive blood culture

Blood culture practices impact the rate ofpositive cultures:

Body temperature threshold for obtaining BC How often are temperatures measured

Number of cultures obtained

Volume of blood in each culture

Threshold for repeating cultures

Use of antipyretics

No cultures obtained and broad-spectrum antibioticsgiven


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Surveillance Aggressiveness ScoreSurvey of 16 PICUs at 14 hospitals

+1 point for each: Blood cultures (BC) obtained from

each CVL present

BC obtained from each lumen

No antipyretics before BC Antibioticsnot initiated prior to BC

BC done 3 mL

-1 point for each: BC sent from single lumen

Antipyretics prior to BC threshold

Aerobic cultures only

BC most commonly sent for

T>38.5C Repeat BC sent less often than 24

hours

BC most commonly sent >1 hourafter fever

Temp monitored > every 2 hours

Neonatal BC


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Surveillance Aggressiveness ScoreSurvey of 16 PICUs at 14 hospitals

Neidner MF. AM J Infect Control 2010;38:585-595.

The harder you look,the more you find


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HAIdefinition

HAIrate

Patient populations

Microbiologyculture

practices

Bed management

Deviceutilization Antimicrobial

utilization


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Antimicrobial utilization

Aggressive use of empiric antibiotics mayreduce infections or partially treatinfections leading to negative blood

cultures


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HAIdefinition

HAIrate

Patient populations

Microbiologyculture

practices

Bed management

Deviceutilization

Resources Administrative pressure

C-suite

Antimicrobialutilization


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Impact of hospital administrators

Allocation of resources Surveillance is resource intense

Requires trained nurses

In most hospitals concurrent surveillance for HAIs still

requires ICPs to review paper-based charts or EMRswithout decision support capability

Under-resourcing of IP programs will likely lead tolower rates of HAIs

Administrative pressure Aggressive talk & actions regarding HAI reduction may

lead to intentional or unintentional alterations inapplication of HAI definitions


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HAIdefinition

HAIrate

Patient populations

Microbiologyculture

practices

Bed management

Deviceutilization

Surveillance bias


C-suite



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Surveillance Bias

In the case of two hypothetical hospitalswith truly identical rates of infection, thehospital with the better surveillance

system for detecting cases will appear tohave higher rates of infection the more you look, the more you find

Importance of surveillance bias ismagnified is magnified in the era of publicreporting


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Surveillance Bias

IP at

Hospital A

IP atHospital B


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HAIdefinition

HAIrate

Patient populations

Microbiologyculture

practices

Bed management

Device

utilization

Surveillance bias


C-suite

IP application of definitions



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Application of HAI definitions

Data collection errors

Errors in the application of definitions

Variability in interpretation of definitions

Examples:

Conversion of primary BSI to secondary by falsely classifyingcolonization as infection(e.g., E. faecium grows in blood culture & perirectal surveillanceculture; BC is falsely classified as secondary)

Redefining PICC lines as peripheral lines

IP is unaware that Abiotriophiais a viridans group streptococcus

IP mistakenly believes that device must be present for > 48hours

Intentional orunintentional


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Lin MY et al. JAMA 2010;304:2035-2041.

Surveillance: Human vs Computer

Comparison of CLABSIrates in 20 ICUs at 4academic medicalcenters comparing IP

surveillance tocomputerizedsurveillance using theCDC definition

Median CLABSI rates: IP: 3.3/1,000 CL days

Computer: 9.0/1,000 CLdays


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Validation of CLABSI

Over 3-month period, validation of CLABSIsurveillance was performed in 30 adult & 3pediatric ICUs

Utility of surveillance by local IPs:

Sensitivity 48% (local IPs captured 23/48cases)

Specificity 99%

Overall CLABSI rate: Local IPs: 1.97/1,000 catheter days

Validators: 3.51/1,000 catheter days

Backman LA et al. Am J Infect Control 2010;38:832-838.


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Validation of CLABSI

Backman LA et al. Am J Infect Control 2010;38:832-838.

Error N %

Incorrectly classified primary vs secondary BSI 16 46

Misinterpreted microbiologic data 4 11

CLABSI rules* 6 17

CLABSI terms 4 11

Other 5 14

29 discordant cases involving 35 errors

*minimum time period rule, patient transfer rule, location of attribution rule, 2 or bloodculture rule, sameness of organism rule

types of central lines, location of devices, definition of infusion


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HAIdefinition

HAIrate

Patient populations

Microbiologyculture

practices

Bed management

Device

utilization

Surveillance bias


C-suite


Post-ascertainmentreview & censure



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Post case ascertainment review

Following case ascertainment by IPs, areview is conducted and cases may becensured

Consensus

Clinician veto

Interpretation & certification by an authority

Overall impact is a reduction in HAI rates


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HAIdefinition

HAIrate

Patient populations

Microbiologyculture

practices

Bed management

Device

utilization

Surveillance bias


C-suite


Post-ascertainmentreview & censure



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Interhospital comparisons of HAI rates


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http://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htm

Accessed 3/5/12

U i t d d C
http://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htmhttp://www.consumerreports.org/health/doctors-hospitals/hospital-infection/deadly-infections-hospitals-can-lower-the-danger/hospitals-with-no-infections/index.htm


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Unintended Consequences

Mandatory Reporting/Disclosure of HAIs

Misleading consumers if data are inaccurate andnot appropriately risk-adjusted

Disproportionate impact on hospitals caring for thesickest patients

Incentive for hospitals to conduct surveillancewith suboptimal sensitivity (gaming)

Inappropriate use of antimicrobials

Diversion of resources from other importantproblems (opportunity cost) inside and outside ofinfection control

Loss of public trust


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Conclusions

HAI rates appear deceptively simple but inactuality are remarkably complex metricswith many confounding influences

Local practices and inadequate riskadjustments make HAI rates difficult tocompare across hospitals

Better HAI definitions that are moreprecise and less prone to interpretationare needed


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Challenges in HAI Surveillance SHEA 04_12

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