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Healthcare Infection Control Practices Advisory Committee (HICPAC)

Slide 1
Division of Healthcare Quality Promotion
HICPAC Meeting
November 13, 2008

Slide 2
Division of Healthcare Quality Promotion (proposed)

Office of the Director

Healthcare Preparedness Activity

Immunization Safety Office

Office of Blood, Tissue and Organ Safety

Office of Antimicrobial Resistance

Clinical and Environmental Laboratory Branch
Bacterial Characterization, Typing, and Identification Team
Environmental & Applied Microbiology Team
Antimicrobial Resistance Team

Prevention and Response Branch
Prevention Team
Response Team

Surveillance Branch
NSHN Development Team
NHSN Implementation Team
Statistics Team
Special Investigations Team

Slide 3
CDC PATIENT SAFETY ACTIVITIES

ADVERSE DRUG EVENTS - TRANSFUSION/TRANSPLANT SAFETY - IMMUNIZATION SAFETY - HEALTHCARE-ASSOCIATED INFECTIONS - ANTIMICROBIAL RESISTANCE - HEALTHCARE PREPAREDNESS

Working through . . .

• Outbreak Investigations
• Surveillance
• Prevention Recommendations
• Intervention Implementation
• Laboratory Research
• Collaborations and Partnerships

Slide 4
Highlights

• Outbreak investigations
• Prevention (extramural) research
• Surveillance activities
• Successes

Slide 5
DHQP Recent Outbreak Investigations

• 35 Epi-Aids in 2007-2008
• Hospital infections caused by emerging pathogens or pathogens with emerging resistance
• Infections transmitted by tissue and organ transplants
• Related to ambulatory procedures
• Related to compounded medical products
• Related to intrinsic contamination of healthcare items
  • Examples: pre-filled heparin and saline syringes contaminated with Serratia marcences, heparin associated with anaphylactic reactions, alcohol-free mouthwash (Burkholderia vanimaris)
• National impact, leading to voluntary or FDA-recalls and changes in national recommendations

Slide 6
Investigation of Anaphylactoid Reactions Among Dialysis Patients

• Investigation at one dialysis clinic in MO showed an association with the receipt of heparin.
• Was the start of the large, national investigation that led to the identification and recall of heparin contaminated with over-sulfated chondroitin sulfate.

Slide 7
Outbreaks of KPC Producing Organisms

• DHQP has gotten several calls to help with these and recently completed a field investigation of a large outbreak of KPC producing organisms in Puerto Rico.
• These outbreaks suggest that this might be the ideal time to intervene to try and halt the spread of these pathogens!

Slide 8
Healthcare-associated Outbreak Investigations

Nevada Epi-Aid investigation: hepatitis C outbreak

• Discovered reuse of syringes and single dose vials
• Resulted in massive patient notification: risks of bloodborne viral infections due to unsafe injection practices

(image: unsafe injection practices)

Slide 9
Protecting Patients in Outpatient Settings

ASC inspections using CDC infection control assessment tool
State
Nevada, 49 facilities
OK, 20 facilities
MD, 32 facilities
NC, 16 facilities
Total: 117 facilities

Outcome: Identified a myriad of deficiencies in basic safe care identified (e.g., widespread reuse of single-use medications)

Need: large scale-up effort to institutionalize safe care practices into education, accreditation and inspection requirements

Slide 10
Clinical Microbiological Laboratory

• National Reference Laboratory
  • Staphylococci
  • Anaerobic bacteria
  • Enteric gram negative rods
  • Antimicrobial susceptibility testing
• Laboratory support for the epidemiologic investigations of outbreaks
  • 41 outbreaks, over 1900 specimens processed by DHQP laboratories in FY 08

Slide 11
Funded Prevention of Healthcare-associated Infections and MRSA

• Prevention Epicenters
  • Innovation for detection and prevention of healthcare-associated infections (HAIs), MRSA, Clostridium difficile infections (CDI)
  • Expansion to the VA to assess HAI prevention interventions
• MRSA prevention activities
  • AHRQ collaboration to prevent MRSA
  • Potential Extramural Projects (PEP)
• Stakeholder meetings
  • National targets for HAIs
  • 2 Stakeholder meetings (MRSA decolonization and MRSA reporting)

Slide 12
Funded Prevention Epicenters/VA Collaboration

• Evaluating the use of electronic data sources to:
  • Detect central-line associated bloodstream infections
  • Detect MRSA outbreaks
  • Evaluate impact of MRSA prevention programs by using clinical microbiology information to create incidence measures
  • Demonstrate impact of current VA MRSA prevention activities using data from Veteran's Integrated Service Network (VISN).
• Evaluating additional ways to detect HAIs
  • Surrogate inpatient surveillance measures for surgical site infections (SSI)
  • Medicare claims to identify hospitals with high SSI rates
  • ICD9 codes for ascertaining device-days of use and related adverse events
  • Surveillance methods for Clostridium difficile infection
  • Measuring variability and appropriateness of antimicrobial utilization

Slide 13
Funded Prevention Epicenters/VA Collaboration

Developing interventions, evaluating effectiveness of interventions

• MRSA prevention:
  • cleansing of patients with chlorhexidine cloths
  • reduce transmission of MRSA and VRE
    • Electronic alerts to flag high risk patients
    • Collection of nasal swab (PCR)
    • Toyota Production System-based quality improvement program large VA multi-site study
    • Evaluate effectiveness of screening and decolonization for MRSA control automated standing orders for routine ICU MRSA surveillance cultures
    • Impact on ICU and total hospital MRSA bacteremia
• Urinary Track Infections prevention:
  • Implementing an intervention to electronically identify and flag patients for whom urinary catheters may no longer be needed
• Evaluating impact of Clostridium difficile infections (CDI) prevention strategies

Slide 14
Funded MRSA Prevention

• Partnering with the Agency for Healthcare Research and Quality (AHRQ)
  • Assess prevention in a healthcare system
    • Acute care hospitals and long-term facilities
    • Healthcare and community-associated infections
• Potential Extramural projects (PEP):
  • Evaluating surrogates for adherence to infection control practices
    • Monitoring adherence with isolation precautions in 5 affiliated hospitals
    • Using radio-frequency-identification (RFID) to monitor hand hygiene compliance among a hospital’s employees
• Delmarva Foundation
  • Assessing the impact of Positive Deviance Model to reduce MRSA colonization and infection

Slide 15
Pilot MRSA Projects

• State surveys on MRSA prevention recommendations
• Evaluation of administrative data to detect MRSA
• Evaluation of impact of MRSA State legislation (IL)

Slide 16

diagram

Slide 17
Surveillance Projects

• Population-based surveillance of MRSA and CDI (EIPs)
• NHSN expansion and enhancement
  • Enrollment, training and validation
  • Operating system enhancements and maintenance
  • Improved analysis and reporting of outcomes and process of care data
  • MDRO module
  • Integration of NHSN data with other HHS Agencies
• NHSN electronic data capture

Slide 18
Current DHQP/CDC Activities to Enhance Use of Electronic Data Sources

eSurveillance Projects

• Clinical Document Architecture (CDA)
• Health Level 7 messaging
• HAI detection

Slide 19
Number of hospitals using National Healthcare System Network (NHSN) has QUADRUPLED in the last year October 2008

April 2007

• 491 facilities enrolled
  • 44% had 201-500 beds
• 8 States using or planning to use NHSN for mandatory reporting

October 2008

• 1930 facilities enrolled (47 States)
  • 33% have 201-500 beds (58% have ≤ 200 beds)
• 19 States using or planning to use NHSN for mandatory reporting

Slide 20
19 States Using NHSN for Public Reporting*

CLABSI	CO, CT, DE, IL, MA, MD, NJ, NY, OK, OR, PA, SC, TN, VA, VT, WA
CAUTI	PA
SSI	CO, DE, MA, NJ, NY, OR, PA, SC, TN, VT
VAP	OK, PA, SC, WA
Dialysis events	PA
MDRO*	CA, MD, NJ, PA
Process measures	CA, DE, MD, NJ, PA, VT

 

Slide 21
Hospitals Participating in NHSN are Preventing Bloodstream Infections

Line chart: Trends in Bloodstream Infections* by ICU Type, United States, 1997-2007

Slide 22
Figure. Trends in %MRSA and Incidences of MRSA and MSSA Central Line-Associated Bloodstream Infections (CLABSIs) in Intensive Care Units-- United States, 1997-2007*

	Pooled Mean Annual CLABSI Rate per 1,000 Central Line Days or %MRSA
	1997	1998	1999	2000	2001	2002	2003	2004	2005	2006	2007
MRSA	.27	.32	.37	.38	.41	.33	.33	.29	no data available	.2	.15
MSSA	.29	.3	.23	.22	.24	.21	.16	.13	no data avaialble	.12	.08

 

Slide 23
Population-based Surveillance of MRSA

[Image of JAMA]
~ Invasive MRSA infections alone are responsible for approximately 94,000 infections and 19,000 deaths each year. Approximately 85% of these serious MRSA infections are healthcare associated. Hospital-onset (approximately 16% decrease; 20% for bacteremia)* Community –onset (approximately 9% decrease)*

Slide 24
National Health and Nutrition Examination Survey Percentage of individuals colonized with
S. aureus and MRSA No. of participants: 9622 in 01-02 and 9004 in 03-04

	% Colonized
	2001–2002	2003–2004
S. aureus	32.3	28.7
MRSA	0.9	1.5

Kuehnert MJ et al. J Infect Dis 2006 192:172-9 Gorwitz RJ et al.

Slide 25
MRSA Was the Most Commonly Identified Cause of Purulent SSTIs Among Adult ED Patients (EMERGEncy ID Net)

[Map of U.S.]
Moran et al NEJM 2006

Slide 26
National Estimates of US Short-Stay Hospital Discharges with C. difficile as First-Listed
or Any Diagnosis, National Inpatient Sample

Year	Number of Discharges
	All	Primary
1997	127580	25200
1998	121664	25885
1999	133151	30060
2000	138954	32763
2001	148872	36647
2002	193588	46722
2003	203042	48877
2004	246139	60137
2005	301213	76416
2006	317325	30063

Elixhauser, A. (AHRQ), and Jhung, MA. (Centers for Disease Control and Prevention). Clostridium Difficile-Associated Disease in U.S. Hospitals, 1993–2005. HCUP Statistical Brief #50. April 2008. Agency for Healthcare Research and Quality, Rockville, MD. And unpublished data http://www.hcup-us.ahrq.gov/reports/statbriefs/sb50.pdf

Slide 27
States with BI/NAP1/027 strain of C. difficile (N=40), October, 2008

Map of the U.S

Slide 28
Public Reporting in Ohio, 2006N=14,100 cases

• Hospital onset
  • 5,000 initial cases; 7–8/10,000 pt-days
  • ~1,200 recurrent cases; 1–2/10,000 pt-days
• Long-term care facility onset
  • ~4,800 initial cases; 2–3/10,000 pt-days
  • ~3,100 recurrent; 1–2/10,000 pt-days

Ohio Department of Health. http://www.odh.ohio.gov/alerts/cdiff1.aspx

Slide 29
CDI in the United States

• As of 2006, the CDI epidemic appears ongoing in the United States
• Marked geographic variation in rates of CDI cases and deaths
  • Impacted by the age of the population
• Exact number of CDI cases and deaths unknown
  • >500,000 CDI cases in 2006
  • >15,000 deaths caused (or contributed to) by CDI in 2006

Slide 30
Blood, Organ, and Other Tissue Safety

• Over 50 transfusion and transplant investigations conducted in FY2008
  • HIV, HCV, LCMV, TB, chagas, babesiosis, anaplasmosis
    • >1/2 of all U.S. states and territories involved in suspected disease transmission events most multi-state events, needing CDC coordination
• Blood safety
  • Hemovigilance module in National Healthcare Safety Network through collaboration with AABB
    • Recipient clinical adverse event recognition
    • Transfusion error event recognition
    • Currently set for pilot launch FY2009
• Organ and Tissue Safety
  • Transplantation Transmission Sentinel Network through cooperative agreement with the United Network for Organ Sharing
    • Enhanced communication concerning transmission of infectious diseases and malignancy
    • Pilot will be completed FY2008 (over 1,000 entries in system)

Slide 31
NEISS-CADES
Adverse Drug Events

Journal of the American Pediatrics

Slide 32
Involving patients……

image of MRSA, Hand Hygeininand C diff fachsheet and brouchers

Slide 33
Moving towards the future:DHQP Strategic Plan

Slide 34
Keys for the Elimination of Healthcare-associated Infections

• Full adherence to recommendations
• Collect data and disseminate results
  • Communication with consumers
  • Evaluate how we’re doing
• Recognize excellence
• Identify and respond to emerging threats
• Improve science for prevention through research

Slide 35
DHQP Strategic Plan

• Goals
• Objectives
• Strategies - Public health functions
• Activities and Tasks
• Targets for 2008-20012
   
• NCPDCID Strategic Plan
• CDC Mission
• HHS Plan

Slide 36
DHQP Strategic Plan

• Goal 1: Eliminate Healthcare-associated Infections
• Goal 2: Eliminate Occupational Infections among Healthcare Personnel
• Goal 3: Remove Threats to Healthcare Quality
• Goal 4: Provide a Supportive, Growth-oriented Environment within DHQP

Slide 37, 38
GOAL 1:
ELIMINATE HEALTHCARE-ASSOCIATED INFECTIONS

• Objective 1: Continually reduce healthcare-associated infections related to medical devices and procedures
• Objective 2: Continually reduce infections in healthcare and community settings caused by healthcare-associated antimicrobial-resistant organisms
• Objective 3: Eliminate failures in basic safe medical practices, including injection safety errors and other “never events”

Slide 39
GOAL 1: ELIMINATE HEALTHCARE-ASSOCIATED INFECTIONS EXAMPLE

• Objective 2: Continually reduce infections in healthcare and community settings caused by healthcare-associated antimicrobial-resistant organisms

EXAMPLE TARGET: Reduce by 50% hospital-onset MRSA bloodstream infections.

Strategies for 2008-2012:

Expand capacity to detect and monitor antimicrobial resistance as demonstrated by

• Implementing the NHSN MDRO module by fall of 2008
• Evaluating and reporting national trends in antimicrobial susceptibility patterns of key pathogens by 2010
• Assessing and reporting on antimicrobial use in U.S. healthcare facilities by 2010
• Conducting population-based surveillance for MRSA and C. difficile in the Emerging Infections Program through 2012
• Publishing reports on the incidence, characteristics and trends of infections caused by MRSA, C. difficile, VRE, multi-drug resistant gram negative rods in U.S. healthcare facilities annually
• Transitioning to electronic reporting of key microorganisms by 2012
• Developing and evaluating laboratory methods to detect antimicrobial resistance

Slide 40
DHQP Budget Over the Years
2002-2009*

Base	2002	2003	2004	2005	2006	2007	2008	2009
	10417961	11696887	10579924	9431789	9820456	8768732	14705268	14264110
AR	3081000	2791000	3814018	4312132	6731742	6663911	7128298	7698531
Supplement	2363000	201700	0	0	0	3184500	0	0
BT	2640789	1092018	845895	1033674	1209334	1133852	903573	776683
FLU	0	0	0	0	3688169	3402234	5175277	1877000

Slide 41
CDC’s Unique Role in Preventing Healthcare-Associated Infections

 

Slide 42
Working with Federal Partners

• CMS
• AHRQ
• FDA
• HRSA
• EPA
• NIH
• DoD
• VA

 

Slide 43
Moving towards 2009...

• Simplify surveillance and NHSN
• Accelerate the use of electronic data sources
• Support State initiatives for prevention
• Support regional initiatives for prevention
• More collaborations to educate patients/consumers

Slide 44
Thank you

 

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