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MISSION AND VISION

Piloting HAI Data Collection in Maryland Long Term Care Facilities : Successes and Challenges Elisabeth Vaeth , MPH Epidemiologist, Emerging Infections Program Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration. MISSION AND VISION. MISSION

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MISSION AND VISION

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  1. Piloting HAI Data Collection in Maryland Long Term Care Facilities: Successes and ChallengesElisabeth Vaeth, MPHEpidemiologist, Emerging Infections ProgramMaryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration

  2. MISSION AND VISION MISSION • The mission of the Prevention and Health Promotion Administration is to protect, promote and improve the health and well-being of all Marylanders and their families through provision of public health leadership and through community-based public health efforts in partnership with local health departments, providers, community based organizations, and public and private sector agencies, giving special attention to at-risk and vulnerable populations. VISION • The Prevention and Health Promotion Administration envisions a future in which all Marylanders and their families enjoy optimal health and well-being. Prevention and Health Promotion Administration June 10, 2013 2

  3. EIP PISToL Project • Pilot of Infection Surveillance Tools for Long Term Care Facilities • 2012 EIP project to pilot new NHSN component Prevention and Health Promotion Administration June 10, 2013 3

  4. EIP PISToL Project • Designed for LTC • UTI and Lab-ID CDI • Voluntary recruitment • Never been done before… Prevention and Health Promotion Administration June 10, 2013 4

  5. MD’s Guinea Pig LTCFs • Recruited from: • Local LTC APIC chapter meeting • Networking with LTC corporate contacts • 8 willing facilities • 6 agree to both modules • 1 UTI only, 1 CDI only Prevention and Health Promotion Administration June 10, 2013 5

  6. MD LTCF Facility Characteristics • All for-profit, chain LTCFs • Sizes: 62 beds to 192 beds • Two with vent units • Baseline hours devoted to infection prevention/control: 10-24* • All send out lab tests* • Two with EMR* Prevention and Health Promotion Administration June 10, 2013 6 * For 5 facilities completing facility surveys

  7. PISToL Activities • Identify surveillance coordinator (S.C.) • Facility Survey • CDC training webinars • Standardized surveillance: UTI events and Lab-ID CDI events • Denominator data • Resident-Days, Urinary Catheter-Days, and New Admissions Prevention and Health Promotion Administration June 10, 2013 7

  8. PISToL Activities • Time Logs • Monthly data submission • Post-pilot survey • Post-pilot feedback conference call Prevention and Health Promotion Administration June 10, 2013 8

  9. SUTI – Criteria 1a SUTI – Criteria 2a SUTI – Criteria 3a Case Definitions: UTISUTI (Symptomatic Urinary Tract Infection) • Either of the following • Acute dysuria • Acute pain, swelling or tenderness of the testes, epididymis or prostate • Fever or Leukocytosis AND • Any ONE of the following: • Costovertebralangle pain or tenderness • Suprapubic pain • Gross hematuria • New or marked increase in incontinence • New or marked increase in urgency • New or marked increase in frequency • Any TWO of the following: • Costovertebral angle pain or tenderness • Suprapubic pain • Gross hematuria • New or marked increase in incontinence • New or marked increase in urgency • New or marked increase in frequency A voided urine culture with 105cfu/ml of no more than 2 species of microorganisms or a specimen collected by in and out catheter specimen with  102cfu/ml of any number of organisms Prevention and Health Promotion Administration June 10, 2013 9 SUTI

  10. Case Definitions: UTICA-SUTI(Catheter-Associated Symptomatic UTI) SUTI – Criteria 1b • At least ONE of the following with no alternate source: • Fever or rigors OR new onset hypotension, with no alternate site of infection. • Any acute functional decline or mental status change AND leukocytosis • New costovertebralangle pain or tenderness • New suprapubic pain • Acute pain, swelling or tenderness of the testes, epididymis or prostate • Purulent discharge from around the catheter A urine culture with  105cfu/ml of any organism(s), collected following placement of a new catheter if current catheter has been in place >14 days Prevention and Health Promotion Administration June 10, 2013 10 CA-SUTI

  11. Case Definitions: UTIABUTI(Asymptomatic Bacteremic UTI) Resident has no localizing urinary signs or symptoms (i.e., no urgency, frequency, acute dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness). If no catheter is in place, fever alone would not exclude ABUTI if other criteria are met. AND A positive urine culture with  105cfu/ml of no more than 2 species of microorganisms, or a specimen collected by in and out catheter specimen with  102cfu/ml of any number of organisms AND A positive blood culture with at least 1 matching uropathogen microorganism to the urine culture. ABUTI Prevention and Health Promotion Administration June 10, 2013 11

  12. Case Definitions: Lab-ID CDI CDI-positive laboratory assay: A positive result for a laboratory assay for C. difficile toxin A and/or B, OR a toxin-producing C. difficile organism detected in the stool sample by culture or other laboratory means • Incident CDI Assay: Any LabID Event from a specimen obtained > 8 weeks after the most recent LabID Event (or with no previous LabID Event documented). • Recurrent CDI Assay: Any LabID Event from a specimen obtained > 2 weeks and ≤ 8 weeks after the most recent LabID Event for that resident. Prevention and Health Promotion Administration June 10, 2013 12

  13. Surveillance Forms • Forms also collect • Demographic info on patient • Infection risk factors • Catheter status (UTI only) • Associated hospitalization (UTI only) • 30-day outcome (UTI only) • Antibiotic susceptibilities (UTI only) Prevention and Health Promotion Administration June 10, 2013 13

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  16. Great, begin on March 1, 2012! Simple enough…? Prevention and Health Promotion Administration June 10, 2013 16

  17. A few early challenges… • Not everyone completes training webinars… • But recorded versions distributed • Emails seem to enter a black hole… • But after repeat phone calls, everyone says they’re ready to start Prevention and Health Promotion Administration June 10, 2013 17

  18. Month 1: March Prevention and Health Promotion Administration June 10, 2013 18

  19. March Madness Definition confusion • Paper forms offer ALL possible UTI signs and symptoms • Surveillance coordinators over-identify UTI events • BUT, Lab-ID CDI event identification is a success Prevention and Health Promotion Administration June 10, 2013 19

  20. Month 2: April Prevention and Health Promotion Administration June 10, 2013 20

  21. Month 3: May Prevention and Health Promotion Administration June 10, 2013 21

  22. Month 4: June Prevention and Health Promotion Administration June 10, 2013 22

  23. Final Tally • Four facilities complete three months of surveillance • Three UTI & CDI • One UTI only • One facility completes one month of surveillance • UTI & CDI Prevention and Health Promotion Administration June 10, 2013 23

  24. Summary Stats:Event Breakdown by Month *Data from 4 facilities completing 3 months of surveillance Prevention and Health Promotion Administration June 10, 2013 24

  25. Summary Stats:CDI Event Breakdown by Month *Data from 4 facilities completing 3 months of surveillance Prevention and Health Promotion Administration June 10, 2013 25

  26. Summary StatsReported Events vs. Events Meeting Surveillance Definition *Data from 4 facilities completing 3 months of surveillance Prevention and Health Promotion Administration June 10, 2013 26

  27. Denominators • Not collected as instructed in protocol (daily counts) • Monthly resident-days • Ranged from 1,750 (62 bed-facility) to 5,272 (192 bed-facility) • Monthly urinary catheter-days • Ranged from 30* (150 bed-facility) to 525 (192 bed-facility) • Monthly resident admissions • Ranged from 0 (155 bed-facility) to 60 (152 bed-facility) Prevention and Health Promotion Administration June 10, 2013 27 * Possible data collection error

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  29. Time Spent on Surveillance • Logs sporadically completed (received 7 total over course of surveillance period) • Reports for combined UTI/CDI surveillance time per month ranged from 4 hours to 18 hours • When completed, showed that surveillance not occurring daily • Often mostly on one day near end of month Prevention and Health Promotion Administration June 10, 2013 29

  30. Validation: Activities and Goals • Five main validation activities • UTI event chart reviews • Stool culture reviews • Urine culture reviews • Review of CDI antibiotic starts • Review of UTI antibiotic starts • Interview S.C.’s on denominator collection practices • Completed at 3 facilities Prevention and Health Promotion Administration June 10, 2013 30

  31. Validation: Process and Conclusions • Challenging chart reviews • Signs and symptoms not always noted in chart • Many discrepancies • Challenging lab and pharmacy reviews • Matching cultures to starts • Lack of indications • Take home: Data sources available but not as useful as hoped Prevention and Health Promotion Administration June 10, 2013 31

  32. PISToL: Lessons Learned • Infection prevention in LTCF • Not like acute care! • Often one IP who wears many hats • Long protocols will not be read • Very wide range of knowledge/experience • Standardized surveillance not the routine • Computer access and know-how not a given Prevention and Health Promotion Administration June 10, 2013 32

  33. PISToL: Lessons Learned However… • NHSN LTC component launched September 14, 2012 • will guide event identification • CMS may require HAI reporting in LTCFs in the future… • Administrators will have to hire more and better-skilled IP staff • Standardized surveillance will hopefully become routine Prevention and Health Promotion Administration June 10, 2013 33

  34. Thank you! • Katie Richards, DHMH • Lucy Wilson, DHMH • David Blythe, DHMH • Pat Ryan, DHMH • Brenda Roup, DHMH • Ruth Belflower, CDC • Nicola Thompson, CDC • Nimalie Stone, CDC • Anonymous Maryland PISToL S.C.’s! Prevention and Health Promotion Administration June 10, 2013 34

  35. Questions? Prevention and Health Promotion Administration Prevention and Health Promotion Administration June 10, 2013 35

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