Progress on HAI progress: CDC portals and data

I spent about 2 hours with the new CDC HAI Progress Report – loosen your belt, it’s a big meal!  We probably had mixed perceptions about the recent alert to the 2016 HA progress report. Loads of information and analysis condensed down to a handful of bullets, all pointing to improvements in patient safety! The (very pleasant) surprise to me was that the format and delivery of the report has advanced to digital!! CDC has added the HAI progress report to the existing (and now updated) HAI AR Patient Safety Atlas Portal If you stop reading now – at least click on that link and explore and I will call this blog a success!

This report is several steps forward.  First, it pushes all of us to go to a place where we, being inquisitive minds, can wander and perhaps connect some dots within and between datasets. With the digitalization and visualization provided in the portal, the novice and experienced can more easily access and utilize these data. One can click through four distinct datasets, which now include state-summary statistics HAI infection rates/SIRs, inpatient stewardship activities, outpatient antibiotic prescribing rates, and inpatient antibiotic resistance metrics.

Now – the email alert. This year, well 2016 data, is the first to use the 2015 “re-baseline” efforts.

Unstated, but implied – the re-baseline effort includes the use of MBI (mucosal barrier injury) LCBSI as an event excluded from reported CLABSI rates, exclusion of yeasts (or low colony counts) from CAUTI rates, exclusion of “infection present on admission” for SSI (along with better patient-level risk adjustment), first use of risk adjusted metrics for VAE, and maybe slightly better models using more contemporary data for MRSA and CDI. 

With that said, 2016 performance suggests nationally patients are safer overall compared to the experience of 2015. Other than VAE which decreased by only 2%, everything else declined about 7-10% (I am rounding) compared to 2015. I understand many of the problems with risk adjustment and reporting bias that make these surveillance events poor performance measures for individual hospitals – but on the national level – I think these data do suggest fewer infections (o.k., perhaps some  widespread under-reporting—mixed reports on validation efforts in place).

Next – the overview of the current HAI Progress Report.   Although at first glance it seems the same as the info posted in the emails – CDC is offering more ways to track progress nationally – the number of states showing improvements (or worsening) compared to 2015, as well as the number states currently performing at levels better (or worse) then their 2016 contemporaries: 12 state perform better on at least 3 infection types compared to other states at the same time (2016). Now positive deviance nerds need to learn from these states to help the other states (or perhaps identify accuracy and validation issues at these states). The contemporary juxtaposition of SIRs is new, perhaps confusing (especially with CDC’s arcane explanation on how to interpret this: “SIRs statistically significantly lower than the 2016 national SIR are considered better than the 2016 national SIR”; curious if it ends up being useful to state programs. This year also is the first with more detail on inpatient rehabilitation facilities and long-term acute care facilities. Fewer data mean fewer statistical significant results, but these data are ripe for academic partners to latch onto as they try to partner with ARHQ, CDC, and state-programs to branch out into stewardship and prevention efforts in these types of facilities.

Finally, the portal – access it here.  Use the table view. No graphics to export for HAIs, only for other datasets. My pet peeve is that CDC still refused to list the no. of SSIs reported next to the number of surgical procedures reported to allow a crude attack rate. We still need to go to the technical tables for these values and calculate ourselves (see below). CDC, please stop making us jump through this hoop to be able to use attack rates for other purposes like planning studies, clinical trials, vaccine research! To all researchers and data nerds - the detailed technical tables should be downloaded examined (here), perhaps parsed out to our students and trainees, and used for different purposes that simply a “reporting requirement”.  I know there are many limitations to the accuracy of any one facilities reports and likely aggregate data up to the state or national level. However, as a long time national surveillance nerd all too familiar with the warts and ugliness of surveillance data, they do inform us, approximate the truth, and can help us ask the right questions and target the right populations. The more eyes using these data the more transparent the process will become, more uses of the data will be identified, patient safety should improve, and CDC will become more accountable to update (c’mon, where’s 2015 and 2016 NHSN AR data?! update the portal please!!),  maintain, and advance the public accessibility of useful data in our field.

SHEA/CDC/AMDA Sponsored Post-Acute and Long-Term Care Certificate Course

The SHEA/CDC/AMDA infection prevention in Post-Acute and Long-Term Care certificate course will take place during the first 2 days of the SHEA 2016 meeting.

Q: What will the SHEA/CDC/AMDA Post-Acute and Long-Term Care course cover?

     A: Starting with an overview of healthcare epidemiology, the course will go over surveillance definitions and how surveillance data can be put to good use (beyond satisfying checkboxes on surveyors’ clipboards). The speakers will also discuss aspects of infection prevention that are unique to skilled nursing facilities, where residents enjoy shared dining, recreation and rehabilitation experiences. Sessions will also address occupational health concerns in long-term care, including outbreaks that affect both staff and residents, such as influenza and norovirus. (Did you know that a box of chocolates is a great vector for norovirus? Poor Forrest Gump…..). The course will also emphasize opportunities to reduce unnecessary and inappropriate antimicrobial use. Speakers will specifically discuss communication at care transitions and ways to educate talking with concerned family members, who may have been taught myths and misinformation about antibiotic use for UTI management (e.g., bad dreams are an indication for treating a positive urine culture with antibiotics). Really.

Q: What does the SHEA/CDC/AMDA Post-Acute and Long-Term Care certificate look like?

     A:

Q: Where can I sign up for SHEA 2016 and the Certificate Course?

     A: At the SHEA 2016 meeting website: here

Q: Is there an early bird discount?

     A: Yes! Register before February 15, 2016

SHEA 2015: *New* Post-Acute and Long-Term Care Track

 

This is a special guest post by Dr. Silvia Munoz-Price, Enterprise Epidemiologist at Froedtert & Medical College of Wisconsin Institute for Health and Society and the Department of Medicine. She is co-directing the new SHEA Certificate Track in Post-Acute and Long-Term Care at the 2015 SHEA Meeting in Orlando.

In healthcare, we are in the process of transforming our approach from caring of an isolated individual to caring for the population as a whole. Similarly, we are slowly migrating from paying attention to single hospital encounters to focusing on the continuum of care of individuals. These facts are important in the fields of Infection Control and Hospital Epidemiology, as in order to control the spread of highly resistant pathogens we need to internalize that our hospital systems are interconnected through patient transfers. This is particularly evident in the interactions between acute care hospitals, long term care acute care hospitals (LTACHs), and nursing homes within regions. A few years ago, this interrelatedness was elegantly described by Won and colleagues in the midst of a regional outbreak of KPC Klebsiella pneumoniae in the Chicago area (Won et al CID 53: 532-540, figure below). Furthermore, controlling the spreadwithin the LTACH changed the whole transmission dynamic in the region (Munoz-Price Infect Control Hosp Epidemiol. 2010 Apr;31(4):341-7).

Research dealing with Infection Control practices in post-acute care settings is progressing, as recently described in this blog here, here and here. Given our interdependence, it is fundamental that providers in post-acute care --who deal directly with these infection control issues-- are knowledgeable and up to date. This year, SHEA’s Spring meeting will have a 2-day post-acute care track specifically designed to provide a general infection control overview to infection control personnel in post-acute care and LTACHs. The co-Director of this track, Dr. Nimalie Stone, is the Medical Epidemiologist for Long-term Care in the Division of Healthcare Quality Promotion (DHQP) at CDC. Additionally, we will have top notch speakers such as David Nace, Lona Mody, Curtis Donskey, among others. Upon completion, attendees will receive a certificate from SHEA.

A full description of the track can be found here. Participation and engagement of our post-acute care/LTACH colleagues is fundamental to succeed in our fight against hospital acquired infections.

We hope to meet you in Orlando!

Discounted registration ends April 17th (save $100), so register now!

HAI Rates are a Red Herring

"Fictional" Hospital CMO: "Why should I care about hand hygiene or environmental cleaning if I have no CLABSI or CAUTI in my hospital?"

Don't take this the wrong way, since I'd never want a patient to develop a CLABSI or VAP, but I think our focus on device infections is actually harming patients in the long run. If we convince ourselves, like that CMO quoted above or QI and patient safety folks, that we can just prevent device infections (never mind define them away) and everything will be fine, we are missing the bigger picture. The bigger picture is antibiotic resistance and I've yet to see any evidence that our antibiograms are improving.

When did hospital epidemiologists forget we were infectious disease physicians?

In September's ICHE Kerri Thom and colleagues in Maryland published a sobering reminder that resistant pathogens are increasing, particularly Gram-negative pathogens. They (COI alert, I'm a co-author) completed an Acinetobacter baumannii prevalence survey of all mechanically ventilated patients in the state of Maryland. They swabbed intubated patients in 40 of 57 hospitals and collected sputum and/or perianal swabs from  92% of all eligible patients in those hospitals.  What they found was staggering.  Fully 34% of patients were colonized or infected with Acinetobacter baumannii with 16% in acute care settings and an astounding 63% in long-term care settings carrying the pathogen. Even more worryingly, many strains were highly drug resistant with 46% of isolates in long-term care described as "extensively drug resistant," meaning there were no effective therapies - polymixin anyone?

Why does this matter?  Resistant pathogens cause untreatable infections and result in terrible situations like patients being removed from organ transplant waiting lists. These pathogens also carry resistance genes and serve as reservoirs for emerging resistance in other pathogens like E. coli. So, while I'm sure these Maryland hospitals all report zero CLABSI or CAUTI, I guarantee that they all have patients infected and dying of Acinetobacter baumannii and other MDR-Gram negative pathogens. Until we make investments in the science behind hand hygiene improvement, environmental cleaning and other methods for transmission prevention and until we invest in antimicrobial discovery, patients will increasingly die of these untreatable infections.

Luckily, when a kidney transplant patient dies of MDR-Acinetobacter sepsis, the hospital CMO can still sleep at night. At least the patient didn't die of a CLABSI.  I'm sure the patient's family will find comfort in that.


red herring image source: misocrazy

Another worry for the hospital epidemiologist

This morning's New York Times has a long piece on long-term acute care hospitals (LTACHs). The article focuses on quality and safety issues in these facilities, many of which are for-profit. From the epidemiologic standpoint, these hospitals pose special problems since patients are admitted there from many acute care hospitals typically after long stays and are colonized or infected with multi-drug resistant organisms (MDROs). The LTACH patients then may require re-admission to the acute care hospital after colonization or infection with other MDROs. So in essence the LTACH serves as an amplifier for MDROs. There's a nice review on the infection control issues associated with LTACHs by Munoz-Price in an issue of CID from last year.