©2014 trinity health. all rights reserved. 1 infection prevention & control in the era of...
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©2014 Trinity Health. All Rights Reserved. 1
Infection Prevention & Control In The Era of Population Health: Building on Legacy & Looking Forward
Russ Olmsted – Dir., Infection Prevention & Control (IPC)System Office, [email protected]
2015 Annual Intermountain Chapter -
23 October 2015
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Objectives & Disclosures1. Describe key elements of Population Health and its
emerging impact on provision of health care in the U.S.
2. Review the current status of healthcare-associated infections (HAIs) across the U.S. and in Georgia.
3. List at least one example of evidence demonstrating effectiveness of Infection Prevention and Control aimed at improving health of populations
4. Formulate at least one skill set of infection preventionists that will support population health and prevent HAIs
Disclosures: R. Olmsted is a member of a Speakers’ Bureau sponsored by Ethicon, Inc. &
consultant to Premier Inc.’s Safety Institute
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Comparison of Definitions; Epidemiology vs Population Health
CDC: Epidemiology –
“the study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to the control of health problems”
Institute of Medicine: Population Health -
“the health outcomes of a group of individuals, including the distribution of such outcomes within the group” (Kindig and Stoddart, 2003).
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Picture of what Population Health Looks Like
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Perspectives on Population Health from Florence – Our Collective Legacy Population health will see a greatly reduced need for high-
acuity healthcare services and offers rewards for keeping people well… However we only need to look to the writings of Florence Nightingale for guidance,
expected nurses to be the moral agents of health by addressing cleanliness, warmth, clean air, and water. She advocated making health contagious and infectious. Had she been able to tweet in 1894, she might have advised her colleagues that “Preventable disease should be looked on as a social crime,” “It is cheaper to promote health than to maintain people in sickness,” and “Money would be better spent in maintaining health in infancy and childhood than in building hospitals to cure diseases.”
Cipriano PF. Reaching the end game. 2014
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Why Population Health? Lives & Resources
“Medicare and Medicaid will cost taxpayers roughly $1 trillion this year (2014) alone. Unless reforms are enacted, entitlements are on track to consume all tax revenues before today‘s 25 year-olds are eligible for Medicare. The status quo is empirically unsustainable.” - U.S. Congressional Budget Office
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Volume of Services/Care Value of Services
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Related to Infection Prevention & Control? Let’s use CAUTI Prevention as an example
√ √ √ √
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How Big of a Problem are Healthcare Associated Infections (HAIs)? Point Prevalence Survey; National Healthcare Safety Network (NHSN) N=183 hospitals, 2011
Patients at risk = 11,282• 452 (4.0%) with > one HAI
• Distribution by site – see pie chart
• C. difficile = 70% of GI infections
Nationwide estimates:• 648,000 patients with 721,800
HAIs/year
% HAIs
Pneu
SSI
GI
UTI
BSI
ENT
LRI
SST
CV
Magill SS et al. NEJM 2014;370:1198-208
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Lessa FC et al. N Engl J Med 2015;372:825-834.
Ongoing Microbial Challenges:C. difficile infection, 2011, U.S.
Estimated no. of deaths = 29,300
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Who Gets HAIs? 1/25 on any given day in U.S. hospitals; many are older adults
McGill SS, et al
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HAIs in Long Term Care Setting
Schweon S, LTC Safety Project, HRET, Cohort 5, 9/2015
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CMS Hospital Acquired Condition (HAC) Reduction Program
The 721 hospitals getting penalties for infections, other patient injuries.
One in seven hospitals will see a 1% reduction in Medicare reimbursements.
HAC Measures: blood stream infections, patient falls, pressure ulcers, urinary tract infections, collapsed lungs, cuts that occur during or after surgery, and blood clots
Source: The Advisory Board Company. Daily briefing. 12/19/14
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Inpatient VBP FY 2018 Finalized Changes
25%
25%25%
25%
FY 2018 Final
• Clinical Care (25%)
• Patient and Caregiver Experience (25%)
• Efficiency and Cost Reduction (25%)
• Safety (25%)
Measure ID NQS-Based Domain
AMI-7a Clinical Care – Process
IMM-2 Clinical Care – Process
PC-01 Safety *FINALIZED CHANGE*
MORT-30-AMI Clinical Care
MORT-30-HF Clinical Care
MORT-30-PN Clinical Care
HCAHPS Patient and Caregiver CenteredExperience of Care / Care CoordinationCTM-3 *NEW*
CAUTI Safety
CLABSI Safety
MRSA Safety
C. Diff Safety
PSI-90 Safety
SSI Safety
MSPB-1 Efficiency and Cost Reduction
HAIs
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Testing Assumptions of Population Health; BPCI
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Examples of Conditions Eligible for BPCI
Acute MI COPD CHF Pneumonia & other respiratory tract infection Spinal fusion Stroke UTI New Proposal as of 8/13/2015:
Comprehensive Care for Joint Replacement (CCJR) Model
“…payment to the hospital encompasses all services furnished by the hospital,
physicians, and other practitioners during the episode of care, which includes the
entire inpatient stay and any related readmissions…” CMS
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ENDOSCOPE REPROCESSING: CHALLENGESNDM-Producing E. coli Associated ERCPEpstein et al. JAMA 2014;312:1447-1455
New Delhi Metallobetalactamase-producing E.coli recovered from elevator channel
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More Media on Reusable Medical Devices
Recommendations
Healthcare facilities should arrange for a healthcare professional with expertise in device reprocessing to immediately assess their reprocessing procedures. This assessment should ensure that reprocessing is done correctly, including allowing enough time for reprocessing personnel to follow all steps recommended by the device manufacturer. To include: Training, Audit & Feedback Infection control policies & procedures
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Tracks most often to cleaning, disinfection and sterilization of reusable devices
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Progress Report for US, CDC’s NHSN SIR by HAI Site, CY 2013
ICDC HAI Progress Report, 2013
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Progress Report for Idaho, CY 2013
ICDC HAI Progress Report, 201322
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HAI Metrics in ID ; a closer look
CDC HAI Progress Report, 2013
Is this the secret CDI weapon for ID Maybe Broncos sporocidal?
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Building the Case for Prevention Across All Settings; Long Term Care Surveillance in ID
Stevenson KB, et al. Infect Control Hosp Epidemiol 2005;26:231-6.
All Inf Resp skin/ST
UTI GI Febrile BSI0
0.51
1.52
2.53
3.54
Incidence of HAIs, Long Term Care, pooled means
Rates/1000 resident days
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Population Health, MDROs & Antimicrobial Stewardship
CDC Vital Signs. Making Healthcare Safer: stop spread of antibiotic resistance
Cause 2 million infections/yr 23,000 of which are fatal
Up to 70% fewer patients will get CRE over 5 years if facilities coordinate to protect patients.
Preventing infections and improving antibiotic prescribing could save 37,000 lives from drug-resistant infections over 5 years
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Legacy of Edward Jenner – Pioneer of Vaccination;Advocacy Role for the Infection Preventionist?
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Jenner administering vaccination against smallpox
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Jenner & smallpox, yes, but – what do these two images have in common?
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Got Vaccine? Efficacy of Vaccines Across the Decades; Rate of Disease/100k pop.
Debold T, Friedman T. WSJ, 2/11/2015 28
Pre vaccine:
3-4 million
cases/ yr
Post vaccine:
220 cases
(2011)
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Lake Breaker: Time to Revisit N95 Respirator for HCP Caring for Patients with Measles.
Gohil SK, et al. Clin Infect Dis 2015
• 4/5 HCP with evidence of immunity developed measles and continued to work after onset
• Total no. of exposed contacts = 1,014; no additional cases seen in these exposed
• Recommend, minimum of N95 respirator for HCP caring for those with suspect measles
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Let’s Talk About Pertussis (Whooping Cough)Need to Protect our most vulnerable populations
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Cause: Bordetella pertussis ; releases toxin that damage cilia and cause inflammation ofrespiratory tract
Transmission: cough/sneeze to close contact
Symptoms: 100 day cough. 7-10 after infection but can be 21 d
Population at risk: infants < 1 yr old
Precautions: Droplet
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Prevention? - Vaccinate; 80% of cases in infants exposed to household member with pertussis
©2015 Trinity Health - Livonia, MI 31Debold T, Friedman T. WSJ, 2/11/2015
Pre-vaccine era:
175,000 cases/yr
Post vaccine:
2900 cases /yr
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The Population Health Legacy of Infection Preventionists in Idaho – BTDT!
Been there and Done that!
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Why? Watching over the health of the community…some recent examples close to home and far away
http://healthandwelfare.idaho.gov/Health/Epidemiology/IdahoDiseaseBulletin/tabid/682/Default.aspx
Plague in Treasury Valley Ground Squirrels and Voles
Emerging and re-emerging infectious diseases; Ebola virus disease (EVD) Avian influenza viruses West Nile Virus Enterovirus D-68….
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Current State of Readiness for Population Health
85% of hospitals reported strong or total commitment to population health or have population health in their vision statement
Over 90% of hospitals agreed or strongly agreed that population health was aligned with their mission
Hospital-community partnerships exist along a spectrum and are highly variable
The most common partnerships were with public health departments, chambers of commerce, health insurance companies and fed. qual. Health center /community clinics
Health Research & Educational Trust. (2015, August). A National Survey of Hospitals. Chicago, IL:
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Most Needed Skills/Background under Population Health
Health Research & Educational Trust. (2015, August). A National Survey of Hospitals. Chicago, IL:
Rank Skills/Background
1 Physicians
2 Nurses
3 Behavioral Health
4 Health needs assessment / strategic planning
5 Other clinicians
6 Change management
7 Community Health / Organizing
8 Public Health
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SPECIAL CHALLENGES IN INFECTION CONTROL; CMS state operations manual, rev. 122, 9/26/14
Multidrug-resistant organisms (MDROs)
Ambulatory Care
Communicable disease outbreaks
Bioterrorism
Antimicrobial stewardship – new in 2015
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§482.41 Condition of participation: Physical environment & §482.28 Food and Dietetic Services. – Connecting the dots; IPC - EOC
Heating, ventilation & air conditioning (HVAC)
temperature, relative humidity, pressure rel., air changes/hr
Food Services – What’s cooking in the kitchen?
refrigerators, freezers
food preparation & work practices
Compliance with FDA Food Code?
Water is everywhere!
drinking fountains, eyewash stations, ice machines
handwashing stations, water features, plumbing,
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ASHRAE Standard 188
https://www.ashrae.org/resources--publications/bookstore/ansi-ashrae-standard-188-2015-legionellosis-risk-management-for-
building-water-systems
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Screen & Clean Away Surgical Site Infections (SSIs)
1. Preoperative nasal screen for S. aureus colonization & if + suppress with topical antimicrobials
2. Preop. cleansing with chlorhexidine gluconate soap or no-rinse cloth
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Does Screen & Clean Work? Yes!
Schweizer ML, et al JAMA 2015;313(21):2162-2171
Spike reflects
non-adherence
with SSI prev.
bundle elements
“…modest, statistically significant decrease in complex S aureus SSIs…” Populations: cardiac surgery or hip or knee arthroplasties
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Hand Hygiene (HH) Intervention, Rural Hospital Network, ID & UT
Stevenson KB, et al. Antimicrobial Resistance & Infection Control 2014;3(10)
“…average absolute change in “any HHcompliance” of 28.4% (range 17.8% to 38.2%) in intervention hospitals compared to 0.7% (range −16.7 to 20.7%) in control hospitals (p = 0.010)…”
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More Evidence on Need for IPC in the Community
Jury LA, et al Plos One July 2013 | Volume 8 | Issue 7 | e70175
Of 67 patients with CDI, 54 (81%) had >1 or more outpatient visits in 12 weeks after diagnosis.
Patients with recent CDI present a significant risk for transmission of spores during outpatient visits.
The outpatient setting may be an underappreciated source of community-associated CDI cases
% Positive imprint cultures of gloved hands after contact in outpatient clinic
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What about S. aureus Bloodstream infections?
AM J Infect Control 2015; e-pub.
N = 354 patients, April 2012 – Oct. 2014 76% community-acquired
The presence of a central venous catheter constituted a robust independent risk factor for MRSA BSI
prior hospital stay >3 days and chronic kidney disease were uniquely associated with MSSA.
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Identifying the Need for IPC in Ambulatory Settings; Schaefer MK, et al. JAMA 2010303(22):2273-2279
•Of 68 Amb. Surg. Centers assessed:
67.6% had at least one lapse in infection control.
•Common lapses included: using single-dose medication vials for > 1 patient
(28.1%), failing to adhere to recommended practices for
reprocessing of equipment (28.4%), lapses in handling of blood glucose monitoring
equipment (46.3%).
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Ambulatory Care Setting & People-Centered 2020
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Same principles apply to Ambulatory care Training of personnel Monitoring for healthcare associated infections Standard precautions, hand hygiene, safe injection practices Environmental cleaning & disinfection Respiratory Hygiene/Cough Etiquette Immunizations for providers & patients
http://www.cdc.gov/HAI/pdfs/guidelines/Ambulatory-Care-04-2011.pdf
IC.01.03.01 Risks
IC.01.04.01 GoalsIC.02.01.01 Implementation
IC.03.01.01 Evaluation
Risk AssessmentInfection risk assessment
GoalReduce or eliminate infection
ImplementationBased on guidelines and organization-specific risk
EvaluationRates reduced?Best practices followed?Implementation complete?
Risk Based Planning; Skill Set of the IP
D. Rumovitz – St. Mary Medical Ctr, Langhorne, PA; Spring 2014 ART Conference
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Skills of the Infection Preventionist in the Era of Population Health
Murphy DM, et al. Am J Infect Control 2012;40:296-303.
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Thank You…. Discussion/Questions
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