©2014 Trinity Health. All Rights Reserved. 1 Infection Prevention & Control In The Era of...

©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

mailto:[email protected]

©2014 Trinity Health. All Rights Reserved. 2©2014 Trinity Health - Livonia, MI 2

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


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).


Picture of what Population Health Looks Like


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


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


Volume of Services/Care Value of Services


√

Related to Infection Prevention & Control? Let’s use CAUTI Prevention as an example

√ √ √ √


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


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


Who Gets HAIs? 1/25 on any given day in U.S. hospitals; many are older adults

McGill SS, et al


HAIs in Long Term Care Setting

Schweon S, LTC Safety Project, HRET, Cohort 5, 9/2015


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


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


Testing Assumptions of Population Health; BPCI


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


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


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


Tracks most often to cleaning, disinfection and sterilization of reusable devices


Progress Report for US, CDC’s NHSN SIR by HAI Site, CY 2013

ICDC HAI Progress Report, 2013


Progress Report for Idaho, CY 2013

ICDC HAI Progress Report, 201322


HAI Metrics in ID ; a closer look

CDC HAI Progress Report, 2013

Is this the secret CDI weapon for ID Maybe Broncos sporocidal?


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


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


Legacy of Edward Jenner – Pioneer of Vaccination;Advocacy Role for the Infection Preventionist?

©2015 Trinity Health - Livonia, MI 26

Jenner administering vaccination against smallpox


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)


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


Let’s Talk About Pertussis (Whooping Cough)Need to Protect our most vulnerable populations

©2015 Trinity Health - Livonia, MI 30

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


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


The Population Health Legacy of Infection Preventionists in Idaho – BTDT!

Been there and Done that!


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


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


§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,


ASHRAE Standard 188

https://www.ashrae.org/resources--publications/bookstore/ansi-ashrae-standard-188-2015-legionellosis-risk-management-for-

building-water-systems


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


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


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)…”


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


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.


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%).


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


Skills of the Infection Preventionist in the Era of Population Health

Murphy DM, et al. Am J Infect Control 2012;40:296-303.


Thank You…. Discussion/Questions

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