Healthcare Safety Advisory Committee APPROVED Meeting … · 2018-10-18 · Healthcare Safety...

Healthcare Safety Advisory Committee • October 18, 2018 • Meeting Minutes • of 13

Healthcare Safety Advisory Committee

APPROVED Meeting Minutes

Thursday, October 18, 2018

9:00 a.m.

Moreton Building - Room M-100

1100 West 49th Street, Austin, TX 78756

Agenda Item 1: Call to Order

The Healthcare Safety Advisory Committee (HSAC) meeting was called to order at 9:00

a.m. by Dr. Ed Septimus.

Mr. John Chacon, Advisory Committee Coordination, Health and Human Services

Commission (HHSC), conducted roll call and announced that the meeting was being

conducted in accordance with the Texas Open Meetings Act, and noted that a quorum was

present for the meeting.

Table 1 notes Task Force member attendance.

Table 1: HSAC member attendance at the Thursday, October 18, 2018 meeting.

Yes: Indicates attended the meeting No: Indicates did not attend the

meeting

P: Indicates phone conference call

Agenda Item 2: Welcome and introductions

Dr. Ed Septimus welcomed committee members and the public who were in attendance.

Dr. Septimus noted that this was the 3rd meeting of the Healthcare Safety Advisory

Committee and offered opening remarks related to the charge and purpose of the HSAC

committee. Dr. Septimus asked HSAC committee members and Department of State Health

Services (DSHS) staff around table to introduce themselves.

Agenda Item 3: Approval of Minutes

Dr. Septimus called for a motion to review and approve the minutes of the July 19, 2018

meeting.

Motion:

Dr. Lawrence Donovan moved to approve the minutes from the July 19, 2018 meeting as

presented. Dr. William Musick seconded the motion. The Committee members

unanimously approved the minutes by voice vote, with eleven yeas, no nays and no

abstentions.

Agenda Item 4: Program Staffing Update

MEMBER NAME Attended MEMBER NAME Attended

Ms. Kelley Boston Yes Dr. William Musick Yes

Ms. Joleen Chambers Yes Ms. Victoria Pham Phone

Dr. Lawrence Donovan Yes Ms. Linda Scribner Yes

Ms. Griselda Flores Yes Dr. Ed Septimus Yes

Mr. Roy John Phone Mr. Patrick Waldron No

Dr. Charles Lerner Phone Ms. Lynda Watkins Yes

Ms. Susan Mellott No


Ms. Shawn Tupy provided a program staffing update. Highlights of the update and

committee member discussion included:

• Shawn Tupy has assumed the role as infectious disease manager which now

supervises her old position. Her previous position, Healthcare Safety Manager, was

posted to fill the vacancy.

• Johnathan Ledbetter has assumed the role of Healthcare Safety manager.

• Vickie Gillespie, Preventable Adverse Event (PAE) expert has retired and DSHS is

currently in process of positing her position.

• Alex Daniels has assumed the role of Program Health Prevention Specialist.

• With retiring employees, how does DSHS maintain the work load?

o Other team members will work together to complete the work load as

required.

• What is the rationale for the reporting suspension waiver being extended again?

o We have elevated the discontinuation of the waiver to executive leadership. It

is currently going through levels of approval to reach the Governor’s office.

• Should we send leadership a new request for reinstating reporting?

o We can send a letter from the committee that we can provide to the DSHS

Commissioner.

Dr. Septimus called for a motion to recommend the resumption of reporting and write a

letter to that effect to Dr. John Hellerstedt, Commissioner of the Department of State Health

Services.

Motion:

Ms. Lynda Watkins moved to recommend the resumption of reporting and write a letter to

that effect to Dr. John Hellerstedt. Ms. Kelley Boston seconded the motion. The Committee

members approved the motion by voice vote, with eleven yeas, no nays and no abstentions.

Action Item:

1. Provide an official letter to the DSHS Commissioner from the Committee asking for

Healthcare-Associated Infections (HAI) and Preventable Adverse Events (PAE)

reporting to resume in the state of Texas.

Agenda Item 5: 2019 Healthcare Safety Advisory Committee Meeting Dates

Ms. Shawn Tupy lead discussion regarding 2019 HSAC meeting dates and confirmed the

dates below for 2019:

• January 15, 2019

• June 20, 2019

• October 17, 2019

Agenda Item 6: Healthcare Safety Conference Topics

Ms. Susana Baumann led a discussion regarding the 2018 Healthcare Safety Conference

Overview and provided conference evaluation and feedback from participants and referred

to handout entitled “Healthcare Safety Conference Survey Results.” Highlights of the


• Overall quality of conference was rated 4.61 (with 5 being the highest rating)

• 99.5% of attendants specified they would attend a future Healthcare Safety

Conference.


• Lessons learned from the conference included:

o Using an electronic format for conference evaluation submissions

o Using an electronic format for Continuing Education requests

o Evaluate sessions to determine if they should be considered general sessions

for all attendees or separated according to HAI or PAE topic.

o Consider inclusion of exhibitors/sponsors early in planning to avoid contract

delays

• Topics suggested for the 2019 conference included:

o Ligature risk for facilities without behavioral health units

o Opioid crisis including the physician standpoint for prescribing and monitoring

opioids

o National Quality Forum (NQF) measures

o Disparities in healthcare delivery

o Pressure ulcers

o One Health

o Enhanced surgical recovery programs Infection and safety risk for ambulatory

and outpatient care facilities

o Immunizations

• What was the degree breakdown of attendees?

o Majority were Infection Preventionists (IP) and nursing attendees.

• Where did people come from geographically?

o Attendees were from all over the state. This is possibly the most attended

conference of the Laboratory and Infectious Disease Services (LIDS) branch.

Information regarding topics suggested by hospital IP staff is shared to the

hospital association. It is possible to work more with physicians to understand

what topics are of interest to them.

• What was the career stage of those who attended?

o It is difficult to provide that information. Some are seasoned attendees. We

also have attendance from local health departments. We are now working

with the University of Texas School of Nursing to bring in attendees that are

new to healthcare safety.

• Is there a date and location for the 2019 conference?

o Not currently

• Dr. Septimus stated that NQF has an opioid play book for physicians.

• Committee members suggested attracting physicians to the conference via enhanced

surgical recovery programs and to include veterinarians as participants.

Agenda Item 7: Antibiotic Stewardship Program and Activities

Dr. Michael Fischer provided an update on Antibiotic Stewardship program and activities and

referred to PowerPoint and Handouts entitled “An Update on Antimicrobial Stewardship

Programs in Texas Healthcare Facilities” and “Definitions and Comments for the Urinary

Tract Infection (UTI) Diagnostic Algorithm for Long-Term Care Facilities.” Highlights of the

overview and committee member discussion included:

• Provided a description of the Urinary Tract Infection (UTI) algorithm for Long-Term

Care (LTCF) Facilities

• A committee member suggested to include urine analysis (UA) results into the

algorithm in determining treatment for a UTI


• Dr. Fischer is currently preparing for Antibiotic Awareness week which runs

November 12-18, 2018. Activities for the week include:

o Promoting local and regional activities and events

o Promoting central office (Austin, TX) activities

o Speaking engagements at local hospitals and at the Dallas/Ft. Worth’s

Association for Professionals in Infection Control and Epidemiology (APIC)

Chapter meeting

o Participating in CDC sponsored events

• DSHS is currently working with healthcare facilities and local/regional health

departments to advertise their antibiotic stewardship programs on the DSHS website

• It was suggested to enlist urgent care centers in antibiotic stewardship

• In 2014, 37% of Texas acute care hospitals reported to the National Healthcare

Safety Network (NHSN) that they utilize all 7 core elements. This number does not

reflect all healthcare facilities reporting in Texas. This number has continued to

increase annually the past 3 years.

• Hospitals in the Dallas/Fort Worth and Houston areas have the highest no response

rates, yet the highest amount of hospital volume in the state

• Majority of facilities reported utilizing all seven core elements are general hospitals,

which has increased from 46% in 2015 to 79% in 2017.

• Is this a NHSN report or Infection Prevention and Control Assessment Tool (ICAR)

report?

o This report is from NHSN.

• In 2015, 40 % Non-teaching hospitals reported utilizing all seven core elements. This

number has increased to 70% in 2017

• In 2017, the top 4 core elements with the highest gap frequencies were: education,

tracking, leadership, and reporting. These 4 core elements account for 81% of gap

frequencies and are were effort should be focused to improve the utilization of all 7

core elements. Education on tracking and reporting is the most important area to

provide education on.

• Hospitals with the lowest number of IPs on staff and less than 200 beds are less

likely to utilize all seven core elements

• Smaller hospitals are in greater need of assistance in education on the seven core

elements.

• All data provided is only for NHSN data that DSHS has access to. We are in process

of getting a data use agreement with CDC to get access to all data.

• There is a deficiency in critical access hospitals utilizing the 7 core elements

according to 2017 ICAR Survey Data

• ICAR hospital data summary:

o Approximately 60% of the 58 hospitals utilized all seven core elements.

o The two least utilized core elements by hospitals are education and leadership

followed by reporting and accountability.

o Over 80% of the no response to utilization of all seven core elements are

seen in hospitals of: public health regions (PHR) 9/10, 11, 4/5N, 2/3, and 1;

less than 200 licensed beds, and less than 1.25 IP full time employees.

• Summary of ICAR LTCF Data

o Only 6.9% of the 116 LTCFs utilized all seven core elements

o The least utilized core elements were reporting, education, followed by action

and accountability, then tracking

o 80% of the no responses to utilization of all seven core elements are seen in

LTCFs of: PHRs 11, 4/5N, 6/5S, 7, and 9/10; licensed beds between 51-150;

greater than 10 but less than 20 IP hours per week.


• Is there a lack of a larger screening protocol in LTCFs?

o The issue in long term care is there is often screening being done when not

needed.

• Is there an educational component that can be provided to LTCFs that will assist in

helping them determine when to screen patients?

o Kicking Catheter-Associated Urinary Tract Infection (CAUTI) campaign can

assist with this.

• What is a Pareto Chart?

o This will be discussed off line.

• Is there a protocol in hospitals to determine flu vs sepsis?

o It is necessary to increase vaccinations. It is difficult to address specific issues

with limited information. Being able to determine if a patient comes in with flu

symptoms and will develop sepsis is difficult to determine.

• Clarification was asked on how ICAR data are obtained vs how NHSN data are

collected.

o The epidemiologist completes the ICAR tool on site with the hospital IP.

Hospitals input their data into NHSN and DSHS staff extract these data

• How many Texas facilities are reporting into the Antimicrobial Use and Resistance

(AUR) module?

o The AUR module consists of 2 module components: Antimicrobial Use (AU)

and Antimicrobial Resistance (AR). As of February 2018, the AU module

contained 75 hospitals reporting at least 1 month of complete data. There

were 50 hospitals reporting in the AR module.

• Is clinical pharmacy availability an area to consider when discussing antibiotic

stewardship?

o Yes

Action Items

1. Dr. Septimus will provide information on the KICKING CAUTI campaign via email to

DSHS staff and committee members

2. Dr. Fischer will provide information on Pareto Charts via email to committee

members

Agenda Item 8: Preventable Adverse Events

a. Revised Definitions and Guidance Document

b. Revised FAQ Document

c. Institute of Clinical Systems Improvement

Ms. Jennifer Vinyard provided a summary on the PAE revised definition and guidance

document, revised FAQ document, and Institute of Clinical Systems Improvement (ICSI)

and referenced handouts entitled “ICSI Non-OR Procedural Safety-PAE,” “PAE FAQs Revised

10.2018,” and “Definitions and Guidance 2018 edited 09.29.2018.” Highlights of the

presentation and committee member discussion included:

a. Revised Definitions and Guidance Document

• Discussed the changes to the definitions and guidance document. No comments were

added.

b. Revised FAQ Document

• Discussed the changes to the revised FAQ document.

• Does the document define serious harm?

o Yes, however because of the size of the document, only the updated material

was provided to the committee for the purpose of this meeting.

c. Institute of Clinical Systems Improvement (ICSI)


• Appendix A of the ICSI document provides a list of invasive, high-risk or non-surgical

procedures. This list has been used as a guideline to determine what is reportable for

PAEs, however this list will no longer be updated by ICSI. It was suggested that the

committee should put together a list for future use.

• Would a vaginal coil put in non-surgically be considered in the ICSI document?

o There is uncertainty if vaginal coil will be considered in the ICSI document.

Majority of procedures that required vaginal coil would be completed in a

medical office setting and not the hospital setting. PAEs are only reported for

events that happen within the hospital setting.

• What is the protocol to changing the reporting for PAEs regarding specific devices

such as vaginal coils to be reported in the setting where the procedure was

conducted i.e. medical office setting?

o We are bound by Chapter 98 of the statute to determine what is reported. If

there are changes to the statue by Texas legislature, this will drive the

changes within the program.

• It was suggested that the committee continue to use other resources for invasive

procedure reporting due to the commitment required to create and manage a

document for reporting PAEs.

Dr. Septimus called for a motion to adapt Appendix A of the ICSI Health Care Protocol as

the guideline for PAE reporting.

Motion:

Ms. Linda Scribner moved to adapt Appendix A of the ICSI Health Care Protocol. Dr.

Lawrence Donovan seconded the motion. The Committee members unanimously approved

the minutes by voice vote, with eleven yeas, no nays and no abstentions.

Public Comment(s)

Ms. Barbara Francis Scott Phillips, representing herself provided verbal public

comment after agenda item #8 and during the public comment agenda item (#16). She

discussed complications following her double hip replacement surgeries. After surgery, she

never got better and developed a variety of secondary symptoms like boils, body pains,

mood and behavioral changes, and mobility difficulties. She found out that Johnson and

Johnson were no longer selling the hips and that others were also having problems with the

hips. Ms. Phillips discovered that the hip prostheses got to market through a loop hole.

Further clinical testing determined that her cobalt and chromium levels were exceptionally

high due to wearing and grinding of the metal hip prostheses that were releasing high levels

of metals into her body and causing all of her secondary symptoms. Everyone who got

these hips are now having to go back to get revisions (new hips). After ten years, she is still

suffering the ill-effects of this product. Ms. Phillips wants to prevent others from getting hurt

by medical devices that could get to market through the loop hole provided by Section 510

K of the legislation. This section of the legislation needs to be updated and revised to

prevent such things from happening.

Agenda Item 9: National Quality Forum (NQF) Update

Dr. Ed Septimus provided an update on the National Quality Forum (NQF) and referred to

Handout entitled “NQF Patient Safety Quality Measures.” Highlights of the update and



• Dr. Septimus provided the NQF Patient Safety Measures that will be under

consideration for endorsement by NQF for Fall 2018.

Agenda Item 10: HAI Investigation Team

a. 2019 ELC Grant Activities

b. Klebsiella aerogenes

c. ARLN Related Education Material

Ms. Bobbiejean Garcia and Ms. Thi Dang provided an update on 2019 ELC Grant Activities,

Klebsiella aerogenes, and Antibiotic Resistance Laboratory Network (ARLN). Related

Educational Materials and referenced Handouts entitled “Interim Guidance for Public Health

Response to Contain Novel or Targeted MDROs,” “Verbal Consent – CRE,” “CDC Vital Signs -

Containing Unusual Resistance,” “Carba-r Assay Swabs,” “Cepheid Swab Shipping

Guidance,” “Rectal swab - how to,” “CRE Infection Clinician FAQs,” and “FAQ-CDC” were

discussed. Highlights of the presentations and committee member discussion included:

a. 2019 ELC Grant Activities

• The HAI Team will continue to respond and track HAI outbreaks that occur in

healthcare settings. Beginning January 2018, the team moved from tracking

outbreaks on an Excel spreadsheet to tracking them in a Microsoft Access database,

built by the Council for Outbreak Response: HAIs and AR Pathogens (CORHA).

Recently, with the help of a data support colleague in the branch, a report was built

into the database so summary data can be more easily retrieved.

• The Antibiotic Resistance Laboratory Network (ARLN) now has the capability to

identify Candida species, conduct antibiotic susceptibility testing, and test for

Candida auris colonization. No additional changes at this time to ARLN.

• Targeted Assessment and Prevention Strategy (TAP Program): In addition to running

Central Line Associated Bloodstream Infection (CLABSI) and Catheter Associated

Urinary Tract Infection (CAUTI) TAP reports quarterly for Acute Care Hospitals

(ACHs) that are required to report in Texas, we plan to expand the TAP initiative to

post-acute care facilities and perform TAP assessments for the C. difficile infection

(CDI) module.

• The HAI team will continue to meet with Shawn to discuss new grant deliverables

b. Klebsiella aerogenes

• Enterobacter aerogenes is now named Klebsiella aerogenes. This nomenclature

change took effect in February 2017, but we were not aware of the change until July

2018. This change was due to bacterial taxonomy changes and it is now considered a

reportable condition.

• How many laboratories have made the name change in their system?

o That number is unknown, however, we are receiving some reports from

facilities.

• K. aerogenes is not one of the ARLN’s targeted pathogens. The ARLN lab is looking at

expanding their organisms, but that is not an immediate option.

• Clostridium difficile is now named Clostridiodies difficile.

• How difficult during the data collection phase is it to include optional/mandatory

fields to provide any additional information that the hospital may have? For example:

KPC producing carbapenemase.

o The information can be provided, yet it has to be obtained from the NBS

comments field.


• Should we request in the newsletter that both carbapenem resistant E. aerogenes

and K. aerogenes isolates should be sent to the ARLN lab?

o Report on both until the conversion is made in the system.

c. ARLN Related Education Material

• Do the labs know which swabs to use for Candida spp. and CRE?

o DSHS provides the correct swabs for the facilities to use.

• Why are facilities declining participation in the colonization studies and what

feedback/justification to they provide for declining?

o A lot of facilities are concerned that they will lose patients if the information is

made available to the public. Other issues include facilities being a part of a

corporation and needing permission to participate.

• Does the Freedom of Information Act (FOIA) trump the state’s open records request

for confidentiality as it relates to disease investigations?

o If the state has restrictions that are tighter than FOIA, the state will trump

the request.

• Joleen Chambers offered to provide assistance with facilities that are resistant to

participating in DSHS investigations (such as colonization studies) by incentivizing

participation via public recognition by patient advocacy groups.

• Providing facilities with information on what is considered “discoverable” or what can

be requested via FOIA may be beneficial with persuading facilities to participate.

Action Item:

1. Add the update of Klebsiella aerogenes name change to the Healthcare Safety (HCS)

newsletter. Include that facilities should report on both K. aerogenes and E.

aerogenes to the ARLN lab.

2. Provide an update on what is considered “discoverable” and what can be requested

via FIOA or open records. Receive information on what is considered protected under

state laws.

Agenda Item 11: Recess for Lunch

The HSAC committee recessed for lunch from 11:50 am - 1:00 pm.

Agenda Item 12: Healthcare-Associated Infections (HAIs) Reporting and Auditing a. Changes to Public Report

b. Data Use Agreement process for NHSN

c. Reporting Suspension Update

Ms. Jennifer Vinyard provided a summary on healthcare-associated infections reporting and

auditing regarding changes to public report, data use agreement process with National

Healthcare Safety Network (NHSN), and reporting suspension update and referenced

handout entitled “HAI Reporting and Auditing.” Highlights of the presentation and


a. Changes to Public Report

• We have updated the Texas Healthcare Safety Network (TxHSN) system to accept

the new NHSN baseline data. We’ve changed our report to show the pediatric and

adult surgical site infection (SSI) data separately. We also included modifications to

allow for accepting and displaying data on the public report for medical, surgical, and

medical-surgical wards if the data becomes reportable in Texas in the future.


• We added a Surgical Site Infection (SSI) Standardized Infection Ratio (SIR) excluded

procedures to the internal data review report. This is for facility use only and will

help with data reconciliation.

• Changes to the facility specific health care safety report include: SSI procedures are

separated by adult and pediatric instead of in-patient/out-patient. We will also be

able to display non-ICU CLABSI and CAUTI data as well if data from these areas

become reportable in the future.

• Can we show current data of NHSN reported events? o Because reporting is still suspended we do not have any data to display in the

new report. We have access to the data from NHSN but will not publish it.

• Why are we not using NHSN data that’s required? o Because the suspension involved all mandated reporting, we will not publish

these data.

• Currently the public reporting page will show that no data is available because

reporting is suspended.

• Can you explain the Centers for Medicare and Medicaid Services (CMS) alignment? o The Texas Hospital Association (THA) has put forth a proposal to align Texas

reporting requirements with CMS mandated requirements. It will go through

legislature within the next legislative session.

• Will this be a reduction in reporting? o The SSI reporting will decrease. We will also lose ambulatory surgery center

(ASC) data. But we will be gaining Methicillin-resistant Staphylococcus aureus

(MRSA), CDI and Laboratory Identified (LAB ID) events, and CAUTI/CLABSI

data from non-ICU locations. This would create less burden on facilities

because these data are already required to be reported for CMS.

• Why would we decrease reporting on certain procedures such as hip and open-heart

procedures? o The alignment will help facilities understand what is required to be reported.

This was a request of the previous committee that asked for alignment.

However, the DSHS commissioner can add or remove procedures as they see

fit. Several of the SSI procedures that we currently collect data on do not

have enough data reported to provide statistically significant results. We

would like to make reporting simpler for facilities and reduce burden.

• Aligning with CMS will allow us to have access to more HAI data from NHSN.

• Dr. Septimus has suggested removing procedures with no statistical data yet keep

procedures that are clinically significant.

• Will the CMS alignment be a “Bill?” o Yes, it must go through legislation.

• If it is not mandated in the CMS bill, will we be able to add procedures as needed? o We can refer to the legislative report to discuss recommendations to the

executive leadership

• The following procedures were suggested for reporting: pelvic and hernia mesh.

b. Data Use Agreement process for NHSN

• We are requesting all available data from NHSN. Long term care, military/VA, Indian

and home health centers, the healthcare personnel module, blood and body fluid

exposure module, and the dialysis prevention process measures are not included in

the proposal because NHSN does release these data with the Data Use Agreement.

We will receive access to all data we do not currently receive. This information will

not be made public, however it will be used for internal review and grant projects.

• Will facilities have to confer rights with that specific data? o CDC will let state facilities know that all data will be visible to the state and

they will have 3 months to opt-out. Historically, facilities have not opted out

because they will no longer be able to utilize NHSN to report HAI data to CMS

for federal reporting requirements.


• Will units that are not currently required to report for CMS be included in this

agreement? o Any data in the system that is in plan will be accessible to Texas regardless of

whether it is required for reporting to CMS or other mandates.

c. Reporting Suspension Update

• The HAI reporting is currently still suspended.

Agenda Item 13: HAI Validation

Ms. Lynda Watkins led a discuss on HAI Validation. Highlights of the presentation and


• It was suggested that we look deeper into reporting especially on facilities that

report no infections.

• For our current validation process for CAUTI and CLABSI we look at facilities in the

top tertile with a high number of infections predicted. They are separated into 3

tiers: a SIR greater than the median, a SIR equal to the median, and a SIR that’s 0.

We select about 21 facilities based on the tier groups then another 5% at random for

any facilities that report.

• In 2016, we reviewed 6,446 records for CAUTI and CLABSI with only 2 staff

members.

• NHSN just released a new method for selecting facilities using the Cumulative

Attributable Difference (CAD) to identify facilities that may be under reporting. The

CAD method identifies facilities by looking at the difference between the number of

infections that should have been reported and what was reported. Jennifer proposed

using the current validation method the first half of the next audit cycle and the new

CAD method on the 2nd audit cycle once reporting resumes.

• A committee member suggested collecting qualitative data such as how a facility

identifies an infection if there are differences in opinion among staff

o We currently do collect data about their current practices before the audit

using our HAI audit survey.

Action item:

1. Provide committee with current HAI audit survey we ask facilities to complete before

the audit.

2. Include a question in the pre-audit survey to provide information on number of HAIs

reported that may meet clinical definition for infection vs meeting surveillance

definition for infection.

3. Create a subcommittee (Kelley Boston, Lynda Watkins, and Jennifer Vinyard)

regarding the surveillance barriers and provide information to the committee during

the January 2019 meeting.

4. Once reporting resumes, conduct a pilot study using the targeted validation method

for selecting facilities for the first audit cycle and the CAD validation method for the

second audit cycle.

Agenda Item 14: Legislative Report Draft Review

Ms. Candace Campbell and Ms. Jennifer Vinyard reviewed the legislative report and

referenced handout entitled “Draft Legislative Report.” Highlights of overview and member

discussion included:

• Suggested adding a section regarding the suspension of reporting.

• Suggested that we reinstate reporting.

o This will go under policy recommendations and committee actions


• Legislation will be proposed to align Texas HAI reporting with the Centers for

Medicaid and Medicare Services (CMS) HAI reporting requirements to reduce the

burden on facilities. Additional HAI data will be gained if this alignment occurs while

other data will be lost. However, most of the data that we are losing are data that

have not historically provided statistically significant results. For example,

Ambulatory Surgery Centers (ASCs) have never had a Standardized Infection Ratio

(SIR) calculated and therefore, these data are not statistically significant and cannot

be validated.

• Can we keep ASC as required reporting though they currently do not have a SIR?

o We can add a recommendation to the policy that once statistical data is

available in this setting, we will require reporting.

• Is there a way for patients to report to the state if they have infections?

o Yes, it is reported as a complaint to the regulatory department. It cannot be

reported as an HAI because you cannot determine if it meets definition

according to NHSN.

• The committee discussed keeping reporting requirements for the following SSI

procedures:

o Colon surgery

o Knee Prosthesis

o Hip Prosthesis

o Coronary artery bypass grafts

o Spinal fusion

o Refusion of spine

o Abdominal hysterectomy

• The committee discussed eliminating reporting requirements for the following SSI

procedures:

o Peripheral vascular bypass grafts

o Abdominal aortic aneurysm repairs

o Carotid endarterectomies

o Laminectomies

o Ventricular shunts

o Cardiac surgery

o Heart transplants

• With the CMS alignment, there would not be separate reporting requirements for

adult and pediatric facilities. All reporting would be the same.

• It was proposed to exclude free standing pediatric facility only reporting

requirements and use one standardized reporting list for all facilities including

facilities with an integrated pediatric area and the free standing pediatric facilities.

• There was a suggestion to collect data on hernia and vaginal mesh.

o We can only use the operative codes that NHSN provides. Vaginal mesh in not

an operative code.

• Suggested looking at procedures according to product recall.

o FDA does not typically recall medical devices.

• Suggested collecting information regarding the capability of including mesh

procedures as a reportable surgical procedure or to allow direct reporting of medical

device harm from patients. Dr. Septimus suggested further discussion is needed for

feasibility. This information is to be presented at the January 2019 meeting.

• There is a component on the notifiable conditions list that discuss diseases that have

an uncommon presentation.

• Ms. Joleen Chambers stated that she would like to present on surgical mesh and

would invite a guest consumer to speak at the January 2019 meeting to discuss

surgical mesh.


• Ms. Joleen Chambers will review reporting codes for NHSN and the tracking of

recalled medical devices offline to discuss at the next meeting.

Motion:

Ms. Lynda Watkins moved to circulate legislative report with edits and comments to

committee members and delegate authority for Dr. Ed Septimus, Chair to finalize legislative

report with edits provided by committee members so the report can be submitted in

accordance with the associated timeframes. Dr. Lawrence Donovan seconded the motion.

The Committee members approved the motion by voice vote, with ten yeas, no nays and no

abstentions.

Action Item:

1. Provide Joleen Chambers with information regarding where patients can report their

infections to regulatory.

Agenda Item 15: Regional HAI Updates

Dr. Ed Septimus introduced the Regional HAI Epidemiologists to provide a regional update.

Ms. Gillian Blackwell (Region 1), Ms. Thi Dang (Region 2/3), Ms. Annie Nutt (Region 4/5N),

Ms. Bobbiejean Garcia (Region 6/5S), Ms. Sandi Arnold (Region 7), Ms. Gretchen Rodriguez

(Region 8), Ms. Susana Baumann (Region 9/10), and Ms. Melba Zambrano (Region 11))

provided updates. Highlights of updates and member discussion included:

• Region 1- Nothing reported.

• Region 2/3- In July DSHS received a positive New Delhi metallo-β-lactamase

(NDM) producing carbapenem resistant Pseudomonas aeruginosa (CRPA) case. The

patient was not on contact precautions and had 5 roommates during admission. NDM

CRPA is not commonly seen in the US. CDC suggested a Tier 1 response. 33 patients

were tested for colonization during this investigation. 4 tested positive for NDM. 3 of

those patients had a clinical infection for NDM. There have been no positive cases

since August 2018. November will be the last month for monitoring.

• Region 4/5N- HAI Epidemiologist for Region 4/5N is leading an outbreak

investigation for Region 6/5S. The outbreak investigation is focused on Klebsiella

pneumoniae carbapenamase (KPC) producing CRPA. This investigation involves 7

healthcare facilities and 2 home health agencies in 4 health department jurisdictions.

Recently, onsite infection control assessments and Point Prevalence Studies (PPS)

were conducted at 2 of the healthcare facilities. These 2 facilities were prioritized

because multiple patients had overlapping stays there in the months prior to the

positive cultures.

o The PPS in both facilities have resulted in additional patients positive for KPC,

and further testing is underway to determine if these additional cases are

related to the outbreak.

o Additional rounds of PPS will be conducted until there are no new positive

cases.

o Retrospective and prospective surveillance is being conducted for CRPA in all

of the healthcare facilities involved.

• Region 6/5S - The HAI Epidemiology Team is also working with the CDC and

multiple local health departments investigating three patients with Enterobacter

cloacae bloodstream infections following injections and infusions with umbilical cord


blood products. The manufacturer has voluntarily recalled the products and

investigation is ongoing.


• Region 8- DSHS was alerted by the ARLN Lab about 4 KPC+ patients from the same

county on the same week. Pulse Field Gel Electrophoresis (PFGE) testing showed that

the organisms had matching patterns and after further investigation we identified a

Long-term Acute Care (LTAC) facility in which the patients had overlapping stays. We

conducted an infection control assessment and performed a colonization screening

that yielded no additional positive results. We are working with the facility to do a

CAUTI TAP Assessment since most of the patients had urinary tract infections with

urinary catheters.

• Region 9/10- Nothing reported.


• Dr. Ed Septimus, Chair inquired how many Verona Integrated Metallo-β-Lactamase

(VIMs) that have been identified. Staff stated that they are working on an

investigation now in an area that you would not expect this to occur.

Action Item:

1. Provide a breakdown of different carbapenemases by regions in Texas

2. If possible, identify which carbapenem resistance identified with no carbapenmase

production

3. Identify carbapenemase productions without a mechanism identified

4. Dr. Musick will provide a graphic regarding carbapenem-resistance

Agenda Item 17: Adjourn

Dr. Ed Septimus adjourned the meeting at 2:42 p.m.

Below is the link to the archived video of the October 18, 2018 Healthcare Safety AC

meeting

https://texashhsc.swagit.com/play/10182018-952

https://texashhsc.swagit.com/play/10182018-952

Healthcare Safety Advisory Committee APPROVED Meeting … · 2018-10-18 · Healthcare Safety...

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Transcript of Healthcare Safety Advisory Committee APPROVED Meeting … · 2018-10-18 · Healthcare Safety...