Surveillance Outside the Hospital: Monitoring Home

Health Outcomes

Regina Nailon RN, PhDClinical Nurse Researcher

The Nebraska Medical Center

State of the Art ConferenceApril 22, 2013

Portions of this work were supported in part by a grant from the Cardinal Health

Foundation.

Session Objectives

• Explain the role of outcomes data in the current health care delivery system.

• Review a case study demonstrating how to achieve measurement of outcomes in outpatient settings.

Partnering Agencies• Alegent Creighton Health at Home• Children’s Home Healthcare/Children’s Hospital &

Medical Center• Home Nursing with Heart• InfuScience, a Bioscrip Company• Methodist Home Health and Hospice• Visiting Nurse Association of the Midlands• The Nebraska Medical Center

– Nursing Research & Quality Outcomes Department– Peggy C. Cowdery Patient Treatment Center

• University of Nebraska Medical Center– Department of Infection Control and Healthcare Epidemiology

Increased emphasis

on reducing hospital

LOS

Increase in patient care

in out patient and

home health

settings

Increased incidence of

patients discharged

from hospital

with CVC in place

Lack of research

examining standardize

d maintenance care and

its association with CVC outcomes

Preventive measures

have largely concentrated

on CVC insertion or the use of

technologic improvements

Significance of CLABSI

• 78,000 central line-associated bloodstream infections are estimated to occur yearly In United States hospitals and dialysis units

1.

• CLABSI are associated with an estimated mortality rate of 12.3%

2 and excess healthcare

costs between $7,288 and $29,156 per episode

3.

1. Srinivasan A, et al. MMWR 60: 2011 2. Umscheid CA, et al. Infect Control Hosp Epidemiol. 2011; 32:101-114. 3. Scott RD. Division of Healthcare Quality Promotion, CDC, 2009.

CVC Adverse Eventsin Out of Hospital Settings

• CLABSI rates in home settings range from 0.771 to 6.72 per 1,000 central line days.

• Thrombosis rates range from 0.063 to 1.354 per 1,000 central line days in pediatric and adolescent populations, as high as 9.3 in adults5.

1. Gorski, L. (2004). Jnl Infusion Nsg, 27(2), 104-111. 2.Tokars et al. (1999). Ann Int Med; 131: 340-7. 3. Pinon et al. (2009). European Jnl Ped; 168(12), 1505-12. 4.Revel-Villk, S., et al. (2010). Cancer, 116(17), 4197-4205. 5.Beckers, M.M. et al. (2009). Thrombosis Research; 125(4), 318-21.

HAI Prevention Outside Hospital

• Healthy People 2020– Prevent, reduce, and ultimately eliminate healthcare-

associated infections (HAIs)• Focuses on acute care, surgical centers, outpatient clinics

• National Action Plan to Prevent HAI: Roadmap to Elimination, 2009

1

– Phase II (Draft April, 2012) extends to ASC, outpatient dialysis

– Phase III (Draft July, 2012) extends to long term care1. Department of Health and Human Services, rev. 2012

Ambulatory Care HAI Prevention Aims

1

• Proactive HAI prevention at the clinic level• Increase education and training in HAI prevention

for providers, as well as patients and families• Sustain and expand improvements in oversight and

monitoring• Develop meaningful HAI surveillance and reporting

procedures

1. Department of Health and Human Services, rev. 2012. National Action Plan to Prevent HAI: Roadmap to Elimination.

"Measurement is the first step that leads to control and eventually to improvement. If you can't measure something, you can't understand it. If you can't understand it, you can't control it. If you can't control it, you can't improve it."

- H. James Harrington

Central Venous Catheter Use Outside the Hospital

• Deficiencies with tracking patients who leave hospital with CVC

• No national surveillance mechanism to monitor CVC-related outcomes in home health or non-acute long term care

“Whenever you can, count.”

- Sir Francis Galton

The Nebraska Medical Center*

Inpatient Total = 5264 % Total

Medicare 2367 45%

Medicaid 777 15%

Other insurance/ self pay 1913 37%

Outpatient Total = 1105 % Total

Medicare 368 33%

Medicaid 91 8%

Other insurance / self pay 646 58%

CVC Procedure Volumes

*7/1/10-7/31/12. Excludes repair and replacement procedures.

Dismissed from Hospital with CVC

The Nebraska Medical Center

Outpatient procedure

2010-2012* 1258*

Avg/month 50.3

Avg/day 1.67

CVC Replacements only 153

Avg/month 6.12

* CVC insertions and replacements 7/1/10-7/31/12.

Standardizing Central Venous Catheter Care in the Outpatient

Realm: Care from Hospital to Home

(SCORCH)

SCORCH Surveillance System

• Engage stakeholders• Describe system• Gather evidence of system’s performance• Lessons learned – ensure use of findings• Conclusions/recommendations

CDC. Updated guidelines for evaluating public health surveillance systems: Recommendations from the guidelines working group . MMWR 2001; 50 (RR13); 1-35.

Engaging Stakeholders• Six Omaha area home health/home infusion

agencies– Consensus building sessions May-November, 2011

• Developed guidelines to standardize CVC care– National Guidelines Clearinghouse

– The Nebraska Medical Center website: http://www.nebraskamed.com/central-line-care

– Surveillance data• Monthly since January 2012• 2011 data to serve as baseline• June 2012 revised data

– More granular analyses

“A public health surveillance system can…be useful if it helps to determine that an adverse health-related event previously thought to be unimportant is actually important” (CDC, 2001).

Public Health Importance of Surveillance System

• Delayed treatment• Costs• Hospital admissions/readmissions• Preventability

– Standardizing care in out of hospital settings

Admissions/Readmissions with CLABSI POA

Year The Nebraska Medical Center

89 UHC Hospitals

FY 2010 232 10,824

*Readmission w/CLABSI POA (rate)

44 (19%) 1692

FY 2011 189 9939

*Readmission w/CLABSI POA

32 (17%) 1354

FY 2012 95 5479

*Readmission w/CLABSI POA

9 (9%) 704

Data source: University Healthsystems Consortium, 10/11/12.

Purpose and Operation of System

Purpose• Monitor impact of

implementing standardized CVC care practices across the continuum of care– BSI and thrombosis rates

using standardized denominator data across HHA/HIA

Objectives• Quality improvement• Formation of research

hypotheses

Operation of System

• System resides at TNMC • Data use agreements to ensure data

confidentiality• System components

– Patients receiving CVC-related care from home health agency nurses

• CLABSI as defined by CDC that occur in patients 48 hours after admission to home care

• CVC occlusion events/use of fibrinolytic agents

"In God we trust,

all others bring data."

- W. Edwards

Deming

Data Elements

• Pediatric (18 and younger) and adult (19 and older)• # of patients on service with CVC in place – receiving CVC care

from agency• Central line (CL) device days• CL-associated blood stream infection count

– Type of CVC*

– # lumens*

• CL line occlusion event count– Type of CVC*

– # lumens*

• # of doses of a fibrinolytic used to dissolve line thromboses• # of patients who received a fibrinolytic to dissolve line thromboses

* Added these more granular data after Q1 reports disseminated

Operation of System

• Data imported into Excel spreadsheet for descriptive analyses• BSI rate/1,000 device days• Occlusion rate/1,000 device days• Ratio of fibrinolytic doses/occlusion event

• Quarterly benchmarking reports• Agency performance compared to aggregated mean• No agency identifiers are exchanged

  Q1 12 Q2 12 Q3 12 Q4 12 4 Qtr Avg

Number Patients on Service with CVC Age <19

118 102 132 134 121.50

Number Pediatric Central Line Days

3061 2547 3415 3614 3159.25

Number Pediatric CLABSI 2 3 0 0 1.25

Number Occlusion Events in Pediatric Patients

5 1 5 8 4.75

Number Pediatric Patients Receiving Fibrinolytic Agent

5 1 5 7 4.50

Number Doses Fibrinolytic Agent given to Pediatric Patients

5 1 5 6 4.25

# of Reporting Agencies 5 5 5 5 5

Table P1. Pediatric Central Line Days, Adverse Events and Use of Fibrinolytic Agents

 Q1 12 Q2 12 Q3 12 Q4 12 4 Qtr Avg

Number Patients on Service with CVC Age >19

499 545 660 687 597.75

Number Adult Central Line Days

9119 10474 12605 13501 11424.75

Number Adult CLABSI 1 3 2 2 2.00

Number Occlusion Events in Adult Patients

58 48 54 59 54.75

Number Adult Patients Receiving Fibrinolytic Agent

48 41 45 45 44.75

Number Doses Fibrinolytic Agent given to Adult Patients

96 61 76 77 77.50

# of Reporting Agencies 5 5 5 5 5

Table A1. Adult Central Line Days, Adverse Events and Use of Fibrinolytic Agents

  Q1 12 Q2 12 Q3 12 Q4 12 4 Qtr Avg

Agency A 1.06 0.63 0.00 0.00 0.42

Agency B 0.00No

pediatric pts 

No pediatric

pts 0.00 0.00

Agency C 0.00No

pediatric pts 

No pediatric

pts 

No pediatric

pts 0.00

Agency D 0.00No

pediatric pts 

No pediatric

pts 

No pediatric

pts 0.00

Agency E 0.00 2.11 0.00 0.00 0.53

Database Aggregate Mean 0.65 1.18 0.00 0.00 0.46

# of Reporting Agencies 5 5 5 5 5

Table P2. Pediatric Central Line Associated Blood Stream Infections per 1,000 Central Line Days

  Q1 12 Q2 12 Q3 12 Q4 12 4 Qtr Avg

Agency A 0.00 0.00 0.80 0.62 0.36

Agency B 0.00 0.00 0.00 0.00 0.00

Agency C 0.00 0.00 0.00 2.35 0.59

Agency D 0.72 0.00 0.35 0.00 0.27

Agency E 0.00 0.50 0.00 0.00 0.12

Database Aggregate Mean 0.11 0.29 0.16 0.15 0.18

# of Reporting Agencies 5 5 5 5 5

Table A2. Adult Central Line Associated Blood Stream Infections per 1,000 Central Line Days

  Q1 12 Q2 12 Q3 12 Q4 12 4 Qtr Avg

Agency A 2.64 0.63 2.36 2.23 1.96

Agency B 0.00 No pediatric pts 

No pediatric pts  29.41 14.71

Agency C 0.00 No pediatric pts 

No pediatric pts 

No pediatric pts  0.00

Agency D 0.00 No pediatric pts 

No pediatric pts 

No pediatric pts  0.00

Agency E 0.00 0.00 0.00 1.49 0.37

Database Aggregate Mean 1.63 0.39 1.46 2.21 1.43

# of Reporting Agencies 5 5 5 5 5

Table P3. Pediatric Central Line Occlusion Rateper 1,000 Central Line Days

  Q1 12 Q2 12 Q3 12 Q4 12 4 Qtr Avg

Agency A 36.36 30.57 25.74 22.22 28.73

Agency B 22.49 20.54 12.53 9.69 16.31

Agency C 2.38 0.00 1.35 0.00 0.93

Agency D 0.72 0.00 0.35 0.77 0.46

Agency E 1.84 1.82 0.91 1.54 1.53

Database Aggregate Mean

6.36 4.58 4.28 4.37 4.90

# of Reporting Agencies 5 5 5 5 5

Table A3. Adult Central Line Occlusion Rate per 1,000 Central Line Days

Pediatric Patient Data Q1 12 Adjusted and Unadjusted

 

Q1 12 Unadjusted

Pediatric Patients on Service with

CVC

Q1 12 Unadjusted

Pediatric Central Line

Days

Q1 12 AdjustedPediatric

Patients on Service with

CVC

Q1 12 AdjustedPediatric

Central Line Days

Total All Agencies

295 8440 118 3061

Agency A 45 1090 45 1090

Agency B 2 49 2 49

Agency C 1 6 1 6

Agency D 246 7272 69 1893Agency E 1 23 1 23

 

Q1 12 Unadjusted

Adult Patients on Service with

CVC

Q1 12 Unadjusted

Adult Central Line

Days

Q1 12Adjusted

Adult Patients on Service with

CVC

Q1 12 Adjusted

Adult Central Line

Days

Total All Agencies

863 21064 499 9119

Agency A 368 9662 52 578

Agency B 53 840 53 840

Agency C 54 880 54 880

Agency D 144 4253 96 1392

Agency E 244 5429 244 5429

Adult Patient Data Q1 12 Adjusted and Unadjusted

Resources to Operate System• First year supported in part by grant from Cardinal Health

Foundation• In-kind support provided by stakeholders:

– The Nebraska Medical Center - Clinical nurse researcher, Department of Nursing Research and Quality Outcomes

• ~ 6 - 8 hours/quarter

– University of Nebraska Medical Center – Director Infection Control and Epidemiology

• Co-Lead/Consultant ~1- 2 hours/quarter

– Omaha region home health agency personnel• Monthly data submission

– 1 - 2 hours/month (Manual versus automated)

• Other resources– Telephone, computer, Internet connections,

hardware and software maintenance

Data Management ResourcesData

Collection Process /

# Individuals Involved

How are Events Identified? Data Validation Hours per MonthOcclusion

countBSI

count

Agency A Manual, 1 person

Rx report Chart review Self, weekly manual review of all cases

2

Agency B Manual2 persons

Rx report Chart review Self, manual review of medical record

2-3

Agency C Manual, 1 person

Rx report RN reports Self, clarify with RN, Rx

1.5 – 2

Agency D Manual, 1 person

Rx report Infection Control

Self, manual review 2

Agency E Automated, 2-3 persons

Rx report Weekly case conference

Self, manual review 2

Agency F Automated, 1 person

Rx report Event report in IT system

Self, daily morning meeting all cases

1-1.5

Evaluating SCORCH Surveillance System

• Data elements refined after Q1 2012 reports– Events tracked by CVC device type and # lumens– Clarified data for patients receiving agency RN care– Ratio of occlusions to fibrinolytic doses given

» Were non-occluded lumens being treated?

– Consensus that all use CDC BSI definition» Communication gaps in knowing BSI occurred

• Generated list of patient-centered research ideas

 Q1 12 Q2 12 Q3 12 Q4 12 4 Qtr

AvgNumber Patients on Service with CVC Age >19

499 545 660 687 522

Number Adult Central Line Days

9119 10474

12605 13501 9796.5

Number Adult CLABSI 1 3 2 2 2.00Number Occlusion Events in Adult Patients

58 48 54 59 53.00

Number Adult Patients Receiving Fibrinolytic Agent

48 41 45 45 44.50

Number Doses Fibrinolytic Agent given to Adult Patients

96 61 76 77 78.50

# of Reporting Agencies 5 5 5 5 5

Table A1. Adult Central Line Days, Occlusion Events and Use of Fibrinolytic Agents

1 agency with 32 occlusions (55%) Q1

21 patients (44%)

48 doses (50%)

Same agency with 36 occlusions (61%) Q4

23 patients (51%) Q4

45 doses (58%) Q4

“Surveillance for outcome measures in ambulatory care settings is challenging because patient encounters may be brief or sporadic and evaluation and treatment of consequent infections may involve different healthcare settings (e.g., hospitals)”

CDC. Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care, 2012, p. 7.

Conclusions and Recommendations

• Home health outcomes are measurable– Develop system of data validation

• Lab data• Claims data• Communication system from receiving hospital to HHA

when CLABSI present on admit

• Focus in on specifics of CVC care to better drive QI– Agency use of reports

• Continue monitoring use of standardized care guidelines

“When you are face to face

with a difficulty,

you are up against

a discovery.”

- Lord Kelvin, British physicist

Next Steps

• Extramural funding – Refine/further develop surveillance system

» BSI rate/1,000 device days by device type» Patient demographics

– Capture in real time hospital admissions/ readmissions attributed to BSI

• Close loop/communicate BSI to HHA/HIA

Next Steps

• Patient-centered outcomes research

• Collaborate with 3rd party payer, HHA/HIA, ambulatory/outpatient clinic providers

• Infection control practices• Reporting structures• Clinician CVC-related behaviors/competencies

Next Steps

• Complete production of patient education DVD aimed at empowering patients to understand what CVC care should look like

• Complete patient-focused study, “Day in the Life of a Line”– 14-day diary of who/when/where/why CVC care is

being provided

Next Steps

• Extend surveillance to long term care settings– CLABSI– CAUTI

• Admissions / readmissions• Standardize urinary catheter care

Questions?