Piloting HAI Data Collection in Maryland Long Term Care Facilities: Successes and Challenges...

Piloting HAI Data Collection in Maryland Long Term Care Facilities:

Successes and Challenges

Elisabeth Vaeth, MPHEpidemiologist, Emerging Infections Program

Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration

MISSION AND VISIONMISSION AND VISION

MISSION• The mission of the Prevention and Health Promotion Administration is

to protect, promote and improve the health and well-being of all Marylanders and their families through provision of public health leadership and through community-based public health efforts in partnership with local health departments, providers, community based organizations, and public and private sector agencies, giving special attention to at-risk and vulnerable populations.

VISION• The Prevention and Health Promotion Administration envisions a future in

which all Marylanders and their families enjoy optimal health and well-being.

Prevention and Health Promotion AdministrationJune 10, 2013

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EIP PISToL Project

• Pilot of Infection Surveillance Tools for Long Term Care Facilities

• 2012 EIP project to pilot new NHSN component


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EIP PISToL Project

• Designed for LTC

• UTI and Lab-ID CDI

• Voluntary recruitment

• Never been done before…


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• Recruited from:– Local LTC APIC chapter meeting

– Networking with LTC corporate contacts

• 8 willing facilities– 6 agree to both modules– 1 UTI only, 1 CDI only

MD’s Guinea Pig LTCFs


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MD LTCF Facility Characteristics

• All for-profit, chain LTCFs

• Sizes: 62 beds to 192 beds

• Two with vent units

• Baseline hours devoted to infection prevention/control: 10-24*

• All send out lab tests*

• Two with EMR*

* For 5 facilities completing facility surveys


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• Identify surveillance coordinator (S.C.)• Facility Survey• CDC training webinars• Standardized surveillance: UTI events and

Lab-ID CDI events• Denominator data

– Resident-Days, Urinary Catheter-Days, and New Admissions

PISToL Activities


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• Time Logs

• Monthly data submission

• Post-pilot survey

• Post-pilot feedback conference call

PISToL Activities


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Case Definitions: UTISUTI

(Symptomatic Urinary Tract Infection)

Either of the following1.Acute dysuria2.Acute pain, swelling or tenderness of the testes, epididymis or prostate

1. Fever or Leukocytosis ANDAny ONE of the following: Costovertebral angle pain

or tenderness Suprapubic pain Gross hematuria New or marked increase in

incontinence New or marked increase in

urgency New or marked increase in

frequency

Any TWO of the following: Costovertebral angle pain or

tenderness Suprapubic pain Gross hematuria New or marked increase in

incontinence New or marked increase in

urgency New or marked increase in

frequency

A voided urine culture with 105 cfu/ml of no more than 2 species of microorganisms or a specimen collected by in and out catheter specimen with 102 cfu/ml of any number of organisms

SUTI – Criteria 1a SUTI – Criteria 2a SUTI – Criteria 3a

SUTIPrevention and Health Promotion Administration

June 10, 20139

Case Definitions: UTICA-SUTI

(Catheter-Associated Symptomatic UTI)

At least ONE of the following with no alternate source:

Fever or rigors OR new onset hypotension, with no alternate site of infection.

Any acute functional decline or mental status change AND leukocytosis

New costovertebral angle pain or tenderness New suprapubic pain Acute pain, swelling or tenderness of the testes,

epididymis or prostate Purulent discharge from around the catheter

A urine culture with 105 cfu/ml of any organism(s), collected following placement of a new catheter if current catheter has been in place >14 days

SUTI – Criteria 1b

CA-SUTI


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Case Definitions: UTIABUTI

(Asymptomatic Bacteremic UTI)Resident has no localizing urinary signs or symptoms (i.e., no urgency, frequency, acute

dysuria, suprapubic tenderness, or costovertebral angle pain or tenderness). If no catheter is in place, fever alone would not exclude ABUTI if other criteria are met.

A positive urine culture with 105 cfu/ml of no more than 2 species of microorganisms, or a specimen collected by in and out catheter specimen with 102 cfu/ml of any number of organisms

AND

ABUTI

AND

A positive blood culture with at least 1 matching uropathogen microorganism to the urine culture.


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Case Definitions: Lab-ID CDI

CDI-positive laboratory assay: A positive result for a laboratory assay for C. difficile toxin A and/or B, OR a toxin-producing C. difficile organism detected in the stool sample by culture or other laboratory means

– Incident CDI Assay: Any LabID Event from a specimen obtained > 8 weeks after the most recent LabID Event (or with no previous LabID Event documented).

– Recurrent CDI Assay: Any LabID Event from a specimen obtained > 2 weeks and ≤ 8 weeks after the most recent LabID

Event for that resident. Prevention and Health Promotion Administration

June 10, 201312

Surveillance Forms

• Forms also collect– Demographic info on patient– Infection risk factors– Catheter status (UTI only)– Associated hospitalization (UTI only)– 30-day outcome (UTI only)– Antibiotic susceptibilities (UTI only)


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Prevention and Health

Promotion AdministrationJune 10, 2013

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Prevention and Health

Promotion AdministrationJune 10, 2013

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Great, begin on March 1, 2012!

Simple enough…?


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• Not everyone completes training webinars…– But recorded versions distributed

• Emails seem to enter a black hole…– But after repeat phone calls, everyone

says they’re ready to start

A few early challenges…


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Month 1: March


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Definition confusion– Paper forms offer ALL possible UTI signs

and symptoms– Surveillance coordinators over-identify UTI

events– BUT, Lab-ID CDI event identification is a

success

March Madness


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Month 2: April


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Month 3: May


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Month 4: June


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Final Tally

• Four facilities complete three months of surveillance– Three UTI & CDI– One UTI only

• One facility completes one month of surveillance– UTI & CDI


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March(n=2)

April(n=4)

May(n=4)

June(n=2)

Total

Total UTI events reported15 20 26 20 81

Total UTI events that met surveillance definitions

14 10 12 6 42

• Total SUTI 11 6 8 3 28

• Total CA-SUTI 3 4 4 3 14

• Total ABUTI 0 0 0 0 0

Summary Stats:Event Breakdown by Month

*Data from 4 facilities completing 3 months of surveillancePrevention and Health Promotion Administration

June 10, 201324

March(n=2)

April(n=3)

May(n=3)

June(n=2)

Total

Total Lab-ID CDI events reported

5 2 4 2 13

Total Lab-ID CDI events that met surveillance definition

5 2 4 2 13

Summary Stats:CDI Event Breakdown by Month


June 10, 201325

Summary StatsReported Events vs. Events Meeting Surveillance Definition


June 10, 201326

Denominators• Not collected as instructed in protocol (daily

counts)• Monthly resident-days

– Ranged from 1,750 (62 bed-facility) to 5,272 (192 bed-facility)

• Monthly urinary catheter-days – Ranged from 30* (150 bed-facility) to 525 (192 bed-

facility)

• Monthly resident admissions– Ranged from 0 (155 bed-facility) to 60 (152 bed-facility)

* Possible data collection error


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Prevention and Health Promotion

AdministrationJune 10, 2013

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Time Spent on Surveillance

• Logs sporadically completed (received 7 total over course of surveillance period)

• Reports for combined UTI/CDI surveillance time per month ranged from 4 hours to 18 hours

• When completed, showed that surveillance not occurring daily– Often mostly on one day near end of month


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Validation: Activities and Goals

• Five main validation activities– UTI event chart reviews– Stool culture reviews– Urine culture reviews– Review of CDI antibiotic starts– Review of UTI antibiotic starts

• Interview S.C.’s on denominator collection practices

• Completed at 3 facilitiesPrevention and Health Promotion Administration

June 10, 201330

Validation: Process and Conclusions

• Challenging chart reviews– Signs and symptoms not always noted in chart– Many discrepancies

• Challenging lab and pharmacy reviews– Matching cultures to starts– Lack of indications

• Take home: Data sources available but not as useful as hoped


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PISToL: Lessons Learned

• Infection prevention in LTCF– Not like acute care!– Often one IP who wears many hats

• Long protocols will not be read

– Very wide range of knowledge/experience– Standardized surveillance not the routine– Computer access and know-how not a

given


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PISToL: Lessons Learned

However…– NHSN LTC component launched September

14, 2012• will guide event identification

– CMS may require HAI reporting in LTCFs in the future…

• Administrators will have to hire more and better-skilled IP staff

• Standardized surveillance will hopefully become routine


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Thank you!

• Katie Richards, DHMH

• Lucy Wilson, DHMH

• David Blythe, DHMH

• Pat Ryan, DHMH

• Brenda Roup, DHMH

• Ruth Belflower, CDC

• Nicola Thompson, CDC

• Nimalie Stone, CDC

• Anonymous Maryland

PISToL S.C.’s!


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Prevention and Health Promotion Administration

Questions?


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Piloting HAI Data Collection in Maryland Long Term Care Facilities: Successes and Challenges...

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