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Challenges in Adherence with National Healthcare Safety Network Definitions: A Central Line-Associated Bloodstream Infection Conundrum
e56
Poster Abstracts / American Journal of Infection Control 40 (2012) e31-e176
Presentation Number 4-042 Total Burden Assessment of Surgical Site Infections in Initial Admissions and Readmissions Using National Administrative Claims Data Anuprita Patkar, Associate Director, Health Economics & Reimbursement, Ethicon, Johnson & Johnson Global Surgery Group; Dr. Somesh Nigam, VP, Healthcare, Johnson and Johnson Corporate; Dr. Mehmet Daskiran, Statistical Analyst, Johnson and Johnson Corporate; Mr. Ronald Levine, Statistician Level III, Johnson and Johnson Corporate; Mr. Scott Wolven, Associate Director Reimbursement, Ethicon, J&J; Dr. Sashi Yadalam, Statistical Analyst, Johnson and Johnson Corporate Background/Objectives: Surgical site infections (SSIs) have a significant negative impact on hospital reimbursement and clinical outcomes. This study quantifies the incidence and economic burden of SSIs in 6 selected surgical categories as an aggregate. Uniquely, this investigation focuses on the impact of patients having SSI in their initial admission with downstream outcomes, including readmission counts, payments and total length of stay (LOS) to assess the complete consequences of SSI, not just a single episode of care. Methods: Patients were drawn from the Thomson Medstat MarketscanÒ Database, a national administrative database that longitudinally tracks commercial claims data from nearly 150 million patients since 1995. The economic impact of SSI was evaluated in selected 6 high-volume surgery specialties specified by ICD9-CM procedure code (cardiac, general, orthopedic, neurological, plastic and ob-gyn) during the period January 2007 to December 2009. Patients qualified if they had no prior surgeries in a 90-day look back period. Subsequently, each patient was observed for readmissions in a 90-day look forward period. Patients developing infections during their index admission were defined by ICD-9-CM codes 998.5x, 998.66 and 998.67 as their secondary diagnosis; patients developing one or more SSI's during their readmissions were defined by the same codes identified as their primary readmission diagnoses. The total burden of SSI was assessed by evaluating differences in LOS and provider payments relative to patients with no SSI: 1) during the initial admission for patients experiencing SSI; (2) during the 90-day post surgery for patients who had developed SSI in their initial admission; and 3) in patients developing SSI in their 90-day post-operative period. Generalized Linear Models adjusting for patient age, gender, region and diabetes were used to compute mean differences and 95% confidence intervals. A constant sample based on the index procedure census was used for all three analyses to maintain a consistent denominator. Results: Patients developing SSI as a complication of index surgery incur an additional LOS of 6.86 days (95% CI: 6.71-7.02 days) and $20,288 (95% CI: $19,369-$21,206) of extra payments. Patients during the 90-day post surgery period who had developed SSI in their initial admission are likely to have 0.21 more downstream readmissions (95% CI: 0.19-0.21), 1.94 days additional LOS (95% CI: 1.81-2.08) and $5,549 additional payments (95% CI: $5,106-$5,993). Patients developing SSI at any time during their 90-day postoperative period are at risk of 1.3 additional readmissions, and incur an average additional LOS of 8.37 days (95% CI: 8.26-8.47) and $25,436 (95% CI: $25,094-$25,779) in additional payments. Conclusions: SSI increases current and downstream burdens by a factor of 3 to 10 times in terms of readmission rates, and additional length of stay and payments. Appreciation of its impact
emphasizes the importance of control and prevention of this surgical complication.
Presentation Number 4-043 Challenges in Adherence with National Healthcare Safety Network Definitions: A Central LineAssociated Bloodstream Infection Conundrum Teresa Chou MPH, CIC, Manager, Infection Control and Epidemiology, Advocate Illinois Masonic Medical Center; Mr. James Kerridge MA, RN, CIC, Infection Preventionist, Advocate Illinois Masonic Medical Center; Ms. Katie Wickman MS, RN, Infection Preventionist, Advocate Illinois Masonic Medical Center; Dr. Mandavi Kulkarni MD, Infectious Disease Attending, Advocate Illinois Masonic Medical Center; Dr. James Malow MD, FIDSA, Chairman Internal Medicine, Chairman Infection Prevention Committee, Medical Director Advocate Healthcare Infection Prevention Team, Advocate Illinois Masonic Medical Center Issue: The Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) has standardized definitions for healthcare-associated infections including central line associatedbloodstream infections (CLABSI) and pneumonia (PNU). In conjunction with the Center for Medicare and Medicaid Services (CMS), the State of Illinois requires hospitals to report CLABSIs using NHSN. Last year, Illinois began conducting audits of CLABSI data to validate adherence with NHSN definitions. Adherence with these definitions may not always concur with clinical diagnoses. The following case demonstrates the conundrum. Project: A 67-year-old male patient with multiple co-morbidities was admitted on October 14, 2011, with dyspnea, fever, and peritoneal dialysis catheter malfunction. On admission, laboratory tests showed leukocytosis and computer tomography of the lungs revealed bilateral infiltrates and multiple nodules. A bronchoalveolar lavage (BAL) culture on October 19 grew few Klebsiella pneumoniae and many yeast, not Cryptococcus. The patient did not respond to antibiotics or high dose steroids. Initial blood cultures were negative. Blood cultures obtained on October 28 from a peripheral site and a central line grew C. neoformans. At the time, he had 2 central lines (dialysis, peripherally inserted) and an arterial line. He expired on October 29; no autopsy was performed. To determine if the patient had a CLABSI, NHSN definitions were reviewed, pulmonologists and infectious disease physicians evaluated the patient, a literature search for CLABSIs associated with Cryptococcus was conducted, and NHSN was consulted. Results: Although the patient exhibited signs and symptoms of pneumonia, it did not appear that the PNU2 definition was met; Cryptococcus was isolated from blood 15 days after admission. The case met the CLABSI criteria 1 definition: the patient had central lines, no Cryptococcus was isolated from the BAL culture, admission blood cultures were negative and the pathogen was isolated from blood during hospitalization. A NHSN nurse consultant advised adherence with definitions but did not specify the infected site. Since imaging revealed infiltrates and lung nodules, 2 pulmonologists and 3 infectious disease physicians stated that the bacteremia was secondary to the pneumonia, not a CLABSI. Cryptococcus is not easily isolated from a BAL, and the nodules were not biopsied (preferred method). Furthermore, the BAL was obtained many days before the patient developed bacteremia. Only 1 cryptococcal CLABSI case has been reported in the literature; the patient was on chronic hemodialysis and had no other sites of infection.
APIC 39th Annual Educational Conference & International Meeting j San Antonio, TX j June 4-6, 2012
Poster Abstracts / American Journal of Infection Control 40 (2012) e31-e176
Lesson Learned: The CLABSI definitions leave no room for clinical interpretation. Hospitals are left in a quandary as whether to adhere to the clinical diagnosis or NHSN definitions. If the CLABSI definition is met and not reported, the hospital risks being cited. We support Sexton, Chen and Anderson's recommendation to revise the definitions and create an indeterminate category.
Presentation Number 4-044 Shared Successes For Surgical Site Infection Reduction: Utilization of CHG-impregnated Cloths as an Adjunct to the Pre-op Shower Linda Miller RN, CIC, Manager, Infection Prevention & Control, Methodist Charlton Medical Center; Ms. Mary A. Fulton RN, BSN, CIC, Infection Prevention Practitioner, Methodist Charlton Medical Center; Dr. Zakir Hussain A. Shaikh MD, MPH, FIDSA, FSHEA, CPE, CMSL, Medical Director and Hospital Epidemiologist, Methodist Heath System of Dallas Issue: Surgical site infections (SSI) increase hospital costs and length of stay as well as adversely impact patient mortality. Reduction efforts have focused on implementation of a set of measures as part of the Surgical Care Improvement Project (SCIP), evidence-based practices that are well documented as a successful reduction strategy. Our facility is a 305-bed, acute care, nonteaching community hospital serving an inner-city population. After intensive implementation of the SCIP measures and compliance monitoring, it was determined that SSI reduction efforts for laminectomy cases could be further enhanced. Project: In early October 2009 the effectiveness of the pre-op CHG shower program was assessed. The existing process, in place for five years, included supplying patients with a CHG product and written/ verbal instructions for showering the night before and the morning of surgery, paying special attention to the surgical area. As part of the SSI reduction strategy, Infection Prevention recommended implementation of a concentrated pre-op wash of the back using the CHG-impregnated cloths in pre-operative holding. All SCIP measures continued as previously implemented and no other variables were changed during the next 12 months. Given consistent success of the new process for laminectomy procedures over a one-year period, the program was expanded to include orthopedic surgeries. Beginning October 2010, the use of the CHGimpregnated cloths in the pre-op holding area was implemented for knee and hip total joint replacement procedures. Results: During FY 2007-09, the combined mean SSI rate for laminectomy procedures was 3.5/100 procedures. Following implementation of the CHG impregnated cloth pre-op wash in October 2009, no additional laminectomy SSI have been identified. The 100% reduction in SSI rate as compared to the previous three years is statistically significant [p value¼0.017]. During FY 2007-10, the combined mean SSI rate for knee and hip total joint replacement SSI was 1.7/100 procedures. Following implementation of the CHG cloth pre-op wash in this population, the decrease in SSI rate for these procedures was noted to be statistically significant [p value ¼ 0.013]. Lesson Learned: Implementation of CHG-impregnated cloths as a pre-op wash applied directly to the operative site as an adjunct to the traditional pre-op CHG shower has been successful in eliminating laminectomy SSI. Expansion of this process to include orthopedic procedures resulted in a significant decrease in knee and hip total joint SSIs. Our sustained success with SSI reduction
e57
supports the practice of a pre-op wash utilizing CHG-impregnated cloths as an adjunct to the traditional pre-op surgical shower, and demonstrates the value of sharing our learning and success beyond the initial implementation group.
Presentation Number 4-045 Micro-Patterned Surfaces for Reducing Platelet Adhesion and Bacterial Attachment Associated With Catheter-Associated Blood Stream Infections Rhea May PhD, Microbial Research Associate, Sharklet Technologies, Inc.; Mr. Matthew G. Hoffman, Microbial Research Associate, Sharklet Technologies Inc; Dr. Shravanthi T. Reddy, Director of Research, Sharklet Technologies Inc Background/Objectives: Central venous catheters (CVCs) are responsible for approximately 90% of all catheter-related bloodstream infections (CRBSIs). The resulting 300,000 infections, commonly caused by Staphylococcus aureus and Staphylococcus epidermidis, are associated with as many as 28,000 deaths per year in America alone. CRBSIs prolong hospital stays, induce human suffering, and magnify healthcare costs (up to $2.68 billion). Infection is four times more likely to occur in patients with catheter-related thrombosis (CRT), and up to 67% of patients with CVC develop CRT. A common strategy used to prevent CRBSIs has been to impregnate CVCs with antimicrobial agents to control microbial colonization, and heparin coatings to prevent CRT. These strategies can be limited by the short duration of efficacy and the potential for contributing to antimicrobial resistance and heparin induced safety concerns. A novel micro-topography (Figure 1, bottom panels) may provide an alternative strategy as it has been shown to reduce bacterial attachment and biofilm formation without the use of antimicrobial agents. This biomimetic micro-pattern also inhibits bacterial migration, offering the possibility of reducing bacterial access into the bloodstream via the CVC. The objectives of this study were to determine the performance of the micro-pattern in reducing S. aureus attachment after whole blood pre-conditioning and to evaluate the innate anti-fouling properties the pattern may
Fig 1. Scanning electron micrographs of two un-patterned replicates (top) and two micro-patterned replicates (bottom) after exposure to highly concentrated platelet rich plasma. The micro-patterned samples retain visibly fewer platelets on the surface. Using Image J area coverage analysis, the reduction in platelet area coverage is 90%, p<0.00001 compared to the un-patterned surface..
APIC 39th Annual Educational Conference & International Meeting j San Antonio, TX j June 4-6, 2012
Poster Abstracts / American Journal of Infection Control 40 (2012) e31-e176
Presentation Number 4-042 Total Burden Assessment of Surgical Site Infections in Initial Admissions and Readmissions Using National Administrative Claims Data Anuprita Patkar, Associate Director, Health Economics & Reimbursement, Ethicon, Johnson & Johnson Global Surgery Group; Dr. Somesh Nigam, VP, Healthcare, Johnson and Johnson Corporate; Dr. Mehmet Daskiran, Statistical Analyst, Johnson and Johnson Corporate; Mr. Ronald Levine, Statistician Level III, Johnson and Johnson Corporate; Mr. Scott Wolven, Associate Director Reimbursement, Ethicon, J&J; Dr. Sashi Yadalam, Statistical Analyst, Johnson and Johnson Corporate Background/Objectives: Surgical site infections (SSIs) have a significant negative impact on hospital reimbursement and clinical outcomes. This study quantifies the incidence and economic burden of SSIs in 6 selected surgical categories as an aggregate. Uniquely, this investigation focuses on the impact of patients having SSI in their initial admission with downstream outcomes, including readmission counts, payments and total length of stay (LOS) to assess the complete consequences of SSI, not just a single episode of care. Methods: Patients were drawn from the Thomson Medstat MarketscanÒ Database, a national administrative database that longitudinally tracks commercial claims data from nearly 150 million patients since 1995. The economic impact of SSI was evaluated in selected 6 high-volume surgery specialties specified by ICD9-CM procedure code (cardiac, general, orthopedic, neurological, plastic and ob-gyn) during the period January 2007 to December 2009. Patients qualified if they had no prior surgeries in a 90-day look back period. Subsequently, each patient was observed for readmissions in a 90-day look forward period. Patients developing infections during their index admission were defined by ICD-9-CM codes 998.5x, 998.66 and 998.67 as their secondary diagnosis; patients developing one or more SSI's during their readmissions were defined by the same codes identified as their primary readmission diagnoses. The total burden of SSI was assessed by evaluating differences in LOS and provider payments relative to patients with no SSI: 1) during the initial admission for patients experiencing SSI; (2) during the 90-day post surgery for patients who had developed SSI in their initial admission; and 3) in patients developing SSI in their 90-day post-operative period. Generalized Linear Models adjusting for patient age, gender, region and diabetes were used to compute mean differences and 95% confidence intervals. A constant sample based on the index procedure census was used for all three analyses to maintain a consistent denominator. Results: Patients developing SSI as a complication of index surgery incur an additional LOS of 6.86 days (95% CI: 6.71-7.02 days) and $20,288 (95% CI: $19,369-$21,206) of extra payments. Patients during the 90-day post surgery period who had developed SSI in their initial admission are likely to have 0.21 more downstream readmissions (95% CI: 0.19-0.21), 1.94 days additional LOS (95% CI: 1.81-2.08) and $5,549 additional payments (95% CI: $5,106-$5,993). Patients developing SSI at any time during their 90-day postoperative period are at risk of 1.3 additional readmissions, and incur an average additional LOS of 8.37 days (95% CI: 8.26-8.47) and $25,436 (95% CI: $25,094-$25,779) in additional payments. Conclusions: SSI increases current and downstream burdens by a factor of 3 to 10 times in terms of readmission rates, and additional length of stay and payments. Appreciation of its impact
emphasizes the importance of control and prevention of this surgical complication.
Presentation Number 4-043 Challenges in Adherence with National Healthcare Safety Network Definitions: A Central LineAssociated Bloodstream Infection Conundrum Teresa Chou MPH, CIC, Manager, Infection Control and Epidemiology, Advocate Illinois Masonic Medical Center; Mr. James Kerridge MA, RN, CIC, Infection Preventionist, Advocate Illinois Masonic Medical Center; Ms. Katie Wickman MS, RN, Infection Preventionist, Advocate Illinois Masonic Medical Center; Dr. Mandavi Kulkarni MD, Infectious Disease Attending, Advocate Illinois Masonic Medical Center; Dr. James Malow MD, FIDSA, Chairman Internal Medicine, Chairman Infection Prevention Committee, Medical Director Advocate Healthcare Infection Prevention Team, Advocate Illinois Masonic Medical Center Issue: The Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) has standardized definitions for healthcare-associated infections including central line associatedbloodstream infections (CLABSI) and pneumonia (PNU). In conjunction with the Center for Medicare and Medicaid Services (CMS), the State of Illinois requires hospitals to report CLABSIs using NHSN. Last year, Illinois began conducting audits of CLABSI data to validate adherence with NHSN definitions. Adherence with these definitions may not always concur with clinical diagnoses. The following case demonstrates the conundrum. Project: A 67-year-old male patient with multiple co-morbidities was admitted on October 14, 2011, with dyspnea, fever, and peritoneal dialysis catheter malfunction. On admission, laboratory tests showed leukocytosis and computer tomography of the lungs revealed bilateral infiltrates and multiple nodules. A bronchoalveolar lavage (BAL) culture on October 19 grew few Klebsiella pneumoniae and many yeast, not Cryptococcus. The patient did not respond to antibiotics or high dose steroids. Initial blood cultures were negative. Blood cultures obtained on October 28 from a peripheral site and a central line grew C. neoformans. At the time, he had 2 central lines (dialysis, peripherally inserted) and an arterial line. He expired on October 29; no autopsy was performed. To determine if the patient had a CLABSI, NHSN definitions were reviewed, pulmonologists and infectious disease physicians evaluated the patient, a literature search for CLABSIs associated with Cryptococcus was conducted, and NHSN was consulted. Results: Although the patient exhibited signs and symptoms of pneumonia, it did not appear that the PNU2 definition was met; Cryptococcus was isolated from blood 15 days after admission. The case met the CLABSI criteria 1 definition: the patient had central lines, no Cryptococcus was isolated from the BAL culture, admission blood cultures were negative and the pathogen was isolated from blood during hospitalization. A NHSN nurse consultant advised adherence with definitions but did not specify the infected site. Since imaging revealed infiltrates and lung nodules, 2 pulmonologists and 3 infectious disease physicians stated that the bacteremia was secondary to the pneumonia, not a CLABSI. Cryptococcus is not easily isolated from a BAL, and the nodules were not biopsied (preferred method). Furthermore, the BAL was obtained many days before the patient developed bacteremia. Only 1 cryptococcal CLABSI case has been reported in the literature; the patient was on chronic hemodialysis and had no other sites of infection.
APIC 39th Annual Educational Conference & International Meeting j San Antonio, TX j June 4-6, 2012
Poster Abstracts / American Journal of Infection Control 40 (2012) e31-e176
Lesson Learned: The CLABSI definitions leave no room for clinical interpretation. Hospitals are left in a quandary as whether to adhere to the clinical diagnosis or NHSN definitions. If the CLABSI definition is met and not reported, the hospital risks being cited. We support Sexton, Chen and Anderson's recommendation to revise the definitions and create an indeterminate category.
Presentation Number 4-044 Shared Successes For Surgical Site Infection Reduction: Utilization of CHG-impregnated Cloths as an Adjunct to the Pre-op Shower Linda Miller RN, CIC, Manager, Infection Prevention & Control, Methodist Charlton Medical Center; Ms. Mary A. Fulton RN, BSN, CIC, Infection Prevention Practitioner, Methodist Charlton Medical Center; Dr. Zakir Hussain A. Shaikh MD, MPH, FIDSA, FSHEA, CPE, CMSL, Medical Director and Hospital Epidemiologist, Methodist Heath System of Dallas Issue: Surgical site infections (SSI) increase hospital costs and length of stay as well as adversely impact patient mortality. Reduction efforts have focused on implementation of a set of measures as part of the Surgical Care Improvement Project (SCIP), evidence-based practices that are well documented as a successful reduction strategy. Our facility is a 305-bed, acute care, nonteaching community hospital serving an inner-city population. After intensive implementation of the SCIP measures and compliance monitoring, it was determined that SSI reduction efforts for laminectomy cases could be further enhanced. Project: In early October 2009 the effectiveness of the pre-op CHG shower program was assessed. The existing process, in place for five years, included supplying patients with a CHG product and written/ verbal instructions for showering the night before and the morning of surgery, paying special attention to the surgical area. As part of the SSI reduction strategy, Infection Prevention recommended implementation of a concentrated pre-op wash of the back using the CHG-impregnated cloths in pre-operative holding. All SCIP measures continued as previously implemented and no other variables were changed during the next 12 months. Given consistent success of the new process for laminectomy procedures over a one-year period, the program was expanded to include orthopedic surgeries. Beginning October 2010, the use of the CHGimpregnated cloths in the pre-op holding area was implemented for knee and hip total joint replacement procedures. Results: During FY 2007-09, the combined mean SSI rate for laminectomy procedures was 3.5/100 procedures. Following implementation of the CHG impregnated cloth pre-op wash in October 2009, no additional laminectomy SSI have been identified. The 100% reduction in SSI rate as compared to the previous three years is statistically significant [p value¼0.017]. During FY 2007-10, the combined mean SSI rate for knee and hip total joint replacement SSI was 1.7/100 procedures. Following implementation of the CHG cloth pre-op wash in this population, the decrease in SSI rate for these procedures was noted to be statistically significant [p value ¼ 0.013]. Lesson Learned: Implementation of CHG-impregnated cloths as a pre-op wash applied directly to the operative site as an adjunct to the traditional pre-op CHG shower has been successful in eliminating laminectomy SSI. Expansion of this process to include orthopedic procedures resulted in a significant decrease in knee and hip total joint SSIs. Our sustained success with SSI reduction
e57
supports the practice of a pre-op wash utilizing CHG-impregnated cloths as an adjunct to the traditional pre-op surgical shower, and demonstrates the value of sharing our learning and success beyond the initial implementation group.
Presentation Number 4-045 Micro-Patterned Surfaces for Reducing Platelet Adhesion and Bacterial Attachment Associated With Catheter-Associated Blood Stream Infections Rhea May PhD, Microbial Research Associate, Sharklet Technologies, Inc.; Mr. Matthew G. Hoffman, Microbial Research Associate, Sharklet Technologies Inc; Dr. Shravanthi T. Reddy, Director of Research, Sharklet Technologies Inc Background/Objectives: Central venous catheters (CVCs) are responsible for approximately 90% of all catheter-related bloodstream infections (CRBSIs). The resulting 300,000 infections, commonly caused by Staphylococcus aureus and Staphylococcus epidermidis, are associated with as many as 28,000 deaths per year in America alone. CRBSIs prolong hospital stays, induce human suffering, and magnify healthcare costs (up to $2.68 billion). Infection is four times more likely to occur in patients with catheter-related thrombosis (CRT), and up to 67% of patients with CVC develop CRT. A common strategy used to prevent CRBSIs has been to impregnate CVCs with antimicrobial agents to control microbial colonization, and heparin coatings to prevent CRT. These strategies can be limited by the short duration of efficacy and the potential for contributing to antimicrobial resistance and heparin induced safety concerns. A novel micro-topography (Figure 1, bottom panels) may provide an alternative strategy as it has been shown to reduce bacterial attachment and biofilm formation without the use of antimicrobial agents. This biomimetic micro-pattern also inhibits bacterial migration, offering the possibility of reducing bacterial access into the bloodstream via the CVC. The objectives of this study were to determine the performance of the micro-pattern in reducing S. aureus attachment after whole blood pre-conditioning and to evaluate the innate anti-fouling properties the pattern may
Fig 1. Scanning electron micrographs of two un-patterned replicates (top) and two micro-patterned replicates (bottom) after exposure to highly concentrated platelet rich plasma. The micro-patterned samples retain visibly fewer platelets on the surface. Using Image J area coverage analysis, the reduction in platelet area coverage is 90%, p<0.00001 compared to the un-patterned surface..
APIC 39th Annual Educational Conference & International Meeting j San Antonio, TX j June 4-6, 2012