Track­ing in­fec­tions with the CDC

Providers find CDC’S track­ing sys­tem for HAIS valu­able but bur­den­some

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En­roll­ment in the Cen­ters for Dis­ease Con­trol and Preven­tion’s Na­tional Health­care Safety Net­work, the fed­eral sys­tem for track­ing health­care-as­so­ci­ated in­fec­tions, has grown ex­po­nen­tially in re­cent years. The num­ber of fa­cil­i­ties re­port­ing to the NHSN has jumped from roughly 3,000 in 2010 to about 8,200 fa­cil­i­ties cur­rently, more than 4,000 of which are hos­pi­tals, ac­cord­ing to the CDC.

But among in­fec­tion pre­ven­tion­ists who are charged with col­lect­ing and sub­mit­ting the data to the net­work, there are some who say par­tic­i­pa­tion in the NHSN is bur­den­some and takes time away from other crit­i­cally im­por­tant du­ties, such as round­ing with nurses and spear­head­ing preven­tion ini­tia­tives.

Mau­reen Spencer, cor­po­rate in­fec­tion pre­ven­tion­ist for 134-hospi­tal Univer­sal Health Ser­vices, King of Prus­sia, Pa., says many of the health sys­tem’s in­fec­tion pre­ven­tion­ists are “ba­si­cally chained to their desks” in or­der to meet the NHSN’S manda­tory re­port­ing re­quire­ments.

“They don’t have the re­sources and the time to do the things they need to do be­cause they’re spend­ing so many hours each day on NHSN sur­veil­lance,” Spencer says.

First launched in 2005, the net­work’s ex­plo­sive growth has been fu­eled by ev­er­in­creas­ing aware­ness of the dan­gers as­so­ci­ated with HAIS, which af­fect an es­ti­mated 1 in ev­ery 20 pa­tients, lead­ing to the deaths of tens of thou­sands and cost­ing health­care sys­tems bil­lions each year, ac­cord­ing to HHS.

More than 20 states man­date some form of HAI re­port­ing via the NHSN, in­clud­ing New York and Penn­syl­va­nia, which were among the first states to re­quire hos­pi­tals to use the net­work to re­port their HAIS.

In Jan­uary 2011, the CMS be­gan re­quir­ing hos­pi­tals to re­port their in­ci­dences of cen­tral line-as­so­ci­ated blood­stream in­fec­tions us­ing the NHSN in or­der to re­ceive their full pay­ment up­date for 2013. And this past Jan­uary, the CMS also man­dated re­port­ing of catheter-as­so­ci­ated uri­nary-tract in­fec­tions and two types of sur­gi­cal site in­fec­tion—in­pa­tient colon and ab­dom­i­nal hys­terec­tomy—via the NHSN for 2014’s pay­ment up­date.

The CDC’S se­cure, on­line track­ing sys­tem has won wide praise for its use of stan­dard­ized sur­veil­lance pro­to­cols and def­i­ni­tions, which ex­perts say has al­lowed for a more through and sci­en­tific view of in­fec­tion preva­lence.

But for in­fec­tion pre­ven­tion­ists, that level of pre­ci­sion can some­times come at a price.

“Like any­thing else, it gets eas­ier as you get used to it, but it does take time away from in­fec­tion pre­ven­tion­ists’ other du­ties,” says Ginny He­berly, an in­fec­tion pre­ven­tion­ist at 27-bed North­ern Mon­tana Hospi­tal in Havre.

Un­like some hos­pi­tals that have in­stalled a spe­cial­ized elec­tronic sur­veil­lance sys­tem, North­ern Mon­tana Health Care col­lects and en­ters data man­u­ally, He­berly says, adding that an au­to­mated sys­tem would likely make the process much eas­ier. De­spite the added work­load, she says she be­lieves the NHSN is a valu­able tool.

“It’s time-con­sum­ing, just like any qual­ity-im­prove­ment process, but I do think that it’s serv­ing its pur­pose,” she says.

When re­port­ing to the NHSN, fa­cil­i­ties must in­clude data on each in­fec­tion, which serves as the nu­mer­a­tor, but they must also sub­mit de­nom­i­na­tor data for each de­vice— cen­tral lines, uri­nary catheters, ven­ti­la­tors— or sur­gi­cal pro­ce­dure. For in­stance, when en­ter­ing data on cen­tral-line as­so­ci­ated blood­stream in­fec­tions, a fa­cil­ity must also in­clude their to­tal num­ber of cen­tral line days as their de­nom­i­na­tor.

Gath­er­ing such data for sur­gi­cal-site in­fec­tions can be even more ar­du­ous, in­fec­tion pre­ven­tion­ists say, be­cause each pro­ce­dure has its own set of spe­cific de­nom­i­na­tor data that must be col­lected for ev­ery pa­tient who un­der­goes that surgery.

“If you’re do­ing 400 cases a year and you’re look­ing at each one man­u­ally, that will take some time, of course,” says Linda Greene, di­rec­tor of in­fec­tion preven­tion and con­trol for two-hospi­tal Rochester (N.Y.) Gen­eral Health Sys­tem. “But there are ways that the elec­tronic med­i­cal record can cap­ture that in­for­ma­tion, trans­mit it to a file and au­to­mat­i­cally up­load it to the NHSN.”

Hav­ing a sys­tem that au­to­mat­i­cally ex­tracts data from an EMR and im­ports it to the CDC’S net­work can free up a lot more time for in­fec­tion pre­ven­tion­ists, says Greene, who also serves as board sec­re­tary of the As­so­ci­a­tion for Pro­fes­sion­als in In­fec­tion Con­trol and Epi­demi­ol­ogy, a pro­fes­sional or­ga­ni­za­tion with more than 14,000 mem­bers. APIC’S web­site lists ven­dors that of­fer such sys­tems, Greene adds.

But even re­source-strapped hos­pi­tals that aren’t yet able to in­vest in a soft­ware prod­uct for re­port­ing can still em­ploy strate­gies to make the process more ef­fi­cient, such as us­ing spread­sheets to skip data-en­try steps or de­vel­op­ing sys­tems in-house, she says.

“From a process-im­prove­ment per­spec­tive, it is an amaz­ing tool,” Greene says of the NHSN. “It gives real-time data and for those or­ga­ni­za­tions that have been us­ing it for a while, it has been in­valu­able. Right now there may be some peo­ple that view it as a la­bor bur­den, but I think as they look on the hori­zon, they’ll see that it gives us the in­for­ma­tion we need to get bet­ter.”

Dr. Daniel Pol­lock, sur­veil­lance branch chief for the CDC’S Di­vi­sion of Health­care Qual­ity Pro­mo­tion, ac­knowl­edges that iden­ti­fy­ing cases and col­lect­ing in­for­ma­tion for the NHSN takes time, but like Greene, he says tech­no­log­i­cal sys­tems can and will stream­line the process.

The CDC has also worked to en­hance the sys­tem’s us­abil­ity and min­i­mize the ad­min­is­tra­tive bur­den, he adds. The agency has con­ducted sev­eral pi­lot stud­ies look­ing at ways to in­tro­duce sam­pling of de­nom­i­na­tor data in or­der to sim­plify the col­lec­tion process. Those stud­ies are in the field-test­ing stage, and the CDC ex­pects to in­cor­po­rate new prac­tices by Jan­uary 2014, Pol­lock says.

“In the mean­time, there are ways to use IT sys­tems to cap­ture de­nom­i­na­tor data elec­tron­i­cally,” Pol­lock says. “We have been work­ing with ven­dors and we see those IT so­lu­tions as the way for­ward.”

Health IT cer­tainly has made par­tic­i­pat­ing in the NHSN eas­ier for the staff at 323-bed Bryn Mawr (Pa.) Hospi­tal, part of five-hospi­tal Main Line Health, says Pa­tri­cia Mcbride, an in­fec­tion pre­ven­tion­ist at Bryn Mawr. The hospi­tal re­cently be­gan us­ing its EMR to col­lect de­nom­i­na­tor data, re­duc­ing its reliance on man­ual en­try.

There have been some glitches, Mcbride says, but over­all the sys­tem has made the sur­veil­lance process run more smoothly.

“Now with the elec­tronic record, we can just search for the op­er­a­tive re­port and find out when the op­er­a­tion started and an­tibi­otic us­age,” she says. “In the past, we had to go up to the floor and hope the chart was on the unit or or­der it from med­i­cal records and hope we got it right away. The in­for­ma­tion is a lot more ac­ces­si­ble now.”

But us­ing elec­tronic sys­tems to col­lect data also can some­times cre­ate more work, says Spencer, cor­po­rate in­fec­tion pre­ven­tion­ist at UHS. The sys­tem re­cently im­ple­mented a spe­cial­ized mod­ule for in­fec­tion sur­veil­lance that has come with its own set of grow­ing pains. For in­stance, she says, in­stead of count­ing cen­tral line days us­ing the in­ser­tion day as day one, the sys­tem be­gan count­ing on the first day that the cen­tral line was in use—a pro­gram­ming er­ror that re­quired a lot of ex­tra back­track­ing and lost time, she says.

Still, Spencer says she’s hopeful that elec­tronic sys­tems’ ca­pa­bil­i­ties will im­prove steadily, al­low­ing bet­ter data col­lec­tion and seam­less in­ter­fac­ing with the NHSN. “That would help a lot,” she says.

In the mean­time, a coali­tion of groups such as APIC, the So­ci­ety for Health­care Epi­demi­ol­ogy of Amer­ica and the In­fec­tious Dis­eases So­ci­ety of Amer­ica, are press­ing Congress to ap­pro­pri­ate $12 mil­lion in ad­di­tional fund­ing for the NHSN in fis­cal 2013 to de­velop pro­grams and ac­com­mo­date the net­work’s siz­able growth in en­roll­ment. Ac­cord­ing to an APIC spokes­woman, the cam­paign has re­sulted in more than 3,000 let­ters to Congress from the or­ga­ni­za­tion’s mem­bers dur­ing the past month.

“Those funds would help us tremen­dously to shore up the net­work’s tech­no­log­i­cal in­fra­struc­ture, ex­pand the ca­pac­ity of our sys­tems, ex­pand re­port­ing and to mod­ern­ize and stream­line op­er­a­tions as we man­age new re­quire­ments,” says Pol­lock of the CDC. “It’s a very high pri­or­ity for us to work with part­ner or­ga­ni­za­tions to se­cure ad­di­tional re­sources that we think are vi­tally im­por­tant.”

GETTY PHO­TOS

Re­port­ing re­quire­ments for the CDC’S track­ing sys­tem has left many in­fec­tion pre­ven­tion­ists “ba­si­cally chained to their desks,” ac­cord­ing to one health sys­tem.

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