Tap­ping federal safety data to re­duce hospi­tal in­fec­tion rates

New CDC ini­tia­tive en­ables fa­cil­i­ties to pin­point hot spots and de­velop so­lu­tions

Modern Healthcare - - NEWS - By El­iz­a­beth Whit­man

Af­ter a South Dakota hospi­tal re­cently ran a stan­dard clin­i­cal re­port through a federal health­care safety data­base, it dis­cov­ered that its pa­tients had a high num­ber of hospi­tal-ac­quired Clostrid­ium dif­fi­cile in­fec­tions.

The hospi­tal then con­ducted a root-cause anal­y­sis that found house­keep­ing wasn’t thor­oughly clean­ing rooms af­ter in­fected pa­tients were dis­charged. Since then, hospi­tal-ac­quired C. dif­fi­cile in­fec­tions have de­creased.

The hospi­tal iden­ti­fied the prob­lem through the Tar­geted Assess­ment for Pre­ven­tion (TAP), a strat­egy launched by the Cen­ters for Dis­ease Con­trol and Pre­ven­tion two years ago to re­duce in­fec­tions. TAP of­fers them tools to iden­tify pos­si­ble gaps in in­fec­tion pre­ven­tion and im­ple­ment so­lu­tions.

A TAP re­port can also rank spe­cific units within health­care fa­cil­i­ties by the num­ber of in­fec­tions above tar­geted levels.

More than 3,700 acute-care hos­pi­tals have run TAP re­ports since the system launched in Jan­uary 2015. That’s 84% of the hos­pi­tals that re­port to the Na­tional Health­care Safety Net­work. The CDC does not track what the hos­pi­tals do with that data or what im­pact these ef­forts di­rectly have had on re­duc­ing rates of hospi­tal-ac­quired in­fec­tions.

“You run this re­port and boom, that’s where you can fo­cus your ef­fort,” said Nancy McDon­ald, a pro­gram man­ager for the Great Plains Qual­ity Im­prove­ment Net­work. Her group worked with the CDC to dis­sem­i­nate the TAP strat­egy to providers in the Dako­tas, Kansas and Ne­braska. “It’s very easy, and it’s very tar­geted.”

Amid a proliferation of health­care qual­ity mea­sures but a dearth of tools that re­li­ably im­prove qual­ity and pa­tient safety, TAP holds prom­ise for be­ing not just ef­fec­tive, but cost-ef­fec­tive too, given that fa­cil­i­ties run re­ports through the Na­tional Health­care Safety Net­work at no added cost. Sev­eral peo­ple work­ing in the hospi­tal sec­tor also de­scribed it as promis­ing be­cause re­ports and feed­back can be in­te­grated with other in­fec­tion-pre­ven­tion ef­forts.

In the U.S., health­care-as­so­ci­ated in­fec­tions rank among the top “dev­as­tat­ing and costly ill­nesses,” com­pet­ing with can­cer, heart at­tack, stroke and di­a­betes, ac­cord­ing to a 2013 study in the Jour­nal of Med­i­cal Eco­nomics. The au­thors es­ti­mated these in­fec­tions cost the na­tion $96 bil­lion to $147 bil­lion a year in med­i­cal, non­med­i­cal and in­di­rect costs. They also are a ma­jor cause of pre­ventable hospi­tal read­mis­sions, for which Medi­care pe­nal­izes hos­pi­tals.

About 722,000 health­care-as­so­ci­ated in­fec­tions oc­curred in acute-care hos­pi­tals in 2011, and about 75,000 peo­ple with such in­fec­tions died while hos­pi­tal­ized, ac­cord­ing to the CDC.

These in­fec­tions can de­velop af­ter surgery or in con­junc­tion with the use of med­i­cal de­vices, such as catheters

or ven­ti­la­tors, that haven’t been prop­erly cleaned. They also can be in­ad­ver­tently spread by providers.

In re­cent years, the rate of some health­care-as­so­ci­ated in­fec­tions has dropped. Be­tween 2008 and 2014, cen­tral line-as­so­ci­ated blood­stream in­fec­tions, or CLABSI, dropped by half, ac­cord­ing to the CDC. Sur­gi­cal-site in­fec­tions for ab­dom­i­nal hys­terec­tomies dropped 17% over the same pe­riod, and sur­gi­cal-site in­fec­tions fol­low­ing colon surgery dropped 2%. The CDC at­trib­uted the de­clines to im­proved aware­ness of in­fec­tions and tar­geted ef­forts to pre­vent them.

Still, hos­pi­tals, in­pa­tient re­ha­bil­i­ta­tion fa­cil­i­ties, long-term acute-care hos­pi­tals and other providers still have room for im­prove­ment. For in­stance, ca­theter-as­so­ci­ated uri­nary tract in­fec­tions, or CAUTI, showed no de­cline be­tween 2009 and 2014. The CDC es­ti­mates that at any point, one out of 25 pa­tients has at least one health­care-as­so­ci­ated in­fec­tion.

The chal­lenge for providers is to de­ter­mine the in­ci­dence, sever­ity and cause of in­fec­tions within their walls. Are CAUTI preva­lent? Which unit of the hospi­tal has the most in­fec­tions, and why? That’s where the TAP system comes in.

Hos­pi­tals re­port in­fec­tions in a va­ri­ety of cat­e­gories to the Na­tional Health­care Safety Net­work. Those in the In­pa­tient Qual­ity Re­port­ing Pro­gram must re­port cases of com­mon health­care-ac­quired in­fec­tions, pro­vid­ing de­tailed in­for­ma­tion about each in­ci­dent, such as the date and lo­ca­tion a ca­theter was inserted, the char­ac­ter­is­tics of the pa­tient, pro­ce­dure codes, lab and di­ag­nos­tic tests, and out­comes like sec­ondary in­fec­tions or death.

Tar­get­ing in­fec­tions

Us­ing all this in­for­ma­tion, TAP’s three-stage frame­work tar­gets in­fec­tions, then as­sesses them with the goal of iden­ti­fy­ing process im­prove­ments to help pre­vent them.

When the CDC rolled out TAP re­ports two years ago, the system gen­er­ated re­ports for CAUTI, CLABSI and C. dif­fi­cile in­fec­tions to acute-care hos­pi­tals. In ad­di­tion, re­ports for CAUTI and CLABSI be­came avail­able to longterm acute-care fa­cil­i­ties. And re­ports for CAUTI were of­fered to in­pa­tient re­ha­bil­i­ta­tion fa­cil­i­ties.

By 2016, fa­cil­i­ties had ac­cess to assess­ment tools, de­vel­oped through­out 2015 through pi­lot projects with Qual­ity In­no­va­tion Net­work-Qual­ity Im­prove­ment Or­ga­ni­za­tions. In March, C. dif­fi­cile in­fec­tion

re­ports be­came avail­able to long-term acute-care and in­pa­tient re­ha­bil­i­ta­tion fa­cil­i­ties.

The CDC plans to ex­pand TAP to cover other in­fec­tions, such as me­thi­cillin-re­sis­tant Sta­phy­lo­coc­cus au­reus.

The TAP system uses in­fec­tion data that hos­pi­tals, un­der the CMS In­pa­tient Qual­ity Re­port­ing Pro­gram, are re­quired to re­port quar­terly to the Na­tional Health­care Safety Net­work. The system gen­er­ates re­ports that show which hospi­tal units have in­fec­tion rates for CAUTI, CLABSI and C. dif­fi­cile in­fec­tions that ex­ceed ex­pected rates.

“Hos­pi­tals dump all of this in­for­ma­tion into the NHSN,” McDon­ald said. “They can go in any time and gen­er­ate a new data set, and then they can get in and run all sorts of re­ports.”

The re­ports cal­cu­late the cu­mu­la­tive at­trib­ut­able dif­fer­ence (CAD), or the dif­fer­ence be­tween the ob­served num­ber of in­fec­tions and a tar­geted pre­ven­tion goal, which is based on a na­tional Stan­dard­ized In­fec­tion Ra­tio. If the CAD mea­sure is pos­i­tive, the fa­cil­ity or unit needs to re­duce the num­ber of in­fec­tions to meet the goal. In rank­ing units by CAD, hos­pi­tals can see where pre­ven­tion ef­forts are needed most.

TAP is unique in its ca­pac­ity to al­low hos­pi­tals to tar­get lo­ca­tions with ex­cess in­fec­tions, said Ronda Sinkowitz-Cochran, a be­hav­ioral sci­en­tist in the CDC’s Di­vi­sion of Health­care Qual­ity Pro­mo­tion. And the CAD mea­sure pro­vides them with con­crete goals to drive cor­rec­tive ac­tion.

Af­ter pin­point­ing a unit such as the in­ten­sive-care for im­prove­ment, the hospi­tal can use TAP’s Fa­cil­ity Assess­ment Tool to help iden­tify pos­si­ble safety gaps. Hospi­tal qual­ity lead­ers then can sur­vey staff and gauge whether best-prac­tice poli­cies are in place and are be­ing fol­lowed.

A tool to as­sess CAUTI, for in­stance, might ask how fre­quently or­der­ing providers ap­pro­pri­ately doc­u­ment the indi­ca­tions for in­sert­ing uri­nary catheters. From there, the hospi­tal can gen­er­ate a feed­back re­port to de­velop a plan to re­duce in­fec­tions. The pre­ven­tion tool for CAUTI would sug­gest ar­eas for im­prove­ment.

Over for the past 18 months, the Wis­con­sin Hospi­tal As­so­ci­a­tion has been work­ing with its mem­ber hos­pi­tals to im­ple­ment the TAP strat­egy and break down data into ac­tion­able com­po­nents.

The de­tailed TAP data make it eas­ier for hos­pi­tals to un­der­stand the source of in­fec­tions, said Kelly Court, the as­so­ci­a­tion’s chief qual­ity of­fi­cer. The TAP re­port com­ple­ments hos­pi­tals’ on­go­ing in­fec­tion-pre­ven­tion work and their Plan-Do-Study-Act model for process im­prove­ment.

“What hos­pi­tals tell us is that the abil­ity to take the tool and drill the data down to the nurs­ing unit level re­ally helped en­gage bed­side nurses at that unit level,” Court said.

Grow­ing pains

“What hos­pi­tals tell us is that the abil­ity to take the tool and drill the data down to the nurs­ing unit level re­ally helped en­gage bed­side nurses at that unit level.” Kelly Court Chief qual­ity of­fi­cer Wis­con­sin Hospi­tal As­so­ci­a­tion

While TAP has re­ceived pos­i­tive feed­back so far, it has kinks that are still be­ing smoothed out. One is­sue is that for some hos­pi­tals, tak­ing ad­van­tage of all the data gen­er­ated by the ini­tial TAP re­port can be a chal­lenge.

“The ques­tion is, what do you do af­ter you’ve run a TAP re­port? The assess­ment and pre­ven­tion pieces are a lit­tle slower on the up­take,” said Katie Coutts-White, a health sci­en­tist in the CDC’s Di­vi­sion of Health­care Qual­ity Pro­mo­tion. It’s one thing for hos­pi­tals to iden­tify ar­eas for im­prove­ment; it’s an­other to fig­ure out how to achieve qual­ity and process im­prove­ment, and then ac­tu­ally im­ple­ment so­lu­tions.

The CDC’s assess­ment and pre­ven­tion tools have not au­to­mat­i­cally been easy for front-line providers to un­der­stand and use. So the CDC has part­nered with Qual­ity Im­prove­ment Net­works, re­gional or­ga­ni­za­tions that use data-driven ini­tia­tives to im­prove pa­tient safety and care and spread best prac­tices across ar­eas span­ning two to six states.

The QINs have helped the CDC im­prove the TAP system. They were key in de­vel­op­ing the CDC’s assess­ment tools and pro­vid­ing feed­back about what providers found rel­e­vant, Coutts-White said.

For ex­am­ple, the CDC might send hos­pi­tals a feed­back chart, strat­i­fied by unit and pathogen. Some­times those charts con­tained jar­gon that was un­clear, or they high­lighted a prac­tice that most nurses never used. The QINs gath­ered this type of feed­back from front-line providers and passed it on to CDC staffers.

“We learned so much from them when we would draft ma­te­ri­als and those ma­te­ri­als would go out into the field,” Sinkowitz-Cochran said. “It was a real light­bulb mo­ment for us. There’s the­ory, and then there’s prac­tice.”

Other chal­lenges have stemmed from issues with the Na­tional Health­care Safety Net­work, not TAP it­self. Some­times hos­pi­tals have to recre­ate re­ports, or they find that the NHSN system is down. The Wis­con­sin Hospi­tal As­so­ci­a­tion’s Court said she ex­pected those ob­sta­cles to even­tu­ally be re­solved.

De­spite the en­thu­si­as­tic feed­back about TAP, no one re­ally knows how much im­pact this CDC ini­tia­tive has had on health­care fa­cil­i­ties’ in­fec­tion rates. That’s partly be­cause the CDC doesn’t track what fa­cil­i­ties do with the in­for­ma­tion gen­er­ated by a TAP re­port. But it’s also be­cause TAP is in­te­grated with so many other ini­tia­tives in in­fec­tion con­trol.

In­di­vid­ual fa­cil­i­ties vary widely in how they im­ple­ment pre­ven­tion ef­forts, Coutts-White noted, but the CDC “looks for­ward to fu­ture shar­ing of lessons learned in us­ing data for ac­tion in (fa­cil­i­ties’) pre­ven­tion ef­forts.”

The Great Plains QIN de­clined to share data about whether and how much in­fec­tion rates have changed since its hospi­tal mem­bers started us­ing TAP. McDon­ald noted that mem­ber hos­pi­tals also are work­ing on hand hy­giene, safety huddles and mul­ti­dis­ci­plinary rounds to re­duce in­fec­tions.

“We couldn’t at­tribute it just to the TAP,” she said.

METASTAR/LAKE SU­PE­RIOR QUAL­ITY IN­NO­VA­TION NET­WORK

Jill Han­son, man­ager of qual­ity im­prove­ment at the Wis­con­sin Hospi­tal As­so­ci­a­tion, cen­ter, dis­cusses TAP tool strate­gies with Janet Sch­legel, left, and El­iz­a­beth Pear­son from Mer­cy­health Hospi­tal and Med­i­cal Cen­ter in Lake Geneva, Wis.

Pages from TAP’s fa­cil­ity assess­ment tool for catheteras­so­ci­ated uri­nary tract in­fec­tions (CAUTI)”

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