healthcare associated infections: what’s on the horizon

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Healthcare Associated Infections: What’s On the Horizon


Objectives

• By the end of today’s presentation, participants will be able to – Define Healthcare-Associated Infections (HAIs)

and identify 5 broad classifications of HAIs – Discuss the financial burden of HAIs– Describe key legislative, regulatory and

reimbursement issues as they relate to HAIs


Healthcare Associated Infections (HAIs)

• Definition: Largely preventable infections that are directly resultant from the delivery of clinical care, that were not present or incubating upon entry into a healthcare setting

• Settings: Hospitals (Intensive Care Units, Special Care Units, other hospital settings), long-term care facilities (LTCFs), outpatient facilities such as ambulatory surgical clinics (ASCs), dialysis centers


HAIs: Broad Classifications

• Catheter-associated urinary tract infections (CAUTI)• Surgical site infections (SSI)• Post-procedure pneumonia (PPP)• Central line-associated blood stream infections

(CLABSI)• Ventilator-associated pneumonia (VAP)• Multi-drug resistant organism (MDRO)• Clostridium difficile infections (CDI)


Annual Burden of HAIs

• 1.7 million infections in hospitals– Most (1.3 million) were outside of ICUs– 9.3 infections per 1,000 patient-days– 4.5 per 100 admissions


HAI Costs• Direct Costs

– Increased LOS– Increased acuity of care– Increased treatment costs– Bed blockage

• Indirect Costs– Lost wages– Lost productivity– Suffering– Travel expenses– Litigation / Reputation


Josie King (1999-2001)

Estimates of preventable infections, deaths, and costs based on existing published literature


Source: Umschied, C. University of Pennsylvania. Presentation at HICPAC, March 2009

The Good News• HAI Prevention

– Implementing what we know for prevention can lead to up to a 70% or more reduction in HAIs


CMS Reimbursement

• Deficit Reduction Act (2005)– No increased Medicare payments for selected

complicating conditions not present at admission• CAUTI• CLABSI• SSI (cardiac, orthopedic)

– Implemented in 2008• Impact?


National Policy Issue 2009


GAO Report: Key Recommendations

• Improve central coordination of HHS-supported prevention and surveillance strategies

• Identify priorities among CDC guidelines to:– Promote implementation of high priority practices– Consider inclusion into CMS Conditions of

Participation and Conditions for Coverage• Establish greater consistency and compatibility of the

HAI-related data across HHS systems to:– Increase reliable national estimates of HAIs


HHS Tier One PrioritiesHAI Priority Areas• Catheter-Associated Urinary Tract Infections• Central Line-Associated Bloodstream Infections• Surgical Site Infections• Ventilator-Associated Pneumonia• MRSA• Clostridium difficileImplementation Focus• Hospitals


Measuring Success

Metric SourceNational 5-year

Prevention Target

Coordinator

Bloodstream infections NHSN 50% reduction CDCAdherence to central-line

insertion practices NHSN 100% adherence CDC

Clostridium difficile (hospitalizations)

NHDSHCUP 30% reduction CDC/

AHRQClostridium difficile infections NHSN 30% reduction CDC

Urinary tract infections NHSN 25% reduction CDC

MRSA invasive infections (population) EIP 50% reduction CDC

MRSA bacteremia (hospital) NHSN 25% reduction CDC

Surgical site infections NHSN 25% reduction CDCSurgical Care Improvement

Project Measures SCIP 95% adherence CMS

HHS Tier Two PrioritiesHAI Priority Areas• Antimicrobial IV Start (process measure)• CLABSI• SSI• Healthcare personnel influenza vaccination*Implementation Focus• End state renal disease • Ambulatory surgical centers• Acute care facilities*


HHS Tier Three PrioritiesHAI Priority Areas• To be determined

Implementation Focus• Likely Long Term Care and CRITICAL ACCESS HOSPITALS


CMS IPPS Final Rule: CLABSI in ICU• Required by CMS FY 2010 IPPS rule

• Locations include:– All adult ICU– All pediatric ICU– Level II/III neonatal intensive care units and – Level III neonatal intensive care units

• Data collection began January 2011 for FY 2013 Medicare payment• First ever de facto mandate


*Reporting of CLABSI in ICUs by 2011 and SSIs by 2012

Status of HAI Reporting

2003 State Laws

2011 State Laws

2011 Federal Requirements*

CMS IPPS Final Rule: SSI

• Required by CMS FY 2011 IPPS rule• CDC and the American College of Surgeons collaborated to develop SSI measure

for CMS reporting• Prototype measure to include colon surgeries and abdominal hysterectomies

– Deep incisional and organ/space SSIs in inpatients age 18+– Prototype will be followed by more comprehensive set of measures that

expand procedures and SSI risk adjustment– Reporting requirements for prototype involve no changes to NHSN Patient

Safety Protocol for SSIs– Measure is currently under review by NQF

• Data collection to begin January 2012 for FY 2014 Medicare payment – no change


FY 2012 Acute Care Hospitals– Proposed Rule

Acute Care Hospitals• Proposed for FY 2014 Medicare payment determination :

• CAUTI – reported through NHSN • CLIP Adherence percentage

• Proposed for FY 2015 Medicare payment determination:• MRSA • C.Diff. • HCP influenza vaccination• All reported through NHSN


LTCH Prospective Payment Systems – Proposed Rule

Long-Term Care Hospitals• For the first time, CMS also proposed quality measure reporting for Long-

term Care Hospitals for FY 2014 payment determination. Measures include:• CAUTI• CLABSI• Pressure ulcers that are new or have worsened


Inpatient Rehabilitation Facilities (IRF) Prospective Payment Systems – Proposed Rule

• Also for the first time, CMS proposed quality measure reporting for IRFs for FY 2014 payment determination. Measures include:

•CAUTI•Pressure ulcers that are new or have worsened


Influenza Vaccination Standard – Proposed Rule

• Proposed Rule would make offering annual influenza vaccination for hospital inpatients and outpatients a Medicare Condition of Participation (CoP)

• Final rule expected from CMS around September 1, 2011• Implementation for 2011-2012 flu season

• Implementation of this program on this timeline raises serious concerns about:

• Supplies• Policies/Procedures• Safe Injection Practices• Who qualifies as an “outpatient”?


Influenza Vaccination Standard – Proposed Rule

• APIC recommendation: delay implementation so that:• Year 1 (2011-2012) flu season – staffing/resource planning• Year 2 (2012-2013) flu season – implement for hospital inpatients• Year 3 (2013-2014) – incorporate outpatients into program ONLY after

detailed evaluation of impact of proposal on outpatient population.


Healthcare Facility HAI Reporting to CMS via NHSN – Current and Proposed Requirements DRAFT (8/5/2011)

HAI Event Facility Type Reporting Start Date

CLABSI Acute Care HospitalsAdult, Pediatric, and Neonatal ICUs January 2011

CAUTI Acute Care HospitalsAdult and Pediatric ICUs January 2012

SSI Acute Care HospitalsColon and abdominal hysterectomy January 2012

I.V. antimicrobial start (proposed) Dialysis Facilities January 2012

Positive blood culture (proposed) Dialysis Facilities January 2012

Signs of vascular access infection (proposed) Dialysis Facilities January 2012

CLABSI Long Term Care Hospitals * October 2012

CAUTI Long Term Care Hospitals * October 2012

CAUTI Inpatient Rehabilitation Facilities October 2012

MRSA Bacteremia Acute Care Hospitals January 2013

C. difficile LabID Event Acute Care Hospitals January 2013

HCW Influenza Vaccination Acute Care Hospitals January 2013

HCW Influenza Vaccination OP Surgery, ASCs October 2013

SSI (proposed) Outpatient Surgery/ASCs January 2014

* Long Term Care Hospitals are called Long Term Acute Care Hospitals in NHSN

Trends in State Legislation

• Infection Control Requirements in Healthcare Facilities - FL: Pain management facilities

- TN: Pain management facilities - NC: adult care homes

- NV: Hospitals and ASCs

• Mandatory Isolation for Tuberculosis Patients - ND and SC

• Compliance with Safe Injection Practices Guidelines - NC: Adult care home medication aides - NV: Healthcare professionals, medical laboratories, radiation facilities


Other Enacted Bills

• Reporting of CLABSIs (redundant with federal requirement), AR

• Reporting by skilled nursing facilities, NV

• MRSA and C. diff reporting, ME

• Expansion of HAI reporting to include infections resulting in death, TX

• Reporting in format that allows for comparison of medical facilities, NV

• Authorization for school-based influenza program, MS

• Influenza vaccinations for healthcare workers, NE


Questions and Discussion


For additional information, please contact

Kansas Department of Health and EnvironmentBureau of Epidemiology and Public Health Informatics

Healthcare Associated Infections Program1000 SW Jackson St., Suite 210

Topeka, KS 66612-1274

Joseph M. Scaletta, MPH, RN, CIC(785) 296-1059

[email protected]


mailto:[email protected]


www.kdheks.gov

healthcare associated infections: what’s on the horizon

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