validation of central-line associated bloodstream infection (clabsi) data reporting, oregon, 2009...
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Validation of Central-Line Associated Bloodstream Infection (CLABSI) Data
Reporting, Oregon, 2009
Zintars Beldavs, MSManager Healthcare-Associated Infections Program
Acute and Communicable Disease Prevention SectionOffice of Disease Prevention and Epidemiology
Public Health DivisionOregon Health Authority
October 13, 2011
Oregon HAI
OPHD OHPR OPSC
NHSN Reporting
NHSN Validation
HAI EIPProjects
Multi-hospitalCollaborative
CLABSI SSI
HAI PointPrevalence
MDRO Surveillance
DenominatorSimplification
CandidemiaSurveillance
C. difficileSurveillance
Validation for Accurate Data
• Research indicates surveillance definitions applied differently by different IPs
– Demonstrated by poor inter-rater reliability (agreement between different people reporting on same case): kappas of .30 to .58
• Previous validation studies: potentially more than half of cases not reported
Central Line-Associated Bloodstream Infection (CLABSI)
• Attributable mortality ~18%– 14,000 deaths/ year in ICU patients
• Estimated cost per episode $3,700 to $29,000• Prolong hospitalization by mean of 7 days• Preventable through hand hygiene, barrier
precautions, skin antisepsis, catheter site selection
Pittet D, Tarara D, Wenzel RP. Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs, and attributable mortality. JAMA. 1994;271:1598-1601.Soufir L et al. Infect Control Hosp Epidemiol 1999 Jun;20(6):396-401.
Objectives
• Evaluate quality of reported data– Assess under- and over-reporting– Gauge the reliability and consistency of surveillance case
definitions
• Provide feedback and guidance to facilities on surveillance case definitions and reporting methods
Methods• Study period: calendar year 2009• Included: 44 acute care hospitals
– 28 with <50 beds– 10 with >200 beds– Median central line days 210, range
4-4956
• OPHD validation team:– Research analyst– Epidemiologist– EIS Officer/Physician– 3 public health nurses
Map: Oregon Association of Hospitals and Healthcare Systems, oahhs.org
Methods
• March 2010 - April 2011: on-site hospital visit for chart review– Retrospective record review by 1-4 reviewers– At 37 hospitals: all ICU patients blood culture(+) – At 7 largest hospitals: all reported CLABSI plus
random sample of 60 patients with ICU blood-culture(+) not reported as CLABSI
– Validators blinded as to whether cases reported as CLABSI
Methods• After visit, all cases with discordant CLABSI
determinations (suspected false positives or false negatives) adjudicated by phone with hospital staff– Participants
• Hospital IP staff• Hospital physician • OPHD validators• OPHD physician
– Review of all findings for final CLABSI determination – If no consensus reached, case referred to CDC staff
• This step unique to Oregon’s validation project (not previously attempted by other states)
Results
• 1199 medical records reviewed– 549 at 7 highest-volume facilities (records sampled)– 722 at small- and medium- volume facilities
• 817 record reviews included in final analysis– 382 records censored as could not meet ICU CLABSI
case definition due to timing rules (positive blood cultures were obtained prior admit or > 48 hours after discharge from ICU)
Change after validation in CLABSI rate No. hospitals %
Rate decreased 0.70 1 2
No change 33a 75
0.01–0.50 higher 2 5
0.51–1.00 higher 2 5
>1.00 higher 6b 14
Total 44
a 23/33 had no CLABSI identified either before or after the validation.b 3/6 had no CLABSI before the validation.
Validation increased the statewide ICU CLABSI rate from 1.21 (95% CI: 0.95–1.51) to 1.54 (95% CI: 1.25–1.88) CLABSI per 1,000 central-line days
CLABSI rate before and after validation
ResultsValidation outcome, unadjusted
Validation findings(after chart review and adjudication)
Originally reported to NHSN?
Yes No
CLABSI 70 (True Positives) 16 (False Negatives)
Non-CLABS I 6 (False Positives) 712 (True Negatives)
Results Estimated number of CLABSI adjusted for sampling fraction
Estimated CLABSIs among All ICU Patients with Positive Blood Cultures, by Initial Hospital Report — Oregon, 2009
CLABSIFinal determination
Present Absent Total
Hospital reportPresent 70 (TP) 6 (FP) 76
Absent 27a (FN) 1089a (TN) 1116
Total 97 1095 1192
Sensitivity = 0.72 (95% CI: 0.62–0.81); Specificity = 0.99 (95% CI: 0.99–1.00).Positive predictive value = 0.92 (95% CI: 0.83–0.77).Negative predictive value = 0.98 (95% CI: 0.96–0.98).Prevalence = 0.08 (95% CI: 0.07–0.10).
Importance of Inter-Agency Follow-up Discussion
• Of 27 unreported cases initially identified as possible CLABSI by OPHD, 16 (59%) actual CLABSI
• Sensitivity of reporting:– 72% based on follow-up adjudication– vs. 60% based on OPHD review alone (P= 0.07),
closer to some previous validation efforts
Reasons for discrepancies
6 CLABSI “just missed”: at some facilities, IP staff had changed since 2009 and current staff unaware of rationale for previous CLABSI reporting/ non-reporting decisions.
CLABSI Pathogens before and after validation
Before validation (n=76) After validation (n= 86)
Conclusions
• Validating hospital CLABSI reporting improves accuracy of hospital-based CLABSI surveillance
• Discussing discordant findings improves the quality of validation
AcknowledgmentsOPHD HAI program staff and others assisting• Paul Cieslak – Public Health Physician• Ann Thomas – Public Health Physician• Margaret Cunningham – HAI Epidemiologist• Diane Roy – HAI Administrative Assistant• John Oh – EIS Officer• Steve Moore – Public Health Nurse• Jennifer Tujo – Infection Preventionist• Valerie Ocampo – HAI Public Health Nurse
Oregon Patient Safety Commission
Office for Oregon Health Policy and Research
Association of Professionals in Infection Control, Oregon-SW Washington Chapter