How Electronic Surveillance Systems Help with CMS-Mandated CDC NHSN Surgical Reporting

The Jan. 1, 2012, NHSN reporting deadline for surgical site infections (SSI) is rapidly approaching, and many infection preventionists and hospital executives are asking whether electronic surveillance systems (ESS) can help meet the workload, quality and cost challenges inherent in the CMS reporting mandate.
We discussed these challenges with Tracy Gustafson, MD, a CDC-trained epidemiologist, software architect and a director of medical affairs in BD Diagnostics’ Infection Prevention and Management unit.

Q: What concerns Infection preventionists and administrators most about responding to the new CMS and NHSN reporting mandates?
A: Beyond the obvious financial pressure to improve performance year-to-year to receive quality-related incentives and avoid penalties, infection preventionists are most concerned that data collection and reporting will divert their resources away from real prevention efforts. This is already a concern with bloodstream infection reporting required in 2011. Surgical procedure and SSI reporting requirements in 2012 will increase the reporting burden ten-fold.
Additional concerns relate to the unique challenges in reducing SSIs. Many steps and personnel are involved in pre-operative, perioperative and post-discharge care of surgical patients. These factors make identifying root causes and opportunities for surgical improvement difficult without a sophisticated surveillance system capable of extracting and mining process-related data.

Q: What makes SSI data collection and reporting so time-consuming?
Before reporting an SSI, the hospital has to report the denominator data. For example, to report a mediastinal infection after coronary artery bypass graft (CABG), at least 19 data elements must be reported on every patient who has a CABG. Then, numerator (infection) data must be collected on every patient who contracts a deep infection in this surgical site within 30 days of surgery. Hospital staff must collect surgical and infection data inside their facilities, and check with surgeons who are seeing patients post-discharge and track those outcomes as well.

Q: Why do infection preventionists need to be involved in collecting surgical data? For example, can non-clinical staff collect and report the data?
A: Identifying SSIs requires clinical judgment. For example, an infection preventionist evaluates signs and symptoms of infection, and uses rules provided by the CDC to help define whether an infection is an HAI. Collection and validation against NHSN rules can be automated to help identify possible infections for investigation, electronically document the infection and provide post-discharge follow-up capability.

Q: You mentioned "data validation." Do ESS now diagnose healthcare-associated infections (HAI)?
A: No, quite the opposite. A viable ESS provides data that help the clinician determine when a HAI might be present, but the clinician must have the final say. Software can help by determining whether the data it receives are valid according to NHSN definitions and business rules. For example, in NHSN:
• Each surgical procedure has slightly different required data elements.
• Only specific sites of infection can follow each type of surgical procedure.
• Each site of infection must be documented by a specific combination of lab results, signs and symptoms.
• Data requirements also vary depending on the patient’s age.

Q: We’ve talked about surgical data. Does NHSN accept other kinds of data electronically?
A: NHSN has enabled electronic reporting of detailed device-day denominators, surgical procedure data, surgical site infections, central line-associated bloodstream infections (CLABSIs), urinary tract infections (UTIs), central line insertion practices (CLIP), and lab-identified MDRO/CDAD results.

Q: How can an ESS help reduce infections?
A: They can help by going beyond single event "alerts" to provide tools to study the epidemiology of infections in a given facility. Many ESS systems focus on providing alerts and line lists, but affecting change requires the ability to easily analyze processes and related outcomes.

Q: If I am an infection preventionist, how do I evaluate an ESS to see if it is right for me?
A: Focus on outcomes—what tools the system provides and how the tools will help you prevent infections. Ask for a list of alerts and reports produced by the system, how easy it is to create graphs and control charts inside the system, whether the system helps track processes as well as outcomes. Ask whether the system can benchmark to NHSN and produce graphs based on Standardized Infection Ratios, which NHSN plans to use to compare hospitals. Ask exactly which NHSN-required data elements can be transferred into coded fields for analysis. Ask whether you own your data at the end of a contract. If the answers to these questions are satisfactory, then you’ve probably found a system that benefits your patients, your healthcare staff and your bottom line.

APIC Guide on Elimination of Orthopedic Infections

Orthopedic surgical site infections represent significant morbidity, cost and mortality. It is estimated that between 6,000 and 20,000 orthopedic surgical site infections occur annually, increasing the average hospital stays by two weeks and increasing the costs of these procedures by as much as 300%. Surgical site infections are one of the categories of infections that have been targeted for reduction by the Department of Health and Human Services.

An effective facility-wide infection preventions and control program comprises many components that can reduce the infection in surgery patients. The purpose of this guide, developed in collaboration with the Association of periOperative Registered Nurses (AORN),  is to provide practical tools, strategies and resources for infection preventionists, care providers, surgical staff and quality improvement teams to use in their efforts to eliminate surgical site infections (SSIs) in orthopedic surgery.

http://www.apic.org/downloads/ortho_guide.pdf

Cruise Ship Outbreak of Norovirus

Norovirus is the leading cause of acute gastroenteritis in the United States and is estimated to cause nearly 21 million cases annually. It is highly transmissible through person-to-person contact and contaminated food, water, and environmental surfaces. The results of an investigation of a 2009 outbreak on a cruise ship shed light on how the infections can spread and the steps both passengers and crew can take to prevent them.
The findings are published in a new study in Clinical Infectious Diseases.
Questionnaires about when people did or did not seek medical care, hygiene practices, and possible norovirus exposure were placed in every cabin after the outbreak began. The ship had 1,842 passengers on board, and 83 percent returned the questionnaires. Of the 15 percent of respondents who met the case definition for acute gastroenteritis, only 60 percent had sought medical care on the ship. Infected passengers were significantly more likely to have an ill cabin mate and to have resided or dined on the deck level where a vomiting incident had occurred during boarding. The most common symptom reported was diarrhea, followed by vomiting. Stool samples from several ill passengers tested positive for norovirus.
Less than 1 percent of the crew reported illness, and their low attack rate may have been due to the few crew members who had direct contact with passengers. This included separate sleeping and dining areas and alternate passages for boarding and exiting the ship. Another factor may have been an acquired short-term immunity from previous cruise ship outbreaks.
"Cruise line personnel should discourage ill passengers from boarding their ships," according to study author Mary Wikswo, MPH, of the Centers for Disease Control and Prevention. "Once on board, passengers and crew who become ill should report to the ship's medical center as soon as possible. These quick actions are crucial in preventing the introduction and spread of norovirus on cruise ships and allow ship personnel to take immediate steps to prevent the spread of illness."

1. M. E. Wikswo, J. Cortes, A. J. Hall, G. Vaughan, C. Howard, N. Gregoricus, E. H. Cramer. Disease Transmission and Passenger Behaviors during a High Morbidity Norovirus Outbreak on a Cruise Ship, January 2009. Clinical Infectious Diseases, 2011; DOI:

Triad Recall of Povidone Iodine Products

The FDA has extended the previous recall of HP Triad alcohol prep pads and swabsticks to include all lot numbers of HP Triad Povidone Iodine prep pads.  The recall is due to microbial contamination with  Elizabethkingia meningoseptica.   

H&P Industries, Inc. Issues a Voluntary Nationwide Recall of All Lots of

Povidine Iodine Prep Pads Due to Potential Microbial Contamination

The Recall affects Multiple Mfct names & catalog numbers

 

I did find this reference on an outbreak due to t his organism:

Transmission of Elizabethkingia meningoseptica (Formerly Chryseobacterium meningosepticum)...Cartwright et al. J Bone Joint Surg Am.2010; 92: 1501-1506

Contaminated Alcohol Prep Pads and Infections

The FDA has announced a recall of ALL LOTS of ALCOHOL PREP PADS, ALCOHOL SWABS, and ALCOHOL SWABSTICKS manufactured by Triad Group due potential contamination of the products with Bacillus cereus, a bacteria that produces toxins that cause diarrhea, nausea and vomiting often related to food poisoning. FDA Recall Announcement.  This bacteria can cause serious injuries and death if it is introduced into the blood stream or cerebrospinal fluid (CSF). The recall covers Triad Group brand alcohol swabs and others which are private labeled for many accounts to the consumer level. This recall also involves those products marked as STERILE as well as non-sterile products. This recall also includes the drugs and medical equipement in which it is co-packaged. 
Regular users of injectable medications, such as Copaxone or Betaseron for Multiple Sclerosis (MS), are at very high risk because they use the alcohol wipes daily and are asked to break the skin with an injection after exposing it to the bacterial contamination on Triad products.

The Food and Drug Administration says that use of contaminated Triad Alcohol Group Prep Pads, Alcohol Swabs or Alcohol Swabsticks could lead to life-threatening infections, especially in at risk populations, including immune suppressed and surgical patients. Triad Group Alcohol Prep Pads, Alcohol Swabs and Alcohol Swabsticks are used to disinfect prior to an injection. They were distributed nationwide to retail pharmacies and are packaged in individual packets and sold in retail pharmacies in a box of 100 packets. The affected alcohol prep pads, alcohol swabs and alcohol swabsticks can be identified by either "Triad Group," listed as the manufacturer, or the products are manufactured for a third party and use the names listed below in their packaging:

Cardinal Health
PSS Select
VersaPro
Boca/ Ultilet
Moore Medical
Walgreens
CVS
Conzellin

But, the problem is bigger than just the prep pads and swabs for individual use. Triad Group also provides prep pads and swabs for inclusion in prepackaged drug and surgical instrument packets. Progenics Pharmaceuticals, Inc. and Pfizer Inc. have issued a Relistor warning because the drug was packaged with the contaminated Triad Group alcohol prep pads. The manufacturers indicate that there are no problems with the actual drug, but the packaged alcohol prep pads with Relistor should not be used. Some of these alcohol prep pads from Triad may have been included in U.S. packaging for ARIXTRA® Starter Kits manufactured by Glaxosmithkline.

The recalled Triad Group alcohol prep pad are also co-pckaged and distributed with the followiing Genentech, Inc. medicines in the United States: Boniva Injections, Fuzeon, Nutropn A.Q. Pen, Pegasys, and TNKase.

http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm239319.htm

BIll Would Require MRSA Screening and Management in Maine Hospitals and Nursing Homes

Meg Haskell of the Bangor Daily News is reporting on new legislation in Maine that would require all hospitals and nursing homes in Maine to screen high-risk patients for methicillin-resistant Staphylococcus aureus  (MRSA)upon admission. If nasal cultures detected MRSA, patients would be isolated and staff and visitors would be required to observe contact precautions.
The bill from Rep. Adam Goode defines high-risk patients include those who are admitted from another hospital or nursing facility or who have been discharged from a hospital or nursing facility within one year; are admitted to the hospital intensive care unit; receive renal dialysis for kidney failure; have open lesions that appear to be infected; are admitted for joint replacement or cardiac surgery; or are admitted from a correctional facility.
In addition to MRSA screening and management, the bill would require hospitals to report MRSA data to the CDC's National Health Safety Network. Information on the prevalence of other drug-resistant organisms, such as Clostridium difficile, also would be collected and made public.
To read further from the Bangor Daily News, CLICK HERE.

APIC Updates MRSA Guide

The Association for Professionals in Infection Control and Epidemiology (APIC) announces that it has published a second edition of its Guide to the Elimination of Methicillin-Resistant Staphylococcus aureus (MRSA) Transmission in Hospital Settings in an effort to provide the most current evidence-based practice guidance to protect patients from healthcare-associated infections. Developed by leading experts in infection prevention and hospital epidemiology, the revised guide includes updates and enhancements to the original APIC guide published in 2007. Additional references, resources, research findings and guidance are integrated into the best practice recommendations for effective hospital MRSA management programs.
MRSA is a type of staph bacteria that is resistant to certain antibiotics called beta-lactams. These antibiotics include methicillin and other more common antibiotics such as oxacillin, penicillin and amoxicillin. Drug-resistant pathogens are a growing threat to all people, especially in healthcare settings. According to the Centers for Disease Control and Prevention (CDC), more than 70 percent of the bacteria that cause hospital-associated infections are resistant to at least one of the drugs commonly used to treat them. In the U.S., MRSA is associated with an estimated 19,000 deaths and $3.2 billion to $4.2 billion in added costs annually.
"The human and financial impact of MRSA infections makes efforts to eliminate MRSA transmission in healthcare settings compelling and necessary," says Kathy Aureden, MS, MT (ASCP), SI, CIC, lead author of the guide and epidemiologist at Sherman Hospital in Elgin, Illinois.
To learn more about the Guide to the Elimination of Methicillin-Resistant Staphylococcus aureus (MRSA) Transmission in Hospital Settings and APIC’s extensive library of other elimination guides, as well as many more infection prevention resources,

http://www.apic.org/downloads/MRSA_elimination_guide_27030.pdf