APIC Chapter Excellence Award 2011

1. APIC Chapter Excellence Award2011 The submission of the Chicago Metropolitan Area Chapter (002) Marc-Oliver Wright, MT(ASCP), MS, CIC President, Chicago APIC

2. A Brief Overview Founded in the Fall of 1975 (We’re # 2!) Current membership: 270 Composition Acute Care Hospitals – 54% Vendors – 23% Ambulatory/Behavioral Health/Other – 8% Nursing Homes – 3% Other – 7% Department of Health – 3%

3. # of Members by Year 4th largest chapter in APIC behind New England, Minnesota, Indiana

4. Our membership area Meetings are held throughout the city and suburbs to distribute transportation distances for members

5. Provides services that promote, retain and serve their members Mentoring program initiated in 2010 in light of our increasing membership Members can register for education events online through the chapter website Scholarships for members to attend National APIC routinely made available

6. Participates in infection prevention, control and epidemiology activities that support the profession Chicago APIC devotes one educational meeting per year to Infection prevention in long-term care Designated chapter Legislative Liaison to monitor and inform members of legislative activities at the regional, state and national level

7. Criteria 2: Continued At least 5 educational meetings are held each year, with continuing education credits usually offered In 2010, 1st Statewide conference partnered with Central IL APIC and IDPH

8. Provides timely mechanisms for communication among members Chapter website: http://www.apicchicago.org Regular newsletter from the President/Board Upcoming events Legislative updates Abstracts and Publications from members National updates

11. Provides mechanisms for assessing Chapter needs and effectiveness of programs Every education session includes evaluation forms and results reviewed at subsequent Board Meeting Online assessments through Survey Monkey 2009: Online Chapter Learning Needs Assessment. Developed educational programs for 2010-2011 based on the results 2010: IL Statewide Conference Needs Assessment. Used response to guide development. 2011: CBIC study group survey, ByLaws electronic voting, Best use of chapter funds survey

14. In Summary Chicago APIC is a large and growing regional chapter with diverse needs among its members By streamlining information through the chapter website and a regular newsletter, the members are kept well informed of activities pertinent to the chapter, the profession, and the science

15. In Summary Recent partnerships with state health agencies and another regional chapter lead to Illinois initiating a statewide conference on healthcare associated infections By using online survey programs, the chapter actively assess the needs of its members and develops activities based on these needs

16. A preliminary assessment of the national data quality collaboration: the case studies Association for Professionals in Infection Control and Epidemiology, Inc. Annual Conference June 28, 2011 Baltimore, MD Marc-Oliver Wright, MT(ASCP), MS, CIC Director of Infection Control NorthShore University HealthSystem

17. Co-Authors University of Maryland Medical Center Joan N Hebden, RN, MS, CIC National Healthcare Safety Network; Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention Kathy Allen-Bridson, RN, BSN, CIC Gloria C Morrell, RN, MS, MSN, CIC Teresa Horan, MPH

18. Disclaimers Excelsior Medical Corporation: Travel expenses and honoraria Cardinal Health Infection Prevention Focus Group: Honoraria Carefusion MedMined: Honoraria Sagittarius, proud father of an 11 month old

19. Background National Healthcare Safety Network (NHSN) definitions for healthcare-associated infections used for years Among NHSN participants Among non-participants looking to compare internal data with external benchmarks For research and quality measures Recently as statewide initiatives for public reporting of HAIs Now as part inpatient prospective payment system

20. Background Definitions are based on common clinical presentation Simplified for widespread use Designed to maximize consistency for surveillance Not intended for diagnosis (surveillance definition vs. clinical definition) Participants undergo initial training and are informed of changes to definitions via updates from NHSN

21. Despite standard definitions, there was variation in Infection Preventionists applying the definitions

22. Began a series of case studies for IPs to test their knowledge about applying the definitions

23. Objectives of the case study series To present challenging case scenarios that will provide rationale and clarity in the use of the NHSN surveillance definitions, To provide an opportunity for personal competency assessment as well as for assessment of consistency between IPs within a facility, To meet the challenge identified 20 years ago, namely, additional means of training IPs.

24. Objectives of this study Assess competency among participants in applying the NHSN definitions to uniform cases Compare areas where participation (therefore NHSN training) are required to areas with no such requirement Identify opportunities for continuing education, clarification and/or definition review

25. Methods Initial drafts written by authors and circulated among coauthors for review/revision Based on real-life examples of IPs or scenarios brought to NHSN for clarification Circulated among NHSN/DHQP/CDC staff for review, revision and approval Case studies developed in SurveyMonkey online survey tool maintained by the authors Sent to AJIC Editorial Staff for publication

26. Methods continued Online anonymous surveys opened prior to publication and remained open for 3-5 months After taking the survey, answers with explanations and references were provided After closing the survey, site visitors were instructed to contact one of the authors to obtain copy of questions and answers Demographic data was voluntary

27. Analysis Proportions were calculated (#correct/#answers) Relative risk and Pearson’s chi-square were used for significance testing of differences between scores of users from mandated versus non-mandated states.

28. Respondents For Cases 2-4 the following categories of respondents participated Infection preventionists = 91.1% Medical Directors of Infection Prevention = 2.3% Public Health (EIS, state based HAI program etc) = 3.5% Other = 3.0%

29. 2,847 individuals participated in the first 4 cases Overall, there were 6,369 correct responses among 9,533 answers (66.8% correct)

30. Case Study #1 A 27-year-old man is admitted on 8/22 from another hospital with alcohol-induced pancreatitis. Admission abdominal CT showed severe pancreatitis with peripancreatic inflammatory changes. Patient is ventilator-dependent requiring a tracheostomy and has vascular catheters in place in the right subclavian and right internal jugular (IJ) veins. • On 9/3, an ultrasound-guided aspiration of pancreatic fluid revealed few polymorphonuclear cells and a negative bacterial culture. • On 9/11, a repeat abdominal CT revealed unchanged pancreatitis but interval development of multi-loculated fluid collections in the abdomen. • On 9/14, patient is taken to the OR for pancreatic debridement and placement of drains. Later that evening, patient had a temperature spike to 102° F. The right IJ line was discontinued and the catheter tip and blood specimens x 2 were sent for culture. • On 9/16, culture results were reported as follows: o Pancreatic fluid = no growth o Catheter tip = <15 CFU/ml of Enterococcus species o Blood cultures = 2 for 2 positive for Enterococcus faecalis. • No other sites of suspected infection were identified.

31. Answered correctly most often

32. Answered least correctly

33. A Case Study Example: Case #2 A 35-year-old man is involved in a multi-vehicular accident and sustains multiple internal and external traumatic injuries. On 12/5 in the emergency department, a triple lumen subclavian line and Foley catheter are placed and the stabilized patient is transferred to the intensive care unit. On 12/8, the patient spikes a temperature to 101°F and is “pan” cultured, including blood cultures x 2. On 12/10, the subclavian line is discontinued and the catheter tip is sent for culture. Later that afternoon, the blood culture results from 12/8 are reported as Staphylococcus hominis in both sets. The physician notes: “Positive blood culture = contaminant; no antibiotics required.” All other specimens cultured are negative. On 12/12, catheter tip results are reported as Staphylococcus epidermidis.

34. Answered correctly most often

35. Answered least correctly

36. Case #3 An 86-year-old female with history of COPD is admitted for cholecystectomy on 4/16. A chest x-ray (CXR) done that day is reported as showing no active infection or pleural effusion. • On 4/21 at 11:33 a.m:. a CXR is done for shortness of breath and is reported as possible left lower lobe infiltrate. Patient is afebrile and white blood cell (WBC) count is 8,000/uL. Patient is started on Prednisone 30 mg daily. At 12:00 p.m: partial pressure of Oxygen (PO2) = 84.9mm/hg. Patient suffers respiratory failure and is intubated. At 13:15 p.m: CXR is re-interpreted and reported as “Previous left lower lobe infiltrate actually represents an elevated hemidiaphragm. Lungs are clear.” At 8:00 p.m: patient is febrile at 101.3 °F. Arterial blood gases (ABG): Oxygen (O2) saturation is 75-96%, PO2 is 63mm/hg. 10:00 p.m: CXR report states that the Endotracheal (ET) tube extended into the right main bronchus causing collapse of the left lung. Tube is properly repositioned. • On the morning of 4/22 patient’s temperature ranges from 100.5-100.9 °F. WBC is 11,300/uL Piperacillin/Tazobactam and Vancomycin therapies are begun. ET aspirate is white and thin.

37. Case #3 Continued 6:00 a.m: CXR states left lower lung (LLL) atelectasis/infiltrate persists. 6:30 p.m: CXR shows LLL has re-expanded. • 4/23 6:00 a.m: CXR: LLL airspace disease and/or pleural effusion present. 12:30 p.m. Temperature: 100.4 °F. Bibasilar rales are present as is blood tinged ET aspirate. • 4/24-4/26 CXR: LLL airspace disease and/or pleural effusion unchanged. Patient is afebrile. WBC: 6,800-9,700/uL. Scattered rhonchi and rales are heard over both lungs, ET aspirate is thick and yellow and is sent for culture. ABGs: PO2 is 59-137mm/hg, O2 Saturation is 85-97%. 4/27 04:40: a.m. CXR shows bilateral airspace disease and /or pleural effusion. 8:00: p.m. temperature is 101.3 °F, moderate thick blood tinged ET aspirate, PO2 76.5mm/hg, O2 saturation 96%. ET aspirate culture positive for Pseudomonas aeruginosa. • 4/28 8:00 a.m: temperature is 102.3 °F. WBC are 8,100/ul, CXR is unchanged. • 4/29 - 4/30: CXR remains unchanged and patient is afebrile. • 5/1: ET aspirate collected for culture. • 5/3: ET aspirate culture positive for Pseudomonas sp. • 5/4: ET aspirate is clearing in color. CXR shows slight clearing of LLL.

38. Question 1

39. Question 2

40. Case #4 (new results) A 64 year-old man who is status-post orthotopic heart transplant 16 years ago is admitted on 2/1 for an elective percutaneous endoscopic gastrostomy (PEG) tube placement. Medical history is significant for respiratory failure due to H1N1 influenza pneumonia resulting in a tracheostomy and ventilator dependency, end-stage renal disease on hemodialysis three times/week, and hypertension. He was transferred from the ventilator unit of a long-term acute care facility (LTAC). A left internal jugular (IJ) tunneled catheter was in place for dialysis and a condom catheter was present, draining clear amber urine. • On 2/2 patient was taken to the Operating Room for elective placement of a PEG feeding tube and tolerated the procedure well. He was transferred to the Surgical ICU due to his ventilator requirement. Temperature range: 37.2°C - 37.6°C. Lungs clear bilaterally. PEG site oozing serosanguinous drainage. Call received from the LTAC facility that a stool specimen collected for abdominal pain and diarrhea prior to transfer was reported as positive for. C.difficile .Metronidazole started. • On 2/4 the patient remains in the SICU due to lack of a bed at the LTAC facility. At 2300, the patient has a temperature of 38.3°C. PEG site is clean and dry. No evidence of inflammation or drainage at the left IJ tunneled catheter site. Lungs clear bilaterally. Blood, urine and sputum cultures are sent.

41. Case #4 continued • On 2/5 in the AM, the urinalysis is reported as 3+ leukocyte esterase, WBC- too numerous to count and moderate bacteria. Patient continues with fever to 38°C. Co-trimoxazole is initiated. Patient receives hemodialysis. • On 2/6, the urine culture from 2/4 is reported as positive for 60,000 CFU/ml gram–negative bacilli which are subsequently identified as Providencia stuartii. Blood and sputum cultures are negative. Plans to send the patient back to the LTAC facility are cancelled due to increasing watery stools and complaints of abdominal pain with an increase in peripheral WBC from 11,000 to 25,000. CT of the abdomen suggestive of colitis. Continues with temperatures of 38°C. • On 2/9 the patient is moved to the intermediate care unit. Late that evening, he has a temperature spike to 38.8°C. Blood cultures are repeated. • On 2/10 the blood culture from 2/9 is reported as positive for gram-negative bacilli, which are subsequently identified as Providencia stuartii.

42. Answered correctly most often

43. Answered least correctly Right answer

44. Reporting vs non-reporting Presumably, states with mandated NHSN participation might differ from non-mandated states All respondents from mandated states would have undergone initial NHSN training whereas some unknown proportion of non-mandated respondents may not have received the same training Cases 2 and 4 (CLABSI) used to compare mandated vs non-mandated performance (CLABSI reporting universal for mandated states)

45. Mandated States AL CA CO CT DC DE IL MA MD NH NJ NY NV OK OR PA SC TN TX VT VA WA WV versus all other respondents (includes international) Mandated states = 64.0% correct Non-mandated locales = 60.5% correct Answers from states with mandatory reporting are 1.06 times more likely to be accurate than responses from areas without such requirements (RR 95% CI: 1.01 > 1.06 > 1.11 p=0.02) NOTE: differs from abstract

46. 2,847 individuals participated in the first 4 cases Overall, there were 6,369 correct responses among 9,533 answers (66.8% correct)

47. So…how did WE do? About the same. Case 2 = 82.9% Correct Case 3 = 62.5% Correct Case 4 = 56.8% Correct

48. A Comment on “Gaming” Recently there have been concerns expressed with regards to the potential for NHSN users to knowingly misreport These case studies address competency not behavior In depth validation and assessment at the facility or individual (IP) level are required

49. “Gaming” continued 74 year old female with ALL, syncope and ankle fracture with historical port accessed during hospitalization Day 5 single temp spike to 101.2; two sets of peripheral blood cultures grow coagulase-negative Staphylococcus. No other symptoms, fever reduced to baseline w/in 4 hours Discharged 4 days later with no antibiotic ever given, port intact, no note of infection in the chart. Not readmitted. Did this patient have a line infection? Probably not. Does she meet CLABSI definition? Yes. Did we do a huddle/RCA? No. Did we count and report it? Yes.

50. A reminder of the initial enrollment