Ronda L. Cochran, MPH Division of Healthcare Quality Promotion

1. The Prevention Collaborative: An Overview Ronda L. Cochran, MPH Division of Healthcare Quality Promotion

2. Background: The Admiral Stockdale Dilemma“Who am I and why am I here?”

3. Who’s Who in Activity “C”DHQP/CDC SMEs Prevention Collaboratives CDI & CAUTI MRSA & CLABSI CLABSI & Dialysis Carolyn Gould Alex Kallen Priti Patel CDI MRSA SSI LTC Ronda Cochran Nimalie Stone Cliff McDonald John Jernigan Sandra Berrios-Torres

4. Who’s Who in Activity “C” Prevention Liaisons Sandra Berrios-Torres Alice Guh Melissa Schaefer John Jernigan Priti Patel Alex Kallen Cliff McDonald Jeff Hageman Ronda Cochran Tara MacCannell Kate Ellingson

5. HAIs: National Burden • Leading cause of morbidity & mortality • Annual burden (2002 data) • 1.7 million HAIs in US healthcare settings • 99,000 deaths associated with HAIs • Annual cost • $33 billion added healthcare costs • Standard prevention recommendations (developed by CDC) can reduce HAIs by 70%; virtually eliminate some types of infection

6. Estimates of HAIs in US HospitalsAnnually

7. HAIs in Non-Hospital Settings • Long-term care • 1.7 million beds with 2.5 million residents/year nationally • Veterans Healthcare System: 133 LTCFs, 11,475 residents • HAI prevalence: 5.2% • Indwelling medical device: 25% of all residents • Ambulatory surgical centers: 5,175 facilities • Data on HAIs from outbreaks; no national surveillance • Example: hepatitis C outbreak associated with syringe reuse resulted in letters to > 40,000 endoscopy center patients • Dialysis centers: 4,950 facilities • Catheter-related bloodstream infections: 4.2 per 100 patient months • Incidence of methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection: 100 x greater than in nondialysis population NCHS, 2009 Tsan, AJIC, 2008 Klevens, Semin Dialysis, 2008 Thompson, Ann Intern Med 2009 MMWR May 16, 2008; 57:19 Kallen, 19th Annual SHEA Meeting, San Diego, 2009

8. Tranquil Gardens Nursing Home Acute Care Facility State Health Departments Home Care Outpatient/ Ambulatory Facility Long Term Care Facility

9. HHS Action Plan In January 2009, the Department of Health and Human Services (HHS) released the HHS Action Plan to Prevent Healthcare-Associated Infections (http://www.hhs.gov/ophs/initiatives/hai).

10. HHS Action Plan for HAI Prevention National 5 Year Goals

11. Timeline: 2009-2010 CDC FOA applications due ($39.8M) HHS summary report due to Congress HHS HAI Action Plan developed ELC & EIP awards made FY09 Omnibus Bill signed State HAI Plan requirement HHS HAI State Plans 52 submissions = (50 States, DC, & Puerto Rico) All States certified that they would submit a State HAI plan Recovery Act Passed $50M to States to prevent HAIs 2010 Jan 2009 Jan Feb Jun Sep June Mar Jul

12. February 13, 2009: Congress passed American Recovery and Reinvestment Act of 2009 February 17, 2009: President signed into law 3 primary goals: Create and save jobs Spur economic activity and invest in long-term economic growth Foster unprecedented levels of accountability and transparency in government spending Recovery Act Overview

13. Prevention and Wellness Fund HHS Office of the Secretary: provide to states to reduce healthcare-associated infections (HAI) Focus: U.S. healthcare infrastructure / costs Requires merit-based selection of recipients Deliver programmatic results Achieve economic stimulus $50 million for HAI prevention $10 million to Centers for Medicare & Medicaid Services (CMS) $40 million to CDC Eligibility limited to states Recovery Act for HAI Overview

14. Recovery Act for HAIEpidemiology & Laboratory Capacity (ELC) $35.8 million to address HHS Action Plan using existing ELC cooperative agreement to build & sustain state programs to prevent HAIs • Activity A: • State HAI Program • State HAI plan & State HAI coordinator • Multidisciplinary committee for State HAI program • Report to CDC on progress in HAI prevention • Activity B: • Expand Surveillance • NHSN state coordinator • Training for hospitals • NHSN expansion • NHSN reporting on HHS targets • Validation studies • Activity C: • Prevention • Collaboratives • Training for hospitals • Linkage to other HHS & private sector initiatives • AHRQ, CMS • Achieving HHS Prevention targets

15. Healthcare-associated Infections (HAI): Recovery ActEpidemiology & Laboratory Capacity (ELC) 2009 KY NC NC TN 4 SC GA MS AL FL AK WA WA 1 NH MN ME VT 10 ND MT ME OR OR ID WI 5 ID MA 8 MI SD WY CT RI OH IL IN 2 PR IA NV UT 7 NE 3 PA NY CO CA NY 9 DE KS MO WV VA MD DC AZ NJ KY HI 6 OK AR DHQP Public Health Advisors Region 1 – Kim Zimmerman Region 2 – Ramona Bennett Region 3 – Ramona Bennett Region 4 – Wendy Vance Region 5 – Jason Snow Region 6 – Jason Snow Region 7 – Ramona Bennett Region 8 – Laura McAllister Region 9 – Kim Zimmerman Region 10 – Wendy Vance EIP sites – Laura McAllister NM Activity Color Legend A Only B Only A & B Only A & C Only B & C Only A, B, & C No Activities TX LA Symbol Legend EIP Sites CSTE Fellows HHS Regional Health Administrators HQ CDC-DHQP, 09/10/2009

16. Performance Analysis • Quarterly Performance Reporting for HAI programs underway. • Preliminary Data • ELC • Recipients that have identified an HAI Coordinator: 51 (100%) • New hospitals enrolled in NHSN since 9/1/10: 467 • State plans submitted: 51 (they were due 1/1/10)

17. Recovery Act for HAI Opportunity & Impact • Promote rapid development and expansion of state-based efforts on HAI prevention • Develop and expand HAI prevention expertise in State Health Departments • Strengthen collaboration with HHS and HHS agencies—AHRQ, CMS • Provide a model for population-based prevention of healthcare safety challenges • Prevent infections, reduce deaths

18. Planned State HAI Activities Prevention Surveillance Prevention Collaborative Establishing HAI Prevention Collaboratives using ARRA Funds

19. Why Collaborate?

20. Definition from Merriam Webster • Main Entry: col·lab·o·rate • Pronunciation: \kə-ˈla-bə-ˌrāt\ • Function: intransitive verb • Inflected Form(s): col·lab·o·rat·ed; col·lab·o·rat·ing • Etymology: Late Latin collaboratus, past participle of collaborare to labor together, from Latin com- + laborare to labor • Date: 1871 • 1: to work jointly with others or together especially in an intellectual endeavor2: to cooperate with an agency or instrumentality with which one is not immediately connected

21. “Collaboration” – What does it mean? • “Coming together is a beginning. Keeping together is progress. Working together is success.” – Henry Ford. • “Teamwork divides the task and multiplies the success.” - Author Unknown • “Individual commitment to a group effort - that is what makes a team work, a company work, a society work, a civilization work.” - Vince Lombardi • “Alone we can do so little; together we can do so much.” – Helen Keller • “Teamwork is the ability to work together toward a common vision; the ability to direct individual accomplishment toward organizational objectives. It is the fuel that allows common people to attain uncommon results.” – Andrew Carnegie • “Strength is derived from unity.  The range of our collective vision is far greater when individual insights become one.” – Andrew Carnegie • “Collaboration equals innovation.” - Michael Dell • “The most important single ingredient in the formula of success is knowing how to get along with people.” – Theodore Roosevelt • “In the long history of humankind (and animal kind, too) those who learned to collaborate most effectively have prevailed.” – Charles Darwin

22. Why Is The Prevention Collaborative Model Important?

23. What is the Preventable Fraction of Healthcare Associated Infections? • Study on the Efficacy of Nosocomial Infection Control (SENIC) study results • 1971-1976 • Suggested 6% of all nosocomial infections could be prevented by minimal infection control efforts, 32% by “well organized and highly effective infection control programs” • Harbarth et al: at least 20% of infections are preventableJ Hosp Infection 2003;54:258

24. What is the Preventable Fraction of Healthcare Associated Infections? • Some may have interpreted these data to mean that most healthcare associated infections are inevitable • What impact has this had on the psychology of prevention? • How has this influenced the way infection control programs operate? • Difficult to define success when achievable results unknown-what should the goal be?

25. Eliminating catheter-related bloodstream infections in the intensive care unit Berenholtz, S et al. Critical Care Medicine. 32(10):2014-2020, October 2004.

26. Overall rate reduction of 68% MMWR 2005;54:1013-6

27. Michigan Keystone ICU Project(103 ICUs, 67 hospitals) Maybe the preventable fraction of HAIs is much larger than we thought? Overall rate reduction of 66% Pronovost et al. NEJM 2006;355:2725-2732

28. Conclusions from Pittsburgh and Michigan Experiences • Decreases in central line-associated BSI rates >60% achieved in hospital ICUs of varying types • The prevention practices utilized during these interventions were not novel • Improving adherence to existing evidence-based practices can prevent BSIs • Collaboration may be helpful in identifying and overcoming commonly shared barriers to adherence

29. Conclusions from Pittsburgh and Michigan Experiences • Results from successful collaborative demonstration projects may be an important strategy for influencing global changes in practice in ways that improve quality • Disarms uncertainties about preventability that can hamper improvement efforts • Helps identify practical strategies that can be successful across many facilities

30. Successful, multi-center, regional Prevention Collaboratives will have national impact! • Must involve motivated acute and/or long-term care facilities who are interested in working in partnership with others to: • Identify setting-specific barriers and challenges (i.e., because long-term care is very different from acute care) • Identify workable and practical solutions to those barriers • Take responsibility as a region of healthcare facilities, work together to address the problem • Create connections and relationships that bridge the gaps between facilities • “Intervention clusters” • Be open to innovation • Collect and share data in a uniform fashion • Be in it for the long haul • Contribute to an effort that will likely have major and enduring impact on the health of patients not only in your center, but across the Nation

31. How Do You Collaborate?A “Cookbook” to CollaborationEstablishing HAI Prevention Collaboratives using ARRA Funds .

32. Cookbook Outline • Recipes* for Success • Staffing: Where to begin • Multidisciplinary Advisory Group • Participating Healthcare Facilities (e.g., Hospitals) • Meetings • Measurement • Communication: How to sustain momentum *Note: “Season” to local taste

33. Where to Begin?: Staffing • Collaboration Metrics: • Project coordinator on staff • Infection control and prevention expertise available or on staff • Expertise in multicenter collaborative improvement projects available or on staff

34. Staffing: Suggested Ingredients • Infection Prevention and Clinical Expertise • Available at Health Department or as a consultant • Review the literature from expert(s) in your state • Important to have experts who are passionate and committed to infection prevention, suitable for championing concepts • Contact local APIC (Association for Professionals in Infection Control and Epidemiology) chapters - http://www.apic.org/ • Consult with academic partners and experts in healthcare epidemiology at local hospitals and/or universities (i.e., Society for Healthcare Epidemiology of America [SHEA] members - http://www.shea-online.org/) • CDC SME expert (Prevention Liaisons)

35. Staffing: Suggested Ingredients • Infection Prevention and Clinical Expertise • Provide facilities with suggestions for performing tasks and assist with data validation • All facilities using same criteria and data elements • Training for hospital staff on data elements and criteria • Help guide facility information sharing sessions • Encourage discussion of what is working and what is not to improve prevention activities • Front line personnel working in the individual hospitals should be involved in finding solutions to problems

36. Create and Convene a Multidisciplinary Advisory Group • Collaboration Metrics: • Letters of commitment from steering group members • Face to face meetings • Selection of targets for prevention collaborative • Selection of specific prevention goal • Feedback of outcomes to steering group

37. Advisory Group + Hospitals = COLLABORATION Multidisciplinary Advisory Group Healthcare Facilities (e.g., Hospitals) Consumers Mentor hospitals Payers Purchasers Professional Organizations Hospital Associations Health Departments Engaging Partners: Suggested Ingredients

38. Engaging Partners • Main Entry: part·ner • Pronunciation: \pärt-nər also pärd-\ • Function: noun • Etymology: Middle English partener, alteration of parcener, from Anglo-French, coparcener • Date: 14th century • 1archaic: one that shares 2: one associated with another especially in an action --- entities/groups working together towards a common HAI prevention goal

39. Partner Groups • Composition (representation/diverse experts) – involve multiple stakeholders • E.g., Health Department, healthcare facilities (i.e., approximately 2-3 mentor hospitals), payors, purchasers, consumers, hospital associations, quality improvement organizations, professional organizations • Not all hospitals participating in the Collaborative should be part of the Multidisciplinary Advisory Group – just the 2-3 mentor hospitals • Consider formalizing structure (i.e., a charter or a memorandum of understanding) – including leadership (Chair, Co-Chair), operating rules, other policies (e.g., conflicts of interest, financial relationships), etc. • Note: the more people involved, the greater the number of communications and coordination needed.

40. Partnering with Hospitals • Identify, recruit, and enroll participating hospitals • Initial contact suggested: Administration/hospital leadership (i.e., CEO, CMO) • Obtaining Hospital Buy-in • Focus on the positives, such as: • The prevention of HAIs are best pursued and served through a collaboration rather than through individual efforts • Immediate and long-range consequences for the public, government, beneficiaries • The specific impact the hospital is likely to experience because of the collaboration effort • Think about what would want to make them join or barriers that may be in place – why is this mutually beneficial?

41. Partnering with Hospitals: Suggested Ingredients • Should be committed and enthusiastic about prevention and able to identify local champion(s) • Encourage active support and engagement from hospital leadership (e.g., CEO, CMO, CNO, CQO) • Also should encourage ideas from unexpected sources (e.g., housekeeping, transport) • Willing to communicate and share ideas including a willingness to participate in measurement system and share data with central coordinator • Get it in writing… letters of support and permission to use data

42. Implementation and Intervention Packages

43. Core Prevention Strategies High levels of scientific evidence Demonstrated feasibility Supplemental Prevention Strategies Some scientific evidence Variable levels of feasibility Prevention Strategies *The Collaborative should at a minimum include core prevention strategies. Supplemental prevention strategies also may be used. Hospitals should not be excluded from participation if they already have ongoing interventions using supplemental prevention strategies.

44. Central Line-Associated Bloodstream Infections (CLABSI) Prevention Strategies Core Supplemental Remove unnecessary central lines Follow proper insertion practices Facilitate proper insertion practices Perform hand hygiene in compliance with CDC/WHO Choose proper insertion sites Perform adequate skin cleansing of insertion site Perform adequate hub/access port cleansing Provide education on insertion and maintenance of central lines Implement chlorhexidine bathing Use antimicrobial-impregnated catheters Apply chlorhexidine-impregnated sponge dressings

45. Surgical Site Infection (SSI)General Prevention Strategies Core Supplemental Identify and treat remote infections before elective operation Administer antimicrobial prophylaxis in accordance with evidence based standards and guidelines Adjust antimicrobial prophylaxis dose for obese patients (body mass index >30) Remove hair at the operative site only when necessary and then only by clipping or depilatory agent Prepare the skin at the surgical site with an appropriate antiseptic agent Redose antibiotic at the 3 hr interval in procedures with duration >3hrs Reduce unnecessary OR traffic and keep doors closed during surgery Protect primary closure incisions with sterile dressing for 24-48 hrs post-op Maintain immediate postoperative normothermia Discontinue antibiotics within 24hrs after surgery end time (48hrs for cardiac) Feedback surgeon specific infection rates

46. Surgical Site Infection (SSI)Specialized Prevention Strategies Core Supplemental • Colorectal surgery patients • Mechanically prepare the colon (Enemas, cathartic agents) • Administer non-absorbable oral antimicrobial agents in divided doses on the day before the operation • Cardiac surgery patients • Measure blood glucose level at 6AM on POD#1 and #2 with procedure day = POD#0 • Maintain post-op blood glucose level at <200mg/dL • Elective orthopedic and neurosurgery patients with implants • Nasal screen and decolonize only Staphylococcus aureus carriers with preoperative mupirocin therapy • Arthroplasty and spinal fusion patients • Screen preoperative blood glucose levels and maintain tight glucose control POD#1 and POD#2 • Patients undergoing other select procedures • Use at least 50% fraction of inspired oxygen intraoperatively and immediately postoperatively

47. Measurement and Feedback

48. Measurement • Collaboration Metrics: • Select measurement system (e.g., NHSN) • Demonstrate willingness of facilities to participate in measurement system and share data with central coordinator (i.e., letters of commitment) • Demonstrate regular feedback of outcome data to participating facilities, to include a comparison of their individual performance to aggregate performance of others

49. Measurement: Suggested Ingredients • Use NHSN • Consistency with NHSN definitions is required • Evaluate prevention practices using standardized questions from CDC (infection toolkits) • Conduct surveys at designated time periods/intervals (i.e., baseline and 6-12 months into collaboration) • Communicate and Feedback Results (Shared Learnings)

50. Measurement: Suggested Ingredients • Identify goals and targets: “The goal is where you want to be. The objectives are the steps needed to get there." • Be “SMART”: Specific – Measurable – Attainable – Relevant – Timely • Define the “who”, “what”, “when”, “why”, and “how” • Evaluate both process and outcome measures • Process: how have specific prevention measures been implemented (i.e., compliance with hand hygiene, insertion practices – available in NHSN) • Outcome: what was the impact of the program and what were the program effects (i.e., a reduction in infection rates using NHSN)