Tuesday, August 31, 2010

HAI related provisions in the new health care reform bill

There has been a lot of buzz (and confusion) about the 1,000-page long health care reform bill that was signed into law in March by President Obama. Over the weekend, I challenged myself to read the entire bill and after failing to make it past the Table of Contents, I decided to read only the parts relevant to the prevention of HAIs.

The bill has several provisions on the public reporting of HAIs. Below is a summary:
  • Beginning in October 2012, non rural-acute care hospitals that meet or exceed federal performance standards for at least five measures, including certain HAIs, will receive higher Medicare payments [HR 3590, Title III, Subtitle A, Sec 3001, p. 235]
  • Beginning in October 2012, hospitals with high readmission rates for patients, including readmissions due to HAIs, will have their Medicare payment reduced [HR3590, Title III, Subtitle A, Sec 3205, p.290]
  • Beginning in 2014, the federal government will reduce Medicare payments by 1% for those hospitals in the top quartile for hospital-acquired conditions, including certain HAIs [HR 3590, Title III, Subtitle A, Sec 3008, p.258]
  • Beginning in 2014, the U.S. Health and Human Services Department will report, on its Hospital Compare website, each hospital’s record for medical errors and infections involving Medicare patients [HR 3590, Title III, Subtitle A, Sec 3008, p.258]

On a side note, there is a funny YouTube video on health care executives’ response to the bill.

Full text of bill

Monday, August 30, 2010

Not all patients with VRE need to be isolated

Findings recently published in Clinical Infectious Diseases indicate that not all strains of VRE require contact isolation, which might be seen as counterintuitive.  However, Sutter et al. looked at records for a 9-year period from a bone marrow transplant unit where contact isolation was not required for patients with VRE of genotype vanC – only for vanA and vanB. 

All patients in the bone marrow transplant unit had routine rectal VRE screening and genotyping.  Sutter et al’s goal was to estimate the risk of blood stream infections (BSIs) in patients colonized with VRE vanC.  During the years from January 2008 to July 2008, only one case of BSI was detected, while 290 isolates of VRE vanC were obtained from 273 patients.  This means that only 0.4% of the patients who had VREvanC developed a BSI, despite there being no contact isolation precautions in place.

Sutter et al. conclude that the study provides strong evidence that carriers of VRE vanC do not require contact isolation.  If there isn’t a high prevalence of VRE vanC in your hospital, this might not be as useful, but if genotyping is done and vanC is detected, the hospital does not need to spend resources on contact isolation, and patient care is improved. 

Article here: http://www.journals.uchicago.edu/doi/abs/10.1086/655824

New Technologies

We’re seeing all sorts of advances in fighting MRSA lately! AdvanSource Biomaterials Corporation recently received a patent for antimicrobial polyurethane resins, which can be used structurally or as coatings in different kinds of catheters, and are intended to help combat methicilin-resistant staphylococcus aureus (MRSA) infections.

Press release here: http://phx.corporate-ir.net/phoenix.zhtml?c=68271&p=irol-newsArticle&ID=1463328

Also, on the heels of the emergence of the NDM-1 gene, BioScience Laboratories announced that they’ve obtained seven clinical isolates of Carbapenem-Resistant (CR) Klebsiella pneumonia and Escherichia coli. BioScience Laboratories intends to use these isolates to test products for their predicted efficacy against bacteria containing the NDM-1 gene.

Press release here: http://www.24-7pressrelease.com/press-release-rss/bioscience-laboratories-announces-testing-capabilities-for-ndm1-165887.php

Octagam lots recalled

Market withdrawal of select Octagam 5% liquid preparation lots was initiated on August 20, due to an increased number of reported thromboembolic events, some of which were serious. Octagam is used to treat primary immunodeficiency diseases. The FDA advises customes not to administer any product from the lots being withdrawn.

See which lots were withdrawn, and read the full recall here: http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/Recalls/ucm223897.htm

Tuesday, August 24, 2010

New Hampshire releases first report on infections

Last week, New Hampshire released its first report on hospital-associated infection (HAI) rates. The report showed 134 infections during 2009, better than the 180 that was expected by state officials and lower compared to national data. Of the total 134 HAIs that were reported, 110 were surgical site infections (SSIs) and 24 were central line-associated bloodstream infections (CLABSIs).

New Hampshire passed the law in 2006 to publicly report hospital infection rates. In January 2009, all acute care hospitals began reporting CLABSIs and SSIs to the New Hampshire Department of Health and Human Services (DHHS). New Hampshire is one of 27 states that requires public reporting of hospital infections and is one of 20 states that have produced reports.

Monday, August 23, 2010

New coating kills MRSA on contact

Researchers have developed a way to coat surfaces with an enzyme that kills MRSA within 20 minutes of contact, says a recent publication in ACS Nano.  The enzyme, lysostaphin, degrades cell walls of Staphylococcus aureus and epidermidis, thus killing the harmful bacteria. 

The researchers had spent several years studying carbon nanotube-enzyme pairs, called conjugates.  Enzymes in coating alone either degrade or leach into the surroundings, but when paired with carbon nanotubes, the authors found that the enzymes were more stable and more densely packed when embedded into polymers such as paint. 

Lysostaphin is extremely selective, killing just S. aureus and epidermidis, is harmless to humans, and does not induce bacterial resistance.  The enzyme-nanotube conjugate also doesn’t become clogged over time, a common problem with other antimicrobial coatings.  Perhaps most impressively, antimicrobial films made with the conjugate were greater than 99% effective in killing all MRSA that came in contact with the film, measured after 2 hours.  And there’s even more: the films are reusable and washable, and stable under dry storage conditions for at least a month.

The lysostaphin-nanotube conjugate could be embedded into paint used in hospital rooms, or into films to put on various other hospital surfaces.  It will be extremely exciting to see how this technology is put to use.

Link to ACS Nano abstract: http://pubs.acs.org/doi/full/10.1021/nn100932t

Friday, August 20, 2010

HAI Reporting Survey

As you’re probably aware, the Centers for Medicare and Medicaid Services (CMS) recently released a rule that details HAI reporting requirements for Medicare-participating hospitals; starting January 1, 2011, hospitals will be required to report CLABSIs to NHSN, and they will be required to report SSIs starting January 2, 2012. 

We would like to ask our readers where they are in the process of meeting the CMS HAI reporting requirement.  We’ve developed a survey, and we would really appreciate it if you could take a few minutes of your time to complete it.  It’s just 10 easy, multiple choice questions.   We’ll publish the results once they’re compiled.

Please click here to take our survey!

Tuesday, August 17, 2010

You didn't really want that data, did you?

Missouri, one of the first states to pass legislation requiring hospitals to reveal annual HAI rates, has possibly  deleted all their infection rate data collected from 2005-2008.  State officials say that the data is too costly to maintain, and mention the sensitivity of the data as another motivating factor. 

However, the law doesn’t explicitly give authority to the state health department to delete the infection data, or the associated tables and results produced from data analysis.  The statute says “The data collected or published shall be available to the department”.  Subsequent requests for the data by the St. Louis Post-Dispatch got conflicting answers; one state official said the data was deleted, another said that the data was available, just “not handy.”

The department later said it would take public requests for information, but they would only be honored if a programmer was available and only if the requester was willing to pay the retrieval costs.  The state data manager, Mark Van Tuinen, cited budgetary constraints as the reason for data deletion, saying “Given our skimpy resources, we’re pretty much doing what the law tells us to do” – keep data compiled for a period of 12 months. 

A note on the state health website says “Due to the sensitive nature of the data and limited resources, DHSS staff cannot provide data or records beyond what are displayed on this website.”  Van Tuinen added, “Hospitals are sensitive about comparisons with each other.”

While it’s impossible to track the changes in infection rates without the data, it is interesting to note that the 2004 law establishing these reporting requirements did not allocate any funds with which to accomplish them. Missouri apparently had to face the question of how to keep the data accessible without any money to do it.  Fortunately for the public, the St. Louis Area Business Health Coalition backed up the data each year before it was removed, so even if Missouri did delete the data, it does still exist.

Regardless of whether the data was actually deleted or not, the issue certainly raises questions about how states should frame and implement the laws that require them to report and store HAI data, and how to best serve the public while doing so.

St. Louis Post-Dispatch story: http://www.stltoday.com/business/article_9959b4e1-2634-5722-b21d-c32876d205a0.html

DHSS website with reporting note: http://www.dhss.mo.gov/HAI/definition.html

What's in a name?

Recent reports of a superbug from India named ‘New Delhi Metallo-beta-lactamase 1’ or NDM-1 are generating criticism from Indian leadership. Director General of Health Services R. K. Srivastava takes issue with naming the bug after the region and for its jab at antibiotics policy.

Srivastava "strongly refuted the naming of the enzyme as New Delhi metallo-beta-lactamase and also refuted that hospitals in India are not safe for treatment including medical tourism."

Medical tourism is growing in nations like India and Pakistan, and concern around a superbug specifically associated with the area could put the entire industry at risk. The UK Department of Health responded to the Lancet journal article by issuing an alert about the New Delhi superbug.

Controversy in naming diseases and organisms is not a new phenomenon; the World Health Organization (WHO) proceeded with caution in naming the SARS virus.

David Heymann of the WHO’s SARS team said, “We did not want to stigmatize particular areas, it could not be called Hong Kong Flu or Hanoi flu.” The WHO finally decided on the acronym SARS, which stands for “Severe Acute Respiratory Syndrome,” not realizing that “SARS” was similar to the common acronym SAR which is used to describe Hong Kong as the “Special Administrative Region.”

The problem also affects animals; naming diseases after animal species (e.g. bird flu, swine flu) can result in stigmatizing livestock, and result in their mass slaughter.

So, we’re left with letters and numbers. MBL-1, anyone?

Monday, August 16, 2010

Western eating habits: worse than you think?

A study recently published in Proceedings of the National Academy of Sciences indicates that a rural diet might protect children from inflammation and noninfectious colonic disease.  Researchers compared the fecal microflora of 14 children ages 1-6 from a rural village in Burkina Faso to that of 15 similarly-aged children in Italy.  The children from the village in Burkina Faso, Boulpon, consumed a traditional diet that is low in fat and animal protein, and high in starch and fiber, whereas the Italian children consumed a typically Western diet high in sugar, fat, animal protein, and starch, and low in fiber. 

The two populations of children's gut microflora were similar while children were still being breast-fed; the differences grew once they started consuming the local diet.  Di Filippo et al. found that the children from Boulpon had roughly twice as many Bacteroidetes species as the Italian children, and that the Italian children had roughly twice as many Firmicutes species as the children from Boulpon.  A high ratio of Firmicutes to Bacteroidetes has been associated with obesity, potentially indicating that the Western diet of the Italian children predisposes them to future obesity. 

The children from Boulpon also had a greater richness and biodiversity of gut microflora, including exclusive possession of a number of species that produce high quantities of short-chain fatty acids (SCFAs), which are known to protect against gut inflammation.  As expected, the levels of SCFAs themselves in the Burkina Fasoian children were significantly higher than those in the Italian children.  Additionally, though the Italian children were healthy, they had a significantly higher level of Enterobacteriaceae that are potentially pathogenic, like Shigella and Escherichia. 

The results indicate that a Western diet could allow potentially harmful bacteria to gain a foothold in the gut, and could predispose children to obesity and gut inflammation.

Link to the article’s full text: http://www.pnas.org/content/early/2010/07/14/1005963107.full.pdf

Thursday, August 12, 2010

APIC and CDC to Provide Guidance on New CMS HAI Data-Reporting Mandate

The big news on July 30th, 2010 was that the Centers for Medicare and Medicaid services (CMS) enacted a rule requiring all Medicare participating hospitals to report data on central line associated bloodstream infections (CLABSIs) and surgical site infections (SSIs). Hospitals not submitting data on CLABSIs and SSIs may experience reduction in reimbursement payments.

APIC has taken the lead on providing information and guidance on the new reporting mandates with a webinar (details, link, and schedule still pending) in mid-August with speakers from CDC and CMS to discuss the reporting requirements. Additionally, both CMS and CDC are updating documents, support, and training.

HHS has also announced that its Hospital Compare web site will begin publicly reporting on infection rates among participating hospitals. Consumer Reports has similar data now, but Hospital Compare data can be expected to be more prevalent and current following the CMS rule and the 3,500 enrollments into the CDC’s NHSN program by Medicare participating hospitals.

Resources and information on CMS HAI Data-Reporting Rule:

CDC: New to NHSN? Page

APIC Statement on New CMS Rule

CDC Blog Posts on the CMS Rule

Text of CMS Rule

Wednesday, August 11, 2010

MRSA infections down, but new threat on the horizon

A study just published in The Journal of the American Medical Association (JAMA) shows that the incidence of hospital-onset methicillin-resistant staphylococcus aureus (MRSA) infection decreased by 28% from 2005 to 2008.  The measurements, taken from 9 major metropolitan areas across the country, also show that MRSA rates for healthcare-associated community-onset infections decreased 17% over the same time period. 

The study’s authors, Kallen et al., are unable to say why the rates decreased, but mention a couple possible factors.  The first possibility is the widespread implementation of MRSA prevention practices.  Kallen et al. note that “the fact that the observed reductions were greater among hospital-onset infections than healthcare–associated community-onset infections suggests that prevention practices in acute care settings contributed” to the decrease in MRSA infection rates.  Another potential factor is a change in the strains associated with MRSA infections, but the authors state that there weren’t changes in MRSA strain composition during that time period, so this is unlikely to be a valid explanation. 

Immediately on the heels of this good news comes a study published in The Lancet Infectious Diseases today, which details how a new bacterial gene might cause worldwide health problems.

NDM-1, which stands for New Dheli metallo-β-lactamase 1, makes bacteria highly resistant to many classes of antibiotics, including the carbapenems.  Unfortunately, the gene has been determined to be readily transmitted and also highly adaptable.  As bacteria that contains NDM-1 encounters bacteria that doesn’t, NDM-1 could insinuate itself into the new bacteria, thus creating a larger resistant population.  The problem is particularly worrying because there is not a single antibiotic in the discovery and production process that is effective against NDM-1-containing bacteria – and because NDM-1 is highly adaptable, it could potentially change itself to resist any drugs that are developed. 

In addition to this already grim news, most of the isolates taken from India were from community-acquired infections, which implies that bacteria with the NDM-1 gene are already pervasive.  The NDM-1 gene has also already spread to the UK and Sweden – and some of the UK patients had recently traveled to India for medical treatments. 

We’re left with a good news/bad news scenario: just as we are starting to see MRSA infection rates fall, we learn that NDM-1-containing bacteria is expected to spread around the globe.

JAMA article: http://jama.ama-assn.org/cgi/content/full/304/6/641
Lancet article: http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2810%2970143-2/fulltext

New Products

Yesterday, RyMed announced that it has received FDA approval for its newest IV connector, InVision-Plus® CS™ with Chlorhexidine-Silver Ion Engineering.  The new needleless connector has a septum that is impregnated with both chlorhexidine and silver ions, as well as a silver-impregnated fluid pathway.  Another new feature is a clear housing that lets clinicians see inside the connector. 

RyMed’s press release: http://www.rymedtech.com/assets/files/press/CS%20release%20FDA%20clearance%20--FINAL%20WEB.pdf

Censis Technologies, Inc. recently introduced their ScopeTrac system, which is an electronic tracking and management solution for endoscope reprocessing.  Inappropriate endoscope reprocessing can be a risk factor for HAIs, and ScopeTrac’s web-based system guides technicians through the required reprocessing procedures.  ScopeTrac also uses RFID and scanning technology to help manage and track the endoscopes.

Product page: http://www.censis.net/scopetrac

BMDI International has updated their line of helmet-based, daily-use respirators with the new MAXAIR 710 DLC.  This new product is a light-weight helmet with the air unit completely integrated so there are no hoses to restrict movement.  DLC stands for disposable lens cuff – easier on/off than traditional mask respirators, with no need for fit testing.  The product includes peripheral vision LEDs that give real-time safe airflow and battery information.

Product line page: http://maxairbmdi.com/01_Pages/systems.htm

Should hospitals adopt universal MRSA screening?

The legislators in Nevada are considering making universal MRSA (Methicillin-resistant Staphylococcus aureus) screening a law according to a recent news article.

MRSA is one of the most serious infections hospitals face today and its prevention has been a focus for hospitals and the CDC. The Veterans Affairs (VA) adopted a MRSA screening strategy that seemed the most aggressive: screen every patient who comes in the hospital. The cost-effectiveness of universal screening is under a lot of debate. Some argue that there is limited evidence to support the effectiveness of universal screening and that the cost as well as effort of screening every patient is too high to justify its adoption.

The VA has demonstrated a lot of success in its MRSA prevention program, and universal screening a key component. The state of Nevada is taking notice and wants the rest of the hospitals to follow suit.

P.S. Dr. Eli Perencevich posted on this topic in his blog. Check out his take on all this here.

Wednesday, August 4, 2010

VRE colonization test approved by FDA

Potentially good news for IPs – Spectra ™ VRE, reportedly the first chromogenic media for the 24-hour detection of VRE colonization, was approved by the FDA a week ago. According to Thermo Fisher Scientific, Spectra ™ VRE can differentiate between vancomycin-resistant E. faecalis and E. faecium within 24 hours, with no required confirmatory testing. Spectra ™ VRE is used with rectal swabs and stool specimens.

Spectra ™ VRE is manufactured, distributed, and sold by Remel, a product brand of Thermo Fisher Scientific.

Product page here: http://www.remel.com/HAI/VRE.aspx

Tuesday, August 3, 2010

Preventing Disease Outbreak in Pakistan Floods

A massive flood on Monday caused by monsoon rains has killed an estimated 1,500 people in Pakistan. The Pakistani government has launched a rescue campaign to save the 15,000 families in the region in need of emergency aid. As the relief efforts ramp up, officials fear that up to 100,000 people have already been hit by cholera and gastroenteritis in the affected Swat Valley.

Having returned recently from the New Orleans APIC show and with friends supporting the re-building effort, Hurricane Katrina is still fresh in memory. To compare the scale of these two disasters, Katrina similarly resulted in about 1,400 deaths in 2005. Even considering criticism of federal response, the triage and infection control effort was relatively fast. Within 5 days, nearly 5,000 people were triaged in New Orleans. Only 5 people died due to E. coli in the drinking water. Among evacuees, targeted surveillance identified 1,169 of the 6,500 in Houston’s Reliant Park medical clinic who reported acute gastroenteritis symptoms. Rehydration, isolation, and distribution of hand sanitizers controlled the outbreak. It continued for a week, but no deaths were reported due to gastroenteritis at Reliant Park.

Please consider giving to charitable organizations addressing the health needs of Pakistani flood victims. Let’s keep this from becoming an even worse disaster than it already is.

Officials fear disease outbreak in flood-hit Pakistan

Jaroka Tele-healthcare blog is following relief efforts on the ground

UNICEF Donations

Monday, August 2, 2010

IP Stories

One of my goals is to learn more about the work that infection preventionists (IPs) do on a daily basis, the challenges they face, and how they overcome them. "Interview an IP" is a project that we recently launched to let IPs share their stories with us and with each other. I am very grateful to Lisa Pope for taking the time to participate in our "Interview an IP" project. Below is her story.

Name: Lisa Pope, RN, BSN (Graduating with MSN in December 2010)

Number of years of infection prevention experience:
3 years

Which department does infection prevention come under at your hospital?
Total Quality Management

1. How did you become interested in infection control?

As an RN I was looking to grow professionally in nursing but continue to have a positive effect on patient care. As I complete my Masters Degree I find myself increasingly interested in the way in which the hospital operates on a daily basis and how day-to-day operations impact the quality of care, treatments, and services a patient receives. I actually began as the Joint Commission Coordinator and was asked to take on the responsibility of Infection Prevention a few months later when the position was vacated. I can’t say I ever considered this department before but I am happy to be in the role I am in today and having the opportunity to have such a large impact on patient stays.

2. Tell us a little bit about your hospital and your work

We are a 25 bed acute care hospital located in Michigan that has adopted the Planetree approach to care giving. A model of patient-centered care in a healing environment, staff is committed to improving medical care from the patient’s perspective, empowering patients and families through education, information and encouraging healing partnerships with caregivers. The hospital offers a newly renovated emergency department with private treatment rooms, an expanded medical imaging department, a regional cancer treatment center and an Eden Care award winning 54-bed Skilled Nursing facility. The hospital has been recognized for its quality care by the Michigan Quality Improvement Organization and has earned the Governor’s Award of Excellence for Improving Care in the Hospital Setting for 4 consecutive years, the Total Benchmark Solution quality award for 2005, and the 2006 and 2007 VHA Leadership Award for clinical excellence.

In my roles, I am responsible for the daily survey preparation coordination for our Joint Commission deemed status, all infection prevention activities, including surveillance, staff and patient education programs, process improvement, IP committee chair, and quality improvement activities for our facility with professional organizations such as MPRO, MHA, and Keystone. I am also responsible for the Employee Health department which involves surveillance of needle stick injury and exposures, new hire/volunteer/intern pre-employment health screening, communicable disease reporting and policy/procedure improvement efforts.

3. What are the top three infection prevention challenges at your hospital?

The top three infection prevention challenges in our facility are reaching all staff members with IP education that is tailored to their specific department needs, accountability for compliance with issues such as Infection Prevention strategies, and compliance with newly updated procedures for issues such as needle stick injury. Change is always difficult and when you bring a multitude of changes in a close time frame it is difficult for everyone to adhere to. Just keeping the most up to date information in front of their faces is often very difficult; even in a small facility.

4. How do you engage leadership to help achieve identified outcomes? Please provide a recent initiative, highlights, and lessons learned

Engaging leadership in a small facility is often very difficult as we all wear multiple hats so we have multiple tasks in front of us each day. Getting a leader who is pulled in multiple directions to focus on “your” tasks takes a lot of one-on-one dedication. You need to be skilled in knowing how to facilitate a lot of what you are asking them to help you with. I find that bringing as much research evidence to the meeting, or providing it ahead of time, helps move the meeting along and gives them an opportunity to come prepared with questions and following up with them is crucial.

Two years ago I began giving hand hygiene education in our local schools as a project for my master’s degree class. While there I discovered that the school had taken money away from their budget that had previously gone to soaps and sanitizers for the classrooms. That left the students and teachers to provide it. This is a low income area so that could be next to impossible for most families. I returned to work to begin discussing with them our opportunity to practice our mission “To improve the health of the communities we serve” and suggested we provide hand sanitizer stations in each classroom and common area. This would be a large financial undertaking but I managed to get EcoLab to donate the sanitizer stations and their staff’s time if we purchased the sanitizer. That provided a significant savings. After having open discussions with Senior Leaders about the benefits of not only teaching hand hygiene to the young but providing them with the necessary tools, they were quick to approve the initiative. Since that time the initiative has come to include a free influenza vaccine clinic that allows access to vaccination to those who may not otherwise be able to afford it. We have seen a great decrease in the number of flu-like symptom illnesses in our local schools. This year we are reaching or to two more local schools to begin to cover our coverage area.

5. How have patient safety initiatives and state reporting impacted you and your facility?

We are very conscientious of best practice initiatives and strive to set the standard for other facilities such as ours so patient safety reporting has not had a huge impact on our facility. Our quality department has some of the finest employees who dedicate a lot of time and attention to our patient’s safety.

6. If you could impact infection control at a national level, what would you do?

If I could impact Infection Prevention at a national level I could easily see myself working in some capacity on Capitol Hill pitching process improvements that would change the way all facilities practice. I believe that every Infection Preventionist should have a standard of practice that should not be deviated from but should be modified to meet the specific need of the community it serves. Hand hygiene best practice should never be a topic of conversation just because one manager or department head thinks it is too tedious of a practice for their staff. It is what is best for our patients and we should never question that…especially if the experts are providing us with the evidence to back it up.