ࡱ>  bjbjyy ޗlJd d   $PH\Nx!$(@(((./d04NPPPPPP$3Pt1(.(.|11t((L !5!5!51((N!51N!5!52`V(f u2\:<h525VV54G:00j0"!500':0:0:0tt4:0:0:011115:0:0:0:0:0:0:0:0:0d : Template for State Healthcare-associated Infection Plan In response to the increasing concerns about the public health impact of healthcare-associated infections (HAIs), the US Department of Health and Human Services (HHS) has developed an Action Plan to help prevent Healthcare-associated Infections. The HHS Action Plan includes recommendations for surveillance, research, communication, and metrics for measuring progress toward national goals. Three overarching priorities have been identified: Progress toward 5-year national prevention targets (e.g., 50-70% reduction in bloodstream infections); Improve use and quality of the metrics and supporting systems needed to assess progress towards meeting the targets; and Prioritization and broad implementation of current evidence-based prevention recommendations Background: The 2009 Omnibus bill required states who received Preventive Health and Health Services (PHHS) Block Grant funds to certify that they would submit a plan to reduce HAIs to the Secretary of Health and Human Services not later than January 1, 2010. In order to assist states in responding within the short timeline required by that language and to facilitate coordination with national HAI prevention efforts, the Centers for Disease Control and Prevention (CDC) created a template to assist state planning efforts. This template helps to ensure progress toward national prevention targets as described in the HHS Action Plan. CDC is leading the implementation of recommendations on national prevention targets and metrics and states should tailor the plan to their state-specific needs. Initial emphasis for HAI prevention focused on acute care, inpatient settings, and then expanded to outpatient settings. The public health model of population-based healthcare delivery places health departments in a unique and important role in this area, particularly given shifts in healthcare delivery from acute care settings to ambulatory and long term care settings. In non-hospital settings, infection control and oversight have been lacking which have resulted in outbreaks which can have a wide-ranging and substantial impact on affected communities. At the same time, trends toward mandatory reporting of HAIs from hospitals reflect increased demand for accountability from the public. The State HAI Action Plan template targets the following areas: Enhance HAI Program Infrastructure Surveillance, Detection, Reporting, and Response Prevention Evaluation, Oversight, and Communication With new Ebola-related, infection control activities, the following two tables have been added to reflect those activities: Infection Control Assessment and Response (Ebola-associated activity from FOA Supplement, CK14-1401PPHFSUPP15, Project A) Targeted Healthcare Infection Prevention Programs (Ebola-associated activity from FOA Supplement, CK14-1401PPHFSUPP15, Project B) Framework and Funding for Prevention of HAIs CDCs framework for the prevention of HAIs builds on a coordinated effort of federal, state, and partner organizations and is based on a collaborative public health approach that includes surveillance, outbreak response, infection control, research, training, education, and systematic implementation of prevention practices. Legislation in support of HAI prevention provides a unique opportunity to strengthen existing state capacity for prevention efforts. Template for developing HAI plan The following template provides choices for enhancing state HAI prevention activities in the six areas identified above. For each section, please choose elements which best support current activities or planned activities. Current activities are those in which the state is presently engaged and includes activities that are scheduled to begin using currently available resources. Planned activities represent future directions the state would like to move in to meet currently unmet needs, contingent on available resources and competing priorities. A section for additional activities is included to accommodate plans beyond the principal categories. 1. Enhance HAI program infrastructure Successful HAI prevention requires close integration and collaboration with state and local infection prevention activities and systems. Consistency and compatibility of HAI data collected across facilities will allow for greater success in reaching state and national goals. Please select areas for development or enhancement of state HAI surveillance, prevention, and control efforts. Table 1: State infrastructure planning for HAI surveillance, prevention, and control. Check Items UnderwayCheck Items PlannedItems Planned for Implementation (or currently underway) Target Dates for Implementation Establish statewide HAI prevention leadership through the formation of multidisciplinary group or state HAI advisory council FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Collaborate with local and regional partners (e.g., state hospital associations, professional societies for infection control and healthcare epidemiology, academic organizations, laboratorians, and networks of acute care hospitals and long term care facilities). NEW: Include hospital preparedness partners (e.g., hospital/healthcare coalitions funded through the ASPR Hospital Preparedness Program). Additional representation from accrediting and/or licensing agency with surveyor authority is ideal. NEW: Engage HAI advisory committee in potential roles and activities to improve antibiotic use in the state (antibiotic stewardship) NEW: Engage HAI advisory committee in activities to increase health departments access to data and subsequently use those data in prevention efforts October 1, 2015 FORMCHECKBOX   FORMCHECKBOX  Identify specific HAI prevention targets consistent with HHS priorities Other activities or descriptions: Establish an HAI surveillance prevention and control program FORMCHECKBOX  FORMCHECKBOX  Designate a State HAI Prevention Coordinator  FORMCHECKBOX  FORMCHECKBOX  Develop dedicated, trained HAI staff with at least one FTE (or contracted equivalent) to oversee HAI activities areas (Integration, Collaboration, and Capacity Building; Reporting, Detection, Response, and Surveillance; Prevention; Evaluation, Oversight, Communication, and Infection Control)Other activities or descriptions: Integrate laboratory activities with HAI surveillance, prevention, and control efforts. FORMCHECKBOX  FORMCHECKBOX  Improve laboratory capacity to confirm emerging resistance in HAI pathogens and perform typing where appropriate (e.g., outbreak investigation support, HL7 messaging of laboratory results)Other activities or descriptions:  FORMCHECKBOX  FORMCHECKBOX  Improve coordination among government agencies or organizations that share responsibility for assuring or overseeing HAI surveillance, prevention, and control (e.g., State Survey agencies, Communicable Disease Control, state licensing boards) Other activities or descriptions:  FORMCHECKBOX  FORMCHECKBOX  Facilitate use of standards-based formats (e.g., Clinical Document Architecture, electronic messages) by healthcare facilities for purposes of electronic reporting of HAI data. Providing technical assistance or other incentives for implementations of standards-based reporting can help develop capacity for HAI surveillance and other types of public health surveillance, such as for conditions deemed reportable to state and local health agencies using electronic laboratory reporting (ELR). Facilitating use of standards-based solutions for external reporting also can strengthen relationships between healthcare facilities and regional nodes of healthcare information, such as Regional Health Information Organizations. (RHIOs) and Health Information Exchanges (HIEs). These relationships, in turn, can yield broader benefits for public health by consolidating electronic reporting through regional nodes. Other activities or descriptions:  2. Surveillance, Detection, Reporting, and Response Timely and accurate monitoring remains necessary to gauge progress towards HAI elimination. Public health surveillance has been defined as the ongoing, systematic collection, analysis, and interpretation of data essential to the planning, implementation, and evaluation of public health practice, and timely dissemination to those responsible for prevention and control. Increased participation in systems such as the National Healthcare Safety Network (NHSN) has been demonstrated to promote HAI reduction. This, combined with improvements to simplify and enhance data collection, and improve dissemination of results to healthcare providers and the public are essential steps toward increasing HAI prevention capacity. The HHS Action Plan identifies targets and metrics for five categories of HAIs and identified Ventilator-associated Pneumonia as an HAI under development for metrics and targets (Appendix 1): Central Line-associated Blood Stream Infections (CLABSI) Clostridium difficile Infections (CDI) Catheter-associated Urinary Tract Infections (CAUTI) Methicillin-resistant Staphylococcus aureus (MRSA) Infections Surgical Site Infections (SSI) Ventilator-associated Pneumonia (VAP) State capacity for investigating and responding to outbreaks and emerging infections among patients and healthcare providers is central to HAI prevention. Investigation of outbreaks helps identify preventable causes of infections including issues with the improper use or handling of medical devices; contamination of medical products; and unsafe clinical practices. Table 2: State planning for surveillance, detection, reporting, and response for HAIs Check Items UnderwayCheck Items PlannedItems Planned for Implementation (or currently underway) Target Dates for ImplementationImprove HAI outbreak detection and investigation  FORMCHECKBOX  FORMCHECKBOX Work with partners including CSTE, CDC, state legislatures, and providers across the healthcare continuum to improve outbreak reporting to state health departments FORMCHECKBOX  FORMCHECKBOX Establish protocols and provide training for health department staff to investigate outbreaks, clusters, or unusual cases of HAIs. FORMCHECKBOX  FORMCHECKBOX Develop mechanisms to protect facility/provider/patient identity when investigating incidents and potential outbreaks during the initial evaluation phase, where possible, to promote reporting of outbreaks FORMCHECKBOX  FORMCHECKBOX Improve overall use of surveillance data to identify and prevent HAI outbreaks or transmission in HC settings (e.g., hepatitis B, hepatitis C, multi-drug resistant organisms (MDRO), and other reportable HAIs)Other activities or descriptions:  FORMCHECKBOX  FORMCHECKBOX Enhance laboratory capacity for state and local detection and response to new and emerging HAI issues.  Other activities or descriptions: Improve communication of HAI outbreaks and infection control breaches FORMCHECKBOX  FORMCHECKBOX Develop standard reporting criteria including, number, size, and type of HAI outbreak for health departments and CDC  FORMCHECKBOX  FORMCHECKBOX Establish mechanisms or protocols for exchanging information about outbreaks or breaches among state and local governmental partners (e.g., State Survey agencies, Communicable Disease Control, state licensing boards)Other activities or descriptions: Identify at least 2 priority prevention targets for surveillance in support of the HHS HAI Action Plan FORMCHECKBOX  FORMCHECKBOX Central Line-associated Bloodstream Infections (CLABSI) FORMCHECKBOX  FORMCHECKBOX Clostridium difficile Infections (CDI) FORMCHECKBOX  FORMCHECKBOX Catheter-associated Urinary Tract Infections (CAUTI) FORMCHECKBOX  FORMCHECKBOX Methicillin-resistant Staphylococcus aureus (MRSA) Infections FORMCHECKBOX  FORMCHECKBOX Surgical Site Infections (SSI) FORMCHECKBOX  FORMCHECKBOX Ventilator-associated Pneumonia (VAP)Other activities or descriptions:Adopt national standards for data and technology to track HAIs (e.g., NHSN).  FORMCHECKBOX  FORMCHECKBOX Develop metrics to measure progress towards national goals (align with targeted state goals). (See Appendix 1). FORMCHECKBOX  FORMCHECKBOX Establish baseline measurements for prevention targetsOther activities or descriptions: Develop state surveillance training competencies  FORMCHECKBOX  FORMCHECKBOX Conduct local training for appropriate use of surveillance systems (e.g., NHSN) including facility and group enrollment, data collection, management, and analysisOther activities or descriptions:  FORMCHECKBOX  FORMCHECKBOX Develop tailored reports of data analyses for state or region prepared by state personnelOther activities or descriptions:  FORMCHECKBOX  FORMCHECKBOX Validate data entered into HAI surveillance (e.g., through healthcare records review, parallel database comparison) to measure accuracy and reliability of HAI data collection FORMCHECKBOX  FORMCHECKBOX Develop a validation plan FORMCHECKBOX  FORMCHECKBOX Pilot test validation methods in a sample of healthcare facilities FORMCHECKBOX  FORMCHECKBOX Modify validation plan and methods in accordance with findings from pilot project FORMCHECKBOX  FORMCHECKBOX Implement validation plan and methods in all healthcare facilities participating in HAI surveillance FORMCHECKBOX  FORMCHECKBOX Analyze and report validation findings FORMCHECKBOX  FORMCHECKBOX Use validation findings to provide operational guidance for healthcare facilities that targets any data shortcomings detectedOther activities or descriptions: Develop preparedness plans for improved response to HAI FORMCHECKBOX  FORMCHECKBOX Define processes and tiered response criteria to handle increased reports of serious infection control breaches (e.g., syringe reuse), suspect cases/clusters, and outbreaksOther activities or descriptions:  FORMCHECKBOX  FORMCHECKBOX Collaborate with professional licensing organizations to identify and investigate complaints related to provider infection control practice in non-hospital settings and set standards for continuing education and training Other activities or descriptions: Adopt integration and interoperability standards for HAI information systems and data sources  FORMCHECKBOX  FORMCHECKBOX Improve overall use of surveillance data to identify and prevent HAI outbreaks or transmission in HC settings (e.g., hepatitis B, hepatitis C, multi-drug resistant organisms (MDRO), and other reportable HAIs) across the spectrum of inpatient and outpatient healthcare settings FORMCHECKBOX  FORMCHECKBOX Promote definitional alignment and data element standardization needed to link HAI data across the nation.Other activities or descriptions: Enhance electronic reporting and information technology for healthcare facilities to reduce reporting burden and increase timeliness, efficiency, comprehensiveness, and reliability of the data FORMCHECKBOX  FORMCHECKBOX Report HAI data to the publicOther activities or descriptions:  FORMCHECKBOX  FORMCHECKBOX Make available risk-adjusted HAI data that enable state agencies to make comparisons between hospitals.Other activities or descriptions:  FORMCHECKBOX  FORMCHECKBOX Enhance surveillance and detection of HAIs in nonhospital settingsOther activities or descriptions:  3. Prevention State implementation of HHS Healthcare Infection Control Practices Advisory Committee (HICPAC) recommendations is a critical step toward the elimination of HAIs. CDC and HICPAC have developed evidence-based HAI prevention guidelines cited in the HHS Action Plan for implementation. These guidelines are translated into practice and implemented by multiple groups in hospital settings for the prevention of HAIs. CDC guidelines have also served as the basis for the Centers for Medicare and Medicaid Services (CMS) Surgical Care Improvement Project. These evidence-based recommendations have also been incorporated into Joint Commission standards for accreditation of U.S. hospitals and have been endorsed by the National Quality Forum. Please select areas for development or enhancement of state HAI prevention efforts. Table 3: State planning for HAI prevention activities Check Items UnderwayCheck Items PlannedItems Planned for Implementation (or currently underway) Target Dates for ImplementationImplement HICPAC recommendations FORMCHECKBOX  FORMCHECKBOX Develop strategies for implementation of HICPAC recommendations for at least 2 prevention targets specified by the state multidisciplinary group.Other activities or descriptions: Establish prevention working group under the state HAI advisory council to coordinate state HAI collaboratives  FORMCHECKBOX  FORMCHECKBOX Assemble expertise to consult, advise, and coach inpatient healthcare facilities involved in HAI prevention collaborativesOther activities or descriptions: Establish HAI collaboratives with at least 10 hospitals (this may require a multi-state or regional collaborative in low population density regions) FORMCHECKBOX  FORMCHECKBOX Identify staff trained in project coordination, infection control, and collaborative coordination FORMCHECKBOX  FORMCHECKBOX Develop a communication strategy to facilitate peer-to-peer learning and sharing of best practices FORMCHECKBOX  FORMCHECKBOX Establish and adhere to feedback from standardized outcome data to track progressOther activities or descriptions: Develop state HAI prevention training competencies  FORMCHECKBOX  FORMCHECKBOX Consider establishing requirements for education and training of healthcare professionals in HAI prevention (e.g., certification requirements, public education campaigns, and targeted provider education) or work with healthcare partners to establish best practices for training and certificationOther activities or descriptions: Implement strategies for compliance to promote adherence to HICPAC recommendations FORMCHECKBOX  FORMCHECKBOX Consider developing statutory or regulatory standards for healthcare infection control and prevention or work with healthcare partners to establish best practices to ensure adherence FORMCHECKBOX  FORMCHECKBOX Coordinate/liaise with regulation and oversight activities such as inpatient or outpatient facility licensing/accrediting bodies and professional licensing organizations to prevent HAIs FORMCHECKBOX  FORMCHECKBOX Improve regulatory oversight of hospitals, enhance surveyor training and tools, and add sources and uses of infection control data FORMCHECKBOX  FORMCHECKBOX Consider expanding regulation and oversight activities to currently unregulated settings where healthcare is delivered and work with healthcare partners to establish best practices to ensure adherenceOther activities or descriptions:  FORMCHECKBOX  FORMCHECKBOX Enhance prevention infrastructure by increasing joint collaboratives with at least 20 hospitals (i.e. this may require a multi-state or regional collaborative in low population density regions)Other activities or descriptions:  FORMCHECKBOX  FORMCHECKBOX Establish collaborative(s) to prevent HAIs in nonhospital settings (e.g., long term care, dialysis)Other activities or descriptions: 4. Evaluation and Communication Program evaluation is an essential organizational practice in public health. Continuous evaluation and communication of findings integrates science as a basis for decision-making and action for the prevention of HAIs. Evaluation and communication allows for learning and ongoing improvement. Routine, practical evaluations can inform strategies for the prevention and control of HAIs. Please select areas for development or enhancement of state HAI prevention efforts. Table 4: State HAI communication and evaluation planning Check Items UnderwayCheck Items PlannedItems Planned for Implementation (or currently underway) Target Dates for ImplementationConduct needs assessment and/or evaluation of the state HAI program to learn how to increase impact FORMCHECKBOX  FORMCHECKBOX Establish evaluation activity to measure progress toward targets and  FORMCHECKBOX  FORMCHECKBOX Establish systems for refining approaches based on data gatheredOther activities or descriptions (not required): Develop and implement a communication plan about the states HAI program and about progress to meet public and private stakeholders needs FORMCHECKBOX  FORMCHECKBOX Disseminate state priorities for HAI prevention to healthcare organizations, professional provider organizations, governmental agencies, non-profit public health organizations, and the public Other activities or descriptions:   FORMCHECKBOX   FORMCHECKBOX Provide consumers access to useful healthcare quality measures Disseminate HAI data to the public Other activities or descriptions:  FORMCHECKBOX  FORMCHECKBOX Guide patient safety initiatives i. Identify priorities and provide input to partners to help guide patient safety initiatives and research aimed at reducing HAIsOther activities or descriptions:  Healthcare Infection Control and Response (Ebola-associated activities) The techniques and practice on which infection control protocols are based form the backbone of infectious disease containment for pathogens that are otherwise amplified and accelerated in healthcare settings. Investments in a more robust infection control infrastructure will prevent many HAIs transmitted to, and among, patients and health care workers. Table 5: Infection Control Assessment and Response Check Items UnderwayCheck Items PlannedItems Planned for Implementation (or currently underway) Target Dates for Implementation FORMCHECKBOX   FORMCHECKBOX    FORMCHECKBOX   FORMCHECKBOX Create an inventory of all healthcare settings in state. List must include at least one infection control point of contact at the facility Identify current regulatory/licensing oversight authorities for each healthcare facility and explore ways to expand oversight October 1, 2015Other activities or descriptions:   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Assess readiness of Ebola-designated facilities within the state Use CDC readiness assessment tool and determine gaps in infection control Address gaps (mitigate gaps) Conduct follow-up assessments October 1, 2015 Other activities or descriptions:   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Assess outbreak reporting and response in healthcare facilities Use standard assessment tool and determine gaps in outbreak reporting and response Address gaps (mitigate gaps) Track HAI outbreak response and outcomeOctober 1, 2015Other activities or descriptions:  Table 6: Targeted Healthcare Infection Prevention Programs Check Items UnderwayCheck Items PlannedItems Planned for Implementation (or currently underway) Target Dates for Implementation  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX    FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Expand infection control assessments Expand assessments to other additional facilities and other healthcare settings and determine gaps in infection control Address gaps (mitigate gaps) Conduct follow-up assessmentsOctober 1, 2015Other activities or descriptions:   FORMCHECKBOX   FORMCHECKBOX    FORMCHECKBOX   FORMCHECKBOX  Increase infection control competency and practice in all healthcare settings through training Incorporate general infection control knowledge and practice assessments of competency into state licensing board requirements, credentialing, and continuing education requirements for clinical care providers (e.g., medical license, admitting privileges) and/or licensing/accreditation requirements for healthcare facilities. Develop a sustainable training program based on CDC guidance and technical assistance to perform training, prioritizing on-site train-the-trainer programs in key domains of infection control, including the incorporation of hands on evaluations and competency assessments of best practices and a system to monitor ongoing compliance and competency.  October 1, 2015 Other activities or descriptions:   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Enhance surveillance capacity to improve situational awareness, describe emerging threats, and target onsite assessments to implement prevention programs Build capacity to analyze data reported by facilities in a defined region to allow for a comprehensive assessment of potential healthcare-associated infection threats, and communicate results with healthcare facilities. Work with CDC to guide analytic direction and identify facilities for prioritized assessments/response Improve outbreak reporting capacity by developing an infrastructure that includes clear definitions of infectious threats of epidemiologic importance that are communicated to facilities Implement a response plan to address potential emerging threats identified by using enhanced surveillance October 1, 2015Other activities or descriptions:  Appendix 1 The HHS Action plan identifies metrics and 5-year national prevention targets. These metrics and prevention targets were developed by representatives from various federal agencies, the Healthcare Infection Control Practices Advisory Committee (HICPAC), professional and scientific organizations, researchers, and other stakeholders. The group of experts was charged with identifying potential targets and metrics for six categories of healthcare-associated infections: Central Line-associated Bloodstream Infections (CLABSI) Clostridium difficile Infections (CDI) Catheter-associated Urinary Tract Infections (CAUTI) Methicillin-resistant Staphylococcus aureus (MRSA) Infections Surgical Site Infections (SSI) Ventilator-associated Pneumonia (VAP) Following the development of draft metrics as part of the HHS Action Plan in January 2009, HHS solicited comments from stakeholders for review. Stakeholder feedback and revisions to the original draft Metrics Comments on the initial draft metrics published as part of the HHS Action Plan in January 2009 were reviewed and incorporated into revised metrics. While comments ranged from high level strategic observations to technical measurement details, commenters encouraged established baselines, both at the national and local level, use of standardized definitions and methods, engagement with the National Quality Forum, raised concerns regarding the use of a national targets for payment or accreditation purposes and of the validity of proposed measures, and would like to have both a target rate and a percent reduction for all metrics. Furthermore, commenters emphasized the need for flexibility in the metrics, to accommodate advances in electronic reporting and information technology and for advances in prevention of HAIs, in particular ventilator-associated pneumonia. To address comments received on the Action Plan Metrics and Targets, proposed metrics have been updated to include source of metric data, baselines, and which agency would coordinate the measure. To respond to the requests for percentage reduction in HAIs in addition to HAI rates, a new type of metric, the standardized infection ratio (SIR), is being proposed. Below is a detailed technical description of the SIR. Below is a table of the revised metrics described in the HHS Action plan. Please select items or add additional items for state planning efforts. Metric Number and LabelOriginal HAI Elimination MetricHAI Comparison MetricMeasurement SystemNational Baseline Established (State Baselines Established)National 5-Year Prevention TargetCoordinator of Measurement SystemIs the metric NQF endorsed?1. CLABSI 1CLABSIs per 1000 device days by ICU and other locationsCLABSI SIRCDC NHSN Device-Associated Module2006-2008 (proposed 2009, in consultation with states)Reduce the CLABSI SIR by at least 50% from baseline or to zero in ICU and other locations CDCYes*2. CLIP 1 (formerly CLABSI 4)Central line bundle complianceCLIP Adherence percentageCDC NHSN CLIP in Device-Associated Module2009 (proposed 2009, in consultation with states)100% adherence with central line bundle CDCYes3a. C diff 1Case rate per patient days; administrative/discharge data for ICD-9 CM coded Clostridium difficile InfectionsHospitalizations with C. difficile per 1000 patient dischargesHospital discharge data2008 (proposed 2008, in consultation with states)At least 30% reduction in hospitalizations with C. difficile per 1000 patient discharges AHRQNo3b. C diff 2 (new)C. difficile SIRCDC NHSN MDRO/CDAD Module LabID2009-2010 Reduce the facility-wide healthcare facility-onset C. difficile LabID event SIR by at least 30% from baseline or to zeroCDCNo4. CAUTI 2# of symptomatic UTI per 1,000 urinary catheter daysCAUTI SIRCDC NHSN Device-Associated Module 2009 for ICUs and other locations 2009 for other hospital units (proposed 2009, in consultation with states)Reduce the CAUTI SIR by at least 25% from baseline or to zero in ICU and other locations CDCYes*5a. MRSA 1Incidence rate (number per 100,000 persons) of invasive MRSA infectionsMRSA Incidence rateCDC EIP/ABCs2007-2008 (for non-EIP states, MRSA metric to be developed in collaboration with EIP states)At least a 50% reductionin incidence of healthcare-associated invasive MRSA infectionsCDCNo5b. MRSA 2 (new)MRSA bacteremia SIRCDC NHSN MDRO/CDAD Module LabID2009-2010Reduce the facility-wide healthcare facility-onset MRSA bacteremia LabID event SIR by at least 25% from baseline or to zeroCDCNo6. SSI 1Deep incision and organ space infection rates using NHSN definitions (SCIP procedures)SSI SIRCDC NHSN Procedure-Associated Module2006-2008 (proposed 2009, in consultation with states)Reduce the admission and readmission SSI SIR by at least 25% from baseline or to zero CDCYes7. SCIP 1 (formerly SSI 2)Adherence to SCIP/NQF infection process measures SCIP Adherence percentageCMS SCIPTo be determined by CMSAt least 95% adherence to process measures to prevent surgical site infectionsCMSYes* NHSN SIR metric is derived from NQF-endorsed metric data NHSN does not collect information on daily review of line necessity, which is part of the NQF LabID, events reported through laboratory detection methods that produce proxy measures for infection surveillance Inclusion of SSI events detected on admission and readmission reduces potential bias introduced by variability in post-discharge surveillance efforts The NQF-endorsed metric includes deep wound and organ space SSIs only which are included the target. Understanding the Relationship between HAI Rate and SIR Comparison Metrics The Original HAI Elimination Metrics listed above are very useful for performing evaluations. Several of these metrics are based on the science employed in the NHSN. For example, metric #1 (CLABSI 1) for CLABSI events measures the number of CLABSI events per 1000 device (central line) days by ICU and other locations. While national aggregate CLABSI data are published in the annual NHSN Reports these rates must be stratified by types of locations to be risk-adjusted. This scientifically sound risk-adjustment strategy creates a practical challenge to summarizing this information nationally, regionally or even for an individual healthcare facility. For instance, when comparing CLABSI rates, there may be quite a number of different types of locations for which a CLABSI rate could be reported. Given CLABSI rates among 15 different types of locations, one may observe many different combinations of patterns of temporal changes. This raises the need for a way to combine CLABSI rate data across location types. A standardized infection ratio (SIR) is identical in concept to a standardized mortality ratio and can be used as an indirect standardization method for summarizing HAI experience across any number of stratified groups of data. To illustrate the method for calculating an SIR and understand how it could be used as an HAI comparison metric, the following example data are displayed below: Risk Group StratifierObserved CLABSI RatesNHSN CLABSI Rates for 2008 (Standard Population) Location Type#CLABSI#Central line-daysCLABSI rate*#CLABSI#Central line-daysCLABSI rate*ICU170100,0001.71200600,0002.0WARD5858,0001.0600400,0001.5SIR =  EMBED Equation.3  95%CI = (0.628,0.989) *defined as the number of CLABSIs per 1000 central line-days In the table above, there are two strata to illustrate risk-adjustment by location type for which national data exist from NHSN. The SIR calculation is based on dividing the total number of observed CLABSI events by an expected number using the CLABSI rates from the standard population. This expected number is calculated by multiplying the national CLABSI rate from the standard population by the observed number of central line-days for each stratum which can also be understood as a prediction or projection. If the observed data represented a follow-up period such as 2009 one would state that an SIR of 0.79 implies that there was a 21% reduction in CLABSIs overall for the nation, region or facility. The SIR concept and calculation is completely based on the underlying CLABSI rate data that exist across a potentially large group of strata. Thus, the SIR provides a single metric for performing comparisons rather than attempting to perform multiple comparisons across many strata which makes the task cumbersome. Given the underlying CLABSI rate data, one retains the option to perform comparisons within a particular set of strata where observed rates may differ significantly from the standard populations. These types of more detailed comparisons could be very useful and necessary for identifying areas for more focused prevention efforts. The National 5-year prevention target for metric #1 could be implemented using the concept of an SIR equal to 0.25 as the goal. That is, an SIR value based on the observed CLABSI rate data at the 5-year mark could be calculated using NHSN CLABSI rate data stratified by location type as the baseline to assess whether the 75% reduction goal was met. There are statistical methods that allow for calculation of confidence intervals, hypothesis testing and graphical presentation using this HAI summary comparison metric called the SIR. The SIR concept and calculation can be applied equitably to other HAI metrics list above. This is especially true for HAI metrics for which national data are available and reasonably precise using a measurement system such as the NHSN. The SIR calculation methods differ in the risk group stratification only. To better understand metric #6 (SSI 1) see the following example data and SIR calculation: Risk Group StratifiersObserved SSI RatesNHSN SSI Rates for 2008 (Standard Population) Procedure CodeRisk Index Category#SSI#proceduresSSI rate*#SSI#proceduresSSI rate*CBGB131512,6002.5210070,0003.0CBGB2,321070003.0100020,0005.0HPRO111174001.5102060,0001.7SIR =  EMBED Equation.3  95%CI = (0.649,0.851) SSI, surgical site infection * defined as the number of deep incision or organ space SSIs per 100 procedures This example uses SSI rate data stratified by procedure and risk index category. Nevertheless, an SIR can be calculated using the same calculation process as for CLABSI data except using different risk group stratifiers for these example data. The SIR for this set of observed data is 0.74 which indicates theres a 26% reduction in the number of SSI events based on the baseline NHSN SSI rates as representing the standard population. Once again, these data can reflect the national picture at the 5-year mark and the SIR can serve as metric that summarizes the SSI experience into a single comparison. There are clear advantages to reporting and comparing a single number for prevention assessment. However, since the SIR calculations are based on standard HAI rates among individual risk groups there is the ability to perform more detailed comparisons within any individual risk group should the need arise. Furthermore, the process for determining the best risk-adjustment for any HAI rate data is flexible and always based on more detailed risk factor analyses that provide ample scientific rigor supporting any SIR calculations. The extent to which any HAI rate data can be risk-adjusted is obviously related to the detail and volume of data that exist in a given measurement system. In addition to the simplicity of the SIR concept and the advantages listed above, its important to note another benefit of using an SIR comparison metric for HAI data. If there was need at any level of aggregation (national, regional, facility-wide, etc.) to combine the SIR values across mutually-exclusive data one could do so. The below table demonstrates how the example data from the previous two metric settings could be summarized.  EMBED Equation.3  Observed HAIsExpected HAIs HAI Metric#CLABSI#SSI#Combined HAI#CLABSI#SSI#Combined HAICLABSI 1228287SSI 1636853.8Combined HAI 228 + 636 = 864287+853.8 = 1140.8SIR =  EMBED Equation.3  95%CI = (0.673,0.849) SSI (surgical site infection)   Thacker SB, Berkelman RL. Public health surveillance in the United States. Epidemiol Rev 1988;10:164-90.      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