REPORT TO THE 26TH LEGISLATURE STATE OF HAWAII 2012

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1 REPORT TO THE 26TH LEGISLATURE STATE OF HAWAII 2012 PURSUANT TO ACT 177(11), SESSION LAWS OF HAWAII, 2011, RELATING TO HEALTHCARE ASSOCIATED INFECTIONS REPORTING Prepared by: State of Hawaii Department of Health December 2011

2 BACKGROUND Hawaii Statute Requirements for Healthcare-Associated Infections In July 2011, Governor Abercrombie signed Act 177 into law, allowing the Hawaii Department of Health (DOH) access to data submitted to the National Healthcare Safety Network (NHSN) for facilities under the Centers for Medicare and Medicaid Services (CMS) regulations and providing protection from disclosure for healthcare-associated infection (HAI) data provided to DOH under these reporting requirements. This will allow DOH to develop statewide surveillance for selected HAI. Specifically, DOH will be able to utilize nationally accepted standards to establish baseline HAI rates for facilities, monitor trends in HAI rates over time, and compare Hawaii HAI rates with national data. Subject to continuing funding from CDC, DOH may also use NHSN data to evaluate HAI reduction/elimination efforts and assist facilities in identifying related issues requiring additional attention. Beginning in June 2013, DOH will prepare a public report using methodology established by NHSN to report HAI rates for facilities in Hawaii. Pursuant to Section 3 of Act 177, this report provides an update regarding the progress toward HAI reporting in Hawaii. National Reporting of Healthcare-Associated Infections HAIs are infections that patients acquire during the course of receiving healthcare treatment for other conditions. These infections can be devastating and even deadly. Although these infections are largely preventable, they create a considerable burden in terms of impact on human life as well as financial costs to the healthcare system. They are among the top 10 leading causes of death in the United States and accounted for an estimated 1.7 million infections and 99,000 associated deaths in The Centers for Disease Control and Prevention (CDC) also estimates that HAIs result in more than $17 billion toward healthcare costs each year. 2 According to estimates from CDC, approximately 1 out of every 20 hospitalized patients will contract an HAI. CDC has developed NHSN, a web-based reporting system for data relating to HAI infections and best practices in HAI prevention. NHSN is now recognized as the gold standard for HAI surveillance. NHSN provides facilities across the country access to standardized HAI surveillance methodology and a system for monitoring compliance with evidence-based practices in infection control. To standardize national HAI reporting, CMS adopted NHSN as the surveillance system for HAI prevention and control for facilities participating in the CMS HAI Inpatient Prospective Payment System (IPPS) Hospital Inpatient Quality Reporting Program, formerly known as Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU). More than 4,900 healthcare facilities currently use NHSN as the foundation of their HAI elimination strategies. CMS will 1 Klevens RM, Edwards J, Richards C, Horan T, Gaynes R, Pollock D, Cardo D. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, Public Health Reports 2007; 122: Bhutta A, Gilliam C, Honeycutt M, et al. Reduction of bloodstream infections associated with catheters in paediatric intensive care unit: stepwise approach. BMJ : Page 2 of 8

3 continue to develop reporting requirements for other facility types in the future (e.g. long-term care facilities, out-patient surgery, and out-patient cancer treatment faculties). Current CMS Reporting Requirements CMS has established reporting requirements through These rules apply to hospitals participating in the Hospital Inpatient Quality Reporting Program and the End Stage Renal Disease (ESRD) Quality Incentive Program. As agreement on technical details is reached among experts in HAI surveillance, additional reporting requirements will be added. The current HAI reporting schedule is listed below: In 2011, acute care hospitals began reporting central line-associated bloodstream infection (CLABSI) data from adult, pediatric, and neonatal intensive care units to NHSN and shared these with CMS. In January 2012, acute care hospitals will begin submitting catheter-associated urinary tract infection (CAUTI) data from adult and pediatric intensive care units and surgical site infection (SSI) data from inpatient colon and abdominal hysterectomy procedures to NHSN. In January 2012, outpatient dialysis facilities will begin reporting data on use of intravenous antimicrobial agents, positive blood cultures, and signs of infections at vascular access. In October 2012, long term acute care hospitals will begin reporting CLABSI and CAUTI. In October 2012, inpatient rehabilitation facilities will begin reporting CAUTI. In January 2013, acute care hospitals will begin reporting Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA). These conditions were selected because they have evidence-based prevention strategies that have documented guidelines for prevention and control. Other conditions will be added in the future as national consensus is reached on the best practice guidelines and on the reliability of NHSN for calculating HAI measures. Recommendations for CLABSI can be found at the CDC website: Recommendations for prevention and control of CAUTI can be found at Recommendations for prevention and control of SSI can be found at Page 3 of 8

4 HAWAII PROGRESS ON NHSN REPORTING Seventeen acute care hospitals are currently enrolled and submitting data to NHSN. Not all of these facilities are reporting under the CMS regulations; some use NHSN voluntarily for HAI surveillance and monitoring prevention practices. Hawaii Facilities Enrolled in NHSN as of November 7, 2011 Castle Medical Center Hilo Medical Center Hawaii Medical Center West Hawaii Medical Center East Kaiser Permanente Medical Center Kapiolani Medical Center for Women and Children Kona Community Hospital Kuakini Medical Center Maui Memorial Medical Center North Hawaii Community Hospital Pali Momi Medical Center Shriners Hospitals for Children Straub Clinic & Hospital The Queens Medical Center Tripler Army Medical Center Wahiawa General Hospital Wilcox Memorial Hospital Location Kailua Hilo Ewa Beach Kealakekua Wailuku Kamuela Aiea Wahiawa Lihue Page 4 of 8

5 Hawaii Hospitals Currently Reporting CLABSI Data to NHSN Fifteen acute care hospitals are currently enrolled and submitting CLABSI data to NHSN. Two hospitals are not subject to the rule at this time. Shriners Hospital does not have intensive care units (ICUs), and Tripler, a U.S. Department of Defense facility, is not subject to CMS rules. Hawaii Facilities Currently Submitting CLABSI 3 data Castle Medical Center Hilo Medical Center Hawaii Medical Center East Hawaii Medical Center West Kaiser Permanente Medical Center Kapiolani Medical Center for Women and Children Kona Community Hospital Kuakini Medical Center Maui Memorial Medical Center North Hawaii Community Hospital Pali Momi Medical Center Shriners Hospitals for Children Straub Clinic & Hospital The Queens Medical Center Tripler Army Medical Center Wahiawa General Hospital Wilcox Memorial Hospital Submitting CLABSI Data 3 CMS rule relates to data on central line-associated bloodstream infections (CLABSI) from adult, pediatric, and neonatal ICUs. Page 5 of 8

6 Hawaii Hospitals Preparing to Report CAUTI Data to NHSN Fifteen acute care hospitals are preparing to submit CAUTI data to NHSN in Two hospitals are not subject to the rule at this time. Shriners Hospital does not have ICUs, and Tripler is not subject to CMS rules. Hawaii Facilities Prepared to Submit CAUTI 4 Data, Effective January 2012 Castle Medical Center Hilo Medical Center Hawaii Medical Center East Hawaii Medical Center West Kaiser Permanente Medical Center Kapiolani Medical Center for Women and Children Kona Community Hospital Kuakini Medical Center Maui Memorial Medical Center North Hawaii Community Hospital Pali Momi Medical Center Shriners Hospitals for Children Straub Clinic & Hospital The Queens Medical Center Tripler Army Medical Center Wahiawa General Hospital Wilcox Memorial Hospital Prepared to Submit Data 4 CMS rule relates to data on catheter-associated urinary tract infections (CAUTI) from adult and pediatric ICUs. Page 6 of 8

7 Hawaii Hospitals Preparing to Report SSI Data to NHSN Fifteen acute care hospitals are preparing to submit SSI data to NHSN in Two hospitals are not subject to the rule at this time. Shriners Hospital does not perform colon surgeries or abdominal hysterectomies. Tripler is not subject to CMS rules. Hawaii Facilities Prepared to Submit SSI 5 Data, Effective January 2012 Castle Medical Center Hilo Medical Center Hawaii Medical Center East Hawaii Medical Center West Kaiser Permanente Medical Center Kapiolani Medical Center for Women and Children Kona Community Hospital Kuakini Medical Center Maui Memorial Medical Center North Hawaii Community Hospital Pali Momi Medical Center Shriners Hospitals for Children Straub Clinic & Hospital The Queens Medical Center Tripler Army Medical Center Wahiawa General Hospital Wilcox Memorial Hospital Prepared to Submit Data 5 CMS rule relates to data on surgical site infections (SSI) for colon surgeries and abdominal hysterectomies. Page 7 of 8

8 Hawaii Out-Patient Dialysis Centers Preparing to Report Data to NHSN All out-patient dialysis centers in Hawaii are managed by one of two companies, Liberty Dialysis Hawaii, LLC or Fresenius Medical Care. Both organizations are preparing to submit data to NHSN in Out-patient dialysis centers will report data on positive blood cultures, use of antimicrobial agents, and signs of infections at vascular access. Hawaii Facilities Prepared to Submit Outpatient Dialysis Data, Effective January 2012 Liberty Dialysis Hawaii LLC Fresenius Medical Care Preparing to Submit Data Page 8 of 8

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