National Healthcare Safety Network Data Research Articles

Successful practices to reduce central line–associated bloodstream infections post pandemic: A qualitative study

Central Line-Associated Bloodstream Infections (CLABSIs) decreased in U.S. hospitals over the last decade, but CLABSI rates increased during the COVID-19 pandemic disrupting the downward trend. This study explored factors contributing to the reduction of CLABSI, identifying deviations in infection prevention and control protocol during the pandemic, actions taken to address the increase in CLABSI, and factors promoting sustained progress. This qualitative study used the National Healthcare Safety Network data. The Centers for Disease Control and Prevention identified hospitals with elevated CLABSI standardized infection ratios (SIR) >1 between Q1 2019 - Q4 2021 followed by four quarters of sustained reduction (CLABSI SIR <1). Joint Commission researchers conducted semi-structured phone interviews with infection preventionist professionals from six hospitals representing these performance patterns. Interview themes suggested that staffing shortages (83%) and less vigilant central line practices (100%) contributed to increased CLABSI SIR during the pandemic. Organizations described evidence-based interventions, such as using chlorhexidine gluconate for skin preparation, along with other innovative strategies they used to establish reduced CLABSI rates. Despite challenges faced during the COVID-19 pandemic, some health care organizations have excelled in their efforts to reduce and sustain low rates of CLABSI by implementing evidence-based practices, innovative solutions, and education.

Aiming for Zero: Success of the Hysterectomy Surgical Site Infection Prevention Bundle

Background: The Center for Disease Control’s National Healthcare Safety Network (NHSN) reported an increased Standardized Infection Ratio (SIR) at a large community hospital, calculated by the number of observed infections over the number of predicted infections. In response to the increased SIR, a multidisciplinary Hysterectomy Surgical Site Infection (SSI) Prevention Workgroup was formed in 2019. Objective: To promote a surgical site infection prevention bundle that was implemented at a large community hospital to reduce hysterectomy associated surgical site infections. Study Design: The Workgroup implemented an evidence-based Hysterectomy SSI Prevention Bundle which enforced standardization of measures and techniques at: The pre-operative clinic appointment, the day of surgery, the intra-operative time prior to incision, the intra-operative time from incision to closure, and in the immediate post-operative recovery. The Hysterectomy SSI Prevention Bundle was implemented November 2, 2020. This study included all hysterectomies for benign pathologies from 10/1/2018 to 9/30/2020 [pre-implementation (n=811)] and 1/1/2021 to 9/30/2022 [post-implementation (n=772)]. Per NHSN data categorization guidelines, a designation of abdominal hysterectomy includes both open and laparoscopic routes. Inpatient surgery was defined as that with a date of discharge different from date of operation; outpatient surgery was defined as the one with the same date of discharge. SSIs included superficial, deep and organ/space, while complex SSIs included deep and organ/space. Patient demographics were categorized and evaluated for statistical significance. Results: After implementation of the SSI bundle, SIR for hysterectomies was reduced to &lt; 1.0, indicating infection prevention. Outpatient abdominal hysterectomy SIR pre-implementation was 2.551 and post-implementation was 0.868 (p=0.007). The outpatient vaginal hysterectomy SIR pre-implementation was 0, and post-implementation remained 0 (p=0.364). Inpatient abdominal hysterectomy SIR pre-implementation was 1.554 and post-implementation was 0.443 (p=0.072). The inpatient vaginal hysterectomy SIR preimple-mentation was 1.064, and post-implementation was 0 (p &lt;0.001). The inpatient complex abdominal hysterectomy SIR pre-implementation was 1.757 and post-implementation was 0 (p=0.040). The inpatient complex vaginal hysterectomy SIR pre-implementation was 1.001, and post-implementation was 0 (p &lt;0.001). Differences between the pre- and post-implementation groups were significant for increased laparoscopic hysterectomies (p&lt;0.001), decreased vaginal hysterectomies (p&lt;0.001), increased number of same day discharges (p&lt;0.001), longer procedure duration (p&lt;0.001), and younger age (p=0.039). Conclusion: Implementation of an evidence-based surgical site infection prevention bundle at a large community hospital has significantly reduced SIR for inpatient vaginal hysterectomies, outpatient abdominal hysterectomies, and all inpatient complex hysterectomies.

2482. Cross Validation of Surgical Procedure Data in National Healthcare Safety Network vs Hospital Discharge Data

Abstract Background California acute care hospitals (ACH) are required to report data on 28 types of inpatient surgical procedures via the National Healthcare Safety Network (NHSN). ACH also report discharge data, including procedure data, to the California Department of Healthcare Access and Information (HCAI). We compared the number of adult (age &amp;gt;=18) procedures reported in NHSN versus HCAI in 2019 for cardiac surgery (CARD), coronary bypass with chest and donor incisions (CBGB), hip prosthesis (HPRO), kidney transplant (KTP), and rectal surgery (REC). Methods For both systems, we aggregated procedure counts to the facility level and matched individual facilities. HCAI ICD-10 codes were mapped to NHSN procedure codes. Because NHSN counts multiple procedures that map to the same procedure code done via the same incision as one procedure and HCAI does not specify how many procedures were done per incision, CARD, CBGB, and REC were counted only once per procedure code per patient per day. HPRO and KTP were counted up to twice per patient per day if ICD-10 codes for both right and left side surgeries were present. ANOVA was used to compare the means of log standardized infection ratio (SIR) by NHSN to HCAI procedure count ratio as categories of less than 0.9, between 0.9 and 1.1, and more than 1.1. Results Three hundred eleven facilities reported 82,847 procedures to NHSN and 300 facilities reported 91,961 procedures to HCAI. Median and interquartile interval for the facility-specific ratio of NHSN to HCAI procedures among facilities that reported procedures in both systems are displayed in Table 1. ANOVA failed to detect any difference in mean of log SIR by different NHSN to HCAI procedure count ratio at α of 0.05. Conclusion For all procedure types, there were more procedures documented in HCAI than NHSN, but the ratios of NHSN procedures to HCAI procedures varied widely by procedure type. However, difference in ratio was not associated with SIR. Ability to compare procedure counts was limited by inability to ascertain operating room deaths (which are not counted in NHSN) and if procedures were done using the same incision in HCAI. Further analysis is recommended since SSI denominator quality is crucial to the accuracy of SIR, which informs many analyses and interventions. Disclosures All Authors: No reported disclosures

Carbapenem-Resistant Klebsiella pneumoniae in Large Public Acute-Care Healthcare System, New York, New York, USA, 2016-2022.

Controlling the spread of carbapenem-resistant Enterobacterales is a global priority. Using National Healthcare Safety Network data, we characterized the changing epidemiology of carbapenem-resistant Klebsiella pneumoniae (CRKP) in a large public health system in New York, New York, USA. During 2016-2020, CRKP cases declined; however, during 2021-June 2022, a notable increase occurred. Of 509 cases, 262 (51%) were considered community-onset, including 149 in patients who were living at home. Of 182 isolates with proven or presumptive (ceftazidime/avibactam susceptible) enzymes, 143 were serine carbapenemases; most confirmed cases were K. pneumoniae carbapenemase. The remaining 39 cases were proven or presumptive metallo-β-lactamases; all confirmed cases were New Delhi metallo-β-lactamases. After 2020, a marked increase occurred in the percentage of isolates possessing metallo-β-lactamases. Most patients with metallo-β-lactamases originated from long-term care facilities. An aggressive and universal program involving surveillance and isolation will be needed to control the spread of CRKP in the city of New York.

Staffing Shortages, Staffing Hours, and Resident Deaths in US Nursing Homes During the COVID-19 Pandemic.

Staffing shortages at nursing homes during the COVID-19 pandemic may have impacted care providers' staffing hours and affected residents' care and outcomes. This study examines the association of staffing shortages with staffing hours and resident deaths in nursing homes during the COVID-19 pandemic. This study measured staffing hours per resident using payroll data and measured weekly resident deaths and staffing shortages using the Centers for Disease Control and Prevention's National Healthcare Safety Network data. Multivariate linear regressions with facility and county-week fixed effects were used to investigate the association of staffing shortages with staffing hours and resident deaths. 15,212 nursing homes. The primary outcomes included staffing hours per resident of registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs) and weekly total deaths per 100 residents. Between May 31, 2020, and May 15, 2022, 18.4% to 33.3% of nursing homes reported staffing shortages during any week. Staffing shortages were associated with lower staffing hours per resident with a 0.009 decrease in RN hours per resident (95% CI 0.005-0.014), a 0.014 decrease in LPN hours per resident (95% CI 0.010-0.018), and a 0.050 decrease in CNA hours per resident (95% CI 0.043-0.057). These are equivalent to a 1.8%, 1.7%, and 2.4% decline, respectively. There was a positive association between staffing shortages and resident deaths with 0.068 (95% CI 0.048-0.088) total deaths per 100 residents. This was equivalent to an increase of 10.5%. Our results showed that self-reported staffing shortages were associated with a statistically significant decrease in staffing hours and with a statistically significant increase in resident deaths. These results suggest that addressing staffing shortages in nursing homes can save lives.

Risk factors for surgical site infection after abdominal hysterectomy, New York State, 2015-2018

To identify risk factors for surgical site infections (SSIs) after abdominal hysterectomy (HYST) procedures using National Healthcare Safety Network (NHSN) data augmented with diagnosis codes available using administrative data. We analyzed 66,001 HYST procedures in 166 New York State hospitals between January 2015 and December 2018, reported in NHSN, and matched to billing data. Risks factors for SSI after abdominal hysterectomy were identified using logistic regression models. A total of 66,001 HYST procedures were analyzed. SSI was reported following 1,093 procedures, resulting in an infection rate of 1.66%. Risk factors associated with SSIs were open approach (not laparoscopic) with an adjusted odds ratio (AOR) of 2.72 and 95% confidence interval (CI) of 2.37-3.12, contaminated or dirty wound class (AOR 2.28, 95% CI 1.61-3.24), body mass index ≥30 (AOR 1.78, 95% CI 1.56-2.02), procedures lasting 186 minutes or more (AOR 1.78, 95% CI 1.56-2.02), American Society of Anesthesia (ASA) score ≥3 (AOR 1.74, 95% CI 1.52-1.99), gynecological cancer (AOR 1.54, 95% CI 1.32-1.80), and diabetes mellitus (AOR 1.46, 95% CI 1.24-1.70). Obesity, prolonged procedure duration, diabetes mellitus, wound contamination, open approach, ASA score ≥3, and gynecological cancer were significant independent risk factors associated with SSI after hysterectomy.

Association of State COVID-19 Vaccine Mandates With Staff Vaccination Coverage and Staffing Shortages in US Nursing Homes

Several states implemented COVID-19 vaccine mandates for nursing home employees, which may have improved vaccine coverage but may have had the unintended consequence of staff departures. To assess whether state vaccine mandates for US nursing home employees are associated with staff vaccination rates and reported staff shortages. This cohort study performed event study analyses using National Healthcare Safety Network data from June 6, 2021, through November 14, 2021. Changes in weekly staff vaccination rates and reported staffing shortages were evaluated for nursing homes in states with mandates after the mandate announcement compared with changes in facilities in nonmandate states. An interaction between the mandates and county political leaning was considered. Data analysis was performed from February to March 2022. Weeks after announcement of a state's COVID-19 vaccine mandate. Weekly percentage of all health care staff at a nursing home who received at least 1 COVID-19 vaccine dose, and a weekly indicator of whether a nursing home reported a staffing shortage. Among 38 study-eligible states, 26 had no COVID-19 vaccine mandate for nursing home employees, 4 had a mandate with a test-out option, and 8 had a mandate with no test-out option. Ten weeks or more after mandate announcement, nursing homes in states with a mandate and no test-out option experienced a 6.9 percentage point (pp) increase in staff vaccination coverage (95% CI, -0.1 to 13.9); nursing homes in mandate states with a test-out option experienced a 3.1 pp increase (95% CI, 0.5 to 5.7) compared with facilities in nonmandate states. No significant increases were detected in the frequency of reported staffing shortages after a mandate announcement in mandate states with or without test-out options. Increases in vaccination rates in states with mandates were larger in Republican-leaning counties (14.3 pp if no test-out option; 4.3 pp with option), and there was no evidence of increased staffing shortages. The findings of this cohort study suggest that state-level vaccine mandates were associated with increased staff vaccination coverage without increases in reported staffing shortages. Vaccination increases were largest when mandates had no test-out option and were also larger in Republican-leaning counties, which had lower mean baseline vaccination rates. These findings support the use of state mandates for booster doses for nursing home employees because they may improve vaccine coverage, even in areas with greater vaccine hesitancy.

Health care-associated infections studies project: An American Journal of Infection Control and National Healthcare Safety Network Data Quality Collaboration Case Study – Chapter 9 Surgical site infection event (SSI) case study

This case study is part of a series centered on the Centers for Disease Control and Prevention/National Healthcare Safety Network (NHSN) healthcare-associated infection (HAI) surveillance definitions. This specific case study focuses on the application of common surveillance concepts included in the Patient Safety Component, Chapter 9 - Surgical Site Infection Event (SSI). The intent of the case study series is to foster standardized application of the NHSN HAI surveillance definitions and encourage accurate HAI event determination among Infection Preventionists (IPs).

COVID-19 Vaccine Uptake Among Nursing Home Staff via Statewide Policy: The Mississippi Vaccinate or Test Out Policy.

Objectives. To examine whether COVID-19 vaccine mandates that allow a test-out exemption for nursing home staff are associated with increased staff vaccination rates in nursing homes. Methods. Using the National Healthcare Safety Network data, we conducted analyses to test trends over time in statewide staff vaccination rates between June 1, 2021, and August 29, 2021, in Mississippi, 4 adjacent states, and the United States overall. Results. COVID-19 staff vaccination rates increased slowly following Mississippi enacting a vaccinate-or-test-out policy, achieving small, but statistically greater gains than most comparator states. Yet, staff vaccination rates in Mississippi remained well below the national average and similar numerically to surrounding states without mandates. Conclusions. Mississippi's COVID-19 vaccinate-or-test policy was ineffective in meaningfully increasing staff vaccination rates. For COVID-19 nursing home mandates to be effective while still balancing the staff turnover risks, facilities might consider a more stringent or hybrid approach (e.g., test-out option not offered to new staff). Public Health Implications. Statewide COVID-19 vaccine mandates, when given a test-out option, do not appear to be an effective strategy to meaningfully increase nursing home staff COVID-19 vaccination. (Am J Public Health. 2022;112(5):762-765. https://doi.org/10.2105/AJPH.2022.306800).

Health care-associated infections studies project: An American journal of infection control and national healthcare safety network data quality collaboration case study - Chapter 2 Identifying Healthcare-associated Infections (HAI) for NHSN Surveillance case study vignettes

This case study is part of a series centered on the Centers for Disease Control and Prevention/National Healthcare Safety Network (NHSN) healthcare-associated infection (HAI) surveillance definitions. This specific case study focuses on the application of three of the surveillance concepts included in the Patient Safety Component, Chapter 2 - Identifying Healthcare-associated Infections (HAI) for NHSN Surveillance. The intent of the case study series is to foster standardized application of the NHSN HAI surveillance definitions and encourage accurate HAI event determination among Infection Preventionists (IPs).

Impact of Statewide Prevention and Reduction of Clostridioides difficile (SPARC), a Maryland public health–academic collaborative: an evaluation of a quality improvement intervention

To evaluate changes in Clostridioides difficile incidence rates for Maryland hospitals that participated in the Statewide Prevention and Reduction of C. difficile (SPARC) collaborative. Pre-post, difference-in-difference analysis of non-randomised intervention...

Estimates of COVID-19 Cases and Deaths Among Nursing Home Residents Not Reported in Federal Data

Federal data underestimate the impact of COVID-19 on US nursing homes because federal reporting guidelines did not require facilities to report case and death data until the week ending May 24, 2020. To assess the magnitude of unreported cases and deaths in the National Healthcare Safety Network (NHSN) and provide national estimates of cases and deaths adjusted for nonreporting. This is a cross-sectional study comparing COVID-19 cases and deaths reported by US nursing homes to the NHSN with those reported to state departments of health in late May 2020. The sample includes nursing homes from 20 states, with 4598 facilities in 12 states that required facilities to report cases and 7401 facilities in 19 states that required facilities to report deaths. Estimates of nonreporting were extrapolated to infer the national (15 397 facilities) unreported cases and deaths in both May and December 2020. Data were analyzed from December 2020 to May 2021. Nursing home ownership (for-profit or not-for-profit), chain affiliation, size, Centers for Medicare & Medicaid Services star rating, and state. The main outcome was the difference between the COVID-19 cases and deaths reported by each facility to their state department of health vs those reported to the NHSN. Among 15 415 US nursing homes, including 4599 with state case data and 7405 with state death data, a mean (SE) of 43.7% (1.4%) of COVID-19 cases and 40.0% (1.1%) of COVID-19 deaths prior to May 24 were not reported in the first NHSN submission in sample states, suggesting that 68 613 cases and 16 623 deaths were omitted nationwide, representing 11.6% of COVID-19 cases and 14.0% of COVID-19 deaths among nursing home residents in 2020. These findings suggest that federal NHSN data understated total cases and deaths in nursing homes. Failure to account for this issue may lead to misleading conclusions about the role of different facility characteristics and state or federal policies in explaining COVID outbreaks.

Building an Interactive Geospatial Visualization Application for National Health Care-Associated Infection Surveillance: Development Study.

BackgroundThe Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN) is the most widely used health care–associated infection (HAI) and antimicrobial use and resistance surveillance program in the United States. Over 37,000 health care facilities participate in the program and submit a large volume of surveillance data. These data are used by the facilities themselves, the CDC, and other agencies and organizations for a variety of purposes, including infection prevention, antimicrobial stewardship, and clinical quality measurement. Among the summary metrics made available by the NHSN are standardized infection ratios, which are used to identify HAI prevention needs and measure progress at the national, regional, state, and local levels.ObjectiveTo extend the use of geospatial methods and tools to NHSN data, and in turn to promote and inspire new uses of the rendered data for analysis and prevention purposes, we developed a web-enabled system that enables integrated visualization of HAI metrics and supporting data.MethodsWe leveraged geocoding and visualization technologies that are readily available and in current use to develop a web-enabled system designed to support visualization and interpretation of data submitted to the NHSN from geographically dispersed sites. The server–client model–based system enables users to access the application via a web browser.ResultsWe integrated multiple data sets into a single-page dashboard designed to enable users to navigate across different HAI event types, choose specific health care facility or geographic locations for data displays, and scale across time units within identified periods. We launched the system for internal CDC use in January 2019.ConclusionsCDC NHSN statisticians, data analysts, and subject matter experts identified opportunities to extend the use of geospatial methods and tools to NHSN data and provided the impetus to develop NHSNViz. The development effort proceeded iteratively, with the developer adding or enhancing functionality and including additional data sets in a series of prototype versions, each of which incorporated user feedback. The initial production version of NHSNViz provides a new geospatial analytic resource built in accordance with CDC user requirements and extensible to additional users and uses in subsequent versions.

Healthcare-associated infections studies project: An American Journal of Infection Control and National Healthcare Safety Network data quality collaboration

This case study is part of a series centered on the Centers for Disease Control and Prevention/National Healthcare Safety Network (NHSN) healthcare-associated infection (HAI) surveillance definitions. This specific case study focuses on the application of the Pneumonia (PNEU), Ventilator-associated event (VAE), and Bloodstream infections (BSI) surveillance definitions to a patient with COVID-19. The intent of the case study series is to foster standardized application of the NHSN HAI surveillance definitions among Infection Preventionists (IPs) and encourage accurate determination of HAI events.

785. Association between Prevalence of Laboratory-Identified Clostridioides difficile Infections (CDIs) and CDI Antibiotic Treatment in U.S. Acute Care Hospitals, 2018

Background Clostridioides difficile infections (CDIs) are an urgent public health threat, accounting for 223,900 infections and 12,800 deaths in hospitalized patients annually. In early 2018, the Infectious Disease Society of America (IDSA) recommended oral vancomycin or fidaxomicin as the first-line antibiotics for CDIs. To track the uptake of IDSA’s recommendations, we evaluated the association between CDI prevalence and use of first-line antibiotics in hospitals reporting to the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN).MethodsWe matched 2018 hospital-level, NHSN data on laboratory-identified CDIs with NHSN antimicrobial use (AU) data for the same time period. Hospitals that submitted < 6 months of either data type in 2018 were excluded. The association between quarterly hospital-level CDI prevalence rates per 100 patient-admissions and use of CDI antibiotics (oral vancomycin plus fidaxomicin) per 1,000 days-present was evaluated using Pearson’s linear correlation coefficient and using Goodman and Kruskal’s gamma (G) on ordinal quartiles to assess rates of discordant pairs.ResultsAmong the 2735 hospital-level quarters based on 714 hospitals included in the study, CDI prevalence (median: 0.46 per 100 patient-admissions) and CDI antibiotic use (median: 8.85 antibiotic-days per 1,000 days-present) demonstrated only a moderately positive correlation (r = 0.48). Among hospitals in the highest quartile for CDI prevalence, 5.1% were in the lowest quartile for antibiotic use. Among hospitals in the highest quartile for antibiotic use, 5.3% were in the lowest quartile for CDI prevalence, and 54.2% were in the highest quartile for CDI prevalence (G = 0.60; 95% CI: 0.57–0.63).Correlation of hospital-level Clostridioides difficile infection (CDI) prevalence rates and oral vancomycin and fidaxomicin use in U.S. acute care hospitals, 2018 Distribution of hospital-level Clostridioides difficile infection (CDI) prevalence rates and oral vancomycin and fidaxomicin use in ordinal quartiles (Q1–Q4) to access rates of discordant pairs ConclusionThe moderate correlation and discordant rates suggest that vancomycin and fidaxomicin are less frequently used as primary antibiotics in some hospitals; whereas in others, CDI antibiotic use is occurring in the absence of positive laboratory tests for CDI. To further investigate this discordance, there is a need to assess hospitals’ prescribing and testing practices in an ongoing manner. These findings may be useful to serve as baseline for measuring progress of appropriateness of treatment and testing for CDIs.Disclosures All Authors: No reported disclosures

621. Reporting Behaviors and Perceptions Towards the National Healthcare Safety Network Antimicrobial Use (AU) and Antimicrobial Resistance (AR) Options

BackgroundAntibiotic use (AU) and antibiotic resistance (AR; AUR) reporting to National Healthcare Safety Network (NHSN) is suboptimal by US hospitals. The Society of Infectious Diseases Pharmacists (SIDP) and the Society for Healthcare Epidemiology of America (SHEA) conducted a survey of their membership to 1) Identify characteristics of US health systems that report AUR data 2) Determine how NHSN AUR data are used by health systems and 3) Identify barriers to AUR reporting.MethodsAn anonymous survey was posted on SurveyMonkey from 1/21- 2/21/2020 and links were emailed to SIDP and SHEA Research Network members. Data were analyzed in Excel and RStudio. Respondent and hospital data were reported as frequencies and percentages. Fisher’s Exact test was used to compare survey responses from NHSN AUR reporters to non-reporters.ResultsA total of 238 individuals from 43 states responded to our survey. Respondents were primarily pharmacists (84%), from urban (45%), non-profit medical centers (80%) with >250 beds (65%). 62% of respondents reported to the AU option while 19% reported to the AR option. Respondents not using software for local AU or AR tracking were less likely than those using any software for local tracking to report to AU (19% vs 64%) and AR (2% vs 30%) options (P< 0.0001). Among AU and AR reporters 41% and 54% used clinical decision support software to aggregate compile data for upload while 54% and 38% used their electronic health record, and 5% and 8% used another method. Over half of AU (56%) and AR (51%) reporters upload data manually. Regular use of the NHSN data analysis tools was reported by 36% and 9% of those reporting AU and AR data respectively. The most common barriers to reporting were related to technical issues (software, IT support, data formatting) and time/salary support. Among non-reporters, increased expectations to report and better software solutions were most commonly identified as the best ways to increase reporting.ConclusionEfforts to improve AUR reporting should focus on software solutions and increasing the utility of AUR analytical tools. Increasing expectations to report may also help to improve reporting rates. The lower rate of AR vs AU reporting suggests that interventions should also target the AR option.Disclosures Brian J. Werth, PharmD, Shionogi Inc. (Grant/Research Support) Kerry LaPlante, PharmD, Merck (Advisor or Review Panel member, Research Grant or Support)Ocean Spray Cranberries, Inc. (Research Grant or Support)Pfizer Pharmaceuticals (Research Grant or Support)Shionogi, Inc. (Research Grant or Support)

Health Care-associated infections studies project: An American Journal of Infection Control and National Healthcare Safety Network data quality collaboration case study

This National Healthcare Safety Network (NHSN) surveillance case study is part of a case-study series in the American Journal of Infection Control (AJIC). These cases reflect some of the complex patient scenarios Infection preventionists have encountered in their daily surveillance of health care-associated infections using NHSN definitions. Objectives have been previously published.

Extending the Use of Healthcare-Associated Infections and Antibiotic Use and Resistance Surveillance Data

Background: The CDC National Healthcare Safety Network (NHSN) is the nation’s most widely used healthcare-associated infection (HAI) and antibiotic use and resistance (AUR) surveillance system. More than 22,000 healthcare facilities report data to the NHSN. The NHSN data are used by facilities, the CDC, health departments, the CMS, among other organizations and agencies. In 2017, the CDC updated the NHSN Agreement to Participate and Consent (Agreement), completed by facilities, broadening health department access to NHSN data and extending eligibility for data use agreements (DUAs) to local and territorial health departments. DUAs enable access to NHSN data reported by facilities in the health department’s jurisdiction and have been available to state health departments since 2011. The updated agreement also enables the CDC to provide NHSN data to health departments for targeted prevention projects outbreak investigations and responses. Methods: We reviewed the current NHSN DUA inventory to assess the extent to which health departments use the NHSN’s new data access provisions and used semistructured interviews with health department staff, conducted via emails, phone, and in person conversations, to identify and describe their NHSN data uses. Results: As of late 2019, the NHSN has DUAs with health departments in 17 states, 7 local health departments (including municipalities and counties), and 1 US territory. The NHSN also has received requests from 2 state health departments for data supporting HAI prevention projects. Health departments with DUAs described improved relationships with facilities in their jurisdictions because of new opportunities to offer NHSN data analysis assistance to facilities. One local health department analyzed their NHSN carbapenem-resistant Enterobacteriaceae (CRE) data to identify (1) facilities in its jurisdiction with comparatively high CRE infection burden and (2) geographic areas to target for a CRE isolate submission program. Outreach to facilities with high CRE burden led to enrollment of 15 clinical laboratories into a voluntary isolate submission program to analyze CRE isolates for additional characterization. Examples of health departments’ use of data for action include: notifying facilities with high standardized infection ratios (SIRs) and sharing Targeted Assessment for Prevention (TAP) reports. Conclusions: The NHSN’s role as a shared surveillance resource has expanded in multiple public health jurisdictions as a result of new data access provisions. Health departments are using NHSN data in their programmatic responses to HAI and AR challenges. New access to NHSN data is enabling public health jurisdictions to assess problems and opportunities, provide guidance for prevention projects, and support program evaluations.Funding: NoneDisclosures: None

Analysis of National Healthcare Safety Network Clostridioides difficile Infection Standardized Infection Ratio by Test Type

Background: The National Healthcare Safety Network (NHSN) has used positive laboratory tests for surveillance of Clostridioides difficile infection (CDI) LabID events since 2009. Typically, CDIs are detected using enzyme immunoassays (EIAs), nucleic acid amplification tests (NAATs), or various test combinations. The NHSN uses a risk-adjusted, standardized infection ratio (SIR) to assess healthcare facility-onset (HO) CDI. Despite including test type in the risk adjustment, some hospital personnel and other stakeholders are concerned that NAAT use is associated with higher SIRs than EIA use. To investigate this issue, we analyzed NHSN data from acute-care hospitals for July 1, 2017, through June 30, 2018. Methods: Calendar quarters where CDI test type was reported as NAAT (includes NAAT, glutamate dehydrogenase (GDH)+NAAT and GDH+EIA followed by NAAT if discrepant) or EIA (includes EIA and GDH+EIA) were selected. HO-CDI SIRs were calculated for facility-wide inpatient locations. We conducted the following 2 analyses: (1) Among hospitals that did not switch their test type, we compared the distribution of HO incident rates and SIRs by those reporting NAAT versus EIA. (2) Among hospitals that switched their test type, we selected quarters with a stable switch pattern of 2 consecutive quarters of each of EIA and NAAT (categorized as EIA-to-NAAT or NAAT-to-EIA). Pooled semiannual SIRs for EIA and NAAT were calculated, and a paired t test was used to evaluate the difference in SIRs by switch pattern. Results: Most hospitals did not switch test types (3,242, 89%), and 2,872 (89%) reported sufficient data to calculate an SIR, with 2,444 (85%) using NAAT. The crude pooled HO CDI incidence rates for hospitals using EIAs clustered at the lower end of the histogram versus rates for NAATs (Fig. 1). The SIR distributions, both NAATs and EIAs, overlapped substantially and covered a similar range of SIR values (Fig. 1). Among hospitals with a switch pattern, hospitals were equally likely to have an increase or decrease in their SIRs (Fig. 2). The mean SIR difference for the 42 hospitals switching from EIA to NAAT was 0.048 (95% CI, −0.189 to 0.284; P = .688). The mean SIR difference for the 26 hospitals switching from NAAT to EIA was 0.162 (95% CI, −0.048 to 0.371; P = .124). Conclusions: The pattern of SIR distribution for both NAAT and EIA substantiate the soundness of the NHSN’s risk adjustment for CDI test types. Switching test type did not produce a consistent directional pattern in SIR that was statistically significant.Funding: NoneDisclosures: None

SPARC-ing Change—The Maryland Statewide Prevention and Reduction of Clostridioides difficile (SPARC) Collaborative

Background: In 2018, the Maryland Department of Health, in collaboration with the University of Maryland and Johns Hopkins University, created the Statewide Prevention and Reduction of Clostridioides difficile (SPARC) collaborative to reduce C. difficile as specified in Healthy People 2020. Methods: The SPARC collaborative recruited hospitals contributing most cases to statewide C. difficile standardized infection ratio (SIR), according to data reported to the National Healthcare Safety Network (NHSN). SPARC developed intervention bundles around 4 domains: infection prevention, environmental cleaning, and diagnostic and antimicrobial stewardship. Each facility completed a self-assessment followed by an on-site, day-long, peer-to-peer (P2P) evaluation with 8–12 SPARC subject matter experts (SMEs) representing each domain. The SMEs met with hospital executive leadership and then led 4 domain-based group discussions with relevant hospital team leaders. To identify policy and practice gaps, SMEs visited hospital inpatient units for informal interviews with frontline staff. In a closing session, SPARC SMEs, hospital executives, and team leaders reconvened to discuss preliminary findings. This included review of covert observation data (hand hygiene, personal protective equipment compliance, environmental cleaning) obtained by SPARC team 1–2 weeks prior. Final SPARC P2P written recommendations guided development of customized interventions at each hospital. SPARC provided continuous support (follow up phone calls, educational webinars, technical support, didactic training for antimicrobial stewardship pharmacists) to enhance facility-specific implementation. For every quarter, we categorized C. difficile NHSN data for each Maryland hospital into “SPARC” or “non-SPARC” based on participation status. Using negative binomial mixed models, we analyzed difference-in-difference of pre- and postincidence rate ratios (IRRs) for SPARC and non-SPARC hospitals, which allowed estimation of change attributable to SPARC participation independent of other time-varying factors. Results: Overall, 13 of 48 (27%) hospitals in Maryland participated in the intervention. The baseline SIR for all Maryland hospitals was 0.92, and the post-SPARC SIR was 0.67. The SPARC hospitals had a greater reduction in hospital-onset C. difficile incidence; 8.6 and 4.3 events per 10,000 patient days for baseline and most recent quarter, respectively. For non-SPARC hospitals, these hospital-onset C. difficile incidences were 5.1 preintervention and 4.3 postintervention. We found a statistically significant difference-in-difference between SPARC and non-SPARC hospital C. difficile reduction rates (ratio of IRR, 0.63; 95% CI, 0.44−0.89; P = .01). Conclusions: The Maryland SPARC collaborative, a public health-academic partnership, was associated with a 25% reduction in the Maryland C. difficile SIR. Hospitals participating in SPARC demonstrated significantly reduced C. difficile incidences to match that of high-performing hospitals in Maryland.Funding: NoneDisclosure: Aaron Milstone, BD – consulting.