Dear Infection Preventionist,
We are excited about our opportunity to launch a new program focusing on healthcare-associated
infections at the Virginia Department of Health (VDH). We apologize for any confusion that
may have occurred as a result of our efforts and want to write this note to clarify our projects and
plans with you.
VDH efforts in this area include some that have been underway for decades and some new ones
that are planned as a result of our receiving American Recovery and Reinvestments Act (ARRA)
funds to support the development of an HAI program. Our projects fall into two main
categories: surveillance and prevention.
The surveillance project has two parts. The first part, which has been underway for many years,
relates to the HAI reporting requirements in our Regulations for Disease Reporting and Control.
You are well aware that CLABSIs in adult ICUs must be reported in Virginia. You have
probably also heard that we were told by the Kaine Administration that we needed to add more
HAI reporting requirements. We have been working with the APIC-VA HAI Task Force and the
VDH/VHHA Advisory Committee to define what these additional measures should be. Many
potential measures have been discussed and the pros and cons of each weighed in trying to
decide how to expand the reporting requirements. Factors considered include severity of illness
caused by a certain procedure or organism; feasibility of collecting information on the measure;
availability of standardized definitions and methods for surveillance, etc. After many meetings
and discussions, the decision was to add a measure for CLABSI outside of the ICU, Clostridium
difficile infection, and Surgical Care Improvement Project measures, and to pilot test surgical site
infection reporting for coronary artery bypass graft, hip replacement, and knee replacement
surgeries. We continue to work with the APIC-VA HAI Task Force to define these measures.
To require more reporting, we must follow a process for changing regulations. We will propose
a change in the regulations, let you know that the change is open for comment, and you will have
60 days to comment on the proposal. It generally takes 18 months or so to make an official
change in regulations. We will keep you updated and encourage your input during the comment
period.
The second surveillance part, related to the ARRA grant, will involve pilot testing of surgical site
infection (SSI) surveillance and validation of a sample of central line-associated bloodstream
infection (CLABSI) data. We have developed a plan for piloting the surgical site infection
reporting. The purpose of the pilot is to evaluate and compare the effort and the benefit of
surveillance for each of the three types of surgery with the goal of selecting one to add to the
disease reporting regulations, making surveillance for that measure a permanent requirement.
The pilot involves asking a hospital in each of three bedsize categories in each of five health
planning regions to test the reporting of one of the three proposed surgical site measures.
Approximately 40 hospitals would be asked to participate. We understand that you are
concerned about the burden of this reporting being added to all your other responsibilities,
especially since tracking surgical site infections requires that all surgeries be entered into CDC’s
NHSN. We are trying to move ahead while being mindful of your workloads. We will be in
touch within the next month with more information about our plans for the pilot SSI surveillance
project.
The second category of activities covered by our HAI program is a prevention project. This is a
new category of activity for us. We put in our ARRA grant application that we were going to
partner with VHQC to implement a collaborative that would focus on two measures. The VHQC
model of quality improvement involves an Expert Panel meeting to identify the measures that
will be the focus of the collaborative. We started moving forward with VHQC on this and
proceeded to the point of having an Expert Panel meeting, at which three APIC-VA
representatives were present. We received a lot of feedback from many different directions that
told us that we were not on the right track with this project and which have led us to reassess it.
One is that the Expert Panel chose CLABSI as a focus for the collaborative but struggled to find
consensus on the second measure since C. diff and SSIs received a similar number of votes.
Second is that VHHA got 25 hospitals to sign on to the CUSP project, which is a national
collaborative to prevent CLABSIs, and we could not figure out how VDH could have a role and
add value to that. While VDH supports CUSP, and we are optimistic that CUSP will bring about
positive changes in Virginia, it is not one of the primary projects of VDH. Thirdly, we have
heard loud and clear and at every meeting how overburdened hospital staff are, especially IPs.
We wanted to be sure you knew that we heard you and heeded your message. We, like you,
want to be sure our project adds value and does not add burden without a positive outcome for
patients and for you. Finally, we acknowledge that we have heard that the approach to
prevention collaboratives that has been used in the past has not always been felt to be effective.
We want to be sure we do the right thing for Virginia. Therefore, we have been and will
continue to seek input from a variety of sources so we can build the best program possible. We
meet regularly as a Steering Committee with our partners on the ARRA HAI grant which
includes the Virginia Hospital & Healthcare Association (VHHA), VHQC (Virginia’s Quality
Improvement Organization), and APIC-VA. Also, the APIC-VA HAI Taskforce and a recently
assembled QI HAI Taskforce will help advise VDH with their facility-level experience and
expertise. The VDH/VHHA Advisory Committee composed of infection prevention, quality
improvement, administration, consumer, and other representatives meets quarterly to advise on
the project, and the Expert Panel might be convened again once we have redefined our
prevention project.
In the second week of February 2010, a needs assessment was sent to infection preventionists
(IPs), quality improvement (QI) contacts, and administration contacts in Virginia acute care
hospitals. The purpose of this needs assessment is to assess current HAI surveillance activities
performed in hospitals across the Commonwealth and identify educational and training needs.
The results of that assessment will help further guide this project.
We believe that IPs have a very important role in hospitals and that the IP unit is often
overworked and under-resourced. What we would like to build is some way to support and
reinforce the work of IPs to help get the important infection prevention messages out to everyone
who works in the hospital and for everyone to understand that they have an important role to
play in preventing infections. VDH cannot do that on site within every institution, but if we
could somehow facilitate better communication, teamwork, or upper level support for infection
prevention, we can feel like we have made a big step toward making a positive difference. Or, if
we could build some tools to make your job easier, that would be great, too.
Some ideas we have include:
 Feeding each hospital’s data back in a way that can be used on the units and given to
physicians, such as creating posters or brochures. VDH and VHQC would work with
hospitals to identify the most effective ways to feedback data, look at how the hospital is
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collecting and presenting data, develop some report templates that could be used to
display data differently so that charts could be placed in visible ways and make key
points to hands-on clinical staff.
Building a collaborative that is smaller in scope and rather than being statewide, consists
of selected hospitals that could use some resource support that could be supplied by
collaborating with other, similar facilities. Hospitals would volunteer to participate with
special emphasis on those with limited resources, or higher infection numbers or rates, or
those with low acceptance of the infection prevention messages. All hospitals in the
collaborative could work together to share ideas about ways to make improvements in
teamwork or communication or hospitals could be paired in a mentorship capacity with
other hospitals that have demonstrated more support for infection prevention.
Focusing on prevention in nursing homes and assisted living facilities instead of acute
care.
Building surveillance, data management, or data presentation tools that you could use or
providing training in outbreak investigation methods. (This might not fit with the
prevention collaborative concept but might be useful to you, thus helping with
prevention.)
We have the flexibility to do one prevention project or a combination of multiple approaches.
We have made suggestions to open the door to discussion and are definitely open to hearing
other ideas. Again, our goal is to help you get the prevention message out and to help support
your important role in the hospital. We need to design a program and define roles for VDH and
partner organizations. We are interested in knowing if the ideas listed above would be valuable,
if you are interested in participating in any of them, or if you have other ideas about ways VDH
might be able to help support your program.
Thank you again for all the great work you do to prevent infections in our hospitals. We
look forward to continuing to engage with you as we build our HAI program. We value
your experiences and opinions and will communicate regularly with you about our HAI
activities.
Sincerely,
Diane Woolard, PhD, MPH
Director, Division of Surveillance and Investigation
Virginia Department of Health