Surveillance Outside the
Hospital: Monitoring Home
Health Outcomes
Regina Nailon RN, PhD
Clinical Nurse Researcher
The Nebraska Medical Center
State of the Art Conference
April 22, 2013
Portions of this work were supported in part
by a grant from the Cardinal Health
Foundation.
Session Objectives
• Explain the role of outcomes data in the current
health care delivery system.
• Review a case study demonstrating how to
achieve measurement of outcomes in
outpatient settings.
Partnering Agencies
• Alegent Creighton Health at Home
• Children’s Home Healthcare/Children’s Hospital &
Medical Center
• Home Nursing with Heart
• InfuScience, a Bioscrip Company
• Methodist Home Health and Hospice
• Visiting Nurse Association of the Midlands
• The Nebraska Medical Center
– Nursing Research & Quality Outcomes Department
– Peggy C. Cowdery Patient Treatment Center
• University of Nebraska Medical Center
– Department of Infection Control and Healthcare Epidemiology
Increased
emphasis
on reducing
hospital
LOS
Increase in
patient care
in out
patient and
home
health
settings
Increased
incidence of
patients
discharged
from
hospital
with CVC in
place
Lack of
research
examining
standardize
d
maintenanc
e care and
its
association
with CVC
outcomes
Preventive
measures
have largely
concentrated
on CVC
insertion or
the use of
technologic
improvements
A much more
difficult issue to
address is the
monitoring of
CVC care
processes and
outcomes after
patients leave
the hospital
Significance of CLABSI
• 78,000 central line-associated bloodstream
infections are estimated to occur yearly In United
1
States hospitals and dialysis units .
• CLABSI are associated with an estimated
2
mortality rate of 12.3% and excess healthcare
costs between $7,288 and $29,156 per
3
episode .
1. Srinivasan A, et al. MMWR 60: 2011 2. Umscheid CA, et al. Infect Control
Hosp Epidemiol. 2011; 32:101-114. 3. Scott RD. Division of Healthcare Quality
Promotion, CDC, 2009.
CVC Adverse Events
in Out of Hospital Settings
• CLABSI rates in home settings range from 0.771 to 6.72 per
1,000 central line days.
• Thrombosis rates range from 0.063 to 1.354 per 1,000
central line days in pediatric and adolescent populations, as
high as 9.3 in adults5.
1. Gorski, L. (2004). Jnl Infusion Nsg, 27(2), 104-111. 2.Tokars et al. (1999). Ann Int
Med; 131: 340-7. 3. Pinon et al. (2009). European Jnl Ped; 168(12), 1505-12.
4.Revel-Villk, S., et al. (2010). Cancer, 116(17), 4197-4205. 5.Beckers, M.M. et al.
(2009). Thrombosis Research; 125(4), 318-21.
HAI Prevention Outside Hospital
• Healthy People 2020
– Prevent, reduce, and ultimately eliminate healthcareassociated infections (HAIs)
• Focuses on acute care, surgical centers, outpatient clinics
• National Action Plan to Prevent HAI: Roadmap to
1
Elimination, 2009
– Phase II (Draft April, 2012) extends to ASC, outpatient
dialysis
– Phase III (Draft July, 2012) extends to long term care
1. Department of Health and Human Services, rev. 2012
Ambulatory Care
1
HAI Prevention Aims
• Proactive HAI prevention at the clinic level
• Increase education and training in HAI prevention
for providers, as well as patients and families
• Sustain and expand improvements in oversight and
monitoring
• Develop meaningful HAI surveillance and reporting
procedures
1. Department of Health and Human Services, rev. 2012. National Action Plan to
Prevent HAI: Roadmap to Elimination.
"Measurement is the first step that leads to
control and eventually to improvement. If
you can't measure something, you can't
understand it. If you can't understand it, you
can't control it. If you can't control it, you
can't improve it."
- H. James Harrington
Central Venous Catheter Use
Outside the Hospital
• Deficiencies with tracking patients who leave
hospital with CVC
• No national surveillance mechanism to monitor
CVC-related outcomes in home health or nonacute long term care
“Whenever you can, count.”
- Sir Francis Galton
CVC Procedure Volumes
The Nebraska Medical Center*
Inpatient
Total = 5264
% Total
Medicare
2367
45%
Medicaid
777
15%
Other insurance/ self pay
1913
37%
Total = 1105
% Total
Medicare
368
33%
Medicaid
91
8%
Other insurance / self pay
646
58%
Outpatient
*7/1/10-7/31/12. Excludes repair and replacement procedures.
Dismissed from Hospital with CVC
The Nebraska Medical Center
Outpatient procedure
2010-2012*
1258*
Avg/month
50.3
Avg/day
1.67
CVC Replacements only
Avg/month
153
6.12
* CVC insertions and replacements 7/1/10-7/31/12.
Standardizing Central Venous
Catheter Care in the Outpatient
Realm:
Care from Hospital to Home
(SCORCH)
SCORCH Surveillance System
•
•
•
•
•
Engage stakeholders
Describe system
Gather evidence of system’s performance
Lessons learned – ensure use of findings
Conclusions/recommendations
CDC. Updated guidelines for evaluating public health surveillance systems:
Recommendations from the guidelines working group . MMWR 2001; 50 (RR13);
1-35.
Engaging Stakeholders
• Six Omaha area home health/home infusion
agencies
– Consensus building sessions May-November, 2011
• Developed guidelines to standardize CVC care
– National Guidelines Clearinghouse
– The Nebraska Medical Center website:
http://www.nebraskamed.com/central-line-care
– Surveillance data
• Monthly since January 2012
• 2011 data to serve as baseline
• June 2012 revised data
– More granular analyses
“A public health surveillance system
can…be useful if it helps to determine
that an adverse health-related event
previously thought to be unimportant
is actually important” (CDC, 2001).
Public Health Importance
of Surveillance System
•
•
•
•
Delayed treatment
Costs
Hospital admissions/readmissions
Preventability
– Standardizing care in out of hospital settings
Admissions/Readmissions
with CLABSI POA
Year
FY 2010
*Readmission w/CLABSI
POA (rate)
FY 2011
*Readmission w/CLABSI
POA
FY 2012
*Readmission w/CLABSI
POA
The Nebraska Medical
Center
89 UHC
Hospitals
232
10,824
44 (19%)
1692
189
9939
32 (17%)
1354
95
5479
9 (9%)
704
Data source: University Healthsystems Consortium, 10/11/12.
Purpose and Operation of System
Purpose
• Monitor impact of
implementing
standardized CVC care
practices across the
continuum of care
– BSI and thrombosis rates
using standardized
denominator data across
HHA/HIA
Objectives
• Quality improvement
• Formation of research
hypotheses
Operation of System
• System resides at TNMC
• Data use agreements to ensure data
confidentiality
• System components
– Patients receiving CVC-related care from home
health agency nurses
• CLABSI as defined by CDC that occur in patients 48 hours
after admission to home care
• CVC occlusion events/use of fibrinolytic agents
"In God we trust,
all others bring data."
- W. Edwards Deming
Data Elements
• Pediatric (18 and younger) and adult (19 and older)
• # of patients on service with CVC in place – receiving CVC care
from agency
• Central line (CL) device days
• CL-associated blood stream infection count
– Type of CVC*
– # lumens*
• CL line occlusion event count
– Type of CVC*
– # lumens*
• # of doses of a fibrinolytic used to dissolve line thromboses
• # of patients who received a fibrinolytic to dissolve line thromboses
* Added these more granular data after Q1 reports disseminated
Operation of System
• Data imported into Excel spreadsheet for
descriptive analyses
• BSI rate/1,000 device days
• Occlusion rate/1,000 device days
• Ratio of fibrinolytic doses/occlusion event
• Quarterly benchmarking reports
• Agency performance compared to aggregated mean
• No agency identifiers are exchanged
Table P1. Pediatric Central Line Days, Adverse
Events and Use of Fibrinolytic Agents
Q1 12
Q2 12
Q3 12
Q4 12
4 Qtr Avg
118
102
132
134
121.50
3061
2547
3415 3614 3159.25
Number Pediatric CLABSI
2
3
0
0
1.25
Number Occlusion Events in
Pediatric Patients
5
1
5
8
4.75
Number Pediatric Patients
Receiving Fibrinolytic Agent
5
1
5
7
4.50
Number Doses Fibrinolytic Agent
given to Pediatric Patients
5
1
5
6
4.25
# of Reporting Agencies
5
5
5
5
5
Number Patients on Service with
CVC Age <19
Number Pediatric Central Line
Days
Table A1. Adult Central Line Days, Adverse Events
and Use of Fibrinolytic Agents
Number Patients on Service
with CVC Age >19
Number Adult Central Line
Days
Number Adult CLABSI
Q1 12
Q2 12
Q3 12
Q4 12
4 Qtr Avg
499
545
660
687
597.75
9119 10474 12605 13501 11424.75
1
3
2
2
2.00
Number Occlusion Events in
Adult Patients
58
48
54
59
54.75
Number Adult Patients
Receiving Fibrinolytic Agent
48
41
45
45
44.75
Number Doses Fibrinolytic
Agent given to Adult Patients
96
61
76
77
77.50
5
5
5
5
5
# of Reporting Agencies
Table P2. Pediatric Central Line Associated Blood Stream
Infections per 1,000 Central Line Days
Q1 12
Q2 12
Q3 12
Q4 12
4 Qtr Avg
Agency A
1.06
0.63
0.00
0.00
0.42
Agency B
0.00
No
pediatric
pts
No
pediatric
pts
0.00
0.00
Agency C
0.00
No
pediatric
pts
No
pediatric
pts
No
pediatric
pts
0.00
Agency D
0.00
No
pediatric
pts
No
pediatric
pts
No
pediatric
pts
0.00
Agency E
0.00
2.11
0.00
0.00
0.53
Database Aggregate Mean
0.65
1.18
0.00
0.00
0.46
5
5
5
5
5
# of Reporting Agencies
Table A2. Adult Central Line Associated Blood
Stream Infections per 1,000 Central Line Days
Q1 12
Q2 12
Q3 12
Q4 12
4 Qtr Avg
Agency A
0.00
0.00
0.80
0.62
0.36
Agency B
0.00
0.00
0.00
0.00
0.00
Agency C
0.00
0.00
0.00
2.35
0.59
Agency D
0.72
0.00
0.35
0.00
0.27
Agency E
0.00
0.50
0.00
0.00
0.12
Database Aggregate Mean
0.11
0.29
0.16
0.15
0.18
5
5
5
5
5
# of Reporting Agencies
Table P3. Pediatric Central Line Occlusion Rate
per 1,000 Central Line Days
Q1 12
Q2 12
Q3 12
Q4 12
Agency A
2.64
0.63
2.36
2.23
4 Qtr
Avg
1.96
Agency B
0.00
No pediatric
pts
No pediatric
pts
29.41
14.71
Agency C
0.00
No pediatric
pts
No pediatric
pts
No pediatric
pts
0.00
Agency D
0.00
No pediatric
pts
No pediatric
pts
No pediatric
pts
0.00
Agency E
0.00
0.00
0.00
1.49
0.37
Database Aggregate Mean
1.63
0.39
1.46
2.21
1.43
5
5
5
5
5
# of Reporting Agencies
Table A3. Adult Central Line Occlusion Rate
per 1,000 Central Line Days
Q1 12
Q2 12
Q3 12
Q4 12
4 Qtr Avg
Agency A
36.36
30.57
25.74
22.22
28.73
Agency B
22.49
20.54
12.53
9.69
16.31
Agency C
2.38
0.00
1.35
0.00
0.93
Agency D
0.72
0.00
0.35
0.77
0.46
Agency E
1.84
1.82
0.91
1.54
1.53
Database Aggregate
Mean
6.36
4.58
4.28
4.37
4.90
5
5
5
5
5
# of Reporting Agencies
Pediatric Patient Data Q1 12 Adjusted and Unadjusted
Q1 12
Unadjusted
Pediatric
Patients on
Service with
CVC
Q1 12
Unadjusted
Pediatric
Central Line
Days
Q1 12
Adjusted
Pediatric
Patients on
Service with
CVC
Q1 12
Adjusted
Pediatric
Central Line
Days
Total All
Agencies
295
8440
118
3061
Agency A
45
1090
45
1090
Agency B
2
49
2
49
Agency C
1
6
1
6
Agency D
246
7272
69
1893
Agency E
1
23
1
23
Adult Patient Data Q1 12 Adjusted and Unadjusted
Q1 12
Unadjusted
Adult Patients
on Service with
CVC
Q1 12
Q1 12
Q1 12
Unadjusted
Adjusted
Adjusted
Adult
Adult
Adult
Central Line Patients on Central Line
Days
Service with
Days
CVC
Total All
Agencies
863
21064
499
9119
Agency A
368
9662
52
578
Agency B
53
840
53
840
Agency C
54
880
54
880
Agency D
144
4253
96
1392
Agency E
244
5429
244
5429
Resources to Operate System
• First year supported in part by grant from Cardinal Health
Foundation
• In-kind support provided by stakeholders:
– The Nebraska Medical Center - Clinical nurse researcher,
Department of Nursing Research and Quality Outcomes
• ~ 6 - 8 hours/quarter
– University of Nebraska Medical Center – Director Infection Control
and Epidemiology
• Co-Lead/Consultant ~1- 2 hours/quarter
– Omaha region home health agency personnel
• Monthly data submission
– 1 - 2 hours/month (Manual versus automated)
• Other resources
– Telephone, computer, Internet connections,
hardware and software maintenance
Data Management Resources
Data
Collection
Process /
# Individuals
Involved
How are Events Identified?
Occlusion
count
BSI
count
Data Validation
Hours per
Month
Agency A
Manual,
1 person
Rx report
Chart review
Self, weekly manual
review of all cases
2
Agency B
Manual
2 persons
Rx report
Chart review
Self, manual review
of medical record
2-3
Agency C
Manual,
1 person
Rx report
RN reports
Self, clarify with RN,
Rx
1.5 – 2
Agency D
Manual,
1 person
Rx report
Infection
Control
Self, manual review
2
Agency E
Automated,
2-3 persons
Rx report
Weekly case
conference
Self, manual review
2
Agency F
Automated, 1
person
Rx report
Event report
in IT system
Self, daily morning
meeting all cases
1-1.5
Evaluating SCORCH Surveillance
System
• Data elements refined after Q1 2012 reports
– Events tracked by CVC device type and # lumens
– Clarified data for patients receiving agency RN care
– Ratio of occlusions to fibrinolytic doses given
» Were non-occluded lumens being treated?
– Consensus that all use CDC BSI definition
» Communication gaps in knowing BSI occurred
• Generated list of patient-centered research ideas
Table A1. Adult Central Line Days, Occlusion Events
and Use of Fibrinolytic Agents
Q1 12 Q2 12
Q3 12
Q4 12
4 Qtr Avg
660
687
522
Number Patients on Service
with CVC Age >19
499
Number Adult Central Line
Days
9119 1047 12605 13501 9796.5
4
Same agency
with 36
1 agency with
1
2 occlusions
2.00
323occlusions2
Number Adult CLABSI
545
(61%) Q4
(55%) Q1
Number Occlusion Events in
21 patients
Adult Patients
(44%)
58
48
54
59
53.00
Number Adult Patients
Receiving Fibrinolytic Agent
48
41
45
45
23 patients
(51%) Q4
Number Doses Fibrinolytic
Agent given to Adult Patients
96
61
76
77
78.50
48 doses
(50%)
# of Reporting Agencies
44.50
45 doses
(58%) Q4
5
5
5
5
5
“Surveillance for outcome measures in
ambulatory care settings is challenging
because patient encounters may be
brief or sporadic and evaluation and
treatment of consequent infections
may involve different healthcare
settings (e.g., hospitals)”
CDC. Guide to Infection Prevention for Outpatient Settings: Minimum
Expectations for Safe Care, 2012, p. 7.
Conclusions and Recommendations
• Home health outcomes are measurable
– Develop system of data validation
• Lab data
• Claims data
• Communication system from receiving hospital to HHA
when CLABSI present on admit
• Focus in on specifics of CVC care to better
drive QI
– Agency use of reports
• Continue monitoring use of standardized
care guidelines
“When you are face to face
with a difficulty,
you are up against
a discovery.”
- Lord Kelvin, British physicist
Next Steps
• Extramural funding
– Refine/further develop surveillance system
» BSI rate/1,000 device days by device type
» Patient demographics
– Capture in real time hospital admissions/
readmissions attributed to BSI
• Close loop/communicate BSI to HHA/HIA
Next Steps
• Patient-centered outcomes research
• Collaborate with 3rd party payer, HHA/HIA,
ambulatory/outpatient clinic providers
• Infection control practices
• Reporting structures
• Clinician CVC-related behaviors/competencies
Next Steps
• Complete production of patient education
DVD aimed at empowering patients to
understand what CVC care should look like
• Complete patient-focused study, “Day in the
Life of a Line”
– 14-day diary of who/when/where/why CVC care is
being provided
Next Steps
• Extend surveillance to long term care settings
– CLABSI
– CAUTI
• Admissions / readmissions
• Standardize urinary catheter care
Standardizing Central Venous
Catheter Care in the Outpatient Realm:
Care from Hospital to Home
SCORCH HAI’s
Questions?