CHAIPIUnderstanding The Changing Role of
Infection PreventionistsThe Columbia/APIC Study
May 7th, 2009
Patricia Stone, PhD, FAANAssociate Professor of Nursing, Columbia University
Primary Investigator, CHAIPI Study
Sarah Jordan, Study Coordinator
The CHAIPI Study
This study is designed to inform our understanding of institutional, procedural, and technological innovations that can assist health professionals in reducing and eliminating the morbidity, mortality, and high costs associated with hospital-associated infections.
The ultimate goal is to generate knowledge that will inform evidence-based decision making for health policy makers, hospital administrators, epidemiologists, and infection preventionists.
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Problem
Infection Preventionists (IPs) are key to reducing HAI
The role of the Infection Preventionist is changing
– Monitor infection rates
– Monitor provider behaviors
– Intervene
– Implement
– Lead
Increased use of technology to perform role
The PNICE Study
The survey and research methodology used in the CHAIPI study are based on the Prevention of Nosocomial Infections & Cost Effectiveness (P-NICE) study
P-NICE is a three-year, two-phase study to describe infection control department staffing and interventions implemented in ICUs across the U.S. The study is conducted by Columbia University
School of Nursing and headed by Dr. Pat Stone.
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PHASE I • Survey of eligible NHSN hospitals• 250 hospitals participated (450 ICUs)• 66% response rate• Completed April 2008
PHASE II• Collection of data from subsample of NHSN hospitals• Medicare and HAI data for 2007• Patient Census• RN Staffing Data
The PNICE Study
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Overview of the CHAIPI IP Study
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Purpose of Research
Understand the changing role of IPs
Evaluate the impact of CHAIPI on
– IP roles
– Department resources
– Infection prevention and control processes
– HAI rates
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Methods
Comparison of data from two time points:– Infection control department characteristics– IP roles– Processes– HAI rates Compare CHAIPI and non-CHAIPI hospitals
Web-based surveys of infection control department staff – First survey took place from Oct 21, 2008 to Jan1, 2009– Second survey will take place in the Spring of 2010
Site visits at six hospitals to be conducted this summer
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Sample:
All California acute care hospitals. Psychiatric, drug/alcohol rehab, nursing
homes, and children’s hospitals were ineligible.
Participation:– 207 hospitals participated out of 350 eligible hospitals contacted; a 59%
recruitment rate
– 45 of 51 CHAIPI hospitals contributed to the survey; a 88% recruitment rate
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Infection Control Department Staffing and Resources
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IP Study HospitalsHospital Demographics
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N (%)Beds
Mean (SD)
Outpatient clinics Long term care Rehab
155 (75)71 (34)56 (27)
--66 (76)31 (27)
Outpatient clinics N = 155 surgery dialysisGI* radiation/oncologyphysical therapyIV therapyOutpatient other
127 (61)42 (20)86 (42)72 (35)
107 (52)63 (30)70 (34)
• Hospitals with outpatient clinics average 3.65 clinics/hospital +/-1.8.
• 176 (85%) of IP departments provide services to at least one outpatient clinic, rehab, or long term care unit.
* CHAIPI hospitals were significantly more likely to provide services to a outpatient GI clinics, 72 % vs. 51 %
Infection control departments providing services to other facilities or outpatient clinics
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Utilization of Electronic Surveillance Systems
CHAIPIN = 40
Non-CHAIPIN = 163 p-value
Electronic Surveillance SystemAICEMedminedTheradocSafety Surveillor CustomOther
13 (32.5)4 (31)9 (69)1 (8)1 (8)1 (8)1 (8)
31 (20)10 (32)
00
3 (10)7 (23)
14 (45)
.10
Staff members who use the systemHospital Epidemiologist Infection PreventionistsOther
3 (23)12 (92)7 (54)
3 (10)29 (94)12 (39)
.24
.88
.36
Years since system implemented Mean (SD) 4.0 (2.0) 4.9 (3.6) .006
Utilize which of the following features:
Use built-in templates to create reports and data summaries
12 (92) 22 (73) .16
Automatic alerts 11 (85) 14 (47) .02
Integration of infection data with CDC definitions and/or reporting requirements
4 (31) 15 (50) .24
Data mining (integrated with clinical, lab, and pharmacy data)
5 (38) 11 (37) .91
Share reports with key committees and hospital administration
0 1 (3) .78
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Comparison of the qualifications and experience of Infection Prevention and Control Department Staff: Infection Control Department Director
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Comparison of the qualifications and experience of Infection Prevention and Control Department Staff: Infection Preventionists
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Comparison of the qualifications and experience of Infection Prevention and Control Department Staff:Hospital Epidemiologists
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N Mean (SD)
CHAIPI Study 2008 - CA hospitals 123 0.55 (0.53) 1 IP / 180 beds
PNICE Study 2008 - U.S. NHSN hospitals 246 0.69 (0.54) 1 IP / 144 beds
Richards et al 1999 - U.S. NNIS hospitals 227 0.87 1 IP / 115 beds
The difference between IP study and PNICE hospital staffing is significant at p < .05 after adjusting for hospital size.
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Proportion of total time that Infection Preventionists spend on specific tasks
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Proportion of total time that Infection Preventionists spend in specific locations
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Mandatory Reporting
*Scale: 1 - much less, 5 - much more
Impact of mandatory reporting on the Infection Control department: Comparison of California and P-NICE study hospitals
IP Study hospitals
PNICE hospitals
N = 192 N = 152
Mandatory reporting has affected departmentN (%)
177 (92)N (%)
104 (71)(35 Missing / DK)
How has mandatory reporting affected the following: Mean (median)*
Influence of the department on hospital decision making 3.52 (4) 3.5 (3)
Resources to department to assist infection control 3.14 (3) 3.13 (3)
Time for routine infection control activities besides mandatory reporting
2.14 (2) 2.27 (2)
Other (e.g. more work, not enough time, not enough help) 3.9 (4) 3.4 (4)
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Hospital- wide HAI Rates and Infection Prevention and
Control Policies
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Hospital –wide mean monthly infection rates, data from July – Sept 2008
All IP Study HospitalsN Mean (SD) Median
CHAIPI N Mean (SD)
Non-CHAIPIN Mean (SD) p-value
BSI / 1000 patient days
98 0.57 (1.53) 0.13 20 0.67 (1.38) 78 .54 (1.57) .74
MRSA- BSI / 1000 patient days
109 0.17 (0.88) 0 20 0.10 (0.20) 89 0.18 (0.97) .44
Hand hygiene practices and leadership involvement
• 97% of hospitals report monitoring hand hygiene, the majority by observation.
• 60% report that hand hygiene is practiced correctly more than 75% of the time
N = 185 N (%)
Hand Hygiene Practices: Antiseptic agent in rooms or high workload areas 177 (96) Educational and reminder posters 17 (92) Education materials given to patients/visitors 123 (67) Provide real-time feedback to employees 113 (62) Education seminars/videos for staff 108 (59) Reward/administrative sanctions 41 (22) Other 24 (13)
Leadership involvement: Including hand hygiene in strategic goals 90 (49) Model hand hygiene during leadership rounds 61 (33) Leading morning huddles 9 (5) Other 21 (11)
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Policies on Infectious Agents
Hospital Wide MRSA Policies: N = 168
Written PolicyN (%)
Implemented Correctly
N (%)
Implement contact precautions for patients with positive cultures for MRSA
161 (96) 89 (55)
Cohort patients colonized with MRSA in the same room 130 (77) 34 (26)
Implement presumptive isolation/contact precautions pending a MRSA screen
70 (42) 23 (33)
Policies on Surveillance CulturesN = 164 N (%)
Collect a surveillance culture upon hospital admission 57 (35)
If yes, for which patients?All admissions (excluding L&D)Readmissions within 30 days Transfers from nursing homesICU patientsDialysis patientsOther
10 (18)10 (18)24 (42)38 (67)17 (30)28 (49)
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Surgical Site Infection Prevention Policies
Implemented correctly is defined as 95% of the time or better. Implementation percentages are a proportion of hospital swith a written policy. Hospitals without policies did not report implementation rates.
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ICU HAI Rates and Infection Prevention and Control
Policies
Infection rates in ICUS: Comparison of the Rates of Device Associated Infections by ICU Type to national NHSN data
IP Study Sample NHSN1
N Mean (SD) Median N Mean MedianCentral Line Associated Blood Stream Infection (CLBSI)
Medical ICU 15 2.1 (2.2) 1.9 144 2.4 1.9
Medical/ Surgical
87 2.3 (3.5) 0.9104 (teach) 2 1.5
343 (other) 1.5 0.6
Ventilator Associated Pneumonia (VAP)Medical ICU 11 1.8 (2.6) 0 93 2.5 1.9
Medical/ Surgical
89 2.6 (4.4) 079 (teach) 3.3 2.3
187 (other) 2.3 1.5
Catheter Associated Urinary Tract Infection (CAUTI)
Medical ICU 6 2.4 (3.7) 0 68 4.1 3.7
Medical/ Surgical
36 3.2 (3.4) 2.059 (teach) 3.3 2.9
130 (other) 3.1 2.6
1 Edwards JR, Peterson KD, Andrus MA, Dudeck MA, Pollock DA, Horan TC. National Healthcare Safety Network (NHSN) Report, data summary for 2006 through 2007, issued November 2008 , Am J Infect Control 2008;36 609-626
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Central Line Associated Blood Stream Infection Prevention Policies
Implemented correctly is defined as 95% of the time or better. Implementation percentages are a proportion of hospital swith a written policy. Hospitals without policies did not report implementation rates.
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Ventilator Associated Pneumonia Prevention Policies
Implemented correctly is defined as 95% of the time or better. Implementation percentages are a proportion of hospital swith a written policy. Hospitals without policies did not report implementation rates.
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Catheter Associated Urinary Tract Infection Prevention Policies
Implemented correctly is defined as 95% of the time or better. Implementation percentages are a proportion of hospital swith a written policy. Hospitals without policies did not report implementation rates.
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Next Steps
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Qualitative Site Visits
• Visiting six CHAIPI hospitals, two from each cohort
• Late June – August 2009
• Research team will conduct one hours interviews with infection control department personnel, the administrator who oversees the department, and one ICU manager
• The goal of site visits is to gain a more in-depth understanding of the changes and challenges affecting infection control professionals and their daily activities
• Currently recruiting hospitals
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TimelinePapers from Survey 1 are in development
– Description of staffing and IP time use – Use of surveillance procedures and contact precautions and their impact on MRSA rates– Overview of utilization of ESS
Dissemination 2010– Scientific abstracts and publications– APIC 2010 session– Prevention strategist article– Webinar– Press releases– Key legislative committees
Goal is to change practice based on
best evidence!
http://cumc.columbia.edu/studies/pnice/chaipi
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