Collecting data for prevention

The Centers for Disease Control and Prevention (CDC) estimated approximately 1.7 million healthcare-associated infections occurred in US hospitals in 2002, with 99,000 associated deaths. To track health care-associated infections, for the last 30 years the CDC has used the National Nosocomial Infection Surveillance (NNIS) system.

The NNIS is a system that was developed to assess risk factors for infections, look at best ways of collecting information and use this information for prevention. It was a voluntary system that comprised 300 hospitals in the US.

A new system

In 2005, the NCPDCID opened enrollment to its new system: the National Healthcare Safety Network (NHSN). “We realized that NNIS had several limitations, including the way infection control professionals had to enter the data and send the data to us. Around 2002, we decided not to allow more hospitals to participate in the old system because we wanted to change it. Based on the lessons learned from that system, we made several improvements,” says Denise Cardo, Director of the CDC’s Division of Healthcare Quality Promotion.

The new network is a web-based system, which makes it easier for healthcare facilities to send information to the CDC. The agency also benefits from the improvements. The system can be updated easily and quickly. The network is also more flexible. Its modules cover healthcare associated infections, but it also collects information about healthcare worker safety.

Adding to the systems’ flexibility, it has less rigid eligibility criteria. “In the past, for hospitals to participate, they had to have more than 100 beds, they had to have an infection control professional collecting information and several other things. Now, any hospital or healthcare facility in the United States can join this system and participate. We do have some specifications, which concern how a specific type of information is collected in a specific amount of time, but small hospitals can join, healthcare facilities like dialysis units can join, and in the future we also hope that we will have nursing homes join the system,” Cardo explains.

Legislation

In 1999, intensive care units (ICUs) of the hospitals that were participating in the old system showed a 35-45 percent decrease in infections. Now, in addition to collecting this kind of information, the CDC is concentrating on developing models for hospitals to collect information about adherence to recommendations to prevent infection. “Hospitals will not only know infection rates, but also how the clinicians are doing. This can be very powerful information. Provided on a regular basis, it can really improve the quality of care.”

Now that more healthcare facilities can enroll in the network, the CDC is keen to show the value added. “We’re working with them to see what else can be done to prove the value of collecting information so they can make improvements to prevent infections. But another thing that is happening in the US is that legislation is being passed in several states for mandatory reporting of healthcare associated infection, with some of them making that information available to the public. Right now, 13 states have decided to use our new system for reporting infections, and the states will have access to that information. It shows that the states are seeing the importance of having a system that everybody is going to use with standardized definitions,” Cardo points out.

The CDC guarantees ‘assurance of confidentiality’, which protects the identity of the patient and the institution. “We have a memoranda of understanding with all the states using NHSN for mandatory reporting to make sure that whatever is done is done protecting patient confidentiality but also doing the best so that that information can be used to prevent the infections that the patients may face,” Cardo assures.

Challenges

Every time there’s a new system, there are problems, Cardo admits – either because of difficulties in understanding the system, joining the system, or using the data. The CDC offers training, which is one of the reasons why it took several hospitals some time to join the NHSN. “We want to train the hospitals first, to make sure that they adhere to the definitions that we have in the system, and do their surveillance accordingly. Secondly, so they know how to enter the data in the system. Thirdly, so they know how to use that data. There’s several tools for analysis that we want them to learn how to use, and we always see some glitches in terms of either the data collection or the system itself. It’s web-based, and sometimes we experience problems with the web. But we work on that and improve it almost on a daily basis; and working directly with the hospitals is a way for us to really see things that need to be improved,” Cardo expresses.

The CDC also organizes work groups with the states that are using NHSN as their reporting tool. In addition, the institution responds to calls to assess problems facilities may have and find potential solutions to those problems.

A step-by-step approach

The NHSN is not a mandatory system, and alternative systems are available for hospitals to use so if they don’t need to report to a specific agency, or if they don’t want to commit to following the NHSN’s protocols. “We aren’t actually aiming to have all the hospitals in the United States enter this system at this time. We prefer to have a step-by-step approach because we want to learn how to better improve the system. If all the hospitals joined the system at once, we would have a big problem,” Cardo admits.

Already, participation is higher than the CDC initially expected. “We thought that we were going to have the 300 hospitals that we had before, with a slow increase in the number of facilities. Instead, we’ve seen a huge increase in the past year. Almost 700 facilities right now participate in the system. Because of the state legislation, now we have many small hospitals that we didn’t have before; and so we need to learn how the protocols that have been used for medium and large hospitals will be applicable to smaller ones.”

The CDC’s primary goal is for the facilities that join the system to use the collected data for prevention. The benefits the NHSN offers are standardized ways of collecting information, defining what an infection is, and collecting information on adherence to recommendations. In the future, Cardo hopes to be able to introduce ways to decrease the burden of surveillance. “We’re already doing studies to evaluate the use of electronic data sources to detect infections,” Cardo explains, adding: “Instead of infection control professionals spending time collecting the data, they can get the data from the electronic data sources and then use that for prevention. So we’re not just improving the system but also the way that the infection control programes are collecting and analyzing the data for prevention.”

The benefit of having more institutions and a diversity of institutions join the system is that it will allow the CDC better assessment of infections and the prevention of infections. Ultimately, Cardo hopes that the center will be able to publish data that is more exact and representative.

Outbreak investigation

The NHSN is just one component of the CDC’s patient safety work. The division also conducts outbreak investigations of emerging infections in healthcare. “We have activities for the prevention of healthcare associated infections that include research we do with the Epicenter program to identify new ways of preventing infections. We also have collaborations to look at the impact of the implementation of existing recommendations. Some of the publications have shown a decrease of infections, for example, bloodstream infections, of up to 70 percent if you implement the recommendations, which are our guidelines,” Cardo points out.

To complement the CDC’s work, the organization’s laboratories are investigating microbial resistance. The information coming from the NHSN, Cardo expects, will help to identify new resistance patterns in healthcare facilities. In addition, the agency is collecting information for emerging problems like MRSA in collaboration with several US states. “Everything we do is complementing each other, so we get a better idea about the big picture.”

Healthcare associated infections, Cardo believes, are a problem in all healthcare institutions. The good news is that if they all promote the implementation of the CDC’s guidelines – recommendations that are known to prevent infections – they are going to see a considerable decrease of infections that will save lives and money. “Collecting information and using it for local action is a very important way for all of us, from the administrators to the clinicians and everybody involved in healthcare, to make a difference in terms of preventing infections and creating a safer healthcare environment.”

BIO

After finishing her medical training in Brazil, Denise Cardo worked in the prevention of hospital infections for 10 years. In 1993, she joined the CDC in the Division formerly called the Hospital Infections Program. Three and a half years ago, she became the Director of the Division of Healthcare Quality Promotion at the National Center for Preparedness, Detection, and Control of Infectious Diseases.