Committee on Healthcare, Las Vegas, Nevada

CDC Statement for Nevada State Legislative Interim Session Legislative Committee on Healthcare, Las Vegas, Nevada

Wednesday, April 21, 2008

Statement of:
Dr. Michael Bell

Introduction

Good morning Assemblywoman Leslie, and members of the Nevada Legislative Committee on Health Care. I am Dr. Michael Bell, Associate Director of Infection Control, for the Division of Healthcare Quality Promotion, National Center for Preparedness, Detection, and Control of Infectious Diseases, Coordinating Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC). With me today is Dr. Joseph Perz, Prevention Team Lead for the Prevention Response Branch of the Division of Healthcare Quality Promotion. CDC very much appreciates your committees attention to this very important matter, and is pleased to have been invited to speak with you today. CDC has been and continues working on issues relevant to the hepatitis C virus outbreak in Nevada with several other Federal Agencies, including the Centers for Medicare and Medicaid Services; and local and state authorities, including the Southern Nevada Health District (SNHD) and the Nevada State Health Division. Additionally we are working with multiple professional societies and other public health organizations, many of which you have invited here today, such as the Joint Commission, the Association for Professionals in Infection Control and Epidemiology, HONOReform, the American Association of Nurse Anesthetists, the American College of Gastroenterology, the Council of State and Territorial Epidemiologists, National Association of County and City Health Officials (NACCHO), and the Association of State and Territorial Health Officials (ASTHO).

CDC is very concerned about the persons recently infected with hepatitis C virus (HCV) and the practices that led to the recent outbreak in Nevada. These threats to patient safety are not unique to Nevada but are found across the nation where healthcare is delivered, including hospitals and medical centers and particularly in the increasing number of outpatient settings like ambulatory surgical centers. The joint efforts of all of these partner groups and many others I have not mentioned are helping to bring together a cohesive response to correct the problems identified here in Nevada, and to ensure that the experience here can have an impact on the larger issue of maintaining complete adherence to safe practices by all healthcare personnel in this country. We look forward to continuing this collaboration and to taking action to promote a culture of safety in the US healthcare system that will ensure that infection control practices and patient safety remain central to all patient care.

The Investigations

CDC appreciates the invitation from the Nevada State Health Division and the Southern Nevada Health District (SNHD) for CDC to assist with the recent investigations. As you know, the first cases of acute or new onset of hepatitis C were detected through disease surveillance conducted by SNHD. At the invitation of local and state health officials, CDC joined the investigation. The investigation has identified 6 persons with HCV infection who underwent endoscopy procedures at a single clinic. In addition to the field team of epidemiologists, CDC provided molecular diagnostic laboratory testing to confirm the relatedness of these infections.

During the initial investigation, CDC and SNHD observed dangerous practices known to have been implicated in previous hepatitis C virus (HCV) transmission and that may have been ongoing for several years. These included reuse of syringes to access medications from a single dose vial, and the use of single dose vials for multiple patients. CDC made recommendations to the staff of the SNHD and the clinical facilities involved regarding correct injection practices, hand hygiene, and appropriate management of patient-care equipment.In follow up to the initial investigation, CDC collaborated with state and local health officials, CMS and local certified Infection Control Specialists to assist Bureau of Licensure & Certification (BLC) survey teams in evaluating all of Nevadas ambulatory surgery centers to ensure their practices adhered to correct infection control and safe injection practices, and advised the State of Nevada regarding additional actions to assure that basic, safe patient-care practices are maintained in ambulatory care settings. CDC assistance included sending a team of CDC personnel to provide on-site expertise and assistance in facility evaluation, providing survey tools for focused infection control inspections, and providing an educational presentation on infection control for use with clinic staff. CDC provided technical input into risk communications, helping the public interpret findings, and worked with BLC staff to assess their findings. CDC has been in close contact with the state health department and the SNHD throughout the investigations, and commends them and the Nevada State Health Division for their thorough and timely work.

National Perspective

CDC is the nations lead agency for research and programs that prevent healthcare-associated infections (HAIs). CDC estimates that approximately 1.7 million HAIs with 99,000 associated deaths occur in U.S. hospitals per year. In addition to the tremendous toll on human health, HAIs result in an estimated $6.7 - $20 billion of excess healthcare costs every year. Increasingly, healthcare delivery is being shifted to outpatient settings where increasingly complex procedures are being performed. For example, the number of ambulatory surgical centers in the United States has grown from around 300 to over 4000 in the last 20+ years. Outpatient settings often have limited capacity for oversight and infection control capacity in comparison to hospital-based settings. At the same time, increasing populations of aging and vulnerable patients are continuing to increase demand for care and stretch the healthcare system.

Although we do not have a clear national picture of the scope of the problem of unsafe practices in outpatient settings, we do have examples from past experiences indicating that breeches in infection control have occurred and that some breeches are particularly likely to cause infections. CDC is seeing an increase in the number of outbreaks of viral and bacterial infections in outpatient settings due to unsafe medical practices and has investigated previous transmissions of infections associated with unsafe injection practices or lapses in infection control in outpatient clinics. In 2007-2008 alone, there have been five recognized syringe-reuse incidents in different states that have resulted in large numbers of patient notifications recommending testing for HIV, HBV, and HCV.

In addition, bacterial outbreaks have also been identified due to unsafe injection practices. The outpatient setting is a common factor in many of these recent outbreaks, including outpatient radiology clinics, ambulatory surgical centers, outpatient pain clinics, infusion centers and dialysis centers.

Not only is it important that patients receive safe care without the risk of infection, but it is also important that patients maintain trust in a safe healthcare system so they continue to receive necessary preventive care such as screenings ,that are so important for maintaining good health.

Looking Forward

Ensuring that basic safe practices are always followed in all healthcare settings requires a multi-pronged approach. Effective public health surveillance and response capacity is needed to detect, respond, confirm, and terminate outbreaks of healthcare-associated infections, including viral hepatitis. Hepatitis C infection is the most common blood borne viral disease in the U.S. and may be a sentinel event revealing errors in infection control practices. Thirty-six states currently require reporting of chronic and acute hepatitis C. Detection of errors in infection control practices requires strong survey capacity in outpatient settings to complement hospital-based capacities. Regulatory and reimbursement channels can be used to provide effective inspections, clinician information, accreditation, and corrective actions if needed. Safe technology innovations and safe designs for medical equipment can increase the likelihood that unsafe practices wont occur.

And, in order to promote and maintain long term adherence to safe practices, enhanced provider education (linked to licensing and accreditation) is essential to change attitudes, perceptions and beliefs about dangerous practices, focus personal responsibility for safe practices and to create a culture of safety throughout the healthcare professions. All of these aspects must work together to successfully move toward the goal of consistent safe healthcare delivery.

CDC will continue to work to promote safe care and adherence to correct practices in all areas of healthcare delivery. CDC develops and promotes the implementation of evidence-based guidelines to prevent healthcare-associated infections; develops and evaluates the effectiveness of interventions for prevention of healthcare-associated infections; develops, disseminates, and evaluates training and other health communications tools designed to protect patients and healthcare personnel and to promote quality healthcare; conducts surveillance, research, and demonstration projects to measure the impact of healthcare-associated infections; provides epidemiologic and laboratory assistance when investigating outbreaks of disease and other adverse events that occur in healthcare settings; and provides assistance for routine disease surveillance. In conjunction with state and local health departments, other Federal agencies, and its partners, CDC is applying all of these tools to eliminate healthcare-associated infections and increase adherence to safe practices throughout our healthcare system.

In closing, thank you again for letting us take part in this discussion today. Overall healthcare is still safe. It is important that people receive the care they need. We look forward to working with you and others to ensure that safe practices are adhered to in all settings where healthcare is delivered and that patients are protected from harm.