Framing the Issue
• About 1 out of every 20 hospitalized patients will contract a health care-associated infection.
• An estimated 1.7 million people got HAIs in U.S. hospitals and an estimated 98,987 died as a result in 2002, the most current year data are available.
• Each year, more than 2 million people in the United States are sickened with antibiotic-resistant infections, and at least 23,000 die as a result. These infections are contracted in many ways, including person-to-person contact in the community, contact with contaminated food and contact within a health care facility.
• The use of antibiotics is the most important factor leading to antibiotic resistance because bacteria with immunity to the drugs eventually evolve.
• Up to 50 percent of all antibiotics prescribed are not needed or are not optimally effective as prescribed.
When Carol McLay, R.N., entered the infection prevention field in the late 1990s, it was "the ugly stepchild relegated to a small office in the basement." Resources were few, and most hospitals had one infection preventionist for hundreds of patients.
Today, the stepchild has moved up from the basement at many facilities as awareness of the importance of preventing health care-associated infections has grown. Fueling the trend are organized state and national infection prevention efforts by the government and health care community, the growing threat of antibiotic-resistant bacteria strains and new Medicare penalties for hospitals with the most infections.
Still, much work needs to be done, says McLay, an infection prevention consultant based in Lexington, Ky., and chair of the Association for Professionals in Infection Control and Epidemiology's communications committee. "The science is out there, but there is a lag between the evidence-based interventions and implementation of those interventions within facilities," she says. "Overall, in the last decade, progress toward eliminating or even reducing health care-associated infections has been very slow, and hospitals are much less safe than they need to be."
That assessment is shared by the authors of a study published in September 2013 by JAMA Internal Medicine. "Only recently have health care organizations begun to achieve successes and overcome the doubts about the scalability of pilot studies and vanguard institutions," the researchers write.
Progress varies by type of infection. The biggest success has been in prevention of central line-associated bloodstream infections — the focus of a nationwide effort run by the American Hospital Association's Health Research & Educational Trust and funded by the Agency for Healthcare Research and Quality. Nationally, the occurrence of CLABSIs fell 41 percent in 2011, according to a February 2013 Centers for Disease Control and Prevention report. Similarly, the HRET-led effort, On the Cusp: Stop BSI, reduced those infections among participating hospitals 40 percent from its start in 2008 to its conclusion in 2012.
Reductions in catheter-associated urinary tract infections (7 percent) and surgical-site infections (17 percent) were much smaller than those for bloodstream infections in 2011, the CDC report found. However, early results from HRET's second national On the Cusp effort, which targets CAUTIs, show that the fight against this type of infection is picking up steam. On average, participating hospitals have reduced CAUTIs 16 percent, says Barbara Edson, R.N., HRET vice president for clinical quality. About 850 hospitals are involved, and more are enrolling as the program rolls out.
The project, which began in 2011 and ends in 2015, has to overcome the perception that CAUTIs aren't that serious, Edson says. On the contrary, these infections increase patient lengths of stay, can seed other infections and exacerbate the problem of antibiotic resistance.
The success of On the Cusp is attributed to its approach of blending hospital culture change and evidence-based best practices to reduce the risk of infection, says Sam Watson, executive director of the Michigan Hospital Association's Keystone Center and its senior vice president for patient safety and quality. "What we found is that the combination of technical — this is what you need to do to prevent this infection — and the adaptive — this is how you change behavior — is very powerful in creating sustainable change," Watson says.
On the technical side, the CDC has published evidence-based guidelines to help hospitals prevent infections. They range from guidelines on hand hygiene and disinfection practices to recommendations specific to devices, procedures and bacteria.
For behavior to change, hospitals first and foremost must build a culture in which staff reject the notion that because people in their facilities are sick, some of them inevitably will develop infections, Watson says. Instead, staff must view infections as unacceptable and determine why an infection has occurred so it can be prevented in the future.
A growing sophistication
The way hospitals apply the evidence-based bundles and a culture of safety to their local situations leads to innovation in their infection prevention programs.
For example, Orlando Health faces the task of implementing its infection control efforts across its eight Florida hospitals. But the infection risks at the system's Winnie Palmer Hospital for Women and Babies differ from those at Orlando Regional Medical Center, a Level 1 trauma center, notes Jamal Hakim, M.D., the system's chief of quality and transformation. He points to ventilator-associated pneumonia as an example. At any given time, perhaps one woman is ventilated at Winnie Palmer versus 20 patients at Orlando Regional, so the VAP risk is much higher at the trauma center.
To spread initiatives across multiple hospitals while respecting their differences, Orlando Health developed what it calls a triad — teaming nursing, medicine and quality to work together on infection prevention. It starts at the corporate level with the chiefs of quality, nursing and medicine, then moves down to the hospital level with the heads of the three departments, and then to the hospital unit level. At each level the focus narrows from broad influence at the corporate level to actual implementation of the infection prevention bundles at the unit level, where the triad consists of the nurse manager, a physician champion and each unit's nurse elected to the nursing practice council.
Almost every unit within Orlando Health now has a triad, Hakim says. "They feel honored to have these positions of influence," he says. "Nobody is demanding anything or cracking any whips. This is about honor, pride and doing the right thing."
In Fort Myers, Fla., six-hospital Lee Memorial Health System has trained more than 500 front-line workers to serve as safety coaches on each unit. The coaches know the infection prevention bundles, identify and report safety issues, and intervene in a nonconfrontational manner when they see a problem, says Charles A. Krivenko, M.D., chief medical officer, clinical services, and chief patient safety officer.
Lee Memorial also conducts safety check-ins every morning at each facility to review the past 24 hours and identify any safety risks in the next 24 hours. During these 15-minute calls, leaders from each department and unit report to the chief administrator on their respective campuses. For example, if sterility protocols weren't followed when an ICU patient got a central line the day before, the incident would be reported and infection control would address it, Krivenko says.
The C. diff battle
In some cases, hospitals add onto the nationally accepted bundle to address the challenges of a specific infection type. The rising incidence of community-acquired Clostridium difficile is driving new approaches in many hospitals. The bacteria, which cause diarrhea and sometimes life-threatening colon inflammation, are particularly problematic because they spread via long-living spores and are resistant to alcohol cleansers. Patients can be asymptomatic carriers. In such cases, the infection is triggered when an antibiotic administered to treat another condition kills protective gut bacteria, allowing C. diff to multiply and release toxins.
Beyond the typical bundle, Stamford (Conn.) Hospital added a number of protocols to attack C. diff and prevent its spread within the hospital. The multifaceted effort reduced its hospital-acquired C. diff rate by about 30 percent over the last four years, says Michael Parry, M.D., director of infectious disease and microbiology.
Because routine environmental screening for the bacteria is impractical and not recommended, all patient rooms at Stamford are treated as if they're infected and are cleaned with a bleach-containing product. Rooms that house any isolation patient, including those with C. diff, additionally are treated with a machine that emits bacteria-killing ultraviolet light. Environmental cleaning quality is tested using invisible florescent markers. A sample of patient rooms on each unit is marked before cleaning and then checked for marks afterward. The results of these monthly checks, conducted without prior notice, are reported at safety meetings with department heads and are shared institutionwide, Parry says.
Stamford's effort includes a newer type of C. diff test, called polymerase chain reaction. With a 99 percent accuracy rate, it's much more sensitive than the older test, which has a 50 percent false negative rate. Another plus is the PCR test can be run 24 hours a day, rather than in batches. "When we detect the bacteria in patients earlier, the patient gets treated more quickly and they get isolated, so we avoid the spread of C. diff," Parry says.
The hospital has an antibiotic stewardship program that includes C. diff measures. In the case of that pathogen, it's important not only to prescribe the right antibiotic when infection is detected, but also to avoid the use of antibiotics that trigger C. diff growth in the first place. Stamford's program provides diagnosis-specific antibiotic order sets that include the antibiotic type, dose, route and treatment duration. The order sets are programmed into the electronic health record system so physicians are guided to use the most appropriate drug for the most appropriate time period, thereby minimizing the risk to the patient.
Similarly, Orlando Health targets C. diff in its antimicrobial stewardship program. About a year and a half ago, the system instituted a policy against prescription of antibiotics in the quinolone class without special consent from an infectious disease physician. The decision was made because that class is known to predispose patients to C. diff overgrowth, Hakim says. Their use also is associated with an increase in infections caused by fluoroquinolone-resistant, hypervirulent strains of C. diff.
"Our physicians at first said, 'We know how to take care of medicine. We don't need people to tell us how,'" Hakim says. "We showed them pictures of what the toxic megacolon (a severe C. diff complication) looks like. Once we showed them sickness that they're causing without knowing it, they agreed. They all stood up and said, 'We're behind this.' "
Only about 48 percent of hospitals have antimicrobial stewardship programs, the CDC reports. One barrier is the lack of an infectious disease physician at some hospitals. But stewardship programs can be led by another champion, a pharmacist, for example, McLay says.
Resistant bacteria proliferate
Beyond C. diff, hospitals are grappling with preventing the spread of other infectious agents that patients unwittingly carry into the hospital.
McLaren–Lapeer Region, part of the McLaren Health Care system in Michigan, conducts a nasal culture for methicillin-resistant Staphylococcus aureus and regular Staph on patients getting any type of implant, including pacemakers and artificial hips or knees, says Florence Elston, the hospital's manager of infection prevention and employee health. Many patients are colonized and have no idea, she says. They run the risk of the bacteria spreading from their noses to their skin and causing surgical-site infections. If the test is positive, surgery is delayed until patients have been treated.
Orlando Health rolled out a surgical-site infection prevention bundle from October 2012 to March 2013 to address the risk of colonized bacteria. Patients are given chlorhexidine wipes to clean their bodies the night before and the day of surgery. When they arrive at the hospital, they gargle with a chlorhexidine mouthwash to eliminate any harmful bacteria in the mouth. Their noses are swabbed with a chlorhexidine-containing product to cut down bacteria there.
"You might say this isn't hospital-acquired, but the truth is these patients carry these bacteria; if you put [an immunocompromised] patient into a stressful environment like surgery for a few days, you set them up for the bacteria to turn into infections, which then can infect the room," Hakim says. Since the bundle's implementation, surgical-site infections have fallen by 15 percent.
Underlying all hospital infection prevention efforts is the recognition of the growing threat of antibiotic-resistant bacteria. The CDC estimates that more than 2 million people are sickened each year with antibiotic-resistant infections and that at least 23,000 die as a result.
McLaren–Lapeer uses its EHR to flag patients who have had an antibiotic-resistant infection in the past. When these patients arrive at the facility, they automatically are isolated until their culture comes back negative, Elston says.
In the emergency department, the intake staff alert the care team so they can take appropriate precautions. Trauma patients who are new to the hospital get a nasal swab before surgery so that when their culture comes back in 24 hours, clinicians can act if the patient is carrying bacteria.
The impact on the bottom line
As hospitals invest more in their infection-prevention programs, the financial implications of these efforts are under debate. Vascular catheter infections, CAUTIs and several types of surgical-site infections are on Medicare's no-payment list for hospital-acquired conditions. Meanwhile, the Affordable Care Act includes new Medicare penalties for hospitals that have the highest rates of health care-associated infections and for hospitals that have more readmissions than expected.
"There is no question that there is a financial incentive to practice safe medicine because, whether it's a readmission or an extended length of stay from a complication, an infection or otherwise, these are expensive both from the standpoint of resource utilization and in terms of noncompensation," Parry says.
Given the Medicare payment penalties and a new government rule authorizing states to identify other preventable conditions for Medicaid nonpayment, "hospitals should see financial benefits from preventing HAIs," concludes the September 2013 JAMA Internal Medicine study. Health care-acquired infections are a burden on the nation's health system, the report finds. The five most common infections cost $9.8 billion annually.
Some experts argue, however, that the cost of implementing comprehensive infection-prevention programs outweighs the penalties. Infectious disease departments generate no revenue, APIC's McLay notes. The Medicare penalties are "just a drop in the bucket" of hospital finances, she adds.
Orlando Health has cut infection rates in half in four years, Hakim notes, and the hospital has lost millions of dollars as a result. Under the current payment system, only payers benefit financially when complications, including infections, are prevented, he says, pointing to an April 2013 JAMA study on surgical-site complications' impact on hospital finances to bolster this argument. New payment models, under which hospitals are paid for quality instead of volume, hold promise, but only if shared savings for quality are high enough.
Regardless of the impact on their bottom lines, hospitals will continue to fight to prevent HAIs. "It's good for the patient, and that's all we talk about," Hakim says.
— Geri Aston is a contributing writer to H&HN.
One of the most important features of successful infection-prevention programs is hospital leadership's support, says Carol McLay, R.N., a consultant from Lexington, Ky. Here are some recommendations from experts in the field and the Centers for Disease Control and Prevention.
1 | Make sure the hospital lab can identify infections and alert clinical and infection-prevention staff.
This is especially important to stop the spread of antibiotic-resistant strains of bacteria. For example, if Enterococcus is causing the infection, knowing whether it's vancomycin-resistant is essential to determine which antibiotic to use, says Jamal Hakim, M.D., Orlando Health chief of quality and transformation.
2 | Know infection and antibiotic resistance trends in your facility.
After the first case of vancomycin-resistant enterococci was found at McLaren–Lapeer Region in 2001 in a patient's urine, the hospital launched a catheter-associated urinary tract infection prevention program, says Florence Elston, manager of infection prevention and employee health. Only by tracking and trending types of bacteria, resistance, where they came from and how they manifested themselves can hospitals adapt their approaches to minimize risk.
3 | Be aware of the infection and antibiotic resistance trends in nearby facilities.
The infection-prevention team at Stamford (Conn.) Hospital constantly monitors the infection landscape nationally and regionally. "We're not insulated from New York state or the surrounding area," says Michael Parry, M.D., director of infectious disease and microbiology. "We see antibiotic resistance first in larger tertiary care hospitals, and it gets to us a couple years later."
4 | Join broader infection-prevention efforts.
Many state hospital associations and state health departments are involved in health care-acquired infectionprevention initiatives that provide myriad resources to hospitals. "It's that mass sharing of data and that mass learning that allow us to accelerate change," says Sam Watson, executive director of the Michigan Hospital Association's Keystone Center.
5 | Show the hospital staff that infection prevention is a leadership priority.
At McLaren–Lapeer, the CEO and the vice president of medical affairs frequently join daily multidisciplinary intensive care unit rounds during which each patient is checked to make sure infection prevention protocols are being followed.
6 | Involve patients in infection prevention.
The Association for Professionals in Infection Control and Epidemiology has launched a campaign, "Infection Protection and You," that includes a consumer-oriented infographic that can be posted in patient rooms. At Orlando Health, patients are encouraged to ask doctors and nurses to wash their hands if they didn't upon entering the room. "It stops you in your tracks if someone asks, 'Doctor, did you wash your hands?' and you have to say 'No,' " Hakim says. "The first time that happens is the last time because it's so embarrassing."