Trends and Strategies for Prevention of Healthcare-Associated Infections Alice Guh, MD, MPH Division...

Trends and Strategies for Prevention of Healthcare-Associated Infections

Alice Guh, MD, MPHDivision of Healthcare Quality Promotion

Centers for Disease Control and Prevention

Healthcare-Associated Infections (HAIs)

Definition: Infections that patients acquire during the course of receiving treatment for other conditions within a healthcare setting

Healthcare settings:– Hospitals: acute care facilities, critical

access hospitals– Long term care facilities (LTCF)– Outpatient settings: dialysis centers,

ambulatory surgical centers, physician’s offices

She was progressing in the neonatal intensive care unit until she developed a bloodstream infection related to her umbilical catheter.

Your baby was born prematurely.

The surgery goes well but he later dies in a nursing home of a

MRSA wound infection that developed after

surgery.

Your father has open heart surgery.

She has lived with this unbearable infection through 6 months of relapses.

Your sister contracts Clostridium difficile after giving birth.

Your mother is being treated for cancer And now has to fight two diseases because she

got Hepatitis C from an unsafe injection

HAI BurdenWhat is Known: Acute Care Settings

1.7 million infections (5% of all admissions)– Most (1.3 million) were outside of ICUs

$28–33 billion in excess costs

99,000 associated deaths

Most common type of infections:– Bloodstream infections (BSI)– Urinary tract infections– Pneumonia– Surgical site infections

Klevens, et al. Pub Health Rep 2007;122:160-6

Estimated Annual Hospital Cost of HAI by Site of Infection

Major Site of Infection Total infections

Hospital Cost per

Infection (2002 $)

Total annualhospital cost(in millions $)

DeathsPer year

Surgical Site Infection 290,485 $25,546 7,421 13,088

Central line associated-Bloodstream Infection 248,678 $36,441 9,062 30,665

Ventilator-associated Pneumonia 250,205 $9,969 2,494 35,967

Catheter associated-Urinary Tract Infection 561,667 $1,006 565 8,205

Roberts RR, et al Clin Infect Dis 2003;36:1424-32.

Social Costs of HAIs

Emerging Threats in Healthcare

Clostridium difficile: “Deadly Superbug”

McDonald LC, et al. Emerg Infect Dis. 2006;12(3):409-15

National Estimates of U.S. Short-Stay Hospital Discharges with C. difficile

Tranquil GardensNursing Home

HomeCare

Acute Care Facility

Outpatient/Ambulatory

Facility

Long Term CareFacility

The Healthcare System More than Just Hospitals

HAI Burden Outside of Acute Care

We know much less about this

What we have learned to date:

HAIs are a substantial problem

outside of acute care settings

HAIs in LTCF

1.7 million beds with 2.5 million residents / yr1

1/3 of long-term care residents affected by respiratory disease outbreaks2

Veterans Healthcare data3

– 133 nursing homes; 11,475 residents– HAI prevalence: 5.2%– Indwelling medical device: 25% of all

residents

1 NCHS, 2009 2Loeb, CMAJ, 2006 3Tsan, AJIC, 2008

Growth in Outpatient Care Shift in healthcare delivery from acute care

settings to ambulatory care, long term care and free standing specialty care sites

Dialysis Centers– 2008: 4,950 (72% increase since 1996)

Ambulatory Surgical Centers – 2009: 5175 (240% increase since 1996)

Approximately 1.2 billion outpatient visits / yr

Surgical Procedures Moving from Inpatient to Outpatient Setting

0

10

20

30

40

50

60

1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005*

Source: Avalere Health analysis of Verispan’s Diagnostic Imaging Center Profiling Solution, 2004, and American Hospital Association Annual Survey data for community hospitals, 1981-2004.*2005 values are estimates.

All Outpatient Settings

Hospital Inpatient

Pro

ced

ure

s (m

illio

ns)

Healthcare-associated Outbreak Investigations by Healthcare Setting,

2004-2008

n = 47, as of April 2008

Increasing number of outbreaks associated with outpatient care

• Wide range of settings (e.g., ambulatory surgery, cancer clinics, pain medicine, dialysis, long-term care, physician offices)

• Unsafe injections, foundation of basic safe care practices lacking Hospital (27)

Outpatient Setting (12)LTCF (3)Community (5)

TRANSMISSION OF BLOODBORNE PATHOGENS VIA CONTAMINATED EQUIPMENT OR MEDICATIONS

SOURCEInfectious person,e.g. chronic, acute

CASESusceptible,

non-immune person

CONTAMINATED EQUIPMENT OR MEDICATION OR

HANDS

33 outbreaks in 15 states– Outpatient clinics, n=12– Dialysis centers, n=6– Long term care, n=15

Thompson et al. Ann Intern Med. 2009;150:33-39.

Viral Hepatitis Outbreaks - Outpatient SettingsState Setting Year Type

NY Private MD office 2001 HCV

NY Private MD office 2001 HBV

NE Oncology clinic 2002 HCV

OK Pain remediation clinic 2002 HBV+HCV

NY Endoscopy clinic 2002 HCV

CA Pain remediation clinic 2003 HCV

MD Nuclear imaging 2004 HCV

FL Chelation therapy 2005 HBV

CA Alternative medicine infusion 2005 HCV

NY Endoscopy/surgery clinics 2006 HBV+HCV

NY Anesthesiologist office 2007 HCV

NV Endoscopy clinic 2008 HCV

NC Cardiology clinic 2008 HCV

NJ Oncology clinic 2009 HBV

Thompson et al. Ann Intern Med. 2009;150:33-39.

Ongoing Threat to Patient Safety Continued outbreaks associated with unsafe injections and other

breakdowns in basic infection control Large public health patient notifications advising testing for

hepatitis B virus, hepatitis C virus, and HIV

Infection Control in Outpatient Settings

Sub-optimal infection control infrastructure and oversight

Approximately 50% of ambulatory surgical centers (ASC) surveyed by CMS and CDC had serious, noncompliance with the Medicare ASC health and safety standards– 28% had unsafe injection practices

A Collaborative Approach to Preventing HAIs

State of Prevention Knowledge and Science

Evidence-based prevention recommendations– Major device and procedure associated

HAIs (CLABSI, VAP, CAUTI, SSI)– Prevention of pathogen transmission

(MRSA, C. difficile)

Suboptimal adherence to key prevention recommendations

Current State of Affairs

Hand hygiene compliance for healthcare worker: 40-50%

Compliance with timing of surgical prophylaxis was ~40%1

Many facilities have yet to implement proven prevention measures:– Bloodstream infections– Urinary tract infections

2005 Data from Surgical Care Improvement Project

What’s Been Missing in the Past to Promote HAI Prevention?

Robust data on HAI Prevention

Focused attention of policymakers on HAI prevention

Incentives / disincentives to promote systems change for sustainable HAI prevention

Framework to extend local / regional successes across the nation

Preventability of Infections

Study on the Efficacy of Nosocomial Infection Control (SENIC)– 6% of all HAIs preventable with minimal

infection control efforts– 32% preventable with “well organized

and highly effective infection control programs”

20-70% of infections are preventable1

1J Hosp Infection 2003;54:258

Estimates of Preventable Infections, Deaths, and Costs

Trends in MRSA Bloodstream Infections by ICU Type, NHSN hospitals, 1997-2007

• Estimated 7000 BSIs prevented

• 1800 lives saved

• $50-180 M in costs averted annually

Significant reductions:– Surgical site infections– Unplanned return to OR– All complications– Deaths

Haynes AB, et al. NEJM 2009;360:491-9.

ILSept-2008

NY

Jan-2007

MS

ORJan-2009

ID

MT

NVMay- 2009

AZ

CO

Jan-2008

NMOK

Jul-2008

MO

AR

TXAugust- 2009

LA

ND

SD

IANE

KY

ME

NJ Jan-2009

MD Jul-2008

TNJan-2008

WY MI

SCJul-2007

FL

HI

AK

MA Jul-2008

VTFeb-2007

WAJul-2008

CAJan-2008

WI

PAFeb-2008

VA

Jul-2008

NH Jan-2009

AL GA

UT

KS

MN

OH

NC

RI

DE Feb-2008 WVJul - 2009

IN

CT Jan-2008

State Legislative Activity for HAIs (as of October 6, 2009)

Month – Year =

Date mandatory reporting using NHSN implemented

Mandates public reporting of infection rates

Mandates reporting only to state government Mandatory data collection, Voluntary reporting

States with study laws

States with no legislationMandates public reporting using NHSN

HHS Steering Committee: HAI Prevention

Charge: Develop an Action Plan to reduce, prevent, and ultimately eliminate HAIs

Plan will:– Establish national goals for reducing HAIs– Include short- and long-term benchmarks– Outline opportunities for collaboration with external

stakeholders– Coordinate and leverage HHS resources to accelerate

and maximize impact

HHS Action Plan: Tier One Priorities

HAI Priority Areas Catheter-associated

urinary tract infection Central line-associated

blood stream infection Surgical site infection Ventilator-associated

pneumonia MRSA Clostridium difficile

Implementation Focus Hospitals*

*Tier Two will address other types of

healthcare facilities

Centers for Medicare and Medicaid Services

October 2008

Non-payment rules for “Never events”– Preventable conditions acquired

during patient’s hospital stay– Includes HAIs

Federal Funding for HAI Prevention

American Recovery and Reinvestment Act of 2009 (ARRA)– Allocated funding to states for HAI

prevention

FY 2009 Omnibus Bill – States to develop HAI prevention plans

to be consistent with HHS Action Plan

Tranquil GardensNursing Home

HomeCare

Acute Care Facility

Outpatient/Ambulatory

Facility

Long Term CareFacility

Increasing Needs and Opportunities for Public Health Approach Across the Continuum of Care

State Health Departments

A New Paradigm: Central Role of State Health Departments

Expanding state public health workforce to make progress toward HAI prevention

Create and expand state-based HAI prevention collaboratives

Sustainable statewide efforts will contribute to national healthcare improvement efforts

A New Model For Prevention:Prevention Collaboratives

Experience is showing that multi-facility collaborative projects are the gold standard in HAI prevention

Many “change methods” that have demonstrated success: – Comprehensive Unit-based Patient

Safety Program (CUSP)– Positive deviance– Six-sigma

Basics of a Prevention Collaborative

Group of healthcare facilities engaged in a common effort to reduce HAIs

Members use a common approach

Discuss progress regularly and share lessons learned in real time

What is the Minimum Size of a Prevention Collaborative?

2 or more facilities working together meaningfully

Ideal size multi-factorial– Specific subject or targeted HAI– Type of healthcare facilities– Available resources– More “cutting edge” ─ smaller number– More established “change packages” can be

quite large– Level of enthusiasm

Prevention Strategies

Supplemental Strategies– Some scientific

evidence– Variable levels of

feasibility

Core Strategies– High levels of

scientific evidence

– Demonstrated feasibility

Regional Prevention CollaborativesExamples of Success

0

2

4

6

8

10

0 18

ICUs at 103 Michigan

hospitals, 18 months

BS

Is/1

,00

0 c

ath

ete

r da

ys

Months

Pittsburgh Regional Healthcare Initiative Michigan Keystone Initiative

Pronovost P. New Engl J Med 2006;355:2725-32.Muto C, et al. MMWR 2005;54:1013-16

Overall rate reduction of 68%

Overall rate reduction of 66%

Lessons Learned from Pittsburgh and Michigan Experience Decreases in BSI rates in hospital ICUs

of varying types

Prevention practices utilized during these interventions were not novel

Practical strategies identified that can be successful across many facilities

If Expanded Nationally….

66% reduction of BSIs would translate into:– 180,000 fewer BSIs– 20,000 fewer BSI-associated deaths– $4–6 billion in healthcare cost

savings

Strengths of a Collaborative

Opportunities to share experiences on what works and does not work

Ability to get advice from others who are working on the same project

Peer pressure is also a motivator

Common Elements for Successful Infection Prevention

Simple Patient-centered, integrated with care Evidence-based recommendations Part of a “package” for prevention Engaging and empowering clinicians Protocols and systems in place Standardized ways for recording information about

infections (e.g., NHSN) Regular feed-back of information to providers Changing to a pro-safety culture Leadership support

Sources: Muto et al, MMWR, Oct 14 2005; Pronovost et al, NEJM 2006

Other Key Factors in Prioritizing Interventions

Burden of the HAI– Cost– Clinical outcomes

Preventability– Are there interventions that are known

to work?– What is the likely return on prevention

investment?

Next Steps Towards Elimination Prevention of CLABSIs in ICU settings

remains important, BUT….– These are a small fraction of all of the HAIs – They likely represent “low-hanging” fruit

Given our goal of eliminating HAIs, we need to “move higher up the tree”

Prevention collaborations create opportunities to do this

Next Steps Towards Elimination Expand to other settings (CLABSI in non-ICU

settings)

Expand to other types of infection (CAUTI, C. difficile, etc.)

Expand success to new problem pathogens (multi-drug resistant organisms)

Expand efforts in outpatient infection control

ICUVA Pittsburgh

Hospital-wide

VA Pittsburgh

VA Pilot• 17 hospitals, multiple states

MarylandInitiative• 15 hospitals

Unit

Facility

Region

NationalLocal

National VA Initiative• 150 hospitals

• nationwide

CMS•9th Scope of Work

National

RWJ Initiative• 6 hospitals, 4 states

Expansion of Local Prevention Success in One State to Across the Nation

>60% Reduction in MRSA

The findings and conclusions are those of the presenter and do not necessarily represent the view of the Centers for Disease Control and Prevention.

Thank you

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Trends and Strategies for Prevention of Healthcare-Associated Infections Alice Guh, MD, MPH Division...

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