Healthcare-associated Infections – Moving from Headlines to Solutions

Dale W. Bratzler, DO, MPHProfessor and Associate Dean

University of Oklahoma Health Sciences CenterCollege of Public Health, Oklahoma City, OK

Texas Partnership for PatientsMay 1, 2013

How big is the problem?• HAIs - Infections that patients acquire while receiving

treatment for medical or surgical conditions.– Significant toll on human life

• 1.7 million infections• 99,000 deaths annually

– Estimated that HAIs incur an estimated $28 to $33 billion in excess healthcare costs each yearFour categories of infections account for

approximately three quarters of HAIs in the acute care hospital setting. These four categories are: 1) Surgical site infections; 2) Central line-associated bloodstream infections; 3) Ventilator-associated

pneumonia, and; 4) Catheter-associated urinary tract infections.

http://www.hhs.gov/ash/initiatives/hai/infection.html

Healthcare-associated Infections

• While can occur in any care setting, are particularly related to:– Use of medical devices– Complications of surgical procedures– Transmission between patients and healthcare

workers– Antibiotic overuse

But, don’t forget…..• The incidence of C. difficile infections in the in- and out-patient setting is increasing• While CLABSI infections are reported far less commonly in the ICU setting, they

remain a serious problem in other settings (PICC lines, dialysis units, non-ICU)• Growing incidence of multi-drug resistant organisms

• Vancomycin Resistant Enterococci (VRE)• Methicillin Resistant Staphylococcus aureus (MRSA)• Extended spectrum ß-lactamse (ESBLs) producing Gram-negative bacteria• Klebsiella pneumonia carbapenemase (KPC) producing Gram-negatives• Multi-drug resistant Acinetobacter baumannii• Multi-drug resistant Pseudomonas aerginosa• Metallo-beta-lactamase (NDM-1) organisms

HAIs in the Nursing Home Setting

• The most common infections are respiratory, urinary, skin and soft tissue, and gastrointestinal infections– Influenza and invasive pneumococcal disease– CAUTI– MRSA and/or VRE colonization and infection– C. difficile

JAMA. 2010;303(22):2273-2279

…….. Sixty-eight ASCs were assessed; 32 in Maryland, 16 in North Carolina, and 20 in Oklahoma……..

….. Overall, 46 of 68 ASCs (67.6%; 95% confidence interval [CI], 55.9%-77.9%) had at least 1 lapse in infection control; 12 of 68 ASCs (17.6%; 95% CI, 9.9%-28.1%) had lapses identified in 3 or more of the 5 infection control categories.

Dialysis Centers• Infection is a leading cause of morbidity and is

second only to cardiovascular disease as the leading cause of death in the chronic uremic patient on hemodialysis (HD). – As compared to the general population, the

incidence of sepsis in patients with end-stage renal disease can be up to 100 times higher.

– Infections also confer a higher risk of mortality than in the general population

http://www.hhs.gov/ash/initiatives/hai/tier2_renal.html

Why the rush to public reporting of healthcare-associated infections?

• Consumer groups are demanding transparency – particularly about complications and healthcare-associated infections

Therefore, legislators respond……State Mandatory And Public Reporting Laws For Hospital-Acquired Infections, 2010.

Halpin H A et al. Health Aff 2011;30:723-729.

…including Federal legislators

Required CMS to adjust hospital payment beginning in

FY 2013 for healthcare-associated infections.

Final Inpatient Prospective Payment System Rule for FY 2011 required that all PPS hospitals participating in the Hospital Inpatient Quality Reporting Program submit data on their rate of CLABSI for all ICUs.

Final Inpatient Prospective Payment System Rule for FY 2012 requires that all PPS hospitals participating in the Hospital Inpatient Quality Reporting Program submit data on CLABSI, CAUTI, and SSI beginning with January 1, 2012 discharges

Exciting time in healthcare quality and infection prevention!

National Quality Strategy

• Three Broad Aims – 1. Better health care;2. Better health for people and

communities;3. Lower costs through

improvement

Available at: http://www.healthcare.gov/center/reports/nationalqualitystrategy032011.pdf

Making Care Safer

Goal:Eliminate preventable health care-acquired conditions

• Opportunities for success:– Eliminate hospital-acquired infections– Reduce the number of serious adverse medication events

• Illustrative measures:– Standardized infection ratio for central line-associated blood

stream infection as reported by CDC’s National Healthcare Safety Network

– Incidence of serious adverse medication events

Available at: http://www.healthcare.gov/center/reports/nationalqualitystrategy032011.pdf

Partnership for Patients• The two goals of this new partnership are to:

– Keep patients from getting injured or sicker. By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010.

– Help patients heal without complication. By the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010.

http://www.healthcare.gov/center/programs/partnership/index.html

Partnership for PatientsAreas of Focus

• The Partnership for Patients has identified nine areas of focus:– Adverse Drug Events (ADE)– Catheter-Associated Urinary Tract Infections (CAUTI)– Central Line Associated Blood Stream Infections (CLABSI)– Injuries from Falls and Immobility– Obstetrical Adverse Events– Pressure Ulcers– Surgical Site Infections– Venous Thromboembolism (VTE)– Ventilator-Associated Pneumonia (VAP)– Other Hospital-Acquired Conditions

http://www.healthcare.gov/center/programs/partnership/index.html

HHS Action Plan to Prevent Healthcare-associated Infections

• Tier One focuses on six high priority HAI-related areas within the acute care hospital setting.– Surgical site infections, central line-associated bloodstream infections,

ventilator-associated pneumonia, and catheter-associated urinary tract infections, Clostridium difficile, and Methicillin-resistant Staphylococcus aureus (MRSA)

• Tier Two expands efforts outside of the acute care setting into outpatient facilities. It includes strategies to reduce HAIs in:– Ambulatory surgical centers and end-stage renal disease facilities, as

well as a strategy to increase influenza vaccination coverage among healthcare personnel

http://www.hhs.gov/ash/initiatives/hai/infection.html

What can you do tomorrow?A systems approach…

Prioritize those things that matter..

What practices do we need every day?

• Focus less on preventing “an” infection

• Focus more on preventing “all” infections

Policies are Important

• Written infection prevention policies are up to date

• Support from a trained infection preventionist

• HCWs receive job-specific training on infection prevention practices

Healthcare Workers are the Model

• They get their influenza vaccine annually

• They are up to date on vaccines such as DTaP, hepatitis vaccination, screened for TB

Universal Precautions!

We give more than lip service to guideline implementation………and we hold people accountable for guideline adherence

http://www.cdc.gov/hicpac/

HICPAC Recent and Ongoing Activities

• New guidelines– Prevention of Catheter-associated Urinary Tract

Infections (Sept 2010)– Prevention of Intravascular Catheter-Related

Bloodstream Infections (2011)– Prevention and Control of Norovirus Gastroenteritis

Outbreaks in Healthcare Settings (2011)– Prevention of Infections Among Patients in NICU– Healthcare Personnel Guidelines– Prevention of Surgical Site Infections

We Implement Checklists that are Evidence Based

Focus on the Environment

• Policies and training on routine cleaning and disinfection

• Periodic monitoring of cleaning procedures

• Focus on reusable medical devices

http://www.oneandonlycampaign.org/

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“The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily under dose himself and, by exposing his microbes to non-lethal quantities of the drug, educate them to resist penicillin.” Nobel lecture, 1945

Sir Alexander Fleming discovered penicillin

We use a lot!

• 200-300 million antibiotics are prescribed annually

• 25-40% of all hospitalized patients receive antibiotics

We use a lot!

• Hospital Antibiotics– At least 30% are unnecessary or sub-optimal– 5% of hospitalized patients experience an

adverse reaction

• Outpatient Antibiotics– >$1.1 billion spent annually on unnecessary adult

antibiotic prescriptions for upper respiratory infections

– 50-80% of outpatient antibiotic use is inappropriate

The Antibiotic Pipeline is Dry….

Adapted from Spellberg B et al. Clin Infect Dis. 2004;38:1279-86.

We’re running out…….New Antibacterial Agents Approved 1983-2011

02468

1012141618

1983-1987

1988-1992

1993-1997

1998-2002

2003-2007

2008-2011

3434

Most Common Reasons for Unnecessary Days of Therapy in Inpatients

192 187

94

0

50

100

150

200

250

Duration of Therapy Longer than Necessary

Noninfectious or Nonbacterial Syndrome

Treatment of Colonization or Contamination

Days

of T

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576 (30%) of 1941 days of antimicrobial therapy deemed unnecessary

Hecker MT et al. Arch Intern Med. 2003;163:972-978.

The bugs are getting tougher!

Antibiotic Consumption Drives Resistance!

Lepper PM et al. Antimicrob Agents Chemother 2002;46:2920-5.

Resistance patterns of strains of P. aeruginosa

Up to 85% of patients with C. difficile-associated disease have antibiotic exposure in the 28 days before infection

Antibiotic exposure is the single most important risk factor for the development of Clostridium difficile associated disease (CDAD).

Impact of Antibiotic ResistanceWhat happens if the patient gets infected?

OrganismIncreased risk of death (OR)

Attributable LOS (days)

Attributable cost

MRSA bacteremia 1.9 2.2 $6,916

MRSA surgical infection 3.4 2.6 $13,901

VRE infection 2.1 6.2 $12,766

Resistant Pseudomonas infection

3.0 5.7 $11,981

Resistant Enterobacter infection

5.0 9 $29,379

Cosgrove SE. Clin Infect Dis. 2006; 42:S82-9.

Antibiotics are unlike any other drug: use of the agent in one

patient can compromise efficacy in another

An issue for Public Health!

Antibiotics and resistance……just the facts

• Changes in use parallel changes in resistance• Patients with resistant infections more likely to

have received prior antimicrobials• Hospital areas of highest resistance associated

with highest antimicrobial use• Increased duration of therapy increases

likeliness of colonization with resistant organisms

Shales DM, et al. Clin Infect Dis 1997; 25:584-99.

Antibiotics and resistance……just the facts

• and……the patients are more likely to die!

Shales DM, et al. Clin Infect Dis 1997; 25:584-99.

Stewardship Decreases Resistance

Rate of Resistant Enterobacteriacae Infections

Rate of VRE

Antimicrobial Use and Cost

Carling P et al. Infect Control Hosp Epidemiol. 2003;24:699.

MRSA rates stayed the same

Carney Hospital

Stewardship Decreases CostsStrategy Type of Institution Annual Cost SavingsPre-prescription approval

County teaching hospital $803,910

Tertiary care hospital $302,400Post-prescription review

Tertiary care hospital Decrease abx charge per patient ($1287 vs. $1873,

p<0.04)VA hospital $145,942Community hospital (175 beds) $200,000-250,000Community hospital (120 beds) $177,000Argentinean hospital (250 beds) $913,236

White AC et al. Clin Infect Dis. 1997;25:230-239. Fishman N. Am J Med. 2006;119:S53-S61.Fraiser GL et al. Arch Intern Med. 1997;157:1689-94. Gentry CA et al. Am J Health Syst Pharm. 2000;57:268-74.

LaRocco A. Clin Infect Dis. 2003;37:742-3; Bantar C et al. Clin Infect Dis. 2003;37:180-6.Carling P et al. Infect Control Hosp Epidemiol. 2003;24:699-706.

Inpatient Stewardship Programs: Core Elements

Antimicrobial Stewardship: A Spectrum of Activities

Comprehensive program led by ID trained

physician and pharmacist

Individual interventions based on goals of institution led by

individual (s) with interest

Many approaches in between

http://www.cdc.gov/getsmart/

Do Surveillance – and be truthful

Should be based on sound epidemiological and statistical principles• Designed in accordance with current recommended practices• Needs to be able to identify risk factors for infection

– Adverse events– Implement risk-reduction measures– Monitor the effectiveness of intervention

• Identify– Outbreaks– Emerging infectious diseases– Antibiotic-resistant organisms– Bioterrorist events

Consequences of HAI Reporting• There is marked variation and low inter-rater

reliability in the interpretation of HAI criteria, even between experienced infection preventionists.

• A recent survey of infectious disease specialists found that 70% of respondent infection prevention and control programs incorporated clinical judgment in the form of clinician veto or consensus adjudication into CLABSI assessments rather than strict adherence to NHSN criteria!

Klompas M. Interobserver variability in ventilator-associated pneumonia surveillance. Am J Infect Control. 2010; 38:237-9.Lin MY, et al. Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates. JAMA. 2011;

304:2035-41.Mayer J, et al. Agreement in classifying bloodstream infections among multiple reviewers conducting surveillance. Clin Infect Dis.

2012; 55:364-70.Beekman SE, et al. Diagnosing and reporting of central line-associated bloodstream infections. in press. 2012.

Get Involved – Learn from Each Other

• No need to “re-invent the wheel”– Engage with the

“learning and action network”

– Everyone learns – everyone contributes!

http://www.texashospitalquality.org/collaboratives/partnership_for_patients/index.asp

• Obtain assistance with reporting and get resources and tools

• Share your successes• Understand the evidence• Engage your leadership, stakeholders,

and the patients you serve

There is Good News

In 2010 - • A 33% reduction in central line-associated bloodstream

infections. This included a 35% reduction among critical care patients and a 26% reduction among non-critical care patients.

• A 7% reduction in catheter-associated urinary tract infections throughout hospitals

• A 10% reduction in surgical site infections• An 18% reduction in the number of people developing

healthcare-associated invasive methicillin-resistant Staphylococcus aureus (MRSA) infections

http://hicprevent.blogs.ahcmedia.com/2011/10/19/key-hais-falling-major-challenges-

remain/

Despite the improvements….• We have not eliminated healthcare-associated

infections– We can’t measure all of the processes of care that

influence rates of infection– No “bundle” that has resulted in elimination of HAIs

• What are the most important components of bundles?– There is still a need for basic science (host factors,

biological factors, healthcare factors)– Some factors that are known to influence infection rates

are very difficult to measure and difficult to change

Can we prevent them all?As many as 65%–70% of cases of CABSI and CAUTI and 55% of cases of VAP and SSI may be preventable with current evidence-based strategies. CAUTI may be the most preventable HAI. CABSI has the highest number of preventable deaths, followed by VAP…..

Our findings suggest that 100% prevention of HAIs may not be attainable with current evidence-based prevention strategies; however, comprehensive implementation of such strategies could prevent hundreds of thousands of HAIs and save tens of thousands of lives and billions of dollars.

Umsheid CA, et al. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol 2011; 32:101-14.

dale-bratzler@ouhsc.edu

“Popularity is not leadership. Results are!” Peter Drucker

dale-bratzler@ouhsc.edu