The Quality ColloquiumThe Quality Colloquium

August 22, 2004August 22, 2004

Strategies for Reducing Strategies for Reducing Infections:Infections:

The Role of the Patient Safety The Role of the Patient Safety OfficerOfficer

Tammy Lundstrom, MDTammy Lundstrom, MDVP, Chief Quality and Safety OfficerVP, Chief Quality and Safety Officer

Detroit Medical CenterDetroit Medical Center

Infection Control in the Infection Control in the HeadlinesHeadlines

“Lax Procedures put Infants at High Risk; “Lax Procedures put Infants at High Risk; Simple Actions by Hospital Workers, Such Simple Actions by Hospital Workers, Such as Diligent Handas Diligent Hand--washing, Could Cut the washing, Could Cut the Number of Fatal Infections.”Number of Fatal Infections.”

Chicago Tribune 2002

JCAHO AccreditationJCAHO Accreditation

Revised IC standardsRevised IC standards–– Focus on traditional surveillance and quality Focus on traditional surveillance and quality

improvementimprovement–– Focus on integration of Infection Control into Focus on integration of Infection Control into

Patient Safety ActivitiesPatient Safety Activities–– Surge CapacitySurge Capacity

HAI as Sentinel EventHAI as Sentinel Event--consequencesconsequences–– Root Cause Analysis (RCA)Root Cause Analysis (RCA)–– Failure Mode and Effects Analysis (FMEA)Failure Mode and Effects Analysis (FMEA)

CDC 7 ChallengesCDC 7 Challenges

Reduce CatheterReduce Catheter--associated adverse eventsassociated adverse eventsReduce surgical adverse eventsReduce surgical adverse eventsReduce mortality and hospitalizations due to Reduce mortality and hospitalizations due to respiratory infection in LTCrespiratory infection in LTCReduce antibiotic resistant infectionsReduce antibiotic resistant infectionsEliminate microbiology lab errorsEliminate microbiology lab errorsEliminate occupational sharps injuriesEliminate occupational sharps injuriesActive compliance with ACIP immunization Active compliance with ACIP immunization recommendationsrecommendations

Historical EvolutionHistorical Evolution

19401940 First description IC OfficerFirst description IC Officer19401940--6060 Penicillin and resistancePenicillin and resistance1970’s1970’s SENIC study; proves valueSENIC study; proves value1980’s1980’s Continued growth of epidemiologyContinued growth of epidemiology1990’s1990’s Expand role to nonExpand role to non--acute settingsacute settings2000’s2000’s Expand role to “quality promotion Expand role to “quality promotion

across the healthcare delivery across the healthcare delivery system”system”

Lancet 1999; 354 (Supp IV):25 Emerging Infect Dis 2001; 7: 286-92, 363-66

Study of Efficacy of Nosocomial Study of Efficacy of Nosocomial Infection Control (SENIC)Infection Control (SENIC)

Hospitals with intensive surveillance and Hospitals with intensive surveillance and control programs had lower rates of control programs had lower rates of nosocomial infectionsnosocomial infectionsRecommended 1 FTE/250 bedsRecommended 1 FTE/250 beds–– OUTDATED!!!OUTDATED!!!

Patterns of Healthcare Associated Patterns of Healthcare Associated Infection (HAI)Infection (HAI)

EndemicEndemic9090--95% of all HAI95% of all HAI

EpidemicEpidemic55--10% of all HAI10% of all HAIEasier to demonstrate investigative techniquesEasier to demonstrate investigative techniques114 investigations by CDC over a decade114 investigations by CDC over a decade6 National in scope (contaminated product/device)6 National in scope (contaminated product/device)

Emerging Infect Dis 2001; 7:295-98 Seminars in IC 2001; 2: 74-84

Infect Control 1985; 6: 233-36

ConsequencesConsequences

2 million HAI2 million HAI90,000 deaths90,000 deaths$4.5$4.5--5.7 billion/ year5.7 billion/ year25% in Intensive Care Units25% in Intensive Care Units70% involve organisms with resistance to one 70% involve organisms with resistance to one

or more antibioticsor more antibiotics

J. Burke. NEJM 2003; 348: 7 Emerging Infect Dis 1998; 4: 416-20

Infect Control Hosp Epi 2001; 22: 708-14

US DataUS Data

9.89.87.27.2NI/1000 pt daysNI/1000 pt days

1.91.92.12.1NI (10NI (1066))

13.313.318.318.3Inpt SurgInpt Surg(10(1066))

5.35.37.97.9Ave LOSAve LOS

190190299299Pt Days(10Pt Days(1066))

35.935.937.737.7admissions(10admissions(1066))

1995199519751975VariableVariable

J. Burke NEJM 2003

Decrease (%) in HAI in NNIS Decrease (%) in HAI in NNIS ICUICU

19901990--19991999

595926263232pediatricpediatric

303038383131surgicalsurgical

464656564444medicalmedical

404042424343coronarycoronary

UTIUTIVAPVAPBSIBSIType ICUType ICU

Emerging Infect Dis 2001; 7: 170-73

Why HAI May IncreaseWhy HAI May Increase

Sicker patientsSicker patientsMore invasive procedures for longer More invasive procedures for longer durationdurationStaff shortagesStaff shortages–– NursingNursing–– PharmacistsPharmacists–– Pharmacy TechsPharmacy Techs–– Radiology TechsRadiology Techs

Why HAI May IncreaseWhy HAI May Increase

Resistant OrganismsResistant Organisms–– 1990’s1990’s P. aeruginosaP. aeruginosa–– 1990’s1990’s VREVRE–– 2002 2002 VRSAVRSA

Emerging Infectious DiseaseEmerging Infectious Disease–– 1980’s1980’s HIVHIV–– 1990’s1990’s hantavirushantavirus–– 2000’s2000’s SARSSARS

Most Common Epidemiology Most Common Epidemiology InterventionsInterventions

Disseminate rates with benchmark dataDisseminate rates with benchmark dataDevelop multidisciplinary teams around Develop multidisciplinary teams around issuesissuesEducationEducationCommunicationCommunication

Am J Infect Control 1999; 27: 221

Focus on EvidenceFocus on Evidence--based based PracticesPractices

HandwashingHandwashingMaximum barrier precautions for vascular Maximum barrier precautions for vascular

device insertiondevice insertionPreoperative antimicrobial prophylaxisPreoperative antimicrobial prophylaxisAppropriate antimicrobial useAppropriate antimicrobial use

HandwashingHandwashing

Compliance 16Compliance 16--81%81%Nurses consistently better than physiciansNurses consistently better than physiciansWaterless hand hygiene agents improve Waterless hand hygiene agents improve compliancecompliance–– Placement considerationsPlacement considerations

Effect of Hand Hygiene on Resistant Organisms

Year Author Setting Impact on organisms1982 Maki adult ICU decreased 1984 Massanari adult ICU decreased 1990 Simmons adult ICU no effect1992 Doebbeling adult ICU decreased with one versus

another hand hygiene product1994 Webster NICU MRSA eliminated1999 Pittet hospital MRSA decreased

ICU = intensive care unit; NICU = neonatal ICU MRSA = methicillin-resistant Staphylococcus aureus

12 Steps to Prevent Antimicrobial Resistance: Hospitalized AdultsStep 12: Contain your contagion

Source: Pittet D: Emerg Infect Dis 2001;7:234-240

The Human Element in Hand Hygiene The Human Element in Hand Hygiene AdherenceAdherence

Of 34 studies evaluated by CDC/HICPAC average Of 34 studies evaluated by CDC/HICPAC average level of adherence by Health care personnel= level of adherence by Health care personnel= 40% (range 540% (range 5--81%)81%)

--overall physicians usually worstoverall physicians usually worstWhy?Why?–– Too busy & not enough timeToo busy & not enough time–– Hand hygiene sinks or products inaccessibleHand hygiene sinks or products inaccessible–– Skin irritationSkin irritation–– Hands don’t appear visibly soiledHands don’t appear visibly soiled–– Influence of opinion leadersInfluence of opinion leaders

Gram positive bacteriaGram positive bacteria–– VREVRE–– Streptococcus pneumoniaeStreptococcus pneumoniae

Gram negative bacteriaGram negative bacteria–– PseudomonasPseudomonas–– SalmonellaSalmonella

FungiFungi–– FluconazoleFluconazole--resistant Candida albicansresistant Candida albicans

VirusesViruses–– MultiMulti--drug resistant HIVdrug resistant HIV–– AcyclovirAcyclovir--resistant herpesresistant herpes

Antimicrobial Resistant OrganismsAntimicrobial Resistant OrganismsThe Scope of the ProblemThe Scope of the Problem

CDC Strategies to Decrease CDC Strategies to Decrease Antimicrobial ResistanceAntimicrobial Resistance

1.1. VaccinateVaccinate2.2. Remove invasive devices as soon as Remove invasive devices as soon as

possiblepossible3.3. Culture (avoid empiric treatment)Culture (avoid empiric treatment)4.4. Treat with intent to eradicate infectionTreat with intent to eradicate infection5.5. Obtain expert advice on antibiotic Obtain expert advice on antibiotic

selectionselection6.6. Consult antibiogramsConsult antibiograms

CDC Strategies to Decrease CDC Strategies to Decrease Antimicrobial ResistanceAntimicrobial Resistance

7. Avoid unnecessary antibiotic use7. Avoid unnecessary antibiotic use8. Target the pathogen8. Target the pathogen9. Do NOT treat colonization9. Do NOT treat colonization10. Stop empiric antibiotics quickly once it 10. Stop empiric antibiotics quickly once it

appears that bacterial infection is unlikelyappears that bacterial infection is unlikely11. Enforce good infection control practices11. Enforce good infection control practices

Factors Contributing to Factors Contributing to Antimicrobial Resistance in Antimicrobial Resistance in

HospitalsHospitalsSerious illnessSerious illnessImmunocompromised stateImmunocompromised stateUse of invasive procedures/devicesUse of invasive procedures/devicesIncreasing introduction of resistant organisms Increasing introduction of resistant organisms from the community (Nursing home/hospital from the community (Nursing home/hospital transfers)transfers)Ineffective infection control practicesIneffective infection control practicesHigh antibiotic use per geographic area per unit of High antibiotic use per geographic area per unit of timetime

Risk Factors for Risk Factors for Staphylococcus aureusStaphylococcus aureuswith Reduced Susceptibility to with Reduced Susceptibility to

Vancomycin (MIC Vancomycin (MIC >> 44 ugug//mLmL))19 cases19 cases Adjusted OR (CI Adjusted OR (CI

95%)95%)Vancomycin (per week) Vancomycin (per week) 5.6 (2.25.6 (2.2--14.3)14.3)in prior 1 monthin prior 1 month

Previous MRSA culturePrevious MRSA culture 15.5 (1.815.5 (1.8-- 134.5)134.5)in prior 2in prior 2ndnd or 3or 3rdrd monthmonth

FridkinFridkin et al.et al. ClinClin InfectInfect DisDis 2003; 36:4292003; 36:429--3939

Antibiotic ResistanceAntibiotic ResistanceDo CDC Strategies Work?Do CDC Strategies Work?

50 ICUs from 20 hospitals50 ICUs from 20 hospitalsMonitored vancomycin useMonitored vancomycin useFeedback of riskFeedback of risk--adjusted comparison dataadjusted comparison dataUnitUnit--specific interventions successfully decreased specific interventions successfully decreased vancomycin use and VRE ratesvancomycin use and VRE rates

Fridkin et al. Emerging Infectious Disease 8(7); 702Fridkin et al. Emerging Infectious Disease 8(7); 702--704 2002704 2002

CDC 12 Steps to Prevent Antimicrobial Resistance Among HospitaliCDC 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized zed PatientsPatients

(In)Appropriate Antimicrobial (In)Appropriate Antimicrobial UseUse

2000 Patients visiting physician for cold or 2000 Patients visiting physician for cold or upper respiratory infection found:upper respiratory infection found:

63% received an antibiotic63% received an antibiotic54% received a broad54% received a broad--spectrum antibioticspectrum antibiotic

JAMA February 2003JAMA February 2003

(In)Appropriate Antimicrobial (In)Appropriate Antimicrobial UseUse

Survey of 4 US medical centersSurvey of 4 US medical centers424 physicians surveyed424 physicians surveyed

85% thought resistance a national problem85% thought resistance a national problem55% thought resistance a problem for their 55% thought resistance a problem for their

patientspatients

WesterWester et al. IDSA abstract 529 1999et al. IDSA abstract 529 1999

WHY?WHY?Human FactorsHuman Factors

Physician:Physician:–– Considering individual patient, not public Considering individual patient, not public

health implicationshealth implications–– Time pressureTime pressure–– Defensive medicineDefensive medicine–– More is betterMore is better

Patient:Patient:–– Belief that antibiotics cure viral infectionsBelief that antibiotics cure viral infections–– Wants something other than reassuranceWants something other than reassurance

Antibiotic ResistanceAntibiotic ResistanceOutpatient PracticesOutpatient Practices

Successful strategies must account for human Successful strategies must account for human factors:factors:

Physician:Physician:–– Knowledge of local resistance ratesKnowledge of local resistance rates–– Restricted formularyRestricted formulary–– “Cold packs”“Cold packs”–– Treatment guidelinesTreatment guidelines–– Patient educational materialsPatient educational materials–– Preprinted order setsPreprinted order sets

Patient:Patient:–– EducationEducation

Expansion Beyond Acute CareExpansion Beyond Acute Care

Long term careLong term care–– 1.8 million in 16,500 LTCF1.8 million in 16,500 LTCF

Home careHome care–– Home IV therapy $5 billion industryHome IV therapy $5 billion industry–– Estimated 20,000 provider agenciesEstimated 20,000 provider agencies

RehabilitationRehabilitationOutpatient surgeryOutpatient surgery–– 52% of hospital52% of hospital--based proceduresbased procedures–– 2.8 million outpatient procedures 19962.8 million outpatient procedures 1996

Ambulatory careAmbulatory care–– 8080--90% of cancer care90% of cancer care

CDC Draft Isolation Guidelines 2004 www.cdc.gov

Roles Beyond Traditional Roles Beyond Traditional Infection ControlInfection Control

Regulatory/AccreditationRegulatory/AccreditationDesign/Planning/Construction/RenovationDesign/Planning/Construction/RenovationOccupational HealthOccupational HealthPatient Safety/QualityPatient Safety/QualityHuman ResourcesHuman Resources--StaffingStaffingProduct SelectionProduct SelectionMedia Relations Media Relations BioterrorismBioterrorism

The FutureThe FutureTransition From:Transition From:

Device associated infections to device Device associated infections to device associated complicationsassociated complicationsSurgical site infections to surgical site Surgical site infections to surgical site complicationscomplicationsAntimicrobial resistance to drugAntimicrobial resistance to drug--related related complicationscomplications

Emerging Infect Dis 2001; 7: 363-66

Sources of EvidenceSources of Evidence--based based Guidelines for EpidemiologyGuidelines for Epidemiology

Centers for Disease Control and PreventionCenters for Disease Control and PreventionNational Guidelines ClearinghouseNational Guidelines ClearinghouseAssociation for Professionals in Infection Association for Professionals in Infection Control and EpidemiologyControl and EpidemiologySociety for Healthcare Epidemiology of Society for Healthcare Epidemiology of AmericaAmericaInstitute for Healthcare ImprovementInstitute for Healthcare Improvement