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
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.
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
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
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
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
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
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