Download The Quality Colloquium

The Quality Colloquium
August 22, 2004
Strategies for Reducing
Infections:
The Role of the Patient Safety
Officer
Tammy Lundstrom, MD
VP, Chief Quality and Safety Officer
Detroit Medical Center
Infection Control in the
Headlines
“Lax Procedures put Infants at High Risk;
Simple Actions by Hospital Workers, Such
as Diligent Hand-washing, Could Cut the
Number of Fatal Infections.”
Chicago Tribune 2002
JCAHO Accreditation

Revised IC standards
– Focus on traditional surveillance and quality
improvement
– Focus on integration of Infection Control into
Patient Safety Activities
– Surge Capacity

HAI as Sentinel Event-consequences
– Root Cause Analysis (RCA)
– Failure Mode and Effects Analysis (FMEA)
CDC 7 Challenges







Reduce Catheter-associated adverse events
Reduce surgical adverse events
Reduce mortality and hospitalizations due to
respiratory infection in LTC
Reduce antibiotic resistant infections
Eliminate microbiology lab errors
Eliminate occupational sharps injuries
Active compliance with ACIP immunization
recommendations
Historical Evolution
1940
1940-60
1970’s
1980’s
1990’s
2000’s
First description IC Officer
Penicillin and resistance
SENIC study; proves value
Continued growth of epidemiology
Expand role to non-acute settings
Expand role to “quality promotion
across the healthcare delivery
system”
Lancet 1999; 354 (Supp IV):25
Emerging Infect Dis 2001; 7: 286-92, 363-66
Study of Efficacy of Nosocomial
Infection Control (SENIC)
Hospitals with intensive surveillance and
control programs had lower rates of
nosocomial infections
 Recommended 1 FTE/250 beds

– OUTDATED!!!
Patterns of Healthcare Associated
Infection (HAI)
Endemic
90-95% of all HAI
Epidemic
5-10% of all HAI
Easier to demonstrate investigative techniques
114 investigations by CDC over a decade
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
Consequences
2 million HAI
90,000 deaths
$4.5-5.7 billion/ year
25% in Intensive Care Units
70% involve organisms with resistance to one
or more antibiotics
J. Burke. NEJM 2003; 348: 7 Emerging Infect Dis 1998; 4: 416-20
Infect Control Hosp Epi 2001; 22: 708-14
US Data
Variable
1975
1995
admissions(106) 37.7
35.9
Pt Days(106)
299
190
Ave LOS
7.9
5.3
Inpt Surg(106)
18.3
13.3
NI (106)
2.1
1.9
NI/1000 pt days 7.2
9.8
J. Burke NEJM 2003
Decrease (%) in HAI in NNIS
ICU
1990-1999
Type ICU
BSI
VAP
UTI
coronary
43
42
40
medical
44
56
46
surgical
31
38
30
pediatric
32
26
59
Emerging Infect Dis 2001; 7: 170-73
Why HAI May Increase
Sicker patients
 More invasive procedures for longer
duration
 Staff shortages

–
–
–
–
Nursing
Pharmacists
Pharmacy Techs
Radiology Techs
Why HAI May Increase

Resistant Organisms
– 1990’s
– 1990’s
– 2002

P. aeruginosa
VRE
VRSA
Emerging Infectious Disease
– 1980’s
– 1990’s
– 2000’s
HIV
hantavirus
SARS
Most Common Epidemiology
Interventions
Disseminate rates with benchmark data
 Develop multidisciplinary teams around
issues
 Education
 Communication

Am J Infect Control 1999; 27: 221
Focus on Evidence-based
Practices
Handwashing
Maximum barrier precautions for vascular
device insertion
Preoperative antimicrobial prophylaxis
Appropriate antimicrobial use
Handwashing
Compliance 16-81%
 Nurses consistently better than physicians
 Waterless hand hygiene agents improve
compliance

– Placement considerations
12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Step 12: Contain your contagion
Effect of Hand Hygiene on Resistant Organisms
Year
1982
1984
1990
1992
Author
Maki
Massanari
Simmons
Doebbeling
Setting
adult ICU
adult ICU
adult ICU
adult ICU
1994
1999
Webster
Pittet
NICU
hospital
Impact on organisms
decreased
decreased
no effect
decreased with one versus
another hand hygiene product
MRSA eliminated
MRSA decreased
ICU = intensive care unit; NICU = neonatal ICU
MRSA = methicillin-resistant Staphylococcus aureus
Source: Pittet D: Emerg Infect Dis 2001;7:234-240
The Human Element in Hand Hygiene
Adherence


Of 34 studies evaluated by CDC/HICPAC average
level of adherence by Health care personnel=
40% (range 5-81%)
-overall physicians usually worst
Why?
–
–
–
–
–
Too busy & not enough time
Hand hygiene sinks or products inaccessible
Skin irritation
Hands don’t appear visibly soiled
Influence of opinion leaders
Antimicrobial Resistant Organisms
The Scope of the Problem




Gram positive bacteria
– VRE
– Streptococcus pneumoniae
Gram negative bacteria
– Pseudomonas
– Salmonella
Fungi
– Fluconazole-resistant Candida albicans
Viruses
– Multi-drug resistant HIV
– Acyclovir-resistant herpes
CDC Strategies to Decrease
Antimicrobial Resistance
1.
2.
3.
4.
5.
6.
Vaccinate
Remove invasive devices as soon as
possible
Culture (avoid empiric treatment)
Treat with intent to eradicate infection
Obtain expert advice on antibiotic
selection
Consult antibiograms
CDC Strategies to Decrease
Antimicrobial Resistance
7. Avoid unnecessary antibiotic use
8. Target the pathogen
9. Do NOT treat colonization
10. Stop empiric antibiotics quickly once it
appears that bacterial infection is unlikely
11. Enforce good infection control practices






Factors Contributing to
Antimicrobial Resistance in
Hospitals
Serious illness
Immunocompromised state
Use of invasive procedures/devices
Increasing introduction of resistant organisms
from the community (Nursing home/hospital
transfers)
Ineffective infection control practices
High antibiotic use per geographic area per unit of
time
Risk Factors for Staphylococcus aureus
with Reduced Susceptibility to
Vancomycin (MIC > 4 ug/mL)
19 cases
Adjusted OR (CI
95%)
Vancomycin (per week)
in prior 1 month
5.6 (2.2-14.3)
Previous MRSA culture
in prior 2nd or 3rd month
Fridkin et al. Clin Infect Dis 2003; 36:429-39
15.5 (1.8- 134.5)
Antibiotic Resistance
Do CDC Strategies Work?
50 ICUs from 20 hospitals
 Monitored vancomycin use
 Feedback of risk-adjusted comparison data
 Unit-specific interventions successfully decreased
vancomycin use and VRE rates

Fridkin et al. Emerging Infectious Disease 8(7); 702-704 2002

CDC 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Patients
(In)Appropriate Antimicrobial
Use
2000 Patients visiting physician for cold or
upper respiratory infection found:
63% received an antibiotic
54% received a broad-spectrum antibiotic
JAMA February 2003
(In)Appropriate Antimicrobial
Use
Survey of 4 US medical centers
424 physicians surveyed
85% thought resistance a national problem
55% thought resistance a problem for their
patients
Wester et al. IDSA abstract 529 1999
WHY?
Human Factors

Physician:
– Considering individual patient, not public
health implications
– Time pressure
– Defensive medicine
– More is better

Patient:
– Belief that antibiotics cure viral infections
– Wants something other than reassurance
Antibiotic Resistance
Outpatient Practices
Successful strategies must account for human
factors:
Physician:
– Knowledge of local resistance rates
– Restricted formulary
– “Cold packs”
– Treatment guidelines
– Patient educational materials
– Preprinted order sets
Patient:
– Education
Expansion Beyond Acute Care

Long term care
– 1.8 million in 16,500 LTCF

Home care
– Home IV therapy $5 billion industry
– Estimated 20,000 provider agencies


Rehabilitation
Outpatient surgery
– 52% of hospital-based procedures
– 2.8 million outpatient procedures 1996

Ambulatory care
– 80-90% of cancer care
CDC Draft Isolation Guidelines 2004 www.cdc.gov
Roles Beyond Traditional
Infection Control
Regulatory/Accreditation
 Design/Planning/Construction/Renovation
 Occupational Health
 Patient Safety/Quality
 Human Resources-Staffing
 Product Selection
 Media Relations
 Bioterrorism

The Future
Transition From:
Device associated infections to device
associated complications
 Surgical site infections to surgical site
complications
 Antimicrobial resistance to drug-related
complications

Emerging Infect Dis 2001; 7: 363-66
Sources of Evidence-based
Guidelines for Epidemiology
Centers for Disease Control and Prevention
 National Guidelines Clearinghouse
 Association for Professionals in Infection
Control and Epidemiology
 Society for Healthcare Epidemiology of
America
 Institute for Healthcare Improvement
