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Challenges for Infection Prevention in the 21st Century William A. Rutala, Ph.D., M.P.H. UNC Health Care and UNC School of Medicine, Chapel Hill, NC Disclosure This educational activity is brought to you, in part, by Advanced Sterilization Products (ASP) and Ethicon. The speaker receives an honorarium from ASP and Ethicon and must present information in compliance with FDA requirements applicable to ASP. CHALLENGES IN THE PREVENTION AND MANAGEMENT OF HEALTHCARE-ASSOCIATED INFECTIONS Changing population of hospital patients Increased severity of illness Increased numbers of immunocompromised patients Shorter duration of hospitalization More and larger intensive care units Larger step-down units Growing frequency of antimicrobial-resistant pathogens Lack of compliance with hand hygiene and other infection preventive measures (e.g., endoscope) CHALLENGES IN THE PREVENTION AND MANAGEMENT OF HEALTHCARE-ASSOCIATED INFECTIONS Limited infection prevention resources Implementation of bundles demonstrated to reduce HAIs Public reporting of HAIs CMS non-reimbursement for HAIs Health insurance reimbursement tied to quality goals State and federal laws legislating care issues Influenza immunization for staff MRSA screening of patients and staff Greater emphasis on infection prevention by The Joint Commission HEALTHCARE SYSTEM OF THE PAST Home Care Outpatient/ Ambulatory Facility Tranquil Gardens Nursing Home Acute Care Facility Long Term Care Facility CURRENT HEALTHCARE SYSTEM Acute Care Facility Outpatient/ Ambulatory Facility Home Care Tranquil Gardens Nursing Home Long Term Care Facility HEALTHCARE-ASSOCIATED INFECTIONS: IMPACT 1.7 million infections per year 98,987 deaths due to HAI Pneumonia 35,967 Bloodstream 30,665 Urinary tract 13,088 SSI 8,205 Other 11,062 6th leading cause of death (after heart disease, cancer, stroke, chronic lower respiratory diseases, and accidents)1 1 National Center for Health Statistics, 2004 MORTALITY RATE OF COMMON HAIs 30.1% 17.7% 5.7% 0.8% Pneumonia 0.7% Bloodstream Urinary Tract Surgical Site No Infections Infections Infections Infections INCREMENTAL HOSPITAL DAYS DUE TO COMMON INFECTIONS Days, 13 Days, 14 Days, 7 Days, 4 Pneumonia Bloodstream Infections Urinary Tract Infections Surgical Site Infectins RATES OF HEALTHCARE-ASSOCIATED INFECTIONS PER 1,000 PATIENT DAYS 14 12 10 8 6 4 2 0 12.2 9.8 69% Increase 7.2 1975 1985 2005 COST ESTIMATES FOR HEALTHCAREASSOCIATED INFECTIONS (HAIs) HAI Cost per HAI + SE Range Ventilator-associated pneumonia 25,072 + 4,132 8,682-31,316 Healthcare-associated bloodstream infections Surgical site infections 23,242 + 5,184 6,908-37,260 10,443 + 3,249 2,527-29,367 758 + 41 728-810 Catheter-associated urinary tract infections Anderson DJ, et al. ICHE 2007;28:767-773 Costs based on literature review 1985-2005; adjusted to US 1995 dollars CHALLENGES IN THE PREVENTION AND MANAGEMENT OF HEALTHCARE-ASSOCIATED INFECTIONS Changing population of hospital patients Increased severity of illness Increased numbers of immunocompromised patients Shorter duration of hospitalization More and larger intensive care units Larger step-down units Growing frequency of antimicrobial-resistant pathogens Lack of compliance with hand hygiene and other infection preventive measures (e.g., endoscope) HAZARDS IN THE ICU Weinstein RA. Am J Med 1991;91(suppl 3B):180S PREVALENCE: ICU (EUROPE) Study design: Point prevalence rate 17 countries, 1447 ICUs, 10,038 patients Frequency of infections: 4,501 (44.8%) Community-acquired: 1,876 (13.7%) Hospital-acquired: 975 (9.7%) ICU-acquired: 2,064 (20.6%) Pneumonia: 967 (46.9%) Other lower respiratory tract: 368 (17.8%) Urinary tract: 363 (17.6%) Bloodstream: 247 (12.0%) Vincent J-L, et al. JAMA 1995;274:639 RISK FACTORS FOR ICU-ACQUIRED INFECTIONS (95% CI) PA Catherization (1.01-1.43) CVP Line (1.16-1.57) Stress Ulcer Prophylaxis (1.20-1.60) Urinary Catherization (1.19-1.69) Mechanical Ventilation (1.51-2.03) Trauma on Admission (1.75-2.44) 0 0.5 1 1.5 Odds Ratio 2 2.5 RISK FACTORS FOR ICU-ACQUIRED INFECTIONS Length of Stay, d (95% CI) 1-2 (1.56-4.13) 3-4 (5.51-14.70) 5-6 (9.33-24.14) 7-13 (19.43-48.67) 14-20 (37.90-96.25) >21 (48.18-120.06) 0 10 20 30 40 Odds Ratio 50 60 70 80 NOSOCOMIAL INFECTIONS IN THE UNITED STATES Variable Admissions Patient-days Average length of stay Inpatient surgical procedures Nosocomial infections Incidence of nosocomial infections (number per 1000 patient-days) 1975 37,700,000 299,000,000 7.9 18,300,000 2,100,000 7.2 Burke JP. NEJM 2003;348:651 1995 35,900,000 190,000,000 5.3 13,300,000 1,900,000 9.8 AGING POPULATION, US CANCER: INCIDENCE & DEATHS, 2006 (estimated) Cancer Oral cavity & pharynx Digestive sysetm Respiratory system Skin Breast Genital system Urinary system Leukemia/multiple myeloma Lymphoma TOTAL New Cases 30,990 263,060 186,370 68,780 214,640 321,490 102,490 35,070 66,670 1,399,790 Deaths 7,430 136,180 167,050 10,710 41,430 56,060 26,670 22,280 20,330 564,830 American Cancer Society CHALLENGES IN THE PREVENTION AND MANAGEMENT OF HEALTHCARE-ASSOCIATED INFECTIONS Changing population of hospital patients Increased severity of illness Increased numbers of immunocompromised patients Shorter duration of hospitalization More and larger intensive care units Larger step-down units Growing frequency of antimicrobial-resistant pathogens and emerging pathogen Lack of compliance with hand hygiene and other infection preventive measures (e.g., endoscope) Evolution of Antimicrobial Resistance in Gram-positive Cocci Penicillin Methicillin [1940s] Penicillin-resistant S. aureus S. aureus [1960s] [1997] [2002] Vancomycinresistant S. aureus Methicillin-resistant S. aureus (MRSA) Vancomycin Ciprofloxacin 1987 Vancomycin Vancomycin-resistant (glycopeptide) enterococcus (VRE) intermediate-resistant S. aureus CA-MRSA UNITED STATES Enterobacter / Ceftazidime 21→19% E. coli / ESBL phenotype 3→5% E. coli / Ciprofloxacin 4→19% Klebsiella / ESBL phenotype 6→15% Klebsiella / Ciprofloxacin 4→13% Klebsiella / Imipenem (2 μg/ml)<1→5 (3.7)% UNITED STATES P. aeruginosa / Imipenem 9→8% P. aeruginosa / Piperacillin-tazobactam 11→12% P. aeruginosa / Ciprofloxacin 17→19% Acinetobacter / Amikacin 11→16% Acinetobacter / Ceftazidime 23→45% Acinetobacter / Imipenem 3→7% EMERGING INFECTIOUS AGENTS Current concerns Vancomycin resistant Staphylococcus aureus Multidrug resistant gram negative pathogens Clostridium difficile (strains that hyperproduce toxin) Norovirus Prions XDR-TB Future concerns but planning required Influenza pandemic (H5N1?) Bioterrorism Gene transfer Xenotransplantation EMERGING INFECTIOUS DISEASES RELEVANT TO THE HOSPITAL 1977 (US) – Legionnaire’s disease 1978 (US) – Staphylococcal toxic shock syndrome 1996 (England US) – Variant Creutzfeld-Jakob disease (vCJD) 2001 (US) - Anthrax (attack via letters)* 2002 (US) – Vancomycin-resistant S. aureus* 2002 (Canada US) – Hypervirulent C. difficile* 2003 (China worldwide) - SARS* 2003 (US) – Monkeypox* 2004 (Asia) – Avian influenza (H5N1)* 2006 (Worldwide) – XDR-TB* * HCWs at risk for infection RISKS FROM EMERGING INFECTIOIUS DISEASES Person-to-person transmission Andes hanta virus Anthrax* C. difficile Monkeypox Norovirus (G-II strain) Plague* Rabies Smallpox* Viral hemorrhagic fever* Fomite transmission Anthrax* C. difficile Norovirus Plague* Q fever* Smallpox* Lab risk Q fever* Monkeypox Smallpox* * BT agent SARS 100 6000 5000 80 % HCW 4000 60 3000 40 2000 20 1000 0 0 China Hong Kong Taiwan Canada Singapore Vietnam % HCW Total No. SARS Cases Total SARS Cases and % Healthcare Workers by Country CHALLENGES IN THE PREVENTION AND MANAGEMENT OF HEALTHCARE-ASSOCIATED INFECTIONS Changing population of hospital patients Increased severity of illness Increased numbers of immunocompromised patients Shorter duration of hospitalization More and larger intensive care units Larger step-down units Growing frequency of antimicrobial-resistant pathogens Lack of compliance with hand hygiene and other infection preventive measures (e.g., endoscope) Lack of Compliance Hand Hygiene Endoscope reprocessing SSI ASSOCIATION BETWEEN HAND HYGIENE COMPLIANCE AND HAI RATES Author, year Casewell, 1977 Maki, 1982 Massanari, 1984 Kohen, 1990 Doebbeling, 1992 Webster, 1994 Zafar, 1995 Larson, 2000 Pittet, 2000 Setting Adult 1CU Adult 1CU Adult 1CU Adult 1CU Adult 1CU NICU Newborn MICU/NICU Hospitalwide Results Reduction HAI due to Klebsiella Reduction HAI rates Reduction HAI rates Trend to improvement Different rates of HAI between 2 agents Elimination of MRSA* Elimination of MRSA* 85% reduction VRE Reduction HAI & MRSA cross-transmission HAI, healthcare-associated infections instituted *Other infection control measures also How Is Our Track Record on Handwashing in Healthcare Facilities? Average Handwashing Adherence of Personnel in 34 Studies 90 80 70 60 50 40 30 20 10 0 Study The average adherence rate was only 40% 34 31 28 25 22 19 16 13 10 7 Average 4 1 A review of 34 published studies of handwashing adherence among healthcare workers found that adherence rates varied from 5% to 81% Percent Adherence Hand Hygiene Adherence an Institutional Priority Multidisciplinary Program Administrative support (IOC, Executive Staff, Dept Heads) Monitor HCWs adherence to policy and provide staff with information about performance Provide HCWs with accessible hand hygiene (HH) products to include alcohol based hand rubs Education regarding types of activities that result in hand contamination and indications for hand hygiene Reminders in the workplace (e.g., posters) Considering ways to include HH in management standards (loss of hospital privileges, tickets for non-compliance, coffee coupons) UNC Hospitals Intensive Care Units Hand Hygiene Compliance 100 80 70 60 Leadership presentations Collected baseline data 50 40 30 20 Began quarterly compliance reports to ICUs Ongoing education Pocket-sized alcohol based gel available Evaluated hand hygiene products Staff HH compliance added to patient satisfaction survey Implemented Infection Control Liaisons 10 0 4Q 03 1Q 04 2Q 04 3Q 04 4Q 04 1Q 05 2Q 05 3Q 05 4Q 05 1Q 06 2Q 06 3Q 0 4t 6 hQ 06 1Q 07 2Q 07 3Q 07 4Q 07 Compliance (%) 90 GI ENDOSCOPES Widely used diagnostic and therapeutic procedure Endoscope contamination during use (109 in/105 out) Semicritical items require high-level disinfection minimally Inappropriate cleaning and disinfection has lead to cross-transmission In the inanimate environment, although the incidence remains very low (35 cases of transmission from 19932002), endoscopes represent a risk of disease transmission Endoscope Reprocessing: Current Status of Cleaning and Disinfection Guidelines Society of Gastroenterology Nurses and Associates, 2000 European Society of Gastrointestinal Endoscopy, 2000 British Society of Gastroenterology Endoscopy, 1998 Gastroenterological Society of Australia, 1999 Gastroenterological Nurses Society of Australia, 1999 American Society for Gastrointestinal Endoscopy, 2003 Association for Professional in Infection Control and Epidemiology, 2000 Multi-society Guideline for Reprocessing Flexible GI Endoscopes, 2003 Centers for Disease Control and Prevention, 2004 (in press) Endoscope Reprocessing, Worldwide Worldwide, endoscopy reprocessing varies greatly India, of 133 endoscopy centers, only 1/3 performed even a minimum disinfection (1% glut for 2 min) Brazil, “a high standard …occur only exceptionally” Western Europe, >30% did not adequately disinfect Japan, found “exceedingly poor” disinfection protocols US, 25% of endoscopes revealed >100,000 bacteria Schembre DB. Gastroint Endoscopy 2000;10:215 TRANSMISSION OF INFECTION Gastrointestinal endoscopy >300 infections transmitted 70% agents Salmonella sp. and P. aeruginosa Clinical spectrum ranged from colonization to death (~4%) Number of reported infections is small, suggesting a very low incidence Endemic transmission may go unrecognized Bronchoscopy 90 infections transmitted M. tuberculosis, atypical Mycobacteria, P. aeruginosa Spach DH et al Ann Intern Med 1993: 118:117-128 and Weber DJ et al Gastroint Dis 2002;87 ENDOSCOPE INFECTIONS Infections traced to deficient practices Inadequate cleaning (clean all channels) Inappropriate/ineffective disinfection (time exposure, perfuse channels, test concentration) Failure to follow recommended disinfection practices (drying, contaminated water bottles, irrigating solutions) Flaws in design/manufacture of endoscopes or AERs ENDOSCOPE DISINFECTION CLEAN-mechanically cleaned with water and enzymatic detergent HLD/STERILIZE-immerse scope and perfuse HLD/sterilant through all channels for at least 1220 min RINSE-scope and channels rinsed with sterile, filtered or tap water followed by alcohol DRY-use forced air to dry insertion tube and channels STORE-prevent recontamination Surgical Site Infection SSIs third most common HAI, accounting for 14-23% of HAIs Among surgical patients, SSIs were most common accounting for ~40% of healthcare-associated infections 67% incisional infections (confined to incision) 33% organ/space infections Increase an average of 7 days to each hospitalization Increase >$10,000 (2005 $) to each hospitalization Appropriate preoperative administration of antibiotics and other prevention measures are effective in preventing infection Surgical Site Infections. Available at: http://www.ihi.org/IHI/Topics/PatientSafety/SurgicalSiteInfections/. Odom-Forren J. Nursing2006. 2006;36(6):58-63. Cost Estimates for Specific Healthcare-Associated Infections HAI type VAP BSI SSI CA-UTI Weight-Adjusted Cost per HAI Range of Published Estimates of Cost per HAI Mean + SE 25,072 + 4,132 8,682-31,316 23,242 + 5,184 6,908-37,260 10,443 + 3,249 758 + 41 2005 US dollars Anderson DJ, et al. ICHE 2007;28:767-773 2,527-29,367 728-810 Clinical and Economic Impact Procedure/Device Devices/yr* Infections/yr Avg. cost Mortality* CARDIO Heart valves 85,000 3,400 $50,000 High Vascular grafts 450,000 16,000 $40,000 Moderate Pacemaker/ICD 300,000 12,000 $35,000 Moderate 700 280 $50,000 High 40,000 2400 $50,000 Moderate LV assist dev. NEURO CNS shunt Adapted from: Darouiche RO. N Engl J Med. 2004;350:1422-429. *Darouiche RO. Clin Infec Dis. 2001;38:1567-1572. Clinical and Economic Impact Procedure/Device Devices/yr* Infections/yr Avg. cost Mortality* ORTHOPEDIC Joint prosthesis 600,000 12,000 $30,000 Low Fracture fixator 2,000,000 100,000 $15,000 Low 130,000 2600 $20,000 Low 15,000 450 $35,000 Low PLASTIC Breast implant UROLOGICAL Penile implant Adapted from: Darouiche RO. N Engl J Med. 2004;350:1422-429. *Darouiche RO. Clin Infec Dis. 2001;38:1567-1572. Surgical Site Infection Advances in infection control practices Improved operating room ventilation Sterilization methods Barriers Surgical technique Antimicrobial prophylaxis SSI: Pathogenesis Risk of surgical site infections = Dose of bacterial contamination x virulence (toxins) Resistance of the host SSI: Primary Risk Factors Endogenous microorganisms Skin-dwelling microorganisms Most common source S aureus most common isolate Fecal flora (gnr) when incisions are near the perineum or groin Exogenous microorganisms Surgical personnel (members of surgical team) OR environment (including air) All tools, instruments, and materials (extremely rare) Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278. SSI: CDC Guidelines Patient characteristics Preoperative issues Intra-operative issues Postoperative issues Mangram AJ, et al. Infect Control Hosp Epidemiol. 1999;20(4):250-278. CDC Surgical Site Infection Prevention Guidelines - 1999 Category IA and IB No prior infections Do not shave in advance Control glucose in D.M. pts Stop tobacco use Shower with antiseptic soap Prep skin with approp. agent Surgical team nails short Surgical team scrub hands Exclude I/C surgical team Give prophylactic antibiotics 15 air changes/hr in OR Keep OR doors closed Use sterile instruments Wear a mask Cover hair Wear sterile gloves Gentle tissue handling DPC for heavily contaminated wounds Closed suction drains (when used) Pos pressure ventilation in OR Sterile dressing x 24-48 hr SSI surveillance with feedback to surgeons Surgical Infection Prevention Arch Surg 2005;140:174 Antibiotic Surgery within 1 hour % (N) Correct Antibiotic % Antibiotic stopped within 24 hours % Cardiac (7,861) 45.3 95.8 34.3 Vascular 40.0 91.9 44.8 Hip/knee (15,030) 52.0 97.4 36.3 Colon 40.6 75.9 41.0 (2,756) 52.4 90.8 79.1 Surgeries (34,133) 47.6 92.9 40.7 (3,207) (5,279) Hysterectomy All CHALLENGES IN THE PREVENTION AND MANAGEMENT OF HEALTHCARE-ASSOCIATED INFECTIONS Limited infection prevention resources Implementation of bundles demonstrated to reduce HAIs Public reporting of HAIs CMS non-reimbursement for HAIs Health insurance reimbursement tied to quality goals State and federal laws legislating care issues Influenza immunization for staff MRSA screening of patients and staff Greater emphasis on infection prevention by The Joint Commission INCREASING DEMANDS ON ICPs WITH ACCOUNTABILITY Public expectation of 0 rate of healthcare-associated infections? Buy in by legislatures and CMS IC accountability and attention rich but resource poor ICP ACTIVITIES 1975 to 1990 Surveillance Outbreak investigations Exposure evaluations Education JCAHO Policy development and review Sterilizer monitoring Dialysis water 1991 to 2003 (new) Targeted surveillance OSHA TB OSHA Bloodborne Molecular epidemiology MRSA, VRE BT preparedness Construction rounds ICP ACTIVITIES 2004 to 2008 (new) IHI bundles CMS core measures NSQUIP (VAs, others) NDNQI (ANA) Other CQI initiatives MRSA active surveillance Unannounced TJC visits Avian influenza preparedness Endoscope sampling Future Public health reporting Mandated influenza vaccine Mandated MRSA surveillance Cost analyses Comprehensive surveillance Transparency CHALLENGES IN THE PREVENTION AND MANAGEMENT OF HEALTHCARE-ASSOCIATED INFECTIONS Limited infection prevention resources Implementation of bundles demonstrated to reduce HAIs Public reporting of HAIs CMS non-reimbursement for HAIs Health insurance reimbursement tied to quality goals State and federal laws legislating care issues Influenza immunization for staff MRSA screening of patients and staff Greater emphasis on infection prevention by The Joint Commission Prevent Surgical Site Infections: Institute for Healthcare Improvement Components or “bundle” if implemented reliably can eliminate SSIs Appropriate use of antibiotics Appropriate hair removal Maintenance of postoperative glucose control for major cardiac surgery patients Establishment of postoperative normothermia for colorectal surgery patients “Bundle” is a group of interventions related to a disease process that, when executed together result in better outcomes than when implemented individually. Institute for Healthcare Improvement VAP AND CA-BSI BUNDLES VAP Bundle Elevation of the head of the bed to between 30 and 45 degrees Daily “sedation vacation” and daily assessment of readiness to extubate Peptic ulcer disease (PUD) prophylaxis Deep venous thrombosis (DVT) prophylaxis (unless contraindicated) CA-BSI Hand hygiene Maximal barrier precautions Chlorhexidine skin antisepsis Optimal catheter site selection, with subclavian vein as the preferred site for non-tunneled catheters Daily review of line necessity, with prompt removal of unnecessary lines University of North Carolina Health Care Ventilator-associated pneumonias Leads to an increased length of stay, 13 days Substantial cost to the healthcare institution, about $24,400 Mortality about 30% Catheter-related bloodstream infections Leads to an increased length of stay, 14 days Substantial cost to the healthcare institution, about $25,000 (not reimbursed by CMS, Oct 2008) Mortality about 20% Infections/1000 Catheter Days UNC Health Care ICUs Central CatheterAssociated Bloodstream Infections 14 12 Medical Staff education 10 8 Dressing kit with Chloraprep Nursing education Custom insertion kits with antiseptic catheters 9.5 9.4 IHI 8.4 6 4 7.5 6.6 6.4 5.9 6.6 5.8 4.7 4.4 4.1 4.7 4.2 3.5 3.4 2 0 99 00 01 02 03 04 05 06 07 99 00 01 02 03 04 05 06 07 c c c c c c c c c e e n n n n n n n Ju l-De -Ju l-De -Ju l-De -Ju l-De -Ju l-De -Ju l-De -Ju l-De Jun l-De Jun l-De n n n n n n n Ju Ja Ju Ja Ju Ja Ju Ja Ju Ja Ju Ja Ju an Ju an Ju Ja J J Hospital Epidemiology Confidential Information for CQI 3 2007 Q4 2007 Q3 2007 Q2 2007 Q1 2006 Q4 2006 Q3 2006 Q2 2006 Q1 2005 Q4 2005 Q3 2005 Q2 2005 Q1 2004 Q4 2004 Q3 2004 Q2 2004 Q1 Infection Rate (# Infections / 1000 Ventilator Days) University of North Carolina Health Care How We Are Doing Overall: VAPs UNC HCS All ICUs VAP Rates 10 8 6 4 2 0 CHALLENGES IN THE PREVENTION AND MANAGEMENT OF HEALTHCARE-ASSOCIATED INFECTIONS Limited infection prevention resources Implementation of bundles demonstrated to reduce HAIs Public reporting of HAIs CMS non-reimbursement for HAIs Health insurance reimbursement tied to quality goals State and federal laws legislating care issues Influenza immunization for staff MRSA screening of patients and staff Greater emphasis on infection prevention by The Joint Commission PUBLIC REPORTING Who decides What’s reported Legislature (with input from advocacy groups) Executive branch Independent commission (NC) Specific infection rates (e.g., CR-BSI) All surveillance data? Who has access to the data Public health department Public CHALLENGES IN THE PREVENTION AND MANAGEMENT OF HEALTHCARE-ASSOCIATED INFECTIONS Limited infection prevention resources Implementation of bundles demonstrated to reduce HAIs Public reporting of HAIs CMS non-reimbursement for HAIs Health insurance reimbursement tied to quality goals State and federal laws legislating care issues Influenza immunization for staff MRSA screening of patients and staff Greater emphasis on infection prevention by The Joint Commission CMS Reimbursement Denied for Healthcare-Associated Infections New CMS guidelines will deny reimbursement for: Vascular catheter-associated infections Catheter-related UTIs Mediastinitis after CABG CMS is proposing to expand the list of conditions by 9 to include: SSI following certain elective procedures Legionnaires’ disease Ventilator-associated pneumonia S. aureus septicemia Clostridium difficile associated disease CHALLENGES IN THE PREVENTION AND MANAGEMENT OF HEALTHCARE-ASSOCIATED INFECTIONS Limited infection prevention resources Implementation of bundles demonstrated to reduce HAIs Public reporting of HAIs CMS non-reimbursement for HAIs Health insurance reimbursement tied to quality goals State and federal laws legislating care issues Influenza immunization for staff MRSA screening of patients and staff Greater emphasis on infection prevention by The Joint Commission CHALLENGES IN THE PREVENTION AND MANAGEMENT OF HEALTHCARE-ASSOCIATED INFECTIONS Health insurance reimbursement tied to meeting quality goals Incentive package would involve metrics that are clinically meaningful and measurable. Patient satisfaction Ventilator-associated pneumonia, target NHSN Central-line associated bacteremia, target NHSN Hand hygiene, compare to literature Prophylactic antibiotics within one hour of surgical incision Targeting Zero D Murphy, APIC 2007 Set goal at zero (BSI, VAP, SSI, MRSA) Strong leadership, MD support, Department champions Use the bundle approach to evidence-based prevention measures Real-time root-cause analysis when a HAI occurs Personalize HAIs (information about people not rates) Data shared relentlessly with staff, leadership Teamwork essential and team success celebrated Market the value of infection prevention to leadership 04 0.0 -1.0 20 Q 04 1 20 Q 04 2 20 Q 04 3 20 Q4 05 20 Q 05 1 20 Q 05 2 20 Q 05 3 20 Q4 06 20 Q 06 1 20 Q 06 2 20 Q 06 3 20 Q 07 4 20 Q1 07 20 Q 07 2 20 Q 07 3 20 Q 08 4 Q 1 20 Infection Rate (# Infections / 1000 Ventilator Days) 04 20 Q1 04 20 Q2 04 20 Q3 04 20 Q4 05 20 Q1 05 20 Q2 05 20 Q3 05 20 Q4 06 20 Q1 06 20 Q2 06 20 Q3 06 20 Q4 07 20 Q1 07 20 Q2 07 20 Q3 07 Q 4 20 Infection Rate (# Infections / 1000 Catheter Days) University of North Carolina Health Care MICU Catheter Associated Bloodstream Infection Rates 12.0 10.0 8.0 6.0 4.0 2.0 0.0 MICU Ventilator Associated Pneumonia Rates 7.0 6.0 5.0 4.0 3.0 2.0 1.0 CHALLENGES IN THE PREVENTION AND MANAGEMENT OF HEALTHCARE-ASSOCIATED INFECTIONS Limited infection prevention resources Implementation of bundles demonstrated to reduce HAIs Public reporting of HAIs CMS non-reimbursement for HAIs Health insurance reimbursement tied to quality goals State and federal laws legislating care issues Influenza immunization for staff MRSA screening of patients and staff Greater emphasis on infection prevention by The Joint Commission MANAGEMENT OF MRSA IN HOSPITALS: IMPACT OF MRSA 126,000 hospitalized patients infected annually 3.95 MRSA infections per 1,000 discharges >5,000 deaths >$2.5 billion excess health care costs due to MRSA 9.1 days excess length of stay (LOS) >$20,000 in excess cost per case (range, $7,000$32,000) 4% in excess in-hospital mortality MANAGEMENT OF MRSA IN HOSPITALS: 5 MILLION LIVES CAMPAIGN (IHI) Improved hand hygiene Decontamination of the environment and equipment Active surveillance cultures for MRSA colonization ~9.5% admission to UNCHC MICU colonized ~6.5% admissions to UNCHC SICU colonized Contact isolation for infected and colonized patients Device bundles (Central Line and Ventilator Bundle) RATIONALE FOR SCREENING PATIENTS FOR MRSA Patients colonized or infected with MRSA represent the major reservoir of MRSA in healthcare settings 33% to 91% of colonized patients are NOT detected by routine clinical cultures Transmission of MRSA from non-isolated patients occurs 16 times more often than from isolated patients Impact of active surveillance cultures on MRSA acquisitions or infections 16/18 (89%) published articles reported substantial reduction CHALLENGES IN THE PREVENTION AND MANAGEMENT OF HEALTHCARE-ASSOCIATED INFECTIONS Limited infection prevention resources Implementation of bundles demonstrated to reduce HAIs Public reporting of HAIs CMS non-reimbursement for HAIs Health insurance reimbursement tied to quality goals State and federal laws legislating care issues Influenza immunization for staff MRSA screening of patients and staff Greater emphasis on infection prevention by The Joint Commission The Joint Commission 2009 Chapter: National Patient Safety Goals Goal 7-reduce the risk of HAIs Compliance with WHO and CDC hand hygiene Implement evidence-based practices to prevent HAIs due to multiply drug-resistant organisms Implement evidence-based practices to prevent central-line associated bloodstream infections Implement best practices for preventing surgical site infections CONCLUSIONS Healthcare-associated infections are associated with significant patient morbidity and mortality Implementation of IHI bundles demonstrated to reduce VAP and CR-BSI infections Compliance with infection prevention recommendations needed to prevent HAIs New issues: public reporting; CMS nonreimbursement for HAIs; National Patient Safety Goals (TJC); insurance reimbursement tied to quality goals CONCLUSIONS Current challenges Increased emphasis on preventing HAIs; increased demands on ICP time Lack of compliance with hand hygiene and policies Institution of IHI bundles and other CQI activities Public reporting, mandated vaccines, mandated practices Multidrug pathogens: VRSA, MDR-GNRs, XDR-TB Emerging pathogens: C. difficile, norovirus Public desire for 0 rate of healthcare-associated infections CONCLUSIONS Future Gene therapy-genes introduced into human cells Xenotransplanation-organs from nonhuman species to human recipients emerged due to shortage of human organs Emerging pathogens? Influenza pandemic? Bioterrorism? Thank you ACKNOWLEDGEMENTS Thanks to the following persons for slides David Weber Karen Hoffmann Jay Fishman Ron Jones Jason Stout