Download nosocomial pneumonia, 1999

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