Download Reducing Healthcare Associated Infections

Prevent Healthcare Associated
Infections
CDR Tammy Servies, MD, MPH
Uniformed Services University of the Health Sciences
1 December 2016
Disclosures
• The presenter has no financial relationships to disclose.
• This continuing education activity is managed and
accredited by Professional Education Services Group in
cooperation with AMSUS.
• Neither PESG, AMSUS, nor any accrediting organization
support or endorse any product or service mentioned
in this activity.
• PESG and AMSUS staff has no financial interest to
disclose.
• Commercial support was not received for this activity.
Disclaimer
• The content of this presentation is the sole
responsibility of the author and does not necessarily
reflect the views or policies of the Uniformed Services
University of the Health Sciences (USUHS), the
Department of Defense (DoD), or the Departments of
the Army, Navy or Air Force.
• Mention of trade names, commercial products, or
organizations does not imply endorsement by the U.S.
Government.
Learning Objectives
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Understand the nature of the problem and importance of this initiative
List the 6|18 recommendations related to healthcare associated infections
Supporting evidence for goals and recommendations
Review current programs within the Military Health System (MHS)
Explore potential programs and interventions
Definition
An infection acquired in hospital by a patient who was admitted for a reason
other than that infection
• An infection occurring in a patient in a hospital or other health care facility in whom the
infection was not present or incubating at the time of admission.
• Infections acquired in the hospital but appearing after discharge, and also occupational
infections among staff of the facility
Prevention of hospital acquired infections, A practical guide. 2nd edition. World Health Organization, 2002
Categories & Impact
• Categories:
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Central line associated blood stream infections (CLABSI)
Catheter- associated urinary tract infections (CAUTI)
Surgical site infections (SSI)
Hospital onset Clostridium difficile infections
Hospital onset methicillin resistant Staphylococcus aureus (MRSA) bacteremia
• Impact: Why is it important?*
• Healthcare associated infections are one of the most common sources of preventable
harm
• Contributes to hospital readmissions, development of antibiotic resistance
• Most of such infections are preventable; represent opportunity to save lives and reduce
cost
*HealthyPeople2020; Scott II, R.
Costs
HAI within the MHS
• All inpatient facilities participate in Partnership for Patients
(https://partnershipforpatients.cms.gov/)*
• Data from CDC’s National Healthcare Safety Network indicate MHS hospitals
are generally meeting national standards**
*MHS Review Final Report
**Health.mil Patient Safety Reports
***CDC HAI Progress report
6|18 Prevent Healthcare Associated
Infections
1. Require antibiotic stewardship programs in all hospitals and skilled nursing
facilities
2. Prevent hemodialysis-related infections through immediate (payer) coverage
for insertion of permanent dialysis ports
Antibiotic Resistant Infections
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*CDC, 2013
Over 2 million antibiotic resistant infections annually
Over 23,000 deaths due to antibiotic resistance annually
$20 billion in direct excess costs
Additional $35 billion to society in lost productivity
Four Core Actions to Prevent Antibiotic
Resistance
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Prevent infections, prevent the spread of resistance
Tracking
Improving antibiotic prescribing/stewardship
Developing new drugs and diagnostic tests
Antibiotic Stewardship Programs in US
DoD Initiatives and Ways Ahead
• Antibiotic stewardship programs in most hospitals
• Ensure hospitals and clinics are following guidelines:
http://www.cdc.gov/getsmart/healthcare/pdfs/checklist.pdf
• DoD Combating Antibiotic Resistant Bacteria (CARB) program*
• Multi-drug Resistant Organism Repository and Surveillance Network (MRSN)*
• Located at WRAIR
• Sequenced mcr-1 transferrable gene from colistin-resistant E. coli
• Research on sepsis in deployed service members*
• Research on drug resistant malaria*
*Levine, P. June 6, 2016 Letter
Scope of Hemodialysis Related
Infections
• Incidence of sepsis in ESRD patients is 100 times as high as general population*
• Over 50% of ESRD patients in the US initiate dialysis with central venous
catheter (CVC)*
• Delays blamed on slow referral process and slow catch up of Medicare for
ESRD patients*
• Relative risk of infection of CVC vs. AV Fistula is 2.3**
• Reducing CVC use by 50% in ESRD patients will save $1 billion in Medicare
costs***
*2013 DHHS
**2006 National Kidney Foundation
***2011 Allon, et al.
DoD/MHS Hemodialysis
• When possible, permanent access is created prior to initiation of hemodialysis
• Exceptions are primarily in emergencies
• Tricare/Tricare for Life covers all-aspects of ESRD up until the fourth month of
dialysis at which point the patient must be enrolled in Medicare
DoD/MHS Dialysis Way Ahead
• Capture/Evaluate data on CVC vs. permanent dialysis access
• Minimize use of CVC in ESRD patients
• Ensure adequate time is allowed for maturation of permanent access prior to
use
Future endeavours
(Ideas/suggestions)
• Risk management of communicable disease (MERS-CoV, Pandemic Influenza,
Tuberculosis)
• Procedure for patient screening at point of entry into MHS (Urgent care, ER)
• Procedure for isolation, quarantine
• Patient/provider education
• Process improvement measures
• Identification of patients at greater risk for readmission
Summary
• DoD is leading the way in HAI initiatives
• MTFs should ensure good adherence to recommendations and move forward
with future initiatives
References
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Centers for Disease Control and Prevention. (2013, April 23). Antibiotic Resistance Threats in the United States, 2013. Retrieved
from http://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf
Levine, Peter. (2016, June 6). “Letter to Honorable Thad Cochran, Chairman, Subcommittee on Defense Committee on
Appropriations.”
Department of Health and Human Services. (2013, April). National Action Plan to Prevent Healthcare Associated Infections: Road
Map to Elimination. Retrieved from https://health.gov/hcq/pdfs/hai-action-plan-esrd.pdf
National Kidney Foundation KDOQI guidelines. Clinical Practice Guidelines and Clinical Practice Recommendations: 2006 Updates.
New York: National Kidney Foundation; 2006. http://www2.kidney.org/professionals/KDOQI/guideline_upHD_PD_VA/
Allon, M., Dinwiddie, L., Lacson, E., Latos D.L., Lok, C.D., Steinman, T., et al. “Medicare reimbursement policies and hemodialysis
vascular access outcomes: a need for change.” Journal of the American Society of Nephrology. 2011; 22(3): 426-30.
Zimlichman, E. et al. “Health Care-Associated Infections: A Meta-analysis of Costs and Financial Impact on the US Health Care
system.” JAMA Intern Med. 2013; 173(22):2039-2046
Scott II, R. “The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention.” Division
of Healthcare Quality Promotion… Centers for Disease Control and Prevention, March 2009.
Office of Disease Prevention and Health Promotion. (2016, September 06). Healthy People 2020: Healthcare-Associated
Infections. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/healthcare-associated-infections
Obtaining CME/CE Credit
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Reserve slides
Risk Assessment
• Urgent threats:
• C. Difficile, Carbapenem-resistant Enterobaceriaceae (CRE), Drug resistant Neisseria
Gonorrhea (cephalosporin resistance)
• Serious threats
• Multi-drug resistant Acinetobacter, Drug resistant Campylobacter, Fluconazole resistant
Candida, Extended spectrum B-lactamase producing Enterobacteraceae (ESBLs),
Vancomycin-resistant Enterococcus (VRE), Multidrug resistant Pseudomonas aeruginosa,
Drug resistant Non-typhoidal Salmonella, Drug resistant Salmonella Typhi, Drug resistant
Shigella, Methicillin- resistant Staphylococcus aureus (MRSA), Drug resistant Streptococcus
pneumonia, Drug resistant tuberculosis (MDR, XDR).