Challenges for Infection Prevention in the 21

st

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 Acute Care Facility Outpatient/ Ambulatory Facility Tranquil Gardens Nursing Home Long Term Care Facility

CURRENT HEALTHCARE SYSTEM

Home Care Acute Care Facility Tranquil Gardens Nursing Home Long Term Care Facility Outpatient/ Ambulatory 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 6 th 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% 0.7% Pneumonia Bloodstream Infections Urinary Tract Infections Surgical Site Infections No Infections

INCREMENTAL HOSPITAL DAYS DUE TO COMMON INFECTIONS

Days, 14 Days, 13 Days, 7 Days, 4 Pneumonia Bloodstream Infections Urinary Tract Infections Surgical Site Infectins

14 12 10 8 2 0 6 4

RATES OF HEALTHCARE-ASSOCIATED INFECTIONS PER 1,000 PATIENT DAYS

7.2

9.8

12.2

69% Increase

1975 1985 2005

COST ESTIMATES FOR HEALTHCARE ASSOCIATED INFECTIONS (HAIs)

HAI Ventilator-associated pneumonia Cost per HAI + SE 25,072 + 4,132 Range 8,682-31,316 Healthcare-associated bloodstream infections Surgical site infections 23,242 + 5,184 10,443 + 3,249 6,908-37,260 2,527-29,367 Catheter-associated urinary tract infections 758 + 41 728-810 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

PA Catherization CVP Line Stress Ulcer Prophylaxis Urinary Catherization Mechanical Ventilation Trauma on Admission 0 0.5

1 Odds Ratio 1.5

2 2.5

(95% CI) (1.01-1.43) (1.16-1.57) (1.20-1.60) (1.19-1.69) (1.51-2.03) (1.75-2.44)

7-13 14-20 >21 1-2 3-4 5-6

RISK FACTORS FOR ICU-ACQUIRED INFECTIONS

0 10 20 30 40 Odds Ratio 50 60 70 80

(95% CI) (1.56-4.13) (5.51-14.70) (9.33-24.14) (19.43-48.67) (37.90-96.25) (48.18-120.06)

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 Deaths

30,990 7,430 263,060 186,370 136,180 167,050 68,780 214,640 321,490 102,490 10,710 41,430 56,060 26,670 35,070 66,670 1,399,790 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

S. aureus

[1940s] Penicillin-resistant

S. aureus

Vancomycin resistant

S. aureus

[2002]

[1960s] [1997] Methicillin-resistant

S. aureus (

MRSA) Vancomycin Ciprofloxacin 1987 Vancomycin (glycopeptide) intermediate-resistant

S. aureus

Vancomycin-resistant enterococcus (VRE) CA-MRSA

UNITED STATES

      Enterobacter / Ceftazidime E. coli / ESBL phenotype E. coli / Ciprofloxacin 21→19% 3→5% 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 P. aeruginosa / Piperacillin-tazobactam P. aeruginosa / Ciprofloxacin Acinetobacter / Amikacin Acinetobacter / Ceftazidime Acinetobacter / Imipenem 9→8% 11→12% 17→19% 11→16% 23→ 45% 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

Total SARS Cases and % Healthcare Workers by Country

6000 100 5000 80 4000

% HCW

60 3000 40 2000 20 1000 0

China Hong Kong Taiwan Canada Singapore Vietnam

0

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 Setting Adult 1CU Adult 1CU Adult 1CU Results Reduction HAI due to Klebsiella Reduction HAI rates Reduction HAI rates Kohen, 1990 Adult 1CU Doebbeling, 1992 Adult 1CU Webster, 1994 Zafar, 1995 Larson, 2000 Pittet, 2000 NICU Newborn Trend to improvement Different rates of HAI between 2 agents Elimination of MRSA* Elimination of MRSA* MICU/NICU 85% reduction VRE Hospitalwide Reduction HAI & MRSA cross-transmission HAI, healthcare-associated infections *Other infection control measures also instituted Boyce JM, Pitter D. MMWR 2002;51(RR-16)

How Is Our Track Record on Handwashing in Healthcare Facilities?



A review of 34 published studies of handwashing adherence among healthcare workers found that adherence rates varied from 5% to 81% 90 80 70 60 50 40 30 20 10 0 Average Handwashing Adherence of Personnel in 34 Studies Average 1 4 7 10 13 16 19 Study 22 25 28 31 34



The average adherence rate was only 40%

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 90 80 70 60 50 40 30 20 10 0

Leadership presentations Collected baseline data



Began quarterly compliance reports to ICUs Ongoing education Evaluated hand hygiene products

 

Staff HH compliance added to patient satisfaction survey Pocket-sized alcohol based gel available



Implemented Infection Control Liaisons

4Q 03 1Q 04 2Q 04 3Q 04 4Q 04 1Q 05 2Q 05 3Q 05 4Q 05 1Q 06 2Q 06 3Q 06 4t hQ 06 1Q 07 2Q 07 3Q 07 4Q 07

GI ENDOSCOPES

     Widely used diagnostic and therapeutic procedure Endoscope contamination during use (10 9 in/10 5 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 1993 2002), 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 12 20 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 Weight-Adjusted Cost per HAI Mean + SE VAP BSI 25,072 + 4,132 23,242 + 5,184 SSI CA-UTI 10,443 + 3,249 758 + 41 Range of Published Estimates of Cost per HAI 8,682-31,316 6,908-37,260 2,527-29,367 728-810 2005 US dollars Anderson DJ, et al. ICHE 2007;28:767-773

Clinical and Economic Impact

Procedure/Device CARDIO

Heart valves Vascular grafts Pacemaker/ICD LV assist dev.

NEURO

CNS shunt

Devices/yr* Infections/yr Avg. cost Mortality*

85,000 450,000 300,000 700 3,400 16,000 12,000 280 $50,000 $40,000 $35,000 $50,000 High Moderate Moderate High 40,000 2400 $50,000 Moderate 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 ORTHOPEDIC

Joint prosthesis Fracture fixator

PLASTIC

Breast implant

UROLOGICAL

Penile implant

Devices/yr* Infections/yr Avg. cost Mortality*

600,000 2,000,000 130,000 15,000 12,000 100,000 2600 450 $30,000 $15,000 $20,000 $35,000 Low Low Low Low 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 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 Exclude I/C surgical team Give prophylactic antibiotics wounds Closed suction drains (when Pos pressure ventilation in OR used) Sterile dressing x 24-48 hr SSI surveillance with feedback to surgeons

 Surgery (N)  Cardiac (7,861)  Vascular (3,207)  Hip/knee (15,030)  Colon (5,279)  Hysterectomy (2,756)  All Surgeries (34,133)

Surgical Infection Prevention Arch Surg 2005;140:174

 Antibiotic within 1 hour  %  45.3

 40.0

 52.0

 40.6

 52.4

 47.6

 Correct Antibiotic  %  95.8

 91.9

 97.4

 75.9

 90.8

 92.9

 Antibiotic stopped within 24 hours  %  34.3

 44.8

 36.3

 41.0

 79.1

 40.7

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%

UNC Health Care ICUs Central Catheter Associated Bloodstream Infections

14 12 10 8 6 4 Medical Staff education 8.4



9.4

Dressing kit with Chloraprep



9.5

6.6

Nursing education 6.4

5.9

5.8

6.6

7.5



Custom insertion kits with antiseptic catheters



IHI



4.7

4.4

4.1

4.7

4.2

3.5

3.4

3 2 0 Ja n Ju n 99 Ju l-D ec 9 Ja 9 n Ju n 00 Ju l-D ec 0 Ja 0 n Ju n 01 Ju l-D ec 0 Ja 1 n Ju n 02 Ju l-D ec 0 Ja 2 n Ju n 03 Ju l-D ec 0 Ja 3 n Ju n 04 Ju l-D ec 0 Ja 4 n Ju n 05 Ju l-D ec Ja 0 n 5 Ju ne 0 Ju 6 l-D ec Ja 0 n 6 Ju ne 0 Ju 7 l-D ec 0 7 Hospital Epidemiology Confidential Information for CQI

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  Legislature (with input from advocacy groups)   Executive branch Independent commission (NC) What’s reported  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

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

20 04 Q 1 20 04 Q 2 20 04 Q 3 20 04 Q 4 20 05 Q 1 20 05 Q 2 20 05 Q 3 20 05 Q 4 20 06 Q 1 20 06 Q 2 20 06 Q 3 20 06 Q 4 20 07 Q 1 20 07 Q 2 20 07 Q 3 20 07 Q 4

MICU Ventilator Associated Pneumonia Rates

7.0

6.0

5.0

4.0

3.0

2.0

1.0

0.0

-1.0

20 04 Q 20 1 04 Q 20 2 04 Q 20 3 04 Q 4 20 05 Q 20 1 05 Q 20 2 05 Q 20 3 05 Q 4 20 06 Q 20 1 06 Q 20 2 06 Q 20 3 06 Q 20 4 07 Q 1 20 07 Q 20 2 07 Q 20 3 07 Q 20 4 08 Q 1

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

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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 non reimbursement for HAIs; National Patient Safety Goals (TJC); insurance reimbursement tied to quality goals

CONCLUSIONS

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Current challenges

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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

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Future

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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