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Government Response to Public Concern about Healthcare Associated Infections
During 2009 in the midst of the economy crisis and the occurrence of an H1N1 Pandemic, the federal government responded to public concern about the safety of healthcare, specifically hospitals, by passing several pieces of legislation to address patient safety. The American Recovery and Reinvestment Act of 2009 which was the $787 billion economic recovery bill that provided $1,000,000,000 for a Prevention and Wellness Fund, of which $50,000,000 is being provided to States to carry out activities to implement healthcare associated infections (HAIs) reduction strategies. The Omnibus Appropriations Act, 2009 finalized federal funding for the programs in the Labor, Health and Human Services and Education. Among the programs addressed under this bill are: the National Health Safety Network (NHSN), CDC funding to address re-use of syringes in outpatient setting, state plans for HAI reduction, additional funding for states to address public health and preventive health activities like addressing HAIs, funding to add hospitals to the Comprehensive Unit Based Program (CUSP) based on the Keystone Program and encourage the Agency for Healthcare Research and Quality (AHRQ) to expand this approach to other HAIs, funding for ARHQ to continue efforts related to MRSA, and funding for agencies to carry out the HHS HAI Action Plan. The Preservation of Antibiotics for Medical Treatment Act of 2009 was designed to strengthen epidemiology and laboratory capacity in state and local health departments and improve national surveillance and reporting of infectious diseases of public health importance.At the same time, ten (10) categories of heathcare associated conditions (HAC) were targeted for prevention by linking performance to reimbursement by CMS beginning on October 1, 2008. These conditions included: 1.Foreign Object Retained After Surgery; 2. Air Embolism; 3. Blood Incompatibility; 4. Stage III and IV Pressure Ulcers; 5. Falls and Trauma including Fractures, Dislocations, Intracranial Injuries, Crushing Injuries, Burns, and Electric Shock; 6. Manifestations of Poor Glycemic Control including Diabetic Ketoacidosis, Nonketotic Hyperosmolar Coma, Hypoglycemic Coma, Secondary Diabetes with Ketoacidosis, and Secondary Diabetes with Hyperosmolarity; 7.Catheter-Associated Urinary Tract Infection (CA-UTI); 8. Vascular CatheterAssociated Infection (Central line associated bacteremias [CVL-BSI]); 9. Surgical Site Infection Following: Coronary Artery Bypass Graft (CABG) – Mediastinitis, Bariatric Surgery, Laparoscopic Gastric Bypass, Gastroenterostomy, Laparoscopic Gastric Restrictive Surgery, Orthopedic Procedures such as spine, neck, shoulder and elbow; and 10. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) associated with total knee and hip replacements. Three of the categories are directly related to infection prevention initiatives. The performance of each facility is available to the public through the CMS website. Some of these measures have been modified, added on to or implement in different time frames over the past year. Additionally the Health and Human Services developed metrics and national 5-Year prevention targets (addressing 17 different components of healthcare associated infection prevention with specific prevention goals) to reduce the impact of HAIs on this country. Through these legislative initiatives the government believes it will be successful in forcing healthcare facilities to evaluate their practices and to implement evidence based practice strategies to prevent HAIs.
These government mandates may seem daunting at first, but there are resources that provide an outstanding platform for devising strategies for prevention and measuring success. Leading infection prevention organizations have evidence based recommendations and guidelines to facilitate implementation and suggest both process monitoring and outcome measurement. For specifics prevention strategies refer to CDC/HICPAC Guidelines; IHI Guides, including Bundles; APIC’s Guidelines, Guides and other documents; SHEA’s Guideline and Papers; Society for Cardiovascular Angiography and Interventions; American Academy of Pediatrics; Health Protection Scotland; and The Joint Commission. In addition, many states and regions have now banded together to improve patient outcomes and prevent healthcare associated infections. Collaboration through collective learning and encouragement has its place as the healthcare industry forges ahead with the goal of preventing healthcare associated infections. See websites for more information.
The Journey to Prevention
Every healthcare organization’s goal must now be to provide safe and effective patient care which minimizes the risk of HAIs. Infection prevention strategies must be applied throughout each setting and address critical processes and practices. The building blocks for an effective prevention program should, at the very minimum, include the following elements: the facility basic design and functions such as utilities, HVAC and water; infection control risk assessment and management of construction and building projects for patient safety; materials management with product evaluation to assure appropriate products are available and that the supplies are handled to maintain sterility and prevent contamination; evidence based policies and procedures based on standards and recommendations and provide up to date guidance for basic activities such as cleaning, disinfection and sterilization practices; healthcare worker safety; immunization programs especially related to influenza; isolation and management of communicable diseases; hand hygiene; and healthcare associated infection strategies. Additionally an infection prevention program must use surveillance data to validate practices and processes that are in place.
National Patient Safety Goal #7
The Joint Commission and CMS have selected several critical infection prevention components to be part of the National Patient Safety Goal # 7 (NPSG) to reduce HAIs. These known prevention strategies are now mandatory for all accredited hospitals. The NPSG # 7 addresses hand hygiene practices, prevention of multi drug resistant organisms (MDROs), prevention of central line associated bloodstream infections (CVL-BSI) and prevention of surgical site infections (SSIs).
Prevention through Hand Hygiene
Hand hygiene practices must be in compliance with recommended practices from the Centers for Disease Control and Prevention (CDC) or by the World Health Organization (WHO). Both guidelines emphasize the use of alcohol based hand rubs as well as the traditional use of soap and water to clean hands. Compliance must be monitored and education of staff and patients on the importance of hand hygiene in preventing infections is critical. The Joint Commission has published a monograph. The hand hygiene monograph, “Measuring Hand Hygiene Adherence: Overcoming the Challenges” evaluates the plethora of ways to monitor hand hygiene compliance. It is available at: (Accessed April 10, 2009) http://www.jointcommission.org/ NR/rdonlyres/68B9CB2F-789F-49DB-9E3F-
2FB387666BCC/0/hh_monograph.pdf
Prevention of MDROs
The control and prevention of MDROs begins with a risk assessment of the epidemiology and occurrence of resistant organisms in the specific practice setting and its feeder communities. In the risk assessment the following organisms should be considered: vancomycin resistant enterococci (VRE), methicillin resistant Staphylococcus aureus (MRSA), resistant gram negative bacilli such as Acinetobacter, Pseudomonas, extended spectrum beta lactamase producing organisms (ESBLs) or Klebsiella (KPC); and Clostridium difficile. The facility then needs to design a program to address prevention and control of the specific organisms. The program should address surveillance for the MDRO and procedures for active screening of patients if indicated, isolation and special precautions antimicrobial stewardship, communication of known carriers/infections, tracking and trending of by unit and service if appropriate, and policies and procedures especially related to environmental control and cleaning of high touch surfaces.
Prevention of Central Line Associated Bacteremias Proven strategies for prevention central line associate are published both by CDC and IHI and are incorporated into the elements for the NPSG.07.04. These elements include: cleaning hands through either waterless alcohol based hand sanitizer or wash hands with soap and water prior to starting procedure or handling central line; selection of the best insertion site with the subclavian site having the lowest risk and should be first choice if clinically possible; using a CHG product for skin preparation (chlorhexidine/alcohol combo rather than betadine); using and maintaining maximal barrier precautions for insertion; and removing catheter as soon as possible. Additional strategies to reduce the risk of Central Line Infections and included in the NPSG elements of performance are: assuring competency of staff placing line through education and observation; monitoring insertion by using a checklist to document observations with the monitor being able to stop procedure if breach occurs; securing the lines to prevent in and out movement; using a CHG impregnated patch over the catheter site; following appropriate maintenance on dressing and site care; using an antimicrobial impregnated catheter such as the antibiotic impregnated cathetersminocycline+rifampin; educating everyone who cares for patients who have central lines about risk reduction practices and proper procedures; educating the patient and family about central lines and the risks associated with them; securing the line; and having trained infection control professionals perform surveillance for CVLBSI, calculating rates per 1000 central line days and providing that data to the patient units.
Preventing Surgical Site Infections
This goal also addressed the prevention of surgical site infections through the use of evidence based practice identified by the CDC, Centers for Medicare and Medicaid (CMS) Surgical Care Improvement Project (SCIP) and professional societies such as the Associate for Professionals in Infection Control and Epidemiology (APIC), the Society of Healthcare Epidemiologists of America (SHEA) and the Infectious Disease Society of America (IDSA) to name a few.
National statistics show that 2.6% of the 30 million operations performed each year are complicated by surgical site infections (SSIs). These infections are the second most common healthcare associated infection and account for 17% of all hospital acquired infections with approximately 500,000 SSIs occur each year. SSIs lead to increased length of stay (up to 10 days or more), increased hospital costs, increased readmission rates and increased pain, suffering, alteration of function and sometimes death (2-11 times higher risk of death compared to patients who do not have an SSI). Attributable costs related to an SSI vary depending on procedure and organisms but range from $3000 to $29,000. SSIs are believed to account for up to $10 billion annually in healthcare expenditures.
Consequently, the Joint Commission in cooperation with CMS initiated NPSG.07.05 which requires the implementation of best practices for the prevention of surgical site infections. This goal emphasizes the Surgical Care Infection Project prevention strategies. These measures are based on the 1999 CDC Surgical Site Prevention Guideline as well as other published evidence based practice. WHO also recommends the use of checklists to improve compliance with recommended surgical practices and patient safety. Individual facilities may also want to develop checklists for surgical practices to facilitate consistent practice in the surgical setting. Another key factor in patient safety is the empowerment of all healthcare providers to speak up and intervene if a breach in safe practice is identified.
The first SCIP measures address pre-operative antimicrobial prophylaxis. The SCIP data indicates that 30% of SSI are preventable with appropriate use of preoperative antibiotics. Pre-Operative Antimicrobial Prophylaxis (antibiotics) must be given prior to incision within 1 hour of surgery. (SCIP Measure #1) The appropriate Antibiotic Selection is SCIP #2. Cefazolin is often the recommended antibiotic of choice. It is important to identify specific procedures recommended antibiotics as listed by CMS for the right drug choice. There is a timing exception for antibiotics that cannot be pushed and must be infused over a longer time. For example, vancomycin must be started 60-90 minutes prior to surgery for safe infusion practices. Because of concern for over utilization of vancomycin, per CMS the rationale for using vancomycin must document in chart by the licensed provider. Re-dosing based on blood loss or length of surgery is appropriate. Finally, pre-operative prophylactic antibiotics must be stopped within 24hours after surgery for all specialties except cardiac patients who must have antibiotics stopped by 48 hours post op (SCIP #3).
SCIP measures also address the administration of other drugs. In SCIP-Card-2, patients who are on beta blockers prior to admission must also receive these medications peri-operatively. SCIP-Inf-4 relates to maintaining glycemic control in cardiac surgery patients as measured by the post-operative glucose.
SCIP #6 addresses appropriate hair removal and prohibits the use of razors to shave a patient to remove hair at the operative site prior to a procedure. Shaving has been shown to increase skin flora colonization. Hair does not increase the risk of infection. If it is to be removed to facilitate the procedure, hair at the surgical site should be removed by using clippers immediately before setting up the sterile fields in the operating room.
Initially, SCIP-Inf-7addressed normothermia only colorectal surgery patients and immediate postoperative normothermia being the goal. As of October 2009, SCIP # 10 expanded this measure to include maintaining normothermia (per SCIP measures) for surgical patients with the goal of not allowing the temperature to go lower than 36° C.
SCIP-VTE-1 states that patients should receive the recommended VTE Prophylaxis.
It is well known that the best way to prevent urinary catheter associated urinary tract infections (CA-UTIs) is to catheterize only for clinical necessity and to remove the catheter as soon as possible. Therefore, a new measure started in October 2009 requires the removal of the foley catheter by 2 days post op or documentation of the rationale for prolonged catheterization in clinical note for on-going clinical necessity (SCIP Measure #9). Additionally, CA-UTIs are one of the never events listed in the healthcare associated conditions (HAC) that CMS is targeting for non-payment of the co-morbidity related to the patient’s care.
Several other pre-operative strategies have been shown to reduce the risk of infection. It is important to treat any existing infections at a remote site prior to surgery if clinically possible. Additionally, some now believe that in high risk procedures where the incidence of MRSA in the population is high, it may be useful to screen the patient for MRSA carriage. (Refer to the facilities risk assessment for management of MDROs to assist in evaluating the need for this process.) If a patient is determined to be positive, the surgeon may want to prescribe a decolonization protocol using Murpirocin in the nares twice a day for 5 days along with daily shower with chlorhexidene gluconate antimicrobial soap (CHG) during that time. Pre-operative showering the night before and the morning of with chlorhexidene gluconate antimicrobial soap has also been shown to reduce the risk of infection with skin flora like staphylococci.
Full compliance with these measures will help to prevent surgical site infections as well as respond to CMS rules and the components of the NPSG 07.05. CMS publishes compliance rates for SCIP measures on their website. Other components of this goal include providing surgical site infection surveillance done by trained infection control practitioners according to NHSN definitions and CDC recommendations with feedback to the surgical team.
Patient and staff education about the essential steps in surgical site prevention is also required by this NPSG. Patient handouts may be developed by a facility or there are handouts available for use via www.shea-online.org based on the compendium for preventing surgical site infections. See figure.
Other web pages also have materials to assist in patient and family education. Some examples are Journal of the American Medical Association; available at: http://jama.ama-assn.org/cgi/ reprint/294/16/2122
Surgical Care Improvement Project consumer info sheet. Available at http://www.ofmq.com/ Websites/ofmq/Images/ FINALconsumer_tips2.pdf
What you need to know about infections after surgery: a fact sheet for patients and their family members. Available at: http://www.ihi.org/NR/ rdonlyres/0EE409F4-2F6A-4B55-AB0116B6D6935EC5/0/
SurgicalSiteInfectionsPtsandFam.pdf
Building a Culture of Patient Safety
The Joint Commission by delineating specific elements for each prevention goal has led the healthcare provider to evidence based strategies that have been proven to work. However, the science of human factor engineering and group dynamics clearly recognizes that the translation of these practices from a written strategic plan to effective, consistent implementation is a complex and multifaceted expedition. The challenge that faces each organization is turning these strategies into collaborative action to make the system work and to build an on-going culture of prevention and patient safety. Successful implementation requires knowledge of the organizations culture, team dynamics and system development. The Recovery Act funded a program through AHRQ that teaches how to do that. The CUSP initiative based on the Keystone Program teaches this process and safety culture strategies which led to a reduction in central line associated infections in Michigan. The CUSP initiative has been expanded to 14 states. The Florida Hospital Association (FHA) and many Florida hospitals are participating in this national CUSP initiative with the goal of building a culture of safety that leads to prevention central line associated blood stream infections.
We enter an exciting and challenging era. It is time for all healthcare providers to clean their hands, roll up the sleeves and work together in partnership with our patients to bring about improvement in patient safety. It can be done in an environment built of collaboration with a culture of patient and healthcare worker safety. Stay tuned as we enter this new decade to see improvement in patient safety resulting from implementation of evidence based practices throughout all of healthcare resulting in prevention of HAIs at levels previously thought to be impossible. The best is yet to come!
Key References for Infection Prevention
SHEA IDSA Compendium: Yokoe DS; Mermel LA; Anderson DA; et. al. A Compendium of Strategies to Prevent HealthcareAssociated Infections in Acute Care Hospitals. Infect Control Hosp Epidemiol 2008; 29:S1-S92. http://www.shea-online.org/ about/compendium.cfm
The Joint Commission web site: www.jc.org and National Patient Safety Goals http://www.jointcommission.org/ PatientSafety/NationalPatientSafetyGoals/
The hand hygiene monograph Measuring Hand Hygiene Adherence: Overcoming the Challenges http:// www.jointcommission.org/NR/rdonlyres/68B9CB2F-789F-49DB
-9E3F-2FB387666BCC/0/hh_monograph.pdf
Institute for Healthcare Improvement website for infection prevention bundles www.IHI.orghttp:// www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ ImplementtheVentilatorBundle.htm and http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ Changes/ImplementtheCentralLineBundle.htm and http://www.ihi.org/IHI/Programs/AudioAndWebPrograms/ ExpeditionReducingCatheterAssociatedUrinaryTractInfections.htm
See Pediatric MRSA Supplement:
Please visit: http://www.nichq.org/NICHQ/Topics/ PurgingHarm/
Institute for Healthcare Improvement Hand Hygiene How-To website: http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Tools/HowtoGuideImprovingHandHygiene.htm
Centers for Disease Control and Prevention (CDC) www.cdc.gov
CDC, HICPAC. Guidelines for preventing health-care-associated pneumonia, 2003. MMWR 2004;53 (No.3). http:// www.cdc.gov/ncidod/dhqp/pdf/guidelines/ CDCpneumo_guidelines.pdf
CDC/HICPAC. Guidelines for Prevention of Intravascular Catheter-Related Infections. MMWR 2002(51RR):1-26 and Erratum http://www.cdc.gov/mmwr/preview/mmwrhtml/ mm5132a9.htm
Centers for Disease Control and Prevention; HICPAC. Guidelines for infection control in health care personnel, 1998. Am J Infect Control 1998;26: 289–354. http://www.cdc.gov/ncidod/dhqp/ gl_hcpersonnel.html
Siegel JD, Emily Rhinehart E, Jackson M, Chiarello L, The Healthcare Infection Control Practices Advisory Committee. “Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings”. June 2007. http:// www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf
Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002; 51(No. RR-16). http://www.cdc.gov/ncidod/dhqp/gl_handhygiene.html
Siegel JD, Emily Rhinehart E, Jackson M, Chiarello L. The Healthcare Infection Control Practices Advisory Committee. Management of Multidrug-Resistant Organisms In Healthcare Settings, 2006. http://www.cdc.gov/ncidod/dhqp/pdf/ar/ MDROGuideline2006.pdf
Sehulster L, Chinn RYW, and HICPAC. Guidelines for Environmental Infection Control in Health-Care Facilities. 2003. http:// cdc.gov/ncidod/dhqp/pdf/guidelines/Enviro_guide_03.pdf Rutala WA, Weber DJ and the Healthcare Infection Control
Practices Advisory Committee. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. http:// www.cdc.gov/ncidod/dhqp/pdf/guidelines/ Disinfection_Nov_2008.pdf
Mangram A, Horan T, Pearson M, Silver LC, Jarvis WR, Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection, 1999. Am J Infect Control 27(2): 97–132, 1999. http://www.cdc.gov/ncidod/dhqp/ gl_surgicalsite.html
Centers for Disease Control and Prevention. Prevention & Control of Influenza Recommendations of the Advisory Committee on Immunization Practices (ACIP) 2008. MMWR. 2008 Aug 8; 57(RR07);1-60.93.
CDC. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline For Prevention Of CatheterAssociated Urinary Tract Infections 2009. http:// www.cdc.gov/hicpac/cauti/001_cauti.html
U.S. Department of Health & Human Services (HHS) Action Plan to Prevent Healthcare-Associated Infections. http:// www.hhs.gov/ophs/initiatives/hai/infection.html
APIC www.apic.org
See site for specific prevention guides on MRSA, C. difficile, etc. and to obtain access to the APIC Text, 2009.
Greene LR, Cain TA, Dolan SA, Oriola S, Grant P, Cox T, Krystofiak SP, Lundstrom TS, and Myers FE. APIC Position Paper: Influenza Immunization of Healthcare Personnel. October 2008. http://www.apic.org/AM/Template.cfm?
Section=Search§ion=Position_Statements1&template=/CM/ ContentDisplay.cfm&ContentFileID=11049 http://www.apic.org/Content/NavigationMenu/ GovernmentAdvocacy/IssuesInitiatives/Influenza/ HealthcareWorkerImmunization/healthcareimmunize.htm Bartley JM, The 1997, 1998, &1999 APIC Guidelines Committees. APIC State-of-the-Art Report: The role of infection control during construction in health care facilities. Am J Infect Control 2000; 28:156-69. http://www.apic.org/AM/ Template.cfm?Section=Practice&Template=/CM/
HTMLDisplay.cfm&ContentID=11431&MicrositeID=0&WebsiteKey=289 80e36-1554-46a7-8e91-d7f06abd0a11
Nelson DB, Jarvis WR, Rutala WA, Foxx-Orenstein AE, Isenberg
G, Dash GP, Alvarado CJ, Ball M, Griffin-Sobel J, Petersen C, Ball KA, Henderson J, Stricof RL. Multi-society Guideline for Reprocessing Flexible Gastrointestinal Endoscopes. Infection Control And Hospital Epidemiology 2003;(Vol. 24 No. 7):532-537. http://www.apic.org/AM/Template.cfm?
Section=Guidelines_and_Standards&template=/CM/ ContentDisplay.cfm§ion=Topics1&ContentID=6381
CMS
Infection prevention and control in pediatric ambulatory settings. [Pediatrics. 2007] 1) Surgical Care Improvement Project. Literature Review, January 2005 Update. http:// www.medqic.org/scip
American College of Surgeons. (2005, September 9). Pay for performance: Developing a quality improvement framework for surgical care. http://www.facs.org/ahp/views/ payforperformance.html
Kevin C. Brennan KC and Spitx G. SCIP Compliance and the Role of Concurrent Documentation. Patient Safety and Quality Healthcare. January/February 2008. http://www.psqh.com/ janfeb08/scip.html
Health Protection Scotland Bundle site http:// www.hps.scot.nhs.uk/haiic/ic/guidelines.aspx#bundles
World Health Organization
WHO “Clean Care is Safer Care” Campaign http:// www.who.int/gpsc/en/
Five Moments for Hand Hygiene Poster. http://www.who.int/ gpsc/tools/Five_moments/en/index.html
WHO Safe Surgery Checklist. http://www.who.int/ patientsafety/safesurgery/ss_checklist/en/index.html Safe Surgery WHO site for video teaching safe OR practices http://www.who.int/patientsafety/safesurgery/en/ index.html
Other References
Altemeir WA, Burke JF, Pruitt, BA, Sandusky WR & the American College of Surgeons, Committee on Control of Surgical Infections of the Committee on Pre-and Postoperative Care.
Manual on Control of Infection in Surgical Patients. Second Edition. JB Lippincott Company. Philadelphia. 1984.
Janelle J, Howard, RJ, and Fry D. Chapter 23 Surgical Site Infections. APIC Text of Infection Control and Epidemiology, 2nd Edition, 2005.
Bratzler DW. Surgical Infection Prevention and Surgical Care Improvement: National Initiatives to Improve Care for Medicare Patients. http://www.medqic.org/dcs/
AHRQ. Saint S. Evidence-Based Medicine Report. Chapter 15. Prevention of Nosocomial Urinary Tract Infections. http:// www.ahrq.gov/clinic/patsafety/chapt15a.htm & http:// www.ahrq.gov/clinic/patsafety/chapt15b.htm 
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