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Trends and Strategies for Prevention of Healthcare-Associated Infections

Trends and Strategies for Prevention of Healthcare-Associated Infections. Alice Guh, MD, MPH Division of Healthcare Quality Promotion Centers for Disease Control and Prevention. Healthcare-Associated Infections (HAIs).

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Trends and Strategies for Prevention of Healthcare-Associated Infections

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  1. Trends and Strategies for Prevention of Healthcare-Associated Infections Alice Guh, MD, MPH Division of Healthcare Quality Promotion Centers for Disease Control and Prevention

  2. Healthcare-Associated Infections (HAIs) • Definition: Infections that patients acquire during the course of receiving treatment for other conditions within a healthcare setting • Healthcare settings: • Hospitals: acute care facilities, critical access hospitals • Long term care facilities (LTCF) • Outpatient settings: dialysis centers, ambulatory surgical centers, physician’s offices

  3. Your baby was born prematurely. She was progressing in the neonatal intensive care unit until she developed a bloodstream infection related to her umbilical catheter.

  4. Your father has open heart surgery. The surgery goes well but he later dies in a nursing home of a MRSA wound infection that developed after surgery.

  5. Your sister contracts Clostridium difficile after giving birth. She has lived with this unbearable infection through 6 months of relapses.

  6. Your mother is being treated for cancer • And now has to fight two diseases because she got Hepatitis C from an unsafe injection

  7. HAI BurdenWhat is Known: Acute Care Settings • 1.7 million infections (5% of all admissions) • Most (1.3 million) were outside of ICUs • $28–33 billion in excess costs • 99,000 associated deaths • Most common type of infections: • Bloodstream infections (BSI) • Urinary tract infections • Pneumonia • Surgical site infections Klevens, et al. Pub Health Rep 2007;122:160-6

  8. Roberts RR, et al Clin Infect Dis 2003;36:1424-32.

  9. Social Costs of HAIs

  10. Emerging Threats in Healthcare

  11. Clostridium difficile: “Deadly Superbug”

  12. National Estimates of U.S. Short-Stay Hospital Discharges with C. difficile McDonald LC, et al. Emerg Infect Dis. 2006;12(3):409-15

  13. Tranquil Gardens Nursing Home The Healthcare System  More than Just Hospitals Acute Care Facility Home Care Outpatient/ Ambulatory Facility Long Term Care Facility

  14. HAI Burden Outside of Acute Care • We know much less about this • What we have learned to date: HAIs are a substantial problem outside of acute care settings

  15. HAIs in LTCF • 1.7 million beds with 2.5 million residents / yr1 • 1/3 of long-term care residents affected by respiratory disease outbreaks2 • Veterans Healthcare data3 • 133 nursing homes; 11,475 residents • HAI prevalence: 5.2% • Indwelling medical device: 25% of all residents 1NCHS, 2009 2Loeb, CMAJ, 2006 3Tsan, AJIC, 2008

  16. Growth in Outpatient Care • Shift in healthcare delivery from acute care settings to ambulatory care, long term care and free standing specialty care sites • Dialysis Centers • 2008: 4,950 (72% increase since 1996) • Ambulatory Surgical Centers • 2009: 5175 (240% increase since 1996) • Approximately 1.2 billion outpatient visits / yr

  17. Surgical Procedures Moving from Inpatient to Outpatient Setting All Outpatient Settings Procedures (millions) Hospital Inpatient Source: Avalere Health analysis of Verispan’s Diagnostic Imaging Center Profiling Solution, 2004, and American Hospital Association Annual Survey data for community hospitals, 1981-2004. *2005 values are estimates.

  18. Hospital (27) OutpatientSetting (12) LTCF (3) Community(5) Healthcare-associated Outbreak Investigations by Healthcare Setting, 2004-2008 • Increasing number of outbreaks associated with outpatient care • Wide range of settings (e.g., ambulatory surgery, cancer clinics, pain medicine, dialysis, long-term care, physician offices) • Unsafe injections, foundation of basic safe care practices lacking n = 47, as of April 2008

  19. SOURCE Infectious person, e.g. chronic, acute CASESusceptible, non-immune person TRANSMISSION OF BLOODBORNE PATHOGENS VIA CONTAMINATED EQUIPMENT OR MEDICATIONS CONTAMINATED EQUIPMENT OR MEDICATION OR HANDS

  20. 33 outbreaks in 15 states • Outpatient clinics, n=12 • Dialysis centers, n=6 • Long term care, n=15 Thompson et al. Ann Intern Med. 2009;150:33-39.

  21. Viral Hepatitis Outbreaks - Outpatient Settings Thompson et al. Ann Intern Med. 2009;150:33-39.

  22. Ongoing Threat to Patient Safety • Continued outbreaks associated with unsafe injections and other breakdowns in basic infection control • Large public health patient notifications advising testing for hepatitis B virus, hepatitis C virus, and HIV

  23. Infection Control in Outpatient Settings • Sub-optimal infection control infrastructure and oversight • Approximately 50% of ambulatory surgical centers (ASC) surveyed by CMS and CDC had serious, noncompliance with the Medicare ASC health and safety standards • 28% had unsafe injection practices

  24. A Collaborative Approach to Preventing HAIs

  25. State of Prevention Knowledge and Science • Evidence-based prevention recommendations • Major device and procedure associated HAIs (CLABSI, VAP, CAUTI, SSI) • Prevention of pathogen transmission (MRSA, C. difficile) • Suboptimal adherence to key prevention recommendations

  26. Current State of Affairs • Hand hygiene compliance for healthcare worker: 40-50% • Compliance with timing of surgical prophylaxis was ~40%1 • Many facilities have yet to implement proven prevention measures: • Bloodstream infections • Urinary tract infections 2005 Data from Surgical Care Improvement Project

  27. What’s Been Missing in the Past to Promote HAI Prevention? • Robust data on HAI Prevention • Focused attention of policymakers on HAI prevention • Incentives / disincentives to promote systems change for sustainable HAI prevention • Framework to extend local / regional successes across the nation

  28. What’s Been Missing in the Past to Promote HAI Prevention? • Robust data on HAI Prevention • Focused attention of policymakers on HAI prevention • Incentives / disincentives to promote systems change for sustainable HAI prevention • Framework to extend local / regional successes across the nation

  29. Preventability of Infections • Study on the Efficacy of Nosocomial Infection Control (SENIC) • 6% of all HAIs preventable with minimal infection control efforts • 32% preventable with “well organized and highly effective infection control programs” • 20-70% of infections are preventable1 1J Hosp Infection 2003;54:258

  30. Estimates of Preventable Infections, Deaths, and Costs

  31. Trends in MRSA Bloodstream Infections by ICU Type, NHSN hospitals, 1997-2007 • Estimated 7000 BSIs prevented • 1800 lives saved • $50-180 M in costs averted annually

  32. Significant reductions: • Surgical site infections • Unplanned return to OR • All complications • Deaths Haynes AB, et al. NEJM 2009;360:491-9.

  33. What’s Been Missing in the Past to Promote HAI Prevention? • Robust data on HAI Prevention • Focused attention of policymakers on HAI prevention • Incentives / disincentives to promote systems change for sustainable HAI prevention • Framework to extend local / regional successes across the nation

  34. State Legislative Activity for HAIs (as of October 6, 2009) WA Jul-2008 VT ME Feb - 2007 MT ND OR MN Jan - 2009 NY NHJan-2009 ID SD WI MA Jul-2008 Jan-2007 WY MI RI PA CT Jan-2008 IA Feb - 2008 NE NJJan-2009 NV May- 2009 OH IN IL UT DEFeb-2008 WV Sept - 2008 CO CA MD Jul-2008 VA Jul - Jan-2008 Jan-2008 2009 KS MO Jul-2008 KY NC TN OK Jan - 2008 AZ SC AR NM Jul-2008 Jul - 2007 GA AL MS TX August- 2009 LA FL AK HI Stateswith no legislation Mandates public reporting using NHSN States with study laws Mandates public reporting of infection rates Mandatory data collection, Voluntary reporting Mandates reporting only to state government

  35. HHS Steering Committee: HAI Prevention • Charge: Develop an Action Plan to reduce, prevent, and ultimately eliminate HAIs • Plan will: • Establish national goals for reducing HAIs • Include short- and long-term benchmarks • Outline opportunities for collaboration with external stakeholders • Coordinate and leverage HHS resources to accelerate and maximize impact

  36. HAI Priority Areas Catheter-associated urinary tract infection Central line-associated blood stream infection Surgical site infection Ventilator-associated pneumonia MRSA Clostridium difficile Implementation Focus Hospitals* HHS Action Plan: Tier One Priorities *Tier Two will address other types of healthcare facilities

  37. What’s Been Missing in the Past to Promote HAI Prevention? • Robust data on HAI Prevention • Focused attention of policymakers on HAI prevention • Incentives / disincentives to promote systems change for sustainable HAI prevention • Framework to extend local / regional successes across the nation

  38. Centers for Medicare and Medicaid Services • October 2008 • Non-payment rules for “Never events” • Preventable conditions acquired during patient’s hospital stay • Includes HAIs

  39. Federal Funding for HAI Prevention • American Recovery and Reinvestment Act of 2009 (ARRA) • Allocated funding to states for HAI prevention • FY 2009 Omnibus Bill • States to develop HAI prevention plans to be consistent with HHS Action Plan

  40. What’s Been Missing in the Past to Promote HAI Prevention? • Robust data on HAI Prevention • Focused attention of policymakers on HAI prevention • Incentives / disincentives to promote systems change for sustainable HAI prevention • Framework to extend local / regional successes across the nation

  41. Tranquil Gardens Nursing Home Increasing Needs and Opportunities for Public Health Approach Across the Continuum of Care Acute Care Facility State Health Departments Home Care Outpatient/ Ambulatory Facility Long Term Care Facility

  42. A New Paradigm: Central Role of State Health Departments • Expanding state public health workforce to make progress toward HAI prevention • Create and expand state-based HAI prevention collaboratives • Sustainable statewide efforts will contribute to national healthcare improvement efforts

  43. A New Model For Prevention:Prevention Collaboratives • Experience is showing that multi-facility collaborative projects are the gold standard in HAI prevention • Many “change methods” that have demonstrated success: • Comprehensive Unit-based Patient Safety Program (CUSP) • Positive deviance • Six-sigma

  44. Basics of a Prevention Collaborative • Group of healthcare facilities engaged in a common effort to reduce HAIs • Members use a common approach • Discuss progress regularly and share lessons learned in real time

  45. What is the Minimum Size of a Prevention Collaborative? • 2 or more facilities working together meaningfully • Ideal size  multi-factorial • Specific subject or targeted HAI • Type of healthcare facilities • Available resources • More “cutting edge” ─ smaller number • More established “change packages” can be quite large • Level of enthusiasm

  46. Prevention Strategies Supplemental Strategies Some scientific evidence Variable levels of feasibility • Core Strategies • High levels of scientific evidence • Demonstrated feasibility

  47. Regional Prevention CollaborativesExamples of Success Pittsburgh Regional Healthcare Initiative Michigan Keystone Initiative ICUs at 103 Michigan hospitals, 18 months BSIs/1,000 catheter days Overall rate reduction of 66% Overall rate reduction of 68% Months Pronovost P. New Engl J Med 2006;355:2725-32. Muto C, et al. MMWR 2005;54:1013-16

  48. Lessons Learned from Pittsburgh and Michigan Experience • Decreases in BSI rates in hospital ICUs of varying types • Prevention practices utilized during these interventions were not novel • Practical strategies identified that can be successful across many facilities

  49. If Expanded Nationally…. • 66% reduction of BSIs would translate into: • 180,000 fewer BSIs • 20,000 fewer BSI-associated deaths • $4–6 billion in healthcare cost savings

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