Healthcare-associated Infections –
Moving from Headlines to Solutions
Dale W. Bratzler, DO, MPH
Professor and Associate Dean
University of Oklahoma Health Sciences Center
College of Public Health, Oklahoma City, OK
Texas Partnership for Patients
May 1, 2013
How big is the problem?
• HAIs - Infections that patients acquire while receiving
treatment for medical or surgical conditions.
– Significant toll on human life
• 1.7 million infections
• 99,000 deaths annually
– Estimated that HAIs incur an estimated $28 to $33 billion
in excess healthcare costs each year
Four categories of infections account for
approximately three quarters of HAIs in the acute
care hospital setting. These four categories are: 1)
Surgical site infections; 2) Central line-associated
bloodstream infections; 3) Ventilator-associated
pneumonia, and; 4) Catheter-associated urinary tract
infections.
http://www.hhs.gov/ash/initiatives/hai/infection.html
Healthcare-associated Infections
• While can occur in any care setting, are
particularly related to:
– Use of medical devices
– Complications of surgical procedures
– Transmission between patients and healthcare
workers
– Antibiotic overuse
But, don’t forget…..
• The incidence of C. difficile infections in the in- and out-patient setting is
increasing
• While CLABSI infections are reported far less commonly in the ICU setting, they
remain a serious problem in other settings (PICC lines, dialysis units, non-ICU)
• Growing incidence of multi-drug resistant organisms
• Vancomycin Resistant Enterococci (VRE)
• Methicillin Resistant Staphylococcus aureus (MRSA)
• Extended spectrum ß-lactamse (ESBLs) producing Gram-negative bacteria
• Klebsiella pneumonia carbapenemase (KPC) producing Gram-negatives
• Multi-drug resistant Acinetobacter baumannii
• Multi-drug resistant Pseudomonas aerginosa
• Metallo-beta-lactamase (NDM-1) organisms
HAIs in the Nursing Home Setting
• The most common infections are respiratory,
urinary, skin and soft tissue, and
gastrointestinal infections
– Influenza and invasive pneumococcal disease
– CAUTI
– MRSA and/or VRE colonization and infection
– C. difficile
…….. Sixty-eight ASCs
were assessed; 32 in
Maryland, 16 in North
Carolina, and 20 in
Oklahoma……..
….. Overall, 46 of 68
ASCs (67.6%; 95%
confidence interval [CI],
55.9%-77.9%) had at
least 1 lapse in infection
control; 12 of 68 ASCs
(17.6%; 95% CI, 9.9%28.1%) had lapses
identified in 3 or more of
the 5 infection control
categories.
JAMA. 2010;303(22):2273-2279
Dialysis Centers
• Infection is a leading cause of morbidity and is
second only to cardiovascular disease as the
leading cause of death in the chronic uremic
patient on hemodialysis (HD).
– As compared to the general population, the
incidence of sepsis in patients with end-stage
renal disease can be up to 100 times higher.
– Infections also confer a higher risk of mortality
than in the general population
http://www.hhs.gov/ash/initiatives/hai/tier2_renal.html
Why the rush to public reporting of
healthcare-associated infections?
• Consumer groups are demanding
transparency – particularly about
complications and healthcare-associated
infections
Therefore, legislators respond……
State Mandatory And Public Reporting Laws For Hospital-Acquired Infections, 2010.
Halpin H A et al. Health Aff 2011;30:723-729.
…including Federal legislators
Required CMS to adjust
hospital payment beginning in
FY 2013 for healthcareassociated infections.
Final Inpatient Prospective Payment System Rule for FY 2011 required that all
PPS hospitals participating in the Hospital Inpatient Quality Reporting Program
submit data on their rate of CLABSI for all ICUs.
Final Inpatient Prospective Payment System Rule for FY 2012 requires that all
PPS hospitals participating in the Hospital Inpatient Quality Reporting Program
submit data on CLABSI, CAUTI, and SSI beginning with January 1, 2012 discharges
Exciting time in healthcare quality and
infection prevention!
National Quality Strategy
• Three Broad Aims –
1. Better health care;
2. Better health for people and
communities;
3. Lower costs through
improvement
Available at: http://www.healthcare.gov/center/reports/nationalqualitystrategy032011.pdf
Making Care Safer
Goal:
Eliminate preventable health care-acquired conditions
• Opportunities for success:
– Eliminate hospital-acquired infections
– Reduce the number of serious adverse medication events
• Illustrative measures:
– Standardized infection ratio for central line-associated
blood stream infection as reported by CDC’s National
Healthcare Safety Network
– Incidence of serious adverse medication events
Available at: http://www.healthcare.gov/center/reports/nationalqualitystrategy032011.pdf
Partnership for Patients
• The two goals of this new partnership are to:
– Keep patients from getting injured or sicker. By the end
of 2013, preventable hospital-acquired conditions would
decrease by 40% compared to 2010.
– Help patients heal without complication. By the end of
2013, preventable complications during a transition from
one care setting to another would be decreased so that all
hospital readmissions would be reduced by 20%
compared to 2010.
http://www.healthcare.gov/center/programs/partnership/index.html
Partnership for Patients
Areas of Focus
• The Partnership for Patients has identified nine areas of
focus:
–
–
–
–
–
–
–
–
–
–
Adverse Drug Events (ADE)
Catheter-Associated Urinary Tract Infections (CAUTI)
Central Line Associated Blood Stream Infections (CLABSI)
Injuries from Falls and Immobility
Obstetrical Adverse Events
Pressure Ulcers
Surgical Site Infections
Venous Thromboembolism (VTE)
Ventilator-Associated Pneumonia (VAP)
Other Hospital-Acquired Conditions
http://www.healthcare.gov/center/programs/partnership/index.html
HHS Action Plan to Prevent
Healthcare-associated Infections
• Tier One focuses on six high priority HAI-related areas within
the acute care hospital setting.
– Surgical site infections, central line-associated bloodstream
infections, ventilator-associated pneumonia, and catheter-associated
urinary tract infections, Clostridium difficile, and Methicillin-resistant
Staphylococcus aureus (MRSA)
• Tier Two expands efforts outside of the acute care setting
into outpatient facilities. It includes strategies to reduce HAIs
in:
– Ambulatory surgical centers and end-stage renal disease facilities, as
well as a strategy to increase influenza vaccination coverage among
healthcare personnel
http://www.hhs.gov/ash/initiatives/hai/infection.html
What can you do tomorrow?
A systems approach…
Prioritize those things that matter..
What practices do we need every
day?
• Focus less on preventing “an” infection
• Focus more on preventing “all” infections
Policies are Important
• Written infection prevention policies are up to
date
• Support from a trained infection preventionist
• HCWs receive job-specific training on infection
prevention practices
Healthcare Workers are the Model
• They get their influenza vaccine annually
• They are up to date on vaccines such as DTaP,
hepatitis vaccination, screened for TB
Universal Precautions!
We give more than lip service to
guideline implementation………and
we hold people accountable for
guideline adherence
http://www.cdc.gov/hicpac/
HICPAC Recent and Ongoing Activities
• New guidelines
– Prevention of Catheter-associated Urinary Tract
Infections (Sept 2010)
– Prevention of Intravascular Catheter-Related
Bloodstream Infections (2011)
– Prevention and Control of Norovirus Gastroenteritis
Outbreaks in Healthcare Settings (2011)
– Prevention of Infections Among Patients in NICU
– Healthcare Personnel Guidelines
– Prevention of Surgical Site Infections
We Implement Checklists that are
Evidence Based
Focus on the Environment
• Policies and training on routine cleaning and
disinfection
• Periodic monitoring of cleaning procedures
• Focus on reusable medical devices
http://www.oneandonlycampaign.org/
Sir Alexander Fleming discovered penicillin
“The time may come when
penicillin can be bought by
anyone in the shops. Then
there is the danger that the
ignorant man may easily
under dose himself and, by
exposing his microbes to
non-lethal quantities of the
drug, educate them to resist
penicillin.”
Nobel lecture, 1945
29
We use a lot!
• 200-300 million antibiotics are
prescribed annually
• 25-40% of all hospitalized patients
receive antibiotics
We use a lot!
• Hospital Antibiotics
– At least 30% are unnecessary or sub-optimal
– 5% of hospitalized patients experience an
adverse reaction
• Outpatient Antibiotics
– >$1.1 billion spent annually on unnecessary adult
antibiotic prescriptions for upper respiratory infections
– 50-80% of outpatient antibiotic use is
inappropriate
The Antibiotic Pipeline is Dry….
We’re running out…….
New Antibacterial Agents Approved 1983-2011
18
16
14
12
10
8
6
4
2
0
19831987
19881992
19931997
19982002
20032007
20082011
Adapted from Spellberg B et al. Clin Infect Dis. 2004;38:1279-86.
Most Common Reasons for
Unnecessary Days of Therapy in Inpatients
576 (30%) of 1941 days of antimicrobial therapy deemed unnecessary
Days of Therapy
250
200
192
187
150
94
100
50
0
Duration of Therapy
Longer than Necessary
Noninfectious or
Treatment of Colonization
Nonbacterial Syndrome
or Contamination
Hecker MT et al. Arch Intern Med. 2003;163:972-978.
34
The bugs are getting tougher!
Antibiotic Consumption Drives
Resistance!
Resistance patterns of strains of P. aeruginosa
Lepper PM et al. Antimicrob Agents Chemother 2002;46:2920-5.
Antibiotic exposure
is the single most
important risk
factor for the
development of
Clostridium difficile
associated disease
(CDAD).
Up to 85% of patients with C. difficile-associated disease
have antibiotic exposure in the 28 days before infection
Impact of Antibiotic Resistance
What happens if the patient gets infected?
Increased risk
of death (OR)
Attributable
LOS (days)
Attributable
cost
MRSA bacteremia
1.9
2.2
$6,916
MRSA surgical infection
3.4
2.6
$13,901
VRE infection
2.1
6.2
$12,766
Resistant Pseudomonas
infection
3.0
5.7
$11,981
Resistant Enterobacter
infection
5.0
9
$29,379
Organism
Cosgrove SE. Clin Infect Dis. 2006; 42:S82-9.
Antibiotics are unlike any other
drug: use of the agent in one
patient can compromise efficacy
in another
An issue for Public Health!
Antibiotics and resistance……just the
facts
• Changes in use parallel changes in resistance
• Patients with resistant infections more likely
to have received prior antimicrobials
• Hospital areas of highest resistance associated
with highest antimicrobial use
• Increased duration of therapy increases
likeliness of colonization with resistant
organisms
Shales DM, et al. Clin Infect Dis 1997; 25:584-99.
Antibiotics and resistance……just the
facts
• and……the patients are more likely to die!
Shales DM, et al. Clin Infect Dis 1997; 25:584-99.
Stewardship Decreases Resistance
Carney Hospital
Rate of Resistant Enterobacteriacae
Infections
Antimicrobial Use and Cost
Rate of VRE
MRSA rates stayed the same
Carling P et al. Infect Control Hosp Epidemiol. 2003;24:699.
Stewardship Decreases Costs
Strategy
Type of Institution
Pre-prescription
approval
County teaching hospital
$803,910
Tertiary care hospital
$302,400
Tertiary care hospital
Decrease abx
charge per patient
($1287 vs. $1873,
p<0.04)
Post-prescription
review
VA hospital
Annual Cost Savings
$145,942
Community hospital (175 beds)
$200,000-250,000
Community hospital (120 beds)
$177,000
Argentinean hospital (250 beds)
$913,236
White AC et al. Clin Infect Dis. 1997;25:230-239. Fishman N. Am J Med. 2006;119:S53-S61.
Fraiser GL et al. Arch Intern Med. 1997;157:1689-94. Gentry CA et al. Am J Health Syst Pharm. 2000;57:268-74.
LaRocco A. Clin Infect Dis. 2003;37:742-3; Bantar C et al. Clin Infect Dis. 2003;37:180-6.
Carling P et al. Infect Control Hosp Epidemiol. 2003;24:699-706.
Inpatient Stewardship Programs:
Core Elements
Antimicrobial Stewardship:
A Spectrum of Activities
Individual interventions
based on goals of
institution led by
individual (s) with interest
Comprehensive program
led by ID trained
physician and pharmacist
Many approaches in between
http://www.cdc.gov/getsmart/
Do Surveillance – and be truthful
Should be based on sound epidemiological and statistical
principles
• Designed in accordance with current recommended
practices
• Needs to be able to identify risk factors for infection
– Adverse events
– Implement risk-reduction measures
– Monitor the effectiveness of intervention
• Identify
–
–
–
–
Outbreaks
Emerging infectious diseases
Antibiotic-resistant organisms
Bioterrorist events
Consequences of HAI Reporting
• There is marked variation and low inter-rater
reliability in the interpretation of HAI criteria, even
between experienced infection preventionists.
• A recent survey of infectious disease specialists
found that 70% of respondent infection prevention
and control programs incorporated clinical judgment
in the form of clinician veto or consensus
adjudication into CLABSI assessments rather than
strict adherence to NHSN criteria!
Klompas M. Interobserver variability in ventilator-associated pneumonia surveillance. Am J Infect Control. 2010; 38:237-9.
Lin MY, et al. Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates. JAMA. 2011;
304:2035-41.
Mayer J, et al. Agreement in classifying bloodstream infections among multiple reviewers conducting surveillance. Clin Infect Dis.
2012; 55:364-70.
Beekman SE, et al. Diagnosing and reporting of central line-associated bloodstream infections. in press. 2012.
Get Involved – Learn from Each Other
• No need to “re-invent
the wheel”
– Engage with the
“learning and action
network”
– Everyone learns –
everyone contributes!
• Obtain assistance with reporting and
get resources and tools
• Share your successes
• Understand the evidence
• Engage your leadership, stakeholders,
and the patients you serve
http://www.texashospitalquality.org/collaboratives/partnership_for_patients/index.asp
There is Good News
http://hicprevent.blogs.ahcmedia.com/2011/1
0/19/key-hais-falling-major-challenges-remain/
In 2010 • A 33% reduction in central line-associated bloodstream
infections. This included a 35% reduction among
critical care patients and a 26% reduction among noncritical care patients.
• A 7% reduction in catheter-associated urinary tract
infections throughout hospitals
• A 10% reduction in surgical site infections
• An 18% reduction in the number of people developing
healthcare-associated invasive methicillin-resistant
Staphylococcus aureus (MRSA) infections
Despite the improvements….
• We have not eliminated healthcare-associated
infections
– We can’t measure all of the processes of care that
influence rates of infection
– No “bundle” that has resulted in elimination of HAIs
• What are the most important components of bundles?
– There is still a need for basic science (host factors,
biological factors, healthcare factors)
– Some factors that are known to influence infection rates
are very difficult to measure and difficult to change
Can we prevent them all?
As many as 65%–70% of cases of CABSI and CAUTI and
55% of cases of VAP and SSI may be preventable with
current evidence-based strategies. CAUTI may be the
most preventable HAI. CABSI has the highest number of
preventable deaths, followed by VAP…..
Our findings suggest that 100% prevention of HAIs may
not be attainable with current evidence-based prevention
strategies; however, comprehensive implementation of
such strategies could prevent hundreds of thousands of
HAIs and save tens of thousands of lives and billions of
dollars.
Umsheid CA, et al. Estimating the proportion of healthcare-associated infections that are reasonably
preventable and the related mortality and costs. Infect Control Hosp Epidemiol 2011; 32:101-14.
“Popularity is not leadership.
Results are!” Peter Drucker
dale-bratzler@ouhsc.edu
dale-bratzler@ouhsc.edu