On The CUSP of Elimination
of HAIs: The Role of APIC &
the Infection Preventionist in
Spreading the belief in zero
Central Line-Associated
Bloodstream Infections
(CLABSIs), 11/16/2010
Russ Olmsted, MPH, CIC - President-Elect, APIC, 2010
Peter J. Pronovost, MD, PhD, FCCM – Professor & Director,
Adult Critical Care Medicine & Quality and Safety Research
Group, Johns Hopkins
Today’s Objectives:
• Understand the On the CUSP Initiative
• List select, updated recommendations in the
upcoming 2010 CDC/HICPAC Guideline for the
Prevention of Intravascular Catheter-Related
Bloodstream Infection
• Describe the experience of the IP in CLABSI
Prevention Collaborative.
• List an example that illustrates the importance
of validation of CLABSI Detection
On The CUSP: HAI Prevention
• Coordinated by AHA’s Health Research &
Educational Trust [HRET] under contract from
Agency for Healthcare Research & Quality
(AHRQ)
• Nationwide initiative using Comprehensive Unitbased Safety Program (CUSP) to prevent HAIs
• HAIs of focus:
– CLABSIs
– Catheter associated UTIs (CAUTIs)
On The CUSP: HAI Prevention
Partnering Organizations:
Ann Arbor VA Medical Center /
University of MI Patient Safety
Enhancement Program
Hospital Recruitment:
Deborah Bohr, 646-678-4280, dbohr@aha.org
Project Management:
Marchelle Djordjevic, 312-422-2614, mdjordjevic@aha.org
General Inquires: onthecuspstophai@aha.org
On The CUSP: HAI Prevention
Core Elements of CUSP:
1.
2.
3.
4.
5.
Educate Staff on the Science of Safety
Identify Defects
Engage Executives
Learn from Defects
Implement Teamwork Tool
On The CUSP: HAI Prevention
The Stimulus for Prevention:





State Hospital Association Survey on CLABSI
Prevention Initiatives; all 50 responded
42 (84%) agreed CLABSI Prevention is a
priority
11 (22%) provided statewide CLABSI rates
Active collaboratives in 6 (12%); 7 (14%)
planning
Need: national collaborative ; build capacity

Murphy DJ, et al. Am J Med Qual 2010;25(4):255-60.
http://www.safercare.net/
OTCSBSI/Participation.html
• No reimbursement for certain Hospital
acquired conditions (HACs):
1) Serious preventable events: Object left in during
surgery; air embolism; Delivering ABO-incompatible
blood or blood products
2) Catheter-associated urinary tract infections
3) pressure ulcers (stages III & IV)
4) Vascular catheter-associated infection
5) SSI: mediastinitis after CABG; certain orthopedic
procedures, bariatric surgery
6) Patient falls
7) Manifestations of poor glycemic control
8) DVT/PE after total knee or hip replacement
• Hospital Inpatient Quality Reporting
Program – for 2011:
• Requires providers to report outcome
metrics to CMS using NHSN –
– CLABSI events beginning in January 2011 for
FY 2013 Medicare Payment Determination
• Pay 4 Reporting: 2% reduction in
reimbursement for Medicare beneficiaries if
providers fail to report.
• For details on NHSN see:
– http://www.cdc.gov/nhsn/cms-ipps-rule_training.html
Action Plan to Prevent HAIs, June 2009
http://www.hhs.gov/ophs/initiatives/hai/draft-hai-plan-01062009.pdf
Tier 1: See Targets/Metrics
Tier 2: Ambulatory Surgery Clinics, Dialysis Centers,
Influenza vaccine for Healthcare Personnel
American Recovery and
Reinvestment Act (ARRA), 2009.
Public Law 111-5
HAI Prevention Plan 5 yr. Targets;
A Progress Report
TOPIC
METRIC & TARGET
Progress Report
Central line-assoc. bloodstream CLABSI Std Infection Ratio (SIR);
infection (CLABSI)
50% reduction
18% drop in 2009 – on target!
CLABSI Insert. Bundle
Proportion of insertions using
bundle; 100% adherence
Sample of Hospitals = 92% - on
target
C. difficile Infection (CDI)
Rate/1000 discharges; 30%
reduction
8.9 in 2009; 9.4 in 2010 – not
likely to meet target
Catheter-assoc. UTI (CAUTI)
CAUTI rate ; 25% reduction
Estimate in ’08 = 5% reduction
but new def. in ’09 - unsure
MRSA
Rate invasive MRSA/100k pop.;
50% reduction
22.72 in 2009 = 13.4% drop
compared to ’07-’08 – on target
SSI
SIR; 25% reduction
5% fewer SSIs in 2009 – on
target
SSI
Proportion SCIP measures; 95%
adherence
> 92% in 2009 – on target
National Patient Safety Goals (NPSG),
Hospital, 2010
• NPSG.07.01.01: Hand Hygiene
• NPSG.07.03.01: Prevent HAIs caused by
multidrug-resistant organisms (MDROs)
• NPSG.07.04.01: CLABSI prevention
• NPSG.07.05.01: SSI prevention
===============================
Coming attractions: CAUTI focused NPSG?
Other Successful CLABSI Prevention
Collaboratives
New York: CDC guidelines basis for prevention implementation
initiatives
–
–
Greater New York Hospital Association prevention initiative
Collaborative partnership with 46 hospitals
•
Focused on
incrementally building
infrastructure needed for
BSI and other future
prevention initiatives
(e.g. C. difficile)
•
Communications to
share best practices
•
Culture of accountability
•
–
CEO to support
staff levels
involved
–
Site visits,
monthly reporting
Adopted bundles of
practices
CLABSI Prevention
Healthcare
Personnel Hand
Contamination
Hub
Contamination
Contamination
of insertion site
Extraluminal
Contamination
Contaminated
Infusate
Hematogenous
spread
HICPAC. Guideline for Prevention of
Intravascular Device-Related Infections. 2002
More Common Mechanisms
1. Pathogen migration along external
surface
- more common early
(< 7days)
2. Hub contamination with
intraluminal colonization
-more common >10 days
Less Common Mechanisms
1. Hematogenous
seeding from another source
2. Contaminated infusates
Select Highlights, CDC/HICPAC CRBSI Prevention
Guideline, 2010 – in press
• Section: Catheter Site Dressing Regimens
– Use a chlorhexidine-impregnated sponge dressing for
temporary short-term catheters in patients older than 2
months of age if the CABSI rate has not been
substantially reduced despite adherence to basic
prevention measures, including education and training,
use of chlorhexidine for skin antisepsis, and MSB.
Category IB
Select Highlights, CDC/HICPAC CRBSI Prevention
Guideline, 2010 – in press
Section: Needleless Intravascular Catheter
Systems
– When needleless systems are used, a split septum valve may be
preferred over a mechanical valve due to increased risk of infection
with some mechanical valves. Category II
– Minimize contamination risk by scrubbing the access port with an
appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor,
or 70% alcohol) and accessing the port only with sterile devices.
Category IA
Select Highlights, CDC/HICPAC CRBSI Prevention
Guideline, 2010 – in press
Section: Skin Preparation
• Prepare clean skin with a > 0.5% alcohol-based
chlorhexidine preparation before central venous
catheter insertion and during dressing changes. If
there is a contraindication to chlorhexidine,
tincture of iodine, an iodophor, or 70% alcohol can
be used as alternatives. Category IA
A Model
For
ImpleMentation
Science
Saint S, et al ICHE 2010
Overcoming
barriers:
The
Golytely
• How active resisters and organizational
constipatorsapproach?
affect health care-acquired
infection prevention efforts. Jt Comm J Qual
Patient Saf 2009
– Resisters: Benchmarking, champions, &
collaboratives
– Constipators: use golytely!
18 %
fewer
CLABSIs
than
predicted
SIR
=0.82
May 25,
2010
The Importance of Validation of
CLABSI:
Lin MY, Hota B, Khan YM, et al.
JAMA 2010; 304 (Nov.10):2035-41.
Compared CLABSI identified by IP vs computer algorithm, 4 medical ctrs,
20 ICUs
Findings: Median CLABSI 3.3 (2.0-4.5) by IP vs 9.0 (6.3-11.3) by algorithm
Significant variation in detection by IP vs algorithm by facility
The Importance of Validation of
CLABSI:
Niedner NF & 2008 NACHRI PICU Focus Group [N=16 PICUs / 14 facilities]
Findings: Substantial variation in CLABSI Surveillance Practices
Units with more aggressive surveillance program = higher CLABSI r
Summary Thoughts
• Let’s Sustain the Momentum from Launch of “I believe in
zero BSIs” at APIC 2010
• Use the On the CUSP tools and resources & encourage
enrollment of your affiliate
• Ingredients of the “secret sauce” of prevention
– individual accountability, teamwork and behavioral change
• Validation of identification of CLABSI is critical
– Being built into ARRA fund HAI prevention initiatives
– APIC education & training
– Complete HAI Studies Project Modules: see Wright MO, et al. Am
J Infect Control 2010; 38:416-8
– Practice, practice, practice….
THANK YOU FOR YOUR PARTICIPATION IN TODAY’s
SESSION