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 Burden What 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. Estimated Annual Hospital Cost of HAI
by Site of Infection
Major Site of Infection
Total infections
Hospital Cost per
Infection
(2002 $)
Total annual
hospital cost
(in millions $)
Deaths
Per year
Surgical Site Infection
290,485
$25,546
7,421
13,088
Central line associated-Bloodstream Infection
248,678
$36,441
9,062
30,665
Ventilator-associated Pneumonia
250,205
$9,969
2,494
35,967
Catheter associated-Urinary Tract Infection
561,667
$1,006
565
8,205
Roberts RR, et al Clin Infect Dis 2003;36:

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
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. The Healthcare System  More than Just Hospitals
Acute Care Facility
Home
Care
Outpatient/
Ambulatory
Facility
Tranquil Gardens
Nursing Home
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
1 NCHS, Loeb, CMAJ, Tsan, 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,
*2005 values are estimates.

18. 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
Hospital (27)
Outpatient Setting (12)
LTCF (3)
Community (5)
n = 47, as of April 2008

19. TRANSMISSION OF BLOODBORNE PATHOGENS VIA
CONTAMINATED EQUIPMENT OR MEDICATIONS
SOURCE
Infectious person,
e.g. chronic, acute
CASE Susceptible,
non-immune person
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
State
Setting
Year
Type NY
Private MD office
2001
HCV
HBV NE
Oncology clinic
2002 OK
Pain remediation clinic
HBV+HCV
Endoscopy clinic CA
2003 MD
Nuclear imaging
2004 FL
Chelation therapy
2005
Alternative medicine infusion
Endoscopy/surgery clinics
2006
Anesthesiologist office
2007 NV
2008 NC
Cardiology clinic NJ
2009
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 BSIs prevented
1800 lives saved
$ 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 MT
Feb -
2007 ME ND OR MN
Jan -
2009 NY ID
NH Jan-2009 SD WI
MA Jul-2008
Jan-2007 WY MI RI PA IA
CT Jan-2008 NE
Feb -
2008
NJ Jan-2009 NV
May- 2009 OH UT IL IN WV
DE Feb-2008
Sept -
2008 CA CO
Jul - VA
MD Jul-2008
Jan-2008
Jan-2008 KS MO
2009 KY
Jul-2008 TN NC AZ OK
Jan -
2008 NM
Jul-2008 AR SC
Jul -
2007 GA MS AL
Month – Year =
Date mandatory reporting using NHSN implemented TX
August- 2009 LA FL AK HI
Mandates public reporting using NHSN
States with no legislation
Mandates public reporting of infection rates
States with study laws
Mandates reporting only to state government
Mandatory data collection,
Voluntary reporting

36. 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

37. HHS Action Plan: Tier One Priorities
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*
*Tier Two will address
other types of
healthcare facilities

38. 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

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

40. 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

41. 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

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

43. 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

44. 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

45. 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

46. 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

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

48. Regional Prevention Collaboratives Examples 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:
Muto C, et al. MMWR 2005;54:

49. 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

50. 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

51. Strengths of a Collaborative
Opportunities to share experiences on what works and does not work
Ability to get advice from others who are working on the same project
Peer pressure is also a motivator

52. Common Elements for Successful Infection Prevention
Simple
Patient-centered, integrated with care
Evidence-based recommendations
Part of a “package” for prevention
Engaging and empowering clinicians
Protocols and systems in place
Standardized ways for recording information about infections (e.g., NHSN)
Regular feed-back of information to providers
Changing to a pro-safety culture
Leadership support
Sources: Muto et al, MMWR, Oct ; Pronovost et al, NEJM 2006

53. Other Key Factors in Prioritizing Interventions
Burden of the HAI
Cost
Clinical outcomes
Preventability
Are there interventions that are known to work?
What is the likely return on prevention investment?

54. Next Steps Towards Elimination
Prevention of CLABSIs in ICU settings remains important, BUT….
These are a small fraction of all of the HAIs
They likely represent “low-hanging” fruit
Given our goal of eliminating HAIs, we need to “move higher up the tree”
Prevention collaborations create opportunities to do this

55. Next Steps Towards Elimination
Expand to other settings (CLABSI in non-ICU settings)
Expand to other types of infection (CAUTI, C. difficile, etc.)
Expand success to new problem pathogens (multi-drug resistant organisms)
Expand efforts in outpatient infection control

56. >60% Reduction in MRSA
Expansion of Local Prevention Success in One State to Across the Nation
National
Region
VA Pilot
17 hospitals, multiple states
Maryland Initiative
15 hospitals
Facility
National VA Initiative
150 hospitals
nationwide
CMS
9th Scope of Work
Unit
Hospital-wide
VA Pittsburgh
ICU VA Pittsburgh
RWJ Initiative
6 hospitals, 4 states
>60% Reduction in MRSA
National
Local

57. Thank you
The findings and conclusions are those of the presenter and do not necessarily represent the view of the Centers for Disease Control and Prevention.