Presentation on theme: "Healthcare-associated Infections – Moving from Headlines to Solutions"— Presentation transcript:
1 Healthcare-associated Infections – Moving from Headlines to Solutions Dale W. Bratzler, DO, MPHProfessor and Associate DeanUniversity of Oklahoma Health Sciences CenterCollege of Public Health, Oklahoma City, OKTexas Partnership for PatientsMay 1, 2013
2 How big is the problem?HAIs - Infections that patients acquire while receiving treatment for medical or surgical conditions.Significant toll on human life1.7 million infections99,000 deaths annuallyEstimated that HAIs incur an estimated $28 to $33 billion in excess healthcare costs each yearFour 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.
4 Healthcare-associated Infections While can occur in any care setting, are particularly related to:Use of medical devicesComplications of surgical proceduresTransmission between patients and healthcare workersAntibiotic overuse
5 But, don’t forget…..The incidence of C. difficile infections in the in- and out-patient setting is increasingWhile 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 organismsVancomycin Resistant Enterococci (VRE)Methicillin Resistant Staphylococcus aureus (MRSA)Extended spectrum ß-lactamse (ESBLs) producing Gram-negative bacteriaKlebsiella pneumonia carbapenemase (KPC) producing Gram-negativesMulti-drug resistant Acinetobacter baumanniiMulti-drug resistant Pseudomonas aerginosaMetallo-beta-lactamase (NDM-1) organisms
6 HAIs in the Nursing Home Setting The most common infections are respiratory, urinary, skin and soft tissue, and gastrointestinal infectionsInfluenza and invasive pneumococcal diseaseCAUTIMRSA and/or VRE colonization and infectionC. difficile
7 …….. 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):
8 Dialysis CentersInfection 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
9 Why the rush to public reporting of healthcare-associated infections? Consumer groups are demanding transparency – particularly about complications and healthcare-associated infections
10 Therefore, legislators respond…… State Mandatory And Public Reporting Laws For Hospital-Acquired Infections, 2010.State Mandatory And Public Reporting Laws For Hospital-Acquired Infections, 2010Halpin H A et al. Health Aff 2011;30:
11 …including Federal legislators Required CMS to adjust hospital payment beginning in FY 2013 for healthcare-associated 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
12 Exciting time in healthcare quality and infection prevention!
13 National Quality Strategy Three Broad Aims –Better health care;Better health for people and communities;Lower costs through improvementAvailable at:
14 Making Care Safer Goal: Eliminate preventable health care-acquired conditionsOpportunities for success:Eliminate hospital-acquired infectionsReduce the number of serious adverse medication eventsIllustrative measures:Standardized infection ratio for central line-associated blood stream infection as reported by CDC’s National Healthcare Safety NetworkIncidence of serious adverse medication eventsAvailable at:
15 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.
16 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 ImmobilityObstetrical Adverse EventsPressure UlcersSurgical Site InfectionsVenous Thromboembolism (VTE)Ventilator-Associated Pneumonia (VAP)Other Hospital-Acquired Conditions
17 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
24 We give more than lip service to guideline implementation………and we hold people accountable for guideline adherence
25 HICPAC Recent and Ongoing Activities New guidelinesPrevention 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 NICUHealthcare Personnel GuidelinesPrevention of Surgical Site Infections
26 We Implement Checklists that are Evidence Based
27 Focus on the Environment Policies and training on routine cleaning and disinfectionPeriodic monitoring of cleaning proceduresFocus on reusable medical devices
29 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, 1945Key Points:Antimicrobials have only been around for about 50 years.Fleming discovered Penicillin and he mentioned the possibility of antimicrobial resistance in his Nobel lecture in 1945.His words are a reminder that what we know doesn’t always translate to practice – and this has consequences!29
30 We use a lot! 200-300 million antibiotics are prescribed annually 25-40% of all hospitalized patients receive antibioticsKey Points:This is a high volume, high cost area so appropriate use is key.Overuse is well documented.The drug class of unique inappropriate use of antibiotics can yield resistance and thus less efficacy in treating other patients.5
31 We use a lot! Hospital Antibiotics Outpatient Antibiotics At least 30% are unnecessary or sub-optimal5% of hospitalized patients experience an adverse reactionOutpatient Antibiotics>$1.1 billion spent annually on unnecessary adult antibiotic prescriptions for upper respiratory infections50-80% of outpatient antibiotic use is inappropriateKey Points:This is a high volume, high cost area so appropriate use is key.Overuse is well documented.The drug class of unique inappropriate use of antibiotics can yield resistance and thus less efficacy in treating other patients.5
33 We’re running out……. New Antibacterial Agents Approved 1983-2011 Key Points:We are down to only 2 new drugs approved for use each year.There won’t be any help from new drugs right now, so we have to use what we have and try our best to extend their lifespan.Adapted from Spellberg B et al. Clin Infect Dis. 2004;38:
34 Most Common Reasons for Unnecessary Days of Therapy in Inpatients 576 (30%) of 1941 days of antimicrobial therapy deemed unnecessaryKey Points:The 3 most common reasons for unnecessary therapy for inpatients areDuration of therapy is longer than necessaryAntibiotics used to treat nonbacterial or noninfectious syndromesInappropriate treatment of colonization or contaminationThe majority of inappropriate outpatient antibiotic use falls into the second category—treatment of non-bacterial infections—sinusitis, bronchitis, otitis media which are largely due to viruses.For outpatients, using antibiotics to treat of non-bacterial or non-infectious organisms is very common.References: Hecker MT et al. Arch Intern Med. 2003;163:Hecker MT et al. Arch Intern Med. 2003;163:
36 Antibiotic Consumption Drives Resistance! Resistance patterns of strains of P. aeruginosaLepper PM et al. Antimicrob Agents Chemother 2002;46:
37 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
38 Increased risk of death (OR) Attributable LOS (days) Impact of Antibiotic Resistance What happens if the patient gets infected?OrganismIncreased risk of death (OR)Attributable LOS (days)Attributable costMRSA bacteremia1.92.2$6,916MRSA surgical infection3.42.6$13,901VRE infection2.16.2$12,766Resistant Pseudomonas infection3.05.7$11,981Resistant Enterobacter infection5.09$29,379Key Points:Multi-drug resistant infections have high cost – both of life and of added medical care.This kind of data gets the health facility administration interested in talking about stewardship.Cosgrove SE. Clin Infect Dis. 2006; 42:S82-9.
39 An issue for Public Health! Antibiotics are unlike any other drug: use of the agent in one patient can compromise efficacy in anotherAn issue for Public Health!
40 Antibiotics and resistance……just the facts Changes in use parallel changes in resistancePatients with resistant infections more likely to have received prior antimicrobialsHospital areas of highest resistance associated with highest antimicrobial useIncreased duration of therapy increases likeliness of colonization with resistant organismsShales DM, et al. Clin Infect Dis 1997; 25:
41 Antibiotics and resistance……just the facts and……the patients are more likely to die!Shales DM, et al. Clin Infect Dis 1997; 25:
42 Stewardship Decreases Resistance Rate of Resistant EnterobacteriacaeInfectionsCarney HospitalAntimicrobial Use and CostRate of VREKey Points:A stewardship program was instituted in Carney Hospital, a community hospital in Boston.They found that antibiotic use, rates of VRE and rates of resistant enterobacteraceae decreased.This data shows that stewardship programs can work in non-academic medical centers as well.MRSA rates stayed the sameCarling P et al. Infect Control Hosp Epidemiol. 2003;24:699.
43 Stewardship Decreases Costs StrategyType of InstitutionAnnual Cost SavingsPre-prescription approvalCounty teaching hospital$803,910Tertiary care hospital$302,400Post-prescription reviewDecrease abx charge per patient ($1287 vs. $1873, p<0.04)VA hospital$145,942Community hospital (175 beds)$200, ,000Community hospital (120 beds)$177,000Argentinean hospital (250 beds)$913,236Key Points:Stewardship programs will save you money.The average cost that a 500 bed hospital will save in the first 6 months is $500,000.Stewardship programs reduce length of stay and increase patient welfare.The challenge is to sustain evidence of value.White AC et al. Clin Infect Dis. 1997;25: Fishman N. Am J Med. 2006;119:S53-S61.Fraiser GL et al. Arch Intern Med. 1997;157: Gentry CA et al. Am J Health Syst Pharm. 2000;57: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:
44 Inpatient Stewardship Programs: Core Elements Instructor Note:This section introduces guidelines-based recommendations and real-world examples of core components of antimicrobial stewardship programs (ASP).
45 Antimicrobial Stewardship: A Spectrum of Activities Comprehensive program led by ID trained physician and pharmacistIndividual interventions based on goals of institution led by individual (s) with interestKey points:There are a lot of different stewardship options that aren’t a comprehensive program led by an ID trained physician or pharmacist.There are many choices, but they all require infrastructure.The key is to assess resources and start small. Building over time can be more sustainable, than having a dedicated program. You will have more cross-stockholder buy-in, more strategic interventions, and an emphasis on proving value from the start.Many approaches in between
47 Do Surveillance – and be truthful Should be based on sound epidemiological and statistical principlesDesigned in accordance with current recommended practicesNeeds to be able to identify risk factors for infectionAdverse eventsImplement risk-reduction measuresMonitor the effectiveness of interventionIdentifyOutbreaksEmerging infectious diseasesAntibiotic-resistant organismsBioterrorist events
48 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:Mayer J, et al. Agreement in classifying bloodstream infections among multiple reviewers conducting surveillance. Clin Infect Dis. 2012; 55:Beekman SE, et al. Diagnosing and reporting of central line-associated bloodstream infections. in press
49 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 toolsShare your successesUnderstand the evidenceEngage your leadership, stakeholders, and the patients you serve
50 There is Good NewsInA 33% reduction in central line-associated bloodstream infections. This included a 35% reduction among critical care patients and a 26% reduction among non-critical care patients.A 7% reduction in catheter-associated urinary tract infections throughout hospitalsA 10% reduction in surgical site infectionsAn 18% reduction in the number of people developing healthcare-associated invasive methicillin-resistant Staphylococcus aureus (MRSA) infections
51 Despite the improvements…. We have not eliminated healthcare-associated infectionsWe can’t measure all of the processes of care that influence rates of infectionNo “bundle” that has resulted in elimination of HAIsWhat 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
52 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:
53 “Popularity is not leadership. Results are!” Peter Drucker