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Healthcare-associated Infections – Moving from Headlines to Solutions Dale W. Bratzler, DO, MPH Professor and Associate Dean University of Oklahoma Health.

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Presentation on theme: "Healthcare-associated Infections – Moving from Headlines to Solutions Dale W. Bratzler, DO, MPH Professor and Associate Dean University of Oklahoma Health."— Presentation transcript:

1 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

2 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.

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4 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

5 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

6 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

7 JAMA. 2010;303(22): …….. 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.

8 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

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, Halpin 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 – 1.Better health care; 2.Better health for people and communities; 3.Lower costs through improvement Available at:

14 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:

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 – 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

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 Immobility – Obstetrical Adverse Events – Pressure Ulcers – Surgical Site Infections – Venous 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

18 What can you do tomorrow? A systems approach…

19 Prioritize those things that matter..

20 What practices do we need every day? Focus less on preventing “an” infection Focus more on preventing “all” infections

21 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

22 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

23 Universal Precautions!

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 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

26 We Implement Checklists that are Evidence Based

27 Focus on the Environment Policies and training on routine cleaning and disinfection Periodic monitoring of cleaning procedures Focus on reusable medical devices

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29 29 “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 Sir Alexander Fleming discovered penicillin

30 We use a lot! million antibiotics are prescribed annually 25-40% of all hospitalized patients receive antibiotics

31 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

32 The Antibiotic Pipeline is Dry….

33 Adapted from Spellberg B et al. Clin Infect Dis. 2004;38: We’re running out……. New Antibacterial Agents Approved

34 34 Most Common Reasons for Unnecessary Days of Therapy in Inpatients 576 (30%) of 1941 days of antimicrobial therapy deemed unnecessary Hecker MT et al. Arch Intern Med. 2003;163:

35 The bugs are getting tougher!

36 Antibiotic Consumption Drives Resistance! Lepper PM et al. Antimicrob Agents Chemother 2002;46: Resistance patterns of strains of P. aeruginosa

37 Up to 85% of patients with C. difficile-associated disease have antibiotic exposure in the 28 days before infection Antibiotic exposure is the single most important risk factor for the development of Clostridium difficile associated disease (CDAD).

38 Impact of Antibiotic Resistance What happens if the patient gets infected? Organism Increased risk of death (OR) Attributable LOS (days) Attributable cost MRSA bacteremia1.92.2$6,916 MRSA surgical infection3.42.6$13,901 VRE infection2.16.2$12,766 Resistant Pseudomonas infection $11,981 Resistant Enterobacter infection 5.09$29,379 Cosgrove SE. Clin Infect Dis. 2006; 42:S82-9.

39 Antibiotics are unlike any other drug: use of the agent in one patient can compromise efficacy in another An issue for Public Health!

40 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:

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 Enterobacteriacae Infections Rate of VRE Antimicrobial Use and Cost Carling P et al. Infect Control Hosp Epidemiol. 2003;24:699. MRSA rates stayed the same Carney Hospital

43 Stewardship Decreases Costs StrategyType of InstitutionAnnual Cost Savings Pre-prescription approval County teaching hospital $803,910 Tertiary care hospital $302,400 Post-prescription review Tertiary care hospital Decrease abx charge per patient ($1287 vs. $1873, p<0.04) VA hospital $145,942 Community hospital (175 beds) $200, ,000 Community hospital (120 beds) $177,000 Argentinean hospital (250 beds) $913,236 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: Carling P et al. Infect Control Hosp Epidemiol. 2003;24:

44 Inpatient Stewardship Programs: Core Elements

45 Antimicrobial Stewardship: A Spectrum of Activities Comprehensive program led by ID trained physician and pharmacist Individual interventions based on goals of institution led by individual (s) with interest Many approaches in between

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47 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

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: 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 tools Share your successes Understand the evidence Engage your leadership, stakeholders, and the patients you serve

50 There is Good News In A 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 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 0/19/key-hais-falling-major-challenges-remain/

51 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

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

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