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Trends and Strategies for Prevention of Healthcare-Associated Infections Alice Guh, MD, MPH Division of Healthcare Quality Promotion Centers for Disease.

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Presentation on theme: "Trends and Strategies for Prevention of Healthcare-Associated Infections Alice Guh, MD, MPH Division of Healthcare Quality Promotion Centers for Disease."— Presentation transcript:

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 She was progressing in the neonatal intensive care unit until she developed a bloodstream infection related to her umbilical catheter. Your baby was born prematurely.

4 The surgery goes well but he later dies in a nursing home of a MRSA wound infection that developed after surgery. Your father has open heart surgery.

5 She has lived with this unbearable infection through 6 months of relapses. Your sister contracts Clostridium difficile after giving birth.

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 InfectionTotal infections Hospital Cost per Infection (2002 $) Total annual hospital cost (in millions $) Deaths Per year Surgical Site Infection290,485$25,5467,42113,088 Central line associated- Bloodstream Infection248,678$36,4419,06230,665 Ventilator-associated Pneumonia250,205$9,9692,49435,967 Catheter associated- Urinary Tract Infection561,667$1, ,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 McDonald LC, et al. Emerg Infect Dis. 2006;12(3): National Estimates of U.S. Short-Stay Hospital Discharges with C. difficile

13 Home Care Acute Care Facility Outpatient/ Ambulatory Facility Long Term Care Facility The Healthcare System  More than Just Hospitals

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 / yr 1 1/3 of long-term care residents affected by respiratory disease outbreaks 2 Veterans Healthcare data 3 – 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 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. All Outpatient Settings Hospital Inpatient Procedures (millions)

18 Healthcare-associated Outbreak Investigations by Healthcare Setting, n = 47, as of April 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)

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 StateSettingYearType NYPrivate MD office2001HCV NYPrivate MD office2001HBV NEOncology clinic2002HCV OKPain remediation clinic2002HBV+HCV NYEndoscopy clinic2002HCV CAPain remediation clinic2003HCV MDNuclear imaging2004HCV FLChelation therapy2005HBV CAAlternative medicine infusion2005HCV NYEndoscopy/surgery clinics2006HBV+HCV NYAnesthesiologist office2007HCV NVEndoscopy clinic2008HCV NCCardiology clinic2008HCV NJOncology clinic2009HBV 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 preventable 1 1 J Hosp Infection 2003;54:258

30 Estimates of Preventable Infections, Deaths, and Costs

31 Trends in MRSA Bloodstream Infections by ICU Type, NHSN hospitals, Estimated 7000 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 IL Sept NY Jan-2007 MS OR Jan ID MT NV May AZ CO Jan-2008 NM OK Jul-2008 MO AR TX August LA ND SD IA NE KY ME NJ Jan-2009 MD Jul-2008 TN Jan WY MI SC Jul FL HI AK MA Jul-2008 VT Feb WA Jul-2008 CA Jan-2008 WI PA Feb-2008 VA Jul-2008 NH Jan-2009 AL GA UT KS MN OH NC RI DE Feb-2008 WV Jul IN CT Jan-2008 State Legislative Activity for HAIs (as of October 6, 2009) Month – Year = Date mandatory reporting using NHSN implemented Mandates public reporting of infection rates Mandates reporting only to state government Mandatory data collection, Voluntary reporting States with study laws States with no legislation Mandates public reporting using NHSN

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

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 Supplemental Strategies – Some scientific evidence – Variable levels of feasibility Core Strategies – High levels of scientific evidence – Demonstrated feasibility

48 Regional Prevention Collaboratives Examples of Success ICUs at 103 Michigan hospitals, 18 months BSIs/1,000 catheter days Months Pittsburgh Regional Healthcare Initiative Michigan Keystone Initiative Pronovost P. New Engl J Med 2006;355: Muto C, et al. MMWR 2005;54: Overall rate reduction of 68% Overall rate reduction of 66%

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

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


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