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Alice Guh, MD, MPH Division of Healthcare Quality Promotion

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Presentation on theme: "Alice Guh, MD, MPH Division of Healthcare Quality Promotion"— 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 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

35

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.


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