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, MPHDivision of Healthcare Quality PromotionCenters 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 settingHealthcare settings:Hospitals: acute care facilities, critical access hospitalsLong 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 costs99,000 associated deathsMost common type of infections:Bloodstream infections (BSI)Urinary tract infectionsPneumoniaSurgical site infectionsKlevens, et al. Pub Health Rep 2007;122:160-6
8 Estimated Annual Hospital Cost of HAI by Site of InfectionMajor Site of InfectionTotal infectionsHospital Cost perInfection(2002 $)Total annualhospital cost(in millions $)DeathsPer yearSurgical Site Infection290,485$25,5467,42113,088Central line associated-Bloodstream Infection248,678$36,4419,06230,665Ventilator-associated Pneumonia250,205$9,9692,49435,967Catheter associated-Urinary Tract Infection561,667$1,0065658,205Roberts RR, et al Clin Infect Dis 2003;36:
12 National Estimates of U. S. Short-Stay Hospital Discharges with C National Estimates of U.S. Short-Stay Hospital Discharges with C. difficileMcDonald LC, et al. Emerg Infect Dis. 2006;12(3):409-15
13 The Healthcare System More than Just Hospitals Acute Care FacilityHomeCareOutpatient/AmbulatoryFacilityTranquil GardensNursing HomeLong Term CareFacility
14 HAI Burden Outside of Acute Care We know much less about thisWhat we have learned to date:HAIs are a substantial problemoutside 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 outbreaks2Veterans Healthcare data3133 nursing homes; 11,475 residentsHAI prevalence: 5.2%Indwelling medical device: 25% of all residents1 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 sitesDialysis Centers2008: 4,950 (72% increase since 1996)Ambulatory Surgical Centers2009: 5175 (240% increase since 1996)Approximately 1.2 billion outpatient visits / yr
17 Surgical Procedures Moving from Inpatient to Outpatient Setting All Outpatient SettingsProcedures (millions)Hospital InpatientSource: 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 careWide 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 lackingHospital (27)Outpatient Setting (12)LTCF (3)Community (5)n = 47, as of April 2008
19 TRANSMISSION OF BLOODBORNE PATHOGENS VIA CONTAMINATED EQUIPMENT OR MEDICATIONSSOURCEInfectious person,e.g. chronic, acuteCASE Susceptible,non-immune personCONTAMINATED EQUIPMENT OR MEDICATION OR HANDS
20 33 outbreaks in 15 states Outpatient clinics, n=12 Dialysis centers, n=6Long term care, n=15Thompson et al. Ann Intern Med. 2009;150:33-39.
21 Viral Hepatitis Outbreaks - Outpatient Settings StateSettingYearTypeNYPrivate MD office2001HCVHBVNEOncology clinic2002OKPain remediation clinicHBV+HCVEndoscopy clinicCA2003MDNuclear imaging2004FLChelation therapy2005Alternative medicine infusionEndoscopy/surgery clinics2006Anesthesiologist office2007NV2008NCCardiology clinicNJ2009Thompson 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 controlLarge 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 oversightApproximately 50% of ambulatory surgical centers (ASC) surveyed by CMS and CDC had serious, noncompliance with the Medicare ASC health and safety standards28% had unsafe injection practices
25 State of Prevention Knowledge and Science Evidence-based prevention recommendationsMajor 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%1Many facilities have yet to implement proven prevention measures:Bloodstream infectionsUrinary tract infections2005 Data from Surgical Care Improvement Project
27 What’s Been Missing in the Past to Promote HAI Prevention? Robust data on HAI PreventionFocused attention of policymakers on HAI preventionIncentives / disincentives to promote systems change for sustainable HAI preventionFramework to extend local / regional successes across the nation
28 What’s Been Missing in the Past to Promote HAI Prevention? Robust data on HAI PreventionFocused attention of policymakers on HAI preventionIncentives / disincentives to promote systems change for sustainable HAI preventionFramework 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 efforts32% preventable with “well organized and highly effective infection control programs”20-70% of infections are preventable11J 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 prevented1800 lives saved$ M in costs averted annually
32 Significant reductions: Surgical site infections Unplanned return to ORAll complicationsDeathsHaynes AB, et al. NEJM 2009;360:491-9.
33 What’s Been Missing in the Past to Promote HAI Prevention? Robust data on HAI PreventionFocused attention of policymakers on HAI preventionIncentives / disincentives to promote systems change for sustainable HAI preventionFramework to extend local / regional successes across the nation
34 State Legislative Activity for HAIs (as of October 6, 2009) WAJul-2008VTMTFeb-2007MENDORMNJan-2009NYIDNH Jan-2009SDWIMA Jul-2008Jan-2007WYMIRIPAIACT Jan-2008NEFeb-2008NJ Jan-2009NVMay- 2009OHUTILINWVDE Feb-2008Sept-2008CACOJul -VAMD Jul-2008Jan-2008Jan-2008KSMO2009KYJul-2008TNNCAZOKJan-2008NMJul-2008ARSCJul-2007GAMSALMonth – Year =Date mandatory reporting using NHSN implementedTXAugust- 2009LAFLAKHIMandates public reporting using NHSNStates with no legislationMandates public reporting of infection ratesStates with study lawsMandates reporting only to state governmentMandatory data collection,Voluntary reporting
36 HHS Steering Committee: HAI Prevention Charge: Develop an Action Plan to reduce, prevent, and ultimately eliminate HAIsPlan will:Establish national goals for reducing HAIsInclude short- and long-term benchmarksOutline opportunities for collaboration with external stakeholdersCoordinate and leverage HHS resources to accelerate and maximize impact
37 HHS Action Plan: Tier One Priorities HAI Priority AreasCatheter-associated urinary tract infectionCentral line-associated blood stream infectionSurgical site infectionVentilator-associated pneumoniaMRSAClostridium difficileImplementation FocusHospitals**Tier Two will addressother types ofhealthcare facilities
38 What’s Been Missing in the Past to Promote HAI Prevention? Robust data on HAI PreventionFocused attention of policymakers on HAI preventionIncentives / disincentives to promote systems change for sustainable HAI preventionFramework to extend local / regional successes across the nation
39 Centers for Medicare and Medicaid Services October 2008Non-payment rules for “Never events”Preventable conditions acquired during patient’s hospital stayIncludes HAIs
40 Federal Funding for HAI Prevention American Recovery and Reinvestment Act of 2009 (ARRA)Allocated funding to states for HAI preventionFY 2009 Omnibus BillStates 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 PreventionFocused attention of policymakers on HAI preventionIncentives / disincentives to promote systems change for sustainable HAI preventionFramework to extend local / regional successes across the nation
42 State Health Departments Increasing Needs and Opportunities for Public Health Approach Across the Continuum of CareAcute Care FacilityState Health DepartmentsHomeCareOutpatient/AmbulatoryFacilityTranquil GardensNursing HomeLong Term CareFacility
43 A New Paradigm: Central Role of State Health Departments Expanding state public health workforce to make progress toward HAI preventionCreate and expand state-based HAI prevention collaborativesSustainable 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 preventionMany “change methods” that have demonstrated success:Comprehensive Unit-based Patient Safety Program (CUSP)Positive devianceSix-sigma
45 Basics of a Prevention Collaborative Group of healthcare facilities engaged in a common effort to reduce HAIsMembers use a common approachDiscuss 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 meaningfullyIdeal size multi-factorialSpecific subject or targeted HAIType of healthcare facilitiesAvailable resourcesMore “cutting edge” ─ smaller numberMore established “change packages” can be quite largeLevel of enthusiasm
47 Prevention Strategies Core StrategiesHigh levels of scientific evidenceDemonstrated feasibilitySupplemental StrategiesSome scientific evidenceVariable levels of feasibility
48 Regional Prevention Collaboratives Examples of Success Pittsburgh Regional Healthcare InitiativeMichigan Keystone InitiativeICUs at 103 Michiganhospitals, 18 monthsBSIs/1,000 catheter daysOverall rate reduction of 66%Overall rate reduction of 68%MonthsPronovost 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 typesPrevention practices utilized during these interventions were not novelPractical strategies identified that can be successful across many facilities
50 If Expanded Nationally…. 66% reduction of BSIs would translate into:180,000 fewer BSIs20,000 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 workAbility to get advice from others who are working on the same projectPeer pressure is also a motivator
52 Common Elements for Successful Infection Prevention SimplePatient-centered, integrated with careEvidence-based recommendationsPart of a “package” for preventionEngaging and empowering cliniciansProtocols and systems in placeStandardized ways for recording information about infections (e.g., NHSN)Regular feed-back of information to providersChanging to a pro-safety cultureLeadership supportSources: Muto et al, MMWR, Oct ; Pronovost et al, NEJM 2006
53 Other Key Factors in Prioritizing Interventions Burden of the HAICostClinical outcomesPreventabilityAre 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 HAIsThey likely represent “low-hanging” fruitGiven 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 NationNationalRegionVA Pilot17 hospitals, multiple statesMaryland Initiative15 hospitalsFacilityNational VA Initiative150 hospitalsnationwideCMS9th Scope of WorkUnitHospital-wideVA PittsburghICU VA PittsburghRWJ Initiative6 hospitals, 4 states>60% Reduction in MRSANationalLocal
57 Thank youThe findings and conclusions are those of the presenter and do not necessarily represent the view of the Centers for Disease Control and Prevention.