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Ensuring Patient Safety: Reducing Health Care-Associated Infections, Domestically and Abroad Daniel Gallardo, MPH Tisha Johnson, MD, MPH Presenters Dale.

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Presentation on theme: "Ensuring Patient Safety: Reducing Health Care-Associated Infections, Domestically and Abroad Daniel Gallardo, MPH Tisha Johnson, MD, MPH Presenters Dale."— Presentation transcript:

1 Ensuring Patient Safety: Reducing Health Care-Associated Infections, Domestically and Abroad Daniel Gallardo, MPH Tisha Johnson, MD, MPH Presenters Dale Hu, MD, MPH Moderator

2 Learning Objectives Understand the burden and impact of health care-associated infections (HAI) in the United States. Learn about the HHS efforts to measure, control, prevent, and reduce HAIs through existing policy and program levers. Understand the global burden and impact of HAIs. Identify opportunities to leverage Federal strategies and techniques by translating principles to Global opportunities.

3 Overview Burden of HAI – United States HAI Action Plan Surveillance – United States Progress in the Reduction of HAIs Burden of HAIs Globally Surveillance – Developing Countries Adaptable Interventions Lessons Learned

4 HAI: UNITED STATES Daniel Gallardo, MPH

5 Health Care-Associated Infections (HAI) Definition Health Care-Associated Infections are infection that people acquire while they are receiving treatment for another condition in healthcare settings: Inpatient Hospitals Ambulatory settings Long-term care facilities Any healthcare setting where people receive care

6 At any given time, 1 in 20 U.S. hospital patients has a health care-associated infection. SOURCE: $33 billion in potentially preventable health care costs annually. Impact of Health Care-Associated Infections in the U.S.

7 The HAI Burden 100,000 lives lost every year in the United States alone

8 The HAI Burden Public Health IssueDeaths Per Year HAIs100,000 Motor Vehicle Traffic42,031 * Breast Cancer40,598 ŧ HIV / AIDS17,489 † SOURCES: * National Vital Statistics Reports. Final Data for 2007; vol. 58(19). Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. ŧ United States Cancer Statistics: 1999–2007 Incidence and Mortality Web-based Report. Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; United States Cancer Statistics: 1999–2007 Incidence and Mortality Web-based Report. †HIV Surveillance United States, 1981 – MMWR 2011; 60(21); Centers for Disease Control and Prevention.

9 The HAI Burden “Implementing what we know for prevention can lead up to a 70% or more reduction in HAIs” SOURCE: Scott RD. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention. Atlanta: Centers for Disease Control and Prevention; 2009.

10 Improve central coordination of HHS-supported prevention and surveillance strategies Identify priorities among CDC guidelines to: – Promote implementation of high priority practices Establish greater consistency and compatibility of the HAI- related data across HHS systems to: – Increase reliable national estimates of HAIs Recommendations for HHS:

11 Cross-Federal Collaboration  U.S. Department of Health & Human Services ̶ Administration for Community Living (ACL) ̶ Agency for Healthcare Research & Quality (AHRQ) ̶ Centers for Disease Control & Prevention (CDC) ̶ Centers for Medicare & Medicaid Services (CMS) ̶ Food and Drug Administration (FDA) ̶ Health Resources & Services Administration (HRSA) ̶ Indian Health Services (IHS) ̶ National Institutes of Health (NIH) ̶ Office of the Secretary (OS)  U.S. Department of Defense (DoD)  U.S. Department of Labor (DoL)  U.S. Department of Veterans Affairs (VA)

12 Phase One Acute Care Hospitals Phase Two Outpatient Settings Phase Three Long-Term Care Facilities

13 HAI Action Plan: Measurable Goals Central line- associated bloodstream infections Catheter- associated urinary tract infections Methicillin- resistant Staphylococcus aureus Clostridium difficile infections Surgical site infections

14 Surveillance – United States National HAI Data Hospitals Dialysis centers Long- term care

15 Surveillance – Public Reporting National Healthcare Safety Network (NHSN) Active Bacterial Core surveillance (ABCs), Emerging Infections Program (EIP) Nationwide Inpatient Sample (NIS), Healthcare Cost Utilization Project (HCUP) U.S. Renal Data System

16 Standardized Infection Ratios The SIR is a measure that compares the number of infections reported to NHSN to the number of infections that would be predicted based on national baseline data

17 NOTES: *Healthy People 2020 objectives HAI-1 and HAI-2 17 Progress Toward the National Action Plan Targets: Elimination of HAIs in Acute Care Hospitals

18 Central Line-Associated Bloodstream Infections SOURCE: National Healthcare Safety Network (NHSN), CDC/NCEZID. NOTES: I = 95% confidence interval. The Standardized Infection Ratio compares the observed number of HAI cases during a reporting period with the baseline number of HAI cases. Standardized Infection Ratio Obj. HAI-1 Decrease desired HP2020 Target:

19 Progress on Additional HAIs Source: CDC, 2013

20 Multiple Levers to Reduce HAIs FederalNon-Federal 1.Measurement a.Investment in resources for improved surveillance 2.Research a.Knowledge development b.Pilot testing of prevention bundles 3.Policy a.Information transparency b.Incentive programs c.Financial penalties d.Regulation 4.Education and Outreach a.Dissemination b.Training 1.Partnerships 1.Recognition programs 2.Information dissemination 2.Outreach/Advocacy 1.Patient-family engagement 2.Consumer groups

21 Programs and Initiatives Comprehensive Unit-based Safety Project (CUSP) CUSP for Safe Surgery (SUSP) Surgical Care Improvement Project (SCIP) Hand Hygiene

22 CLABSI: United States Successes Actual Changes in Clinical Practice are Required – Engagement of all frontline professionals – Requires a change in culture too Comprehensive Unit-based Safety Program – Developed at Johns Hopkins Medical Center – Large scale test by Keystone Project in Michigan

23 CUSP & CLABSI Interventions 1.Educate on the science of safety 2.Identify defects 3.Assign executive to adopt unit 4.Learn from Defects 5.Implement teamwork & communication tools CUSPCLABSI 1.Wash Hands Prior to Procedure 2.Use Maximal Barrier Precautions 3.Clean skin with Chlorhexidine 4.Avoid Femoral Lines 5.Remove Unnecessary Lines

24 Building on Success Because the method works – CLABSI rates in Michigan dropped to less than 1 per thousand and remained at this level for an extended period Launched On the CUSP: Stop CLABSI nationally – Reduced the rate of bloodstream infections in ICUs by 40 percent – Saved more than 500 lives and prevented more than 2,000 bloodstream infections – Averted $34 million in health care costs

25 SSI: CUSP for Safe Surgery (SUSP) Surgical safety program – National Project Team Johns Hopkins University Armstrong Institute for Patient Safety and Quality American College of Surgeons University of Pennsylvania World Health Organization – 200 participating hospitals in US and Puerto Rico

26 SUSP: Surgical Safety Strategy Engage front-line clinicians and hospital leaders Utilize performance measures clinicians believe are valid Adapt methods based on local context Implement a process to improve culture and teamwork

27 SUSP: Johns Hopkins Hospital Initial focus on colorectal surgery Reduced SSI in colorectal procedures by 33% Success attributed to: – Use of simple safety checklists – Urging caregivers to speak up

28 SUSP: Limited Data Insufficient data to draw conclusion about SSI rates Ethnographic research data available – 12 hospitals in 4 states – Sites: academic, critical access, and community hospitals – 100 individual and group interviews – Interviews are currently being transcribed – Coding data and analyzing

29 SSI: SCIP Surgical Care Improvement Project – Implemented 2006 – Quality Improvement Organizations provide technical assistance to hospitals Process Measures – Antibiotic within 1 hour before incision – Prophylactic antibiotics consistent with recommendations – Antibiotics discontinued within 24 hours of surgery end time – Appropriate hair removal

30 SCIP National Progress FY 2008 – 2012

31 HAND HYGIENE Health care providers – Podcasts – Clean Hands Save Lives campaign Patients and hospital visitors – Hand Hygiene Saves Lives campaign – Partnering to Heal interactive training video – Do the WAVE

32 Challenges with C. difficile hospitalization An Environmental Disinfection Intervention to Control C. difficile (AHRQ) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007 (CDC) Guideline for Environmental Infection Control in Health-Care Facilities, 2003 (CDC) HCUP discharge data shows an increase in rate Varies by regions and states Opportunities for improvement include effective antimicrobial use and environmental decontamination

33 Challenges with CAUTI National Implementation of CUSP to Reduce CAUTI (AHRQ) Guideline for Prevention of CAUTI, 2009 (CDC) Small reduction from baseline in 2011 Increase in reporting facilities and locations in 2012 – Possible explanation for increase to 1.02 SIR

34 HAI: GLOBALLY Tisha Johnson, MD, MPH

35 Impact of Health Care-Associated Infections in the EU SOURCE: European Centre for Disease Prevention and Control. Annual Epidemiological Report Reporting on 2011 surveillance data and 2012 epidemic intelligence data. Stockholm: ECDC; In comparison, 1 in 18 EU hospital patients has a health care-associated infection.

36 Global Burden: Incidence SOURCES: 1. Klevens, R. M., Edwards, J. R., Richards, C. L., Horan, T. C., Gaynes, R. P., Pollock, D. A., & Cardo, D. M. (2007). Estimating health care-associated infections and deaths in U.S. hospitals, Public Health Reports, 122, Allegranzi, B., Nejad, S. B., Combescure, C., Graafmans, W., Attar, H., Donaldson, L., & Pittet, D. (2011). Burden of endemic health-care-associated infection in developing countries: Systematic review and meta-analysis. Lancet, 377,

37 Global Burden: Prevalence SOURCES: 1. World Health Organization. (2011). Report on the Burden of Endemic Health Care-Associated Infection Worldwide: Clean Care is Safer Care. Retrieved from 2. Allegranzi, B., Nejad, S. B., Combescure, C., Graafmans, W., Attar, H., Donaldson, L., & Pittet, D. (2011). Burden of endemic health-care-associated infection in developing countries: Systematic review and meta-analysis. Lancet, 377, European Centre for Disease Prevention and Control. Annual Epidemiological Report Reporting on 2011 surveillance data and 2012 epidemic intelligence data. Stockholm: ECDC; 2013.

38 Frequency of HAI by Type SOURCES: 1. Allegranzi, B., Nejad, S. B., Combescure, C., Graafmans, W., Attar, H., Donaldson, L., & Pittet, D. (2011). Burden of endemic health-care-associated infection in developing countries: Systematic review and meta-analysis. Lancet, 377, European Centre for Disease Prevention and Control. Annual Epidemiological Report Reporting on 2011 surveillance data and 2012 epidemic intelligence data. Stockholm: ECDC; 2013.

39 Selected CLABSI Rates Internationally SOURCES: 1. Allegranzi, B., Nejad, S. B., Combescure, C., Graafmans, W., Attar, H., Donaldson, L., & Pittet, D. (2011). Burden of endemic health-care-associated infection in developing countries: Systematic review and meta-analysis. Lancet, 377, Rosenthal et. Al. (2012). International Nosocomial Infection Control Consortium (INICC) report, data summary of 36 countries for American Journal of Infection Control, 40,

40 Estimated International SSI Rates SOURCES: 1. Allegranzi, B., Nejad, S. B., Combescure, C., Graafmans, W., Attar, H., Donaldson, L., & Pittet, D. (2011). Burden of endemic health-care-associated infection in developing countries: Systematic review and meta-analysis. Lancet, 377, Gastmeier, P., Geffers, C., Brandt, C., Zuschneid, I., Sohr, D., Schwab, F., Behnke, Ml, Daschner, F., & Rϋden, H. (2006). Effectiveness of a nationwide nosocomial infection surveillance system for reducing nosocomial infections. J Hosp Infect, 64, Gaynes, R. P., Culver, D. H., Horan, T. C., Edwards, J. R., Richards, C., & Tolson, J. S. (2001). Surgical site infection (SSI) rates in the United States, : the National Nosocomial Infections Surveillance System basic SSI risk index. Clin Infect Dis, 33(suppl 2), S69-77.

41 Surveillance – Developing Countries National Surveillance System in 15.6% – Burden is greatly underestimated Limited resources – Expertise knowledge of diagnosis use of standardized definitions – Finances dollars to invest in monitoring – electronic patient records – Time competing priorities Limited generalizability SOURCES: 1. World Health Organization. (2010). The burden of health care-associated infection worldwide: A summary. Retrieved from 2. World Health Organization. (2011). Report on the Burden of Endemic Health Care-Associated Infection Worldwide: Clean Care is Safer Care. Retrieved from

42 Surveillance – Developing Countries Types - passive, active, retrospective, prospective Passive surveillance best option when limited resources – Less sensitive – Requires electronic health records SOURCE: World Health Organization. (2011). Report on the Burden of Endemic Health Care-Associated Infection Worldwide: Clean Care is Safer Care. Retrieved from

43 International HAI Burden Health care-associated infections can be prevented and reduced by as much as 50% in developing countries. Device-associated health care-associated infections can be decreased by as much as 30%. SOURCES: 1. World Health Organization. (2011). Report on the Burden of Endemic Health Care-Associated Infection Worldwide: Clean Care is Safer Care. Retrieved from 2. Rosenthal et. Al. (2012). International Nosocomial Infection Control Consortium (INICC) report, data summary of 36 countries for American Journal of Infection Control, 40,

44 Additional Factors in Developing Countries Poor hygiene and sanitation Limited basic equipment Insufficient infrastructure Poor nutrition Other infection and/or disease not present in developed countries Cultural and social differences SOURCE: World Health Organization. (2011). Report on the Burden of Endemic Health Care-Associated Infection Worldwide: Clean Care is Safer Care. Retrieved from

45 Commitment to Improving HAI WHO Patient Safety First Global Patient Safety Challenge: Clean Care is Safer Care – Between October 2005 and April Ministries of Health pledged to address HAIs Over 40 countries began hand hygiene campaigns International Nosocomial Infection Control Consortium (INICC) – Established in Argentina 1998 – 46 countries on 4 continents SOURCES: 1. World Health Organization. Clean Care is Safer Care: About SAVE LIVES: Clean Your Hands. Retrieved from 2. Rosenthal et. Al. (2012). International Nosocomial Infection Control Consortium (INICC) report, data summary of 36 countries for American Journal of Infection Control, 40, INICC. (2013). Retrieved from

46 CLABSI INICC – 15 countries studied with improved Hand hygiene Consistent use of maximal sterile barriers at catheter insertion Chlorhexidine at insertion Prompt removal of unnecessary catheters – CLABSI rates and mortality reduced Similar To CUSP interventions SOURCE: Rosenthal et. al. (2010). Impact of International Nosocomial Infection Control Consortium (INICC) strategy on central line-associated bloodstream infection rates in the intensive care units of 15 developing countries. Infection Control and Hospital Epidemiology, 31(12),

47 SSI INICC – Process surveillance – Disinfection and sterilization of supplies program – Adequate use of therapeutic and presurgical prophylactic antibiotics program SOURCE: INICC. (2013). Programs and services. Retrieved from

48 SSI National Project Team for CUSP for Safe Surgery partnered with WHO to implement SUSP – Engaged five hospitals in Africa – SUSP protocol and tools will be adapted for settings with limited resources – Harare, Zimbabwe August 2013 Finalize project tools and toolkits Kick off TBD

49 Hand Hygiene Low compliance WHO – First international guidelines WHO multimodal hand hygiene strategy – Implemented in many countries SOURCES: 1. Rosenthal et. Al. (2012). International Nosocomial Infection Control Consortium (INICC) report, data summary of 36 countries for American Journal of Infection Control, 40, World Health Organization. Clean Care is Safer Care: Background to Clean Care is Safer Care. Retrieved from 3. Allegranzi, B., Gayet-Ageron, A., Damani, N., Bengaly, L., McLaws, M. L., Moro, M. L., Memish, Z., Urroz, O., Richet, H., Storr, J., Donaldson, L., & Pittet, D. (2013). Global implementation of WHO’s multimodal strategy for improvement of hand hygiene: a quasi-experimental study. Lancet, 13,

50 Clostridium difficile More needs to be done to reduce C. difficile in US UK Guidance – All health care providers staff should take personal responsibility for good infection control practices – Hand Hygiene – Prevention through isolation – Restrictive antibiotic guidelines 35% reduction in elderly >65 years SOURCE: Department of Health Clostridium difficile infection: How to deal with the problem. London.

51 CDI Rates in UK SOURCE: Public Health England July Summary Points on Clostridium Infections (CDI).

52 Lessons Learned The Adaptive Work of Culture Change is Challenging Strategies or approach to safety varies by hospital Teams want flexibility within a defined program structure Willingness to Accept and Motivated to Implement when valued as part of the project

53 For More Information Contact – – National Action Plan to Prevent Health Care- Associated Infections: Road Map to Elimination –

54 Next Session Room Numbers: Please fill out an evaluation by going to this session’s page on your mobile app OR by filling out a paper evaluation in the back of the room. Thank you! Listen Up: What African MSM Want in the Response to HIV301 A Practical Way to Maintain Skills Wherever Providers Deliver Babies302 Establishing an Interactive Education System for Frontline Health Workers307 Health Finance Food Court: What's Cooking?308 Shaken, Not Stirred: The Intersection of Alcohol, Gender, and Health310 A Vaccine's Journey: The Many Steps to Saving Lives311 Postpartum Family Planning: Bridging Barriers and Motivating Change405 Combating Counterfeit and Substandard Medicines407 How Much Will It Cost to Reach Key Populations?413 Antenatal Corticosteroid Jeopardy!: Exploring Maternal Interventions for Preterm Birth414 Innovations to an M&E System Improves Data Quality and Speed of Malaria Prevention Program ResultsBetts Theatre Business Planning for the Rest of Us Continental Ballroom Bringing Together Public and Private Sectors for Health Impact Grand Ballroom


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