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

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. http://www.hhs.gov/ash/initiatives/hai/infection.html

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

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

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

…….. 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. JAMA. 2010;303(22):2273-2279

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 http://www.hhs.gov/ash/initiatives/hai/tier2_renal.html

Why the rush to public reporting of healthcare-associated infections? Consumer groups are demanding transparency – particularly about complications and healthcare-associated infections

Therefore, legislators respond…… State Mandatory And Public Reporting Laws For Hospital-Acquired Infections, 2010. State Mandatory And Public Reporting Laws For Hospital-Acquired Infections, 2010 Halpin H A et al. Health Aff 2011;30:723-729.

…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

Exciting time in healthcare quality and infection prevention!

National Quality Strategy Three Broad Aims – Better health care; Better health for people and communities; Lower costs through improvement Available at: http://www.healthcare.gov/center/reports/nationalqualitystrategy032011.pdf

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: http://www.healthcare.gov/center/reports/nationalqualitystrategy032011.pdf

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 2010. 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 2010. http://www.healthcare.gov/center/programs/partnership/index.html

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 http://www.healthcare.gov/center/programs/partnership/index.html

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 http://www.hhs.gov/ash/initiatives/hai/infection.html

What can you do tomorrow? A systems approach…

Prioritize those things that matter..

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

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

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

Universal Precautions!

We give more than lip service to guideline implementation………and we hold people accountable for guideline adherence http://www.cdc.gov/hicpac/

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

We Implement Checklists that are Evidence Based

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

http://www.oneandonlycampaign.org/

Sir Alexander Fleming discovered penicillin “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 Key Points: Antimicrobials have only been around for about 50 years. Fleming discovered Penicillin and he mentioned the possibility of antimicrobial resistance in his Nobel lecture in 1945. His words are a reminder that what we know doesn’t always translate to practice – and this has consequences! 29

We use a lot! 200-300 million antibiotics are prescribed annually 25-40% of all hospitalized patients receive antibiotics Key Points: This is a high volume, high cost area so appropriate use is key. Overuse is well documented. The drug class of unique inappropriate use of antibiotics can yield resistance and thus less efficacy in treating other patients. 5

We use a lot! Hospital Antibiotics Outpatient 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 Key Points: This is a high volume, high cost area so appropriate use is key. Overuse is well documented. The drug class of unique inappropriate use of antibiotics can yield resistance and thus less efficacy in treating other patients. 5

The Antibiotic Pipeline is Dry….

We’re running out……. New Antibacterial Agents Approved 1983-2011 Key Points: We are down to only 2 new drugs approved for use each year. There won’t be any help from new drugs right now, so we have to use what we have and try our best to extend their lifespan. Adapted from Spellberg B et al. Clin Infect Dis. 2004;38:1279-86.

Most Common Reasons for Unnecessary Days of Therapy in Inpatients 576 (30%) of 1941 days of antimicrobial therapy deemed unnecessary Key Points: The 3 most common reasons for unnecessary therapy for inpatients are Duration of therapy is longer than necessary Antibiotics used to treat nonbacterial or noninfectious syndromes Inappropriate treatment of colonization or contamination The majority of inappropriate outpatient antibiotic use falls into the second category—treatment of non-bacterial infections—sinusitis, bronchitis, otitis media which are largely due to viruses. For outpatients, using antibiotics to treat of non-bacterial or non-infectious organisms is very common. References: Hecker MT et al. Arch Intern Med. 2003;163:972-978. Hecker MT et al. Arch Intern Med. 2003;163:972-978.

The bugs are getting tougher!

Antibiotic Consumption Drives Resistance! Resistance patterns of strains of P. aeruginosa Lepper PM et al. Antimicrob Agents Chemother 2002;46:2920-5.

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

Increased risk of death (OR) Attributable LOS (days) Impact of Antibiotic Resistance What happens if the patient gets infected? Organism Increased risk of death (OR) Attributable LOS (days) Attributable cost MRSA bacteremia 1.9 2.2 $6,916 MRSA surgical infection 3.4 2.6 $13,901 VRE infection 2.1 6.2 $12,766 Resistant Pseudomonas infection 3.0 5.7 $11,981 Resistant Enterobacter infection 5.0 9 $29,379 Key Points: Multi-drug resistant infections have high cost – both of life and of added medical care. This kind of data gets the health facility administration interested in talking about stewardship. Cosgrove SE. Clin Infect Dis. 2006; 42:S82-9.

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

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; 25:584-99.

Antibiotics and resistance……just the facts and……the patients are more likely to die! Shales DM, et al. Clin Infect Dis 1997; 25:584-99.

Stewardship Decreases Resistance Rate of Resistant Enterobacteriacae Infections Carney Hospital Antimicrobial Use and Cost Rate of VRE Key Points: A stewardship program was instituted in Carney Hospital, a community hospital in Boston. They found that antibiotic use, rates of VRE and rates of resistant enterobacteraceae decreased. This data shows that stewardship programs can work in non-academic medical centers as well. MRSA rates stayed the same Carling P et al. Infect Control Hosp Epidemiol. 2003;24:699.

Stewardship Decreases Costs Strategy Type of Institution Annual Cost Savings Pre-prescription approval County teaching hospital $803,910 Tertiary care hospital $302,400 Post-prescription review Decrease abx charge per patient ($1287 vs. $1873, p<0.04) VA hospital $145,942 Community hospital (175 beds) $200,000-250,000 Community hospital (120 beds) $177,000 Argentinean hospital (250 beds) $913,236 Key Points: Stewardship programs will save you money. The average cost that a 500 bed hospital will save in the first 6 months is $500,000. Stewardship programs reduce length of stay and increase patient welfare. The challenge is to sustain evidence of value. White AC et al. Clin Infect Dis. 1997;25:230-239. Fishman N. Am J Med. 2006;119:S53-S61. Fraiser GL et al. Arch Intern Med. 1997;157:1689-94. Gentry CA et al. Am J Health Syst Pharm. 2000;57:268-74. LaRocco A. Clin Infect Dis. 2003;37:742-3; Bantar C et al. Clin Infect Dis. 2003;37:180-6. Carling P et al. Infect Control Hosp Epidemiol. 2003;24:699-706.

Inpatient Stewardship Programs: Core Elements Instructor Note: This section introduces guidelines-based recommendations and real-world examples of core components of antimicrobial stewardship programs (ASP).

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 Key points: There are a lot of different stewardship options that aren’t a comprehensive program led by an ID trained physician or pharmacist. There are many choices, but they all require infrastructure. The key is to assess resources and start small. Building over time can be more sustainable, than having a dedicated program. You will have more cross-stockholder buy-in, more strategic interventions, and an emphasis on proving value from the start. Many approaches in between

http://www.cdc.gov/getsmart/

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

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; 38:237-9. Lin MY, et al. Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates. JAMA. 2011; 304:2035-41. Mayer J, et al. Agreement in classifying bloodstream infections among multiple reviewers conducting surveillance. Clin Infect Dis. 2012; 55:364-70. Beekman SE, et al. Diagnosing and reporting of central line-associated bloodstream infections. in press. 2012.

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 http://www.texashospitalquality.org/collaboratives/partnership_for_patients/index.asp

There is Good News http://hicprevent.blogs.ahcmedia.com/2011/10/19/key-hais-falling-major-challenges-remain/ In 2010 - 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

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

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; 32:101-14.

“Popularity is not leadership. Results are!” Peter Drucker dale-bratzler@ouhsc.edu

dale-bratzler@ouhsc.edu