Preventing Healthcare-Associated Infections: Initiating Promising Solutions and Expanding Proven Ones
By Carolyn M. Clancy, M.D., Director, Agency for Healthcare Research and Quality
This commentary first appeared in the March/April 2011 issue of the American Journal of Medical Quality.
Healthcare-associated infections (HAIs) are on everyone's hit list, as they should be, because no patient should get sicker from a preventable infection they pick up in a hospital or other health care facility. National goals call for significant reductions in HAIs, as evidenced by Department of Health and Human Services' (HHS) Secretary Kathleen Sebelius' challenge to hospitals that they reduce central line-associated blood stream infections (CLABSIs) by 75 percent over 3 years (U.S. HHS, 2009, May).
For health care organizations, the pressure is mounting to reduce and prevent HAIs, among the leading causes of preventable death in the United States. HAIs—infections that patients acquire during medical treatment or surgical procedures—infect nearly 2 million patients, contribute to 99,000 deaths, and cost as much as $33 billion each year (Klevens et al., 2007; Scott, 2009).
The increased scrutiny on HAIs comes from stepped-up public reporting efforts, increased focus from accreditation bodies, and greater accountability among payers. For example, Medicare has stopped paying hospitals for the additional costs associated with certain hospital-acquired conditions, including vascular catheter-associated infections. Protecting patients from HAIs is an increasingly wise business decision for organizations, in addition to being in patients' best interests.
Secretary Sebelius' recent call to action is part of a comprehensive Federal strategy to prevent and reduce all types of HAIs. Last year, HHS released its "Action Plan to Prevent Healthcare-Associated Infections," (2009, June) intended to strengthen coordination and impact of national efforts by establishing national goals for HAI prevention and outlining short- and long-term objectives.
The Agency for Healthcare Research and Quality (AHRQ) has an important role in this Federal effort. In addition to mechanisms to implement and test promising solutions in the field, AHRQ has developed a wealth of practical, evidence-based information and tools that clinicians and health care organizations can use to improve care and reduce or prevent instances of HAIs.
Agency-funded projects already have produced very promising and scalable initiatives, including one that helped more than 100 Michigan intensive care units (ICUs) significantly reduce—and sustain for 3 years—the rate of CLABSI (Pronovost et al., 2010). Another project helped several Indianapolis hospital systems reduce methicillin-resistant Staphylococcus aureus (MRSA) infections in ICUs by 60 percent. A recent $17 million national initiative from AHRQ to fight HAIs will expand these projects and fund efforts to find other promising solutions to reduce and prevent HAIs.
Putting HAI Research Into Practice
A large part of the $17 million in recent awards to fight costly and deadly HAIs focuses prevention efforts on reducing the incidence of bacterial infection in four targeted areas: surgical site infections, catheter-associated urinary tract infections (CAUTI), CLABSI, and ventilator-associated pneumonia (VAP). Combined, these four infections account for more than 80 percent of all HAIs (AHRQ, 2009, September).
Other projects being funded include those to prevent the transmission of antibiotic-resistant bacteria, such as MRSA, and Carbapenem-resistant Enterobacteriaceae infections (CRE), another bacterial agent that is emerging as a challenge in health care settings. One type of CRE, Klebsiella pneumoniae carbapenermase (KPC), poses significant treatment challenges because it is resistant to almost all available antimicrobial agents. In collaboration with the Centers for Disease Control and Prevention (CDC), AHRQ identified these and several other high-priority areas to apply the remaining funding, including:
- Reducing Clostridium difficile infections through a regional hospital collaborative.
- Reducing the overuse of antibiotics by primary care clinicians treating patients in ambulatory and long-term care settings.
- Evaluating two ways to eliminate MRSA in ICUs.
- Improving measurement of the risk of infections after surgery.
- Identifying national-, regional-, and State-level rates of HAIs that are acquired in the acute care setting.
- Standardizing antibiotic use in long-term care settings.
The package of awards expands proven solutions to reduce HAIs in the hospital setting and tests other strategies in different locales, including ambulatory and long-term care settings. Meanwhile, in December 2009, AHRQ issued a request for investigator-initiated research on HAIs in ambulatory care settings, helping to round out the portfolio of projects on HAIs.
Recent efforts have demonstrated that relatively simple measures can prevent the majority of HAIs. However, important strategies to reduce and control infections, such as routine hand hygiene, have not always been adopted or strictly monitored. Adherence to guidelines developed specifically to combat the incidence of specific infections, such as CAUTI and VAP, has been suboptimal (U.S. HHS, 2009, June).
There are a host of reasons for low uptake, but as patient safety and quality improvement officers know, an organization's culture will quickly determine the fate of even the most comprehensive HAI-prevention strategy. Tools such as AHRQ's "Hospital Survey on Patient Safety Culture" (2009, March) can objectively assess an organization's culture and give a benchmark for measuring progress. Another proven tool is the Comprehensive Unit-based Safety Program (CUSP), a set of changes that can improve care related to central lines.
CUSP and the Keystone Project
The Keystone Project exemplifies research that generates enormous patient safety dividends. The success that Michigan hospitals have seen with Keystone—an estimated 1,800 lives and $281 million saved, and 140,700 fewer hospital days—stems from work conducted by Johns Hopkins University researchers to close the gap between the best evidence of catheter-related infection prevention and best clinical practices.
Researchers observed that clinicians did not always follow, or missed, basic infection-prevention steps amid the highly complex and sometimes chaotic routines of postsurgical and critical care. That led to the introduction of five specific interventions in the hospital's surgical ICU. The result: CLABSI rates decreased from 11.3 per 1,000 catheter days in January 1998 to zero by late 2002 (Berenholtz et al., 2004).
The program that resulted from those interventions is known today as CUSP, a collection of key changes to improve care practices related to central lines (AHRQ, 2009, October). Elements include: improving clinician-to-clinician communication; improving teamwork; engaging the organization's leadership; focusing on surveillance, monitoring, and feedback; and using a patient safety culture survey assessment.
CUSP provides a structured strategic framework for safety improvement, yet it is flexible to accommodate staff experiences and fix hazards that they perceive as posing the greatest risks. CUSP is implemented at the unit level and can be implemented throughout an organization.
Basic techniques can prove highly effective. For example, implementing a checklist, combined with easy data collection with quarterly feedback to track progress, proved especially effective to remind clinicians of simple-but-crucial steps in safe care. Hopkins researchers found at the outset that physicians followed all of the evidence-based infection control guidelines only 62 percent of the time (Berenholtz et al., 2004). The checklist targeted clinicians' use of five evidence-based procedures recommended by the CDC:
- Hand washing and hygiene.
- Using full-barrier precautions during the insertion of central venous catheters.
- Cleaning the skin with chlorhexidine.
- Avoiding the femoral site when possible.
- Removing unnecessary catheters.
Under an AHRQ grant, Hopkins researcher Peter Pronovost, M.D., partnered with the Michigan Health and Hospital Association to implement the CUSP program across an entire State. The CUSP approach included organizing a team at each facility to collect required data, participate in regular project conference calls, and attend meetings annually. Each team implements the required interventions and shares results with other hospital teams.
The project showed equally impressive results on a statewide basis. Its implementation in more than 100 Michigan ICUs was credited with reducing the rate of blood stream infections from intravenous lines by two-thirds within 3 months, and helped the average ICU decrease its infection rate from 4 percent to 0. Rates have been sustained over 3 years. Michigan hospitals have since expanded the focus to include reducing the rate of VAP and other patient safety problems.
In 2008, AHRQ funded an expansion of CUSP to 10 States, helping providers apply and test the program as a strategy for reducing CLABSIs over a 3-year period. With additional funding from AHRQ and a private foundation, CUSP operates nationally. The recent infusion of Federal funds last fall expands the effort to more hospitals, extends it to other settings in addition to ICUs, and broadens the focus to address other types of infections.
Several of the newly funded research efforts could prove to be as dramatic in their HAI-prevention impact as the Keystone Project has been in hospital ICUs. But hospitals and other health care organizations don't have to wait to improve their HAI prevention efforts. The knowledge, tools, and resources are available now for organizations to make major progress in reducing rates of HAIs in their facilities.
CUSP, for example, is a proven way for hospitals to answer Secretary Sebelius' call to sharply reduce CLABSIs. Once thought impossible, the results of evidence-based research and careful implementation through the Keystone Project have shown that certain infection rates can even be eliminated.
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