Tuesday, January 30, 2018
The Study that Changed Health Care Associated Infection
Health care–associated infections, long viewed as the nearly inevitable result of hospitalization, have been falling as hospitals and other health-care facilities ensure compliance with science-based protocols.
In 2015, 25% of hospitals reported zero central line–associated infections and 15% reported no catheter–associated urinary tract infections, according to a report by the hospital rating organization Leapfrog Group and health care price transparency company Castlight Health.
“My sense is that we’re getting on top of this and that things are getting better. The frustrating thing is they’re not getting better fast enough,” says Jeffrey Glasheen, MD, chief quality officer for UCHealth and a professor of internal medicine at the University of Colorado School of Medicine.
One in 25 patients gets an infection related to their hospital stay, according to a Centers for Disease Control and Prevention (CDC) survey discussed in a 2014 article in the New England Journal of Medicine. From the survey, researchers estimated that 648,000 patients in acute care hospitals developed infections in 2011, and about 75,000 patients with health care–associated infections died in the hospital.
“Our goal is not to control things after they happen but to prevent them before they happen.”
David Weber, MD, MPH
UNC Health Care
These infections affected the lungs (pneumonia is the most common infection), gastrointestinal tract (such as Clostridium difficile), surgical sites, and bloodstream. Many were associated with devices such as central venous or urinary catheters.
In the past, these health care–associated infections (HAIs) were sometimes viewed as the inevitable result of a hospital stay, says Karen Curtiss, who founded the founded the patient advocacy group CampaignZERO to help prevent common hazards in hospital care. Her father, Bill Aydt, had successful surgery for a lung transplant in 2005 but soon developed pneumonia and infections of methicillin-resistant Staphylococcus aureus (MRSA), the bacteria Clostridium difficile and yet another, untreatable, infection before dying in the hospital.
“The attitude at the time expressed sort of overtly and covertly was that if you’re here long enough it’s just going to happen,” says Curtiss.
In the past decade, however, hospitals have driven down infection rates significantly (see sidebar). But while individual hospitals may record no infections for a reporting period or two, they will not get rid of all infections, warns David Weber, MD, MPH, professor of medicine and pediatrics at the University of North Carolina School of Medicine and associate chief medical officer at UNC Health Care. Humans live in a sea of microbes, and skin and mucus membranes can’t be completely sterilized. “While we can minimize that risk through many different ways, we can’t entirely eliminate it,” he says.
Nonetheless, hospitals can do better, says Weber.
Engineering trumps behavior
“Engineering always trumps behavior change. We make cars with seat belts and airbags so when people make errors they don’t die. There have been technologic inventions in preventing infections,” says Weber.
Among these inventions are central lines coated inside and out with antibiotics or antiseptics. Antiseptic patches placed at the entry site of a central line can keep bacteria from sneaking in. Researchers at the Ohio State University Wexner Medical Center recently reported that bandages using weak electric fields disrupt bacterial biofilm infection to prevent infections.
Monday, January 29, 2018
A Turning Point in Preventing Health Care–Associated Infections
For a long time, health care-associated infections were viewed as an inevitable misfortune of hospitalization. But an inflection point occurred with the publication of a report by Peter Pronovost, MD, PhD, in the New England Journal of Medicine in 2006.
“Peter’s work has really been seminal in how we approach things,” says Jeffrey Glasheen, MD, chief quality officer for UCHealth and a professor of internal medicine at the University of Colorado School of Medicine. “I think people are much more apt to see a line infection not as some sort of unfortunate consequence of hospitalization but rather as a failure to protect patients.... [This is] a huge sea change from where it was when I first started practicing in the mid-90s.”
Pronovost, now senior vice president for patient safety and quality at Johns Hopkins Medicine, led a team that implemented five “evidence-based procedures recommended by the CDC and identified as having the greatest effect on the rate of catheter-related bloodstream infection and the lowest barriers to implementation” in Michigan intensive care units, according to the 2006 NEJM study. The procedures were straightforward: hand washing, full-barrier protection during the insertion of central line catheters, cleansing skin with chlorhexidine rather than other antiseptics, avoiding femoral site central lines, and removing unnecessary catheters.
The result was a stunning reduction in catheter-related bloodstream infections, from an average 7.3 per 1,000 catheter days to 2.3.
After Pronovost’s study, more hospitals began adopting bundles of science-based protocols for common hospital procedures that had been linked to infections in the past. The result? According to the CDC, there was a 50% decrease in central line–associated infections between 2008 and 2014, a 17% decrease in surgical site infections between 2008 and 2014, an 8% decrease in C. difficile infections between 2011 and 2014, and a 13% decrease in hospital-onset MRSA bloodstream infections between 2011 and 2014. Catheter-associated urinary tract infections were more resistant: the CDC reported no change between 2009 and 2014.
The use of laparoscopic surgery versus open surgery has “dramatically decreased infection rates with surgery,” Weber says. Recently, researchers and surgeons have recognized that endoscopes and colonoscopes must be sterilized to higher levels than in the past. “They’re the most dangerous device we use in the hospital,” Weber says.
There are also gains to be made in treating HAIs once they occur. More judicious use of antibiotics would reduce the evolution of resistant bacteria. Says Weber, “We need to work on getting both patients and physicians to use antibiotics appropriately to decrease resistance.”
But prevention remains the focus. UNC Health Care some time ago changed its terminology for addressing HAIs from “infection control” to “infection prevention.” Says Weber, “Our goal is not to control things after they happen but to prevent them before they happen.”
Hospitals have adopted science-based checklists of procedures to prevent infections. But for these standardized “bundles” to be effective, hospitals have had to build systems of compliance, reporting, and examination when something goes wrong. “If you don’t have the data to be able to check how often you’re doing the right thing, you’re probably not that far ahead of where you were before you created the checklist,” says Glasheen.
Donna Armellino RN, DNP, vice president of infection prevention at Northwell Health on Long Island, says hospitals must make proper procedures as easy to follow as possible.
“A number of years ago, the central lines nurse or physician would have to go to a storeroom, and they would have to pick five different things in order to perform a central line insertion,” Armellino says. “So, as leadership, we make kits. It’s an easy grab. You go get one kit that has all the needed items to insert this particular device. We also did the same thing with indwelling urinary catheters, IV start kits—anything that could help drive compliance.”
To ensure buy-in, Armellino says, it’s essential to identify “champions” in each department. Champions can be doctors, nurses, or others. “You have to have individuals at those particular sites that want to go in and educate, communicate, and be the bedside caretaker that makes those practice changes,” she says. “Getting individuals who are proud to say on their units, we have no central line infections for, you know, 150 days. And then when they do have an infection, they really want to get involved with the root-cause analysis.”
When infections do occur, health care has moved beyond blame. Instead, Armellino says, “We need to figure out how we support the employee so that situation doesn’t happen again.”