By Kelly M. Pyrek
Consistent implementation of proven measures to reduce and eliminate healthcare-acquired infections (HAIs), and building these measures into work flows are among some of the biggest challenges to healthcare institutions today, says a group of experts who convened for a special panel hosted by Infection Control Today magazine to pinpoint the opportunities and challenges related to infection prevention and control. Our panel of experts included Rabih Darouiche, MD, director of the Center of Prostheses Infection at Baylor College of Medicine; Charles Edmiston, PhD, SM (ASCP), CIC, professor of surgery and hospital epidemiologist at Froedtert Hospital - Medical College of Wisconsin, and adjunct professor at Vanderbilt University School of Medicine; Glenn Mitchell, MD, chief medical officer at the Sisters of Mercy Health System; Denise Murphy, RN, MPH, CIC, vice president for quality and patient Safety at Main Line Health System; and Ruth Shumaker, RN, BSN, CNOR, a healthcare management and perioperative consultant.
HAIs are a major public health concern in the United States, with the CDC estimating that 1.7 million people develop HAIs each year. Patients who experience HAIs have longer hospital stays, utilize more healthcare resources and are at greater risk for readmission and death. Additionally, HAIs contribute to increased healthcare costs, with an estimated annual economic impact of more than $17 billion in the U.S. Our panelists discussed what healthcare institutions can and are doing to reduce the risk of HAIs.
"One of the biggest problems is inconsistent implementation of proven infection prevention and control measures," says Shumaker. "Everyone is doing his or her own thing." As the HHS Action Plan to Prevent Health Care-Associated Infections seems to confirm, " Adherence to current prevention recommendations in healthcare settings has been generally suboptimal, even when knowledge of recommended practices is sufficient. Several lines of evidence suggest that merely increasing adherence to currently recommended practices can result in a dramatic reduction in infection rates, at least for some infection types."
Edmiston says he believes this questionable healthcare worker behavior occurs when directives relating to risk-reduction strategies fail to come from the top and trickle down throughout the healthcare facility. "If you look at the most successful institutions, they are the ones that have a top-down mandate. I think it’s difficult to get the CEO's attention when he or she is engaged with other issues. It’s often difficult for the infection preventionist to get the support needed to be able to implement HAI prevention programs, especially if that support requires an expenditure of money. I think a good example of a top-down program that has had a remarkable impact is what Maureen Spencer and the New England Baptist Hospital were able to implement, and that's a MRSA surveillance program with other interventional measures that have had a significant impact on their total joint infection rate. Their rate is 0.34 percent, which is an extraordinarily low number. The way she was able to make that happen was the top-down mandate, and the interest at the highest level of the hospital in reducing risk."
Mitchell says that in his system's 28 hospitals, members of the executive suite realized the significant financial impact involved with doing the right things to prevent infections. "Our CEO established a goal of zero for HAIs, and declared that management's incentive packages were going to depend on progress toward that goal. That was the clarion call for everybody and it really focused attention on HAI prevention at all of our hospitals. We have dramatically driven down our HAI rates, and it's absolutely the CEO's responsibility at every meeting to ask about HAIs and to make leadership at all of the system's hospitals accountable -- and that's the way it gets down to the front line."
Murphy says that the involvement of a healthcare institution's board is "very powerful" and adds, "I think the normalization of deviance goes so deep in organizations, much beyond the leadership. I think we are all from organizations where the leaders are incentivized and participating in infection prevention and patient safety. But as you get down to the front lines, the concept that 'this patient is really sick so it's not surprising that they develop an HAI,' really points out the need for us to educate about the concept of elimination as an achievable goal. It may not be sustainable for all patients, for all time, for every type of infection, but the belief in zero and the belief in elimination is a culture change that in turn triggers a response from the frontline staff that if there is even one infection, they are calling everyone on it. High-performing organizations are looking at every infection as though it should never happen."
Murphy points to a "power gradient" that exists in organizations between the leadership and the frontline staff that acts as a barrier to progress and communication about infection prevention. "The more we can involve the frontline and make that connection between the leadership-driven priority of HAI elimination, the more we will have that critical trickle-down effect through the goals and objectives of every manager in the organization, down to every frontline staff member. And we need to celebrate any staff member who comes up with something innovative or courageous like stopping the line, or speaking up if they see something that could negatively impact a patient."
Murphy says that in her organization, 75 percent of people indicated they would speak up every time that they witnessed an action that could jeopardize a patient. "What was frightening is when the question, and this is from AHRQ Safety Climate Survey -- was asked in a way that said 'would you speak up to someone higher in authority if you thought something might negatively impact a patient?' the numbers get a little worse. Those data tell us that we need to address not only the clinical measures, such as the important evidence-based bundles that we have put in place, but also look at the important cultural issues such as empowerment of staff."
Darouiche indicates that bureaucracy can be a significant barrier to HAI elimination, in that institutional hierarchies delay timeliness of interventions. "I work at a Veterans Affairs (VA) hospital and the VA is different from other healthcare systems in many ways. Within the VA system there are opposing forces over the implementation of new, potentially more expensive measures or products that could result in lower rates of HAIs. On one hand it's important to note that within the VA system there are Veterans Integrated Service Networks (VISNs), and each VISN has 10 to 12 hospitals. In some VISNs, an individual hospital does not make a tremendous shift in implementing one measure or using a certain product until something comes down from the central VISN. So because of bureaucracy, there could be a delay in the implementation of what could appear to be more effective measures than traditional interventions. On the other hand, the VA system is self-paid; if a patient undergoes surgery, gets a vascular catheter placed and acquires a bloodstream infection, the VA system is going to pay for that because only a small portion of the cost will come from insurance companies. From that perspective it is important for individuals, for the VISNs, for the VA headquarters, to make sure that the frequency of expensive-to-manage complications goes down. That would enhance our chance to convince hospital administration and VISN managers to implement new measures and anti-infective products."