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2017 Outlook: Basics of Infection Prevention, Advances in Antimicrobial Stewardship are Priorities

Article

By Kelly M. Pyrek

2017 promises to present a number of continuing and new challenges for the infection prevention and healthcare epidemiology community. One of the most significant for the field as well as the entire country is a new Presidential Administration. Sara Cosgrove, MD, MS, FSHEA, FIDSA, associate professor of medicine and epidemiology at Johns Hopkins University, and the 2017 president of the Society of Healthcare Epidemiologists of America (SHEA), acknowledges what she characterizes as "an enormous amount of uncertainty" about how a revamped White House and Congress could impact infection prevention and antibiotic stewardship-related issues.

Cosgrove, an infectious diseases physician, director of the antimicrobial stewardship program and associate hospital epidemiologist at the Johns Hopkins Hospital, alludes to the slow progress made on incorporating matters of interest to healthcare epidemiologists and infection preventionists into healthcare reform efforts.

"Over the past several years we have developed policy levers in infection prevention largely through value-based purchasing which puts more attention at the level of hospital administration on infection prevention and control activities," Cosgrove says. "I don't think the Affordable Care Act (ACA) is in any danger even though after the election people were asking themselves, is this the end of the ACA; I'm not certain that we know anything conclusive yet. It's still hearsay at this point that elements of the ACA that drive better and less expensive care, like value-based purchasing, could be separated from the more hot-button components of the ACA, at least based on campaign rhetoric. I don't necessarily think it's the end of value-based purchasing and I think those infection prevention-based levers will still be there, and be potentially unchanged. I think we need to wait and see what happens.

The legislation known as Obamacare has been polarizing, and Americans are divided on what should happen following the election's sweeping changes. According to the Kaiser Family Foundation Health Tracking Poll from October 2016, one-third of all voters recently polled want the law expanded, one-third want it repealed, and only 9 percent want the administration to scale back what it offers.

Cosgrove continues, "With antibiotic stewardship, our levers were still in development, so I think there is more uncertainty there.  I'm fairly sure the Medicare conditions for participation for long-term care are going forward since they were essentially finalized and meant to go into play at the end of November. But the acute-care conditions -- which have infection prevention language also -- will probably be on hold for a little while, and hopefully not permanently. Fortunately, this is not really a partisan issue. The fact that the Joint Commission has put forth the standard on antimicrobial stewardship which goes into play on Jan. 1, 2017, will allow us to move forward. Hospitals tend to respond more to accreditation standards than they do these global conditions for participation, so from that standpoint I think that lever is still in place. SHEA is a relatively small organization and so we don't have a lobbying arm; however, I think we can work strategically within our own membership because many of our members are in academic settings in institutions that have government affairs staff and we may be able to rally the troops beyond just our membership. We will also work closely with APIC and IDSA when appropriate in order to have a united front."

Healthcare epidemiologists and infection preventionists have a critical role to play in advocacy work, Crosgrove says, from the standpoint of holding steady on existing work. "I think there is value in just pushing forward with the message we are already giving to hospital administrators, and that is,  maybe we don't have acute-care conditions for participation but we have a Joint Commission standard and we need to move forward and increase the resources that are available to make sure we have good infection prevention and antimicrobial stewardship programs. We recognize that something could happen with the Affordable Care Act and value-based purchasing in 2017, but for now, we need to focus on how we have implemented solid work to have the safest environment possible for patients, so why would we stop doing that? So I would advise people to persevere with their current good work and all we can do right now is watch and see -- we may not be at risk at all."

Regarding a state of readiness to follow antimicrobial stewardship mandates that exist, Cosgrove remarks, "Speaking first for acute-care, I have been very happy and reassured to see that many more hospitals are having discussions about what stewardship looks like for them, examining more closely the different models they think will work with their institution's infectious disease mission, and ensuring that pharmacists without infectious disease training get some knowledge. I think we have come a long way from even five years ago when it was really only the academic medical centers that had antimicrobial stewardship programs, to having this renaissance of many more institutions getting involved in antimicrobial stewardship.  It's important that as a group, we make sure that implementation is going well. One of my passions is that we not have people say for the purpose of a Joint Commission visit that they have identified a physician and a pharmacist to lead their program and they have an IV-to-PO conversion program in place and that's their entire stewardship effort. Obviously, to combat antibiotic resistance we have to have serious, well-implemented and actionable stewardship programs. We can't ask for too much too soon, and so the fact that people are getting organized and are thinking about this seriously, is a wonderful first step; we also want to encourage everyone to think about this -- not just the leadership of a stewardship program but all antibiotic prescribers."

Cosgrove continues, "Another critical component is to take it outside of the acute-care hospital and so I think we'll be watching with great interest how stewardship is implemented in the long-term care setting. I know there is a great deal of interest in supporting that work, and recognizing staffing challenges in that environment. We continue to work with our colleagues who are SHEA members and who work in long-term care environments to truly understand what's helpful and how we can assist them in their valiant efforts of doing more with fewer resources. We must also think about the ambulatory setting; now that the CDC has released its core elements document for stewardship in the ambulatory setting, we have the triad in place."

Cosgrove, along with a colleague, will be undertaking an AHRQ-funded research project to conduct true implementation work in antibiotic stewardship across the three settings. "It's broken down into several phases, the first being putting together a toolkit," Cosgrove explains. "It will address issues such as safety culture and behavioral change about antibiotic prescribing. AHRQ has made a significant investment in antibiotic stewardship and it's important to recognize that because there is concern the agency's funding could be affected by the Administration change."

Cosgrove adds, "One feature that crosses all infection prevention and patient safety initiatives is that we must do a better job in implementation. Essentially, how do we take what we know to be good evidence of anything that helps a patient have a safer hospital stay, and how do we make that be the standard practice? We are not so good at that across the country, and so AHRQ has been a leader in providing funding for true implementation work; I fear if that were to go away, we would understand the practice but fail to implement that practice. When we talk about implementation, it's not just stewardship implementation, it's also implementation of hand hygiene, prevention of SSIs, and other key basics. I feel we often get lured by the siren song of new technology and I think hospital administrators sometimes do too, and I get why it is more enticing to spend on technology than on more people. However, we shouldn't just throw up our hands and say technology will save us, when we haven't implemented basic practices. It's a harder approach because it involves behavior change, constant education and human-to-human interaction, but it is important that we not lose sight of that work."

To that end, Cosgrove says a project funded by the CDC and underway currently at Johns Hopkins Hospital opened her eyes to the need to reassess old presumptions. "We are interested in understanding more about how hospital rooms are cleaned so we are conducting a qualitative research project on environmental services workers' perceptions of their job. We want to learn about what they feel is hard about their job and how they view their role as part of the healthcare team. We haven't stopped to talk to the actual human beings doing the cleaning and how is it going; we need to ask them if they have the right tools for the job and we must ask them about what they perceive as the barriers to good cleaning and disinfection. These are the people who need to be considered as part of the healthcare team, and we have sometimes failed to include EVS workers, medical assistants, CNAs, those who interact with patients. We perhaps don't provide enough attention in our infection control work to these people who are so important."

Cosgrove emphasizes a return to not only the basics but a real-world approach to infection prevention and control. "SHEA has put some thought into whether it should be writing guidelines or whether it should be writing guidance documents instead," Cosgrove says. "There are so many issues in infection prevention and control that do not have a strong evidence base, so we all struggle with the same issues but there's not a paper we can point to that necessarily fully answers our questions. So SHEA has moved more into the area of developing guidance documents. One example that has been very popular is last year's guidance on animals in the hospital environment and how to balance the importance of interaction with the animal but not having an animal-associated outbreak. Our upcoming work includes three guidance documents of interest. The first is in the stewardship arena, looking at legal issues; this is an area that has not been investigated that much and we always get questions about it. Another guidance document in the works looks at how we diagnose infection and how we use antibiotics in the best possible way in the long-term care setting. I think it's a significant issue for practitioners in that setting. The third impending guidance document focuses on issues relating to anesthesia processes and infection prevention. By opening ourselves to writing guidance documents as opposed to guidelines, it allows expert opinion to play a role;  I think for our membership, this may be more helpful than calling something a guideline and being more tied to the literature, which in infection prevention can be challenging."

Let's take a look at other imperatives for the New Year.

HAI Action Plan Target Goals
In late 2016, the U.S. Department of Health and Human Services (HHS) announced new targets for the national acute-care hospital metrics for the National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination (HAI Action Plan). The target goals, which use data from calendar year 2015 as a baseline, replace the previous targets that expired in December 2013. The measures will track population-based harm from healthcare-associated infections (HAIs) at the national level. These measures address the following goals from the HAI Action Plan:
- Reduce central line-associated bloodstream infections (CLABSI) in intensive care units and ward-located patients
- Reduce catheter-associated urinary tracts infections (CAUTI) in intensive care units and ward-located patients
- Reduce the incidence of invasive healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA) infections
- Reduce facility-onset methicillin-resistant Staphylococcus aureus (MRSA) in facility-wide healthcare
- Reduce facility-onset Clostridium difficile infections in facility-wide healthcare
- Reduce the rate of Clostridium difficile hospitalizations
- Reduce surgical site infection (SSI) admission and readmission
- Adherence to process measures to prevent surgical site infection (SSI)

The initial set of acute care hospital targets and metrics included a measure on Surgical Care Improvement Project (SCIP) processes. That measure is no longer part of the HAI Action Plan because these processes are now widely accepted as standards of practice. To access the action plan overview, visit: https://health.gov/hcq/prevent-hai-action-plan.asp

Long-Term Care
On Sept. 28, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a final rule to make major changes to improve the care and safety of the nearly 1.5 million residents in the more than 15,000 long-term care facilities that participate in the Medicare and Medicaid programs. The policies in this final rule are targeted at reducing unnecessary hospital readmissions and infections, improving the quality of care, and strengthening safety measures for residents in these facilities. These changes are an integral part of CMS’s commitment to transform our health system to deliver better quality care and spend U.S. healthcare dollars in a smarter way, setting high standards for quality and safety in long-term care facilities.

The health and safety of residents of long-term care facilities are our top priorities,” said CMS acting administrator Andy Slavitt in a statement “The advances we are announcing today will give residents and families greater assurances of the care they receive.”

To learn more about these efforts to support person-centered care and improved safety for long-term care facility residents, visit the CMS Blog at http://blog.cms.gov/2016/09/28/commitment-to-person-centered-care-for-long-term-care-facility-residents/.

As the first comprehensive update since 1991, this rule will bring best practices for resident care to all facilities that participate in Medicare or Medicaid, implement a number of important safeguards that have been identified by resident advocates and other stakeholders, and include additional protections required by the Affordable Care Act. CMS received nearly 10,000 public comments, which were considered in finalizing this rule.

Changes finalized in this rule include:
- Strengthening the rights of long-term care facility residents, including prohibiting the use of pre-dispute binding arbitration agreements.
- Ensuring that long-term care facility staff members are properly trained on caring for residents with dementia and in preventing elder abuse.
- Ensuring that long-term care facilities take into consideration the health of residents when making decisions on the kinds and levels of staffing a facility needs to properly take care of its residents.
- Ensuring that staff members have the right skill sets and competencies to provide person-centered care to residents. The care plans developed for residents will take into consideration their goals of care and preferences.
- Improving care planning, including discharge planning for all residents with involvement of the facility’s interdisciplinary team and consideration of the caregiver’s capacity, giving residents information they need for follow-up after discharge, and ensuring that instructions are transmitted to any receiving facilities or services.
- Allowing dietitians and therapy providers the authority to write orders in their areas of expertise when a physician delegates the responsibility and state licensing laws allow.
- Updating the long-term care facility’s infection prevention and control program, including requiring an infection prevention and control officer and an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.

CMS set out to revise the long-term care facility standards and originally issued the proposal being finalized today, in conjunction with the White House Conference on Aging in 2015, which marked the 50th anniversary of Medicare and Medicaid. The final rule is available on the Federal Register at https://www.federalregister.gov/public-inspection/.

Additionally in the long-term care arena, the Joint Commission and the CDC are in the process of identifying strategies for improving nursing home infection measurement. While multiple risk factors often put more than 1.5 million U.S. nursing home residents at risk for common infections and high rates of preventable adverse events due to infection, little is known about the challenges nursing homes face in implementing a standardized measurement program to track infections. To address this gap, The Joint Commission’s Department of Health Services Research is conducting a 12-month study of nursing home infection measurement supported through a research contract from the Center for Disease Control and Prevention’s (CDC) Antibiotic Resistance Solutions Initiative.

The study will utilize the CDC’s National Healthcare Safety Network (NHSN), a measurement system for infection rates at U.S. healthcare facilities. NHSN provides a free, systematic way to track infections, identify problematic trends, measure progress with prevention strategies and help reduce the prevalence of healthcare-associated infections. NHSN’s Long Term Care Facility component was released in 2012, but only a small percentage of more than 16,000 nursing care facilities have enrolled.

The Joint Commission’s study “Implementing standardized measurement of infections in nursing homes: challenges and facilitators” will: train a new cohort of nursing homes to enroll and initiate data reporting into the CDC National Healthcare Safety Network for infections caused by Clostridium difficile and multidrug-resistant organisms; measure organizational and individual characteristics and perceptions known to affect the ability to successfully implement quality improvement initiatives; and prospectively identify challenges and facilitators to implementation and analyze these factors relative to organizational characteristics.
The results of the study will inform policy makers on how prepared nursing homes are to implement standardized measurement of infections. Most importantly, standardized measurement has the potential to benefit residents and families. The overall goal is to prevent healthcare-associated infections.  Understanding infection rates helps target improvement efforts.
“Standardized measurement of infections is critical to improving health, enhancing patient safety, and reducing morbidity and mortality, and this study will help uncover the challenges nursing homes face when enrolling and collecting National Healthcare Safety Network data,” says Beth Ann Longo, RN, NHA, MBA, MSN, associate project director in the Department of Health Services Research, Division of Healthcare Quality Evaluation, at the Joint Commission. “As more nursing homes participate in the CDC’s National Healthcare Safety Network, benchmarks for healthcare-associated infections can be determined—which aids national efforts to understand the spread and prevention of infections.”

Antibiotic Stewardship
Antibiotic stewardship will be a key driver of interventions for 2017. Antibiotic overuse has contributed to the growing problem of C. difficile infection and antibiotic resistance, and although progress has been made, more work is needed to address Clostridium difficile infection and CAUTI. In response to this challenge, the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS) have both developed initiatives for antibiotic stewardship. HHS has also developed an Agency Priority Goal to increase antibiotic stewardship programs.

Antibiotics have been a critical public health tool since the discovery of penicillin in 1928, saving the lives of millions of people around the world. Today, however, the emergence of drug resistance in bacteria is reversing the miracles of the past eighty years, with drug choices for the treatment of many bacterial infections becoming increasingly limited, expensive, and, in some cases, nonexistent. The Centers for Disease Control and Prevention (CDC) estimates that drug-resistant bacteria cause 2 million illnesses and approximately 23,000 deaths each year in the United States alone. Thus, combatting antibiotic resistance has become a priority for both the White House and the Department of Health Human Services (DHHS) Secretary. In response to outgoing-President Barack Obama’s Executive Order: Combating Antibiotic-Resistant Bacteria (CARB), the National Strategy and the National Action Plan for CARB were developed to provide a roadmap to guide the Nation in rising to this challenge. One of the core strategies within the action plan is improving the use of antibiotics, also known as antibiotic stewardship. This Agency Priority Goal (APG) will help advance efforts related to antibiotic stewardship in hospitals, where complications of and risk factors for antibiotic resistance are most concentrated. The APG also aligns with the strategic goals listed in the 2014-2018 HHS Strategic Plan.

At least one-third of antibiotics used in inpatient settings are either unnecessary or inappropriately prescribed. Antibiotic stewardship interventions have been proven to improve individual patient outcomes, reduce the overall burden of antibiotic resistance, and save healthcare dollars. Implementation of antibiotic stewardship programs in hospitals will help ensure that hospitalized patients receive the right antibiotic, at the right dose, at the right time, and for the right duration. Improved antibiotic use leads to reduced mortality, reduced risk of Clostridium difficile-associated diarrhea, shorter hospital stays, reduced overall antibiotic resistance within the hospital, and increased cost savings. Despite all of these benefits, the uptake of antibiotic stewardship programs and interventions among U.S. hospitals is variable. Data from 2014 show that only about 40 percent of U.S. acute-care hospitals report having antibiotic stewardship programs that incorporate all of the CDC Core Elements for Hospital Antibiotic Stewardship Programs.

HHS OPDivs and STAFFDivs are exploring a variety of strategies to accelerate the implementation of high-quality antibiotic stewardship programs in hospitals. These include:
- Working with existing quality improvement efforts (e.g., Quality Improvement Networks-Quality Improvement Organizations (QIN- QIOs)) to enhance stewardship programs
- Working with state health departments to support the implementation of stewardship programs
- Conducting research to build the evidence base that will support stewardship programs and interventions and to develop improved methods for conducting stewardship and for promoting the implementation of stewardship programs.
- Developing tools and recommendations and disseminating them to help with implementation of stewardship programs and interventions, and raising awareness about the importance of implementing stewardship programs as part of the National Strategy for CARB
- Increasing data for action by expanding enrollment in the National Healthcare Safety Network’s Antibiotic Use Option.
- Exploring regulatory/accreditation mechanisms to enhance compliance with antibiotic stewardship program recommendations.
- Developing diagnostic tools to allow clinicians to swiftly determine appropriate treatments for infected individuals and use antibiotics effectively.
- Identifying new treatment strategies to optimize and preserve the use of currently available antibiotic agents for healthcare-associated and drug-resistant pathogens.

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