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From Stewardship to Scopes: Infection Prevention Imperatives for 2018


By Kelly M. Pyrek

Stewardship and scopes are just two issues that are top of mind for stakeholders in infection prevention and healthcare epidemiology for the new year. Let's explore the imperatives, as suggested by leaders in the infection prevention and control community.

Antibiotic stewardship refers to a set of coordinated strategies to improve the use of antimicrobial medications with the goal of enhancing patient health outcomes, reducing resistance to antibiotics, and decreasing unnecessary costs. Antibiotic/antimicrobial stewardship (AS) has garnered a great deal of attention lately as a solution to multidrug-resistant organisms and a diminished pipeline of therapeutics with which to treat them. As we know, the discovery of antibiotics transformed healthcare and significantly improved physicians' ability to reduce morbidity and mortality; however, medical practitioners and researchers soon discovered that bacteria exposed to antimicrobials quickly developed a resistance to those treatments. Today, there is global consensus that resistance to antimicrobial treatment is a critical issue, contributing to rapid spread of multiple organisms for which few treatments are available.  The dramatic reduction in the development and approval of new antibacterial agents complicates this global health problem and portends a future in which many more infections have no effective treatment option, asserts the Society for Healthcare Epidemiology of America (SHEA).

"A critically important issue for 2018 is to continue to champion the clinical impact of infection prevention and control as well as  antimicrobial stewardship," confirms Keith Kaye, MD, MPH, a professor of internal medicine and infectious diseases at the University of Michigan, and incoming president of SHEA. "There's a role that everyone, from patient to provider to healthcare administrator, epidemiologists and public health officials, can play in helping to prevent infection and prevent antimicrobial resistance. And that extends from hospitals to outpatient facilities, to long-term care facilities, as well as to schools and prisons. Stewardship runs across the continuum of healthcare and community institutions."

SHEA is among many entities that support the consistent management of antimicrobials in all healthcare settings as a fundamental step in slowing resistance and improving patient health. The major objectives of antimicrobial stewardship are to achieve optimal clinical outcomes related to antimicrobial use, to minimize toxicity and other adverse events, and to limit the selection for antimicrobial resistant strains. Antimicrobial stewardship may also reduce excessive costs attributable to suboptimal antimicrobial use.

"I think we know a lot more about stewardship and infection prevention today more than we have known 10 or 15 years ago, but one of the big challenges has been implementation," Kaye continues. "Meaning we take what we know -- things like optimal hand hygiene practices or optimal environmental hygiene practices -- and implement them in a way so that there is buy-in and top-level compliance with these efficacious interventions. SHEA has been supportive of implementation science but I think coupling that with simple as well as technically more advanced aspects of infection control and stewardship is on a short list of things that we need to continue to push forward in 2018."

Addressing gaps is critical, according to Kaye, who emphasizes that many institutional infection prevention and epidemiology programs lack resources and support. "We don't bill for infection control and AS services, as these are prevention- and cost-avoidance-type ventures," he says. "Unfortunately, many times budgets for infection prevention and AS are on the chopping block among the members of the hospital C-suite. Without adequate effort and time and data management and administrative support, it is very difficult to get things done in infection prevention and AS. While resources and support decrease, I think our knowledge and the work required of us has grown significantly. For example, we know so much more about  C. difficile, what antibiotics we know are particularly risky, what types of drugs and interventions are newer and effective, like fecal transplants, but when we try to implement that knowledge -- such as which technologies and treatments to implement, how to get healthcare workers to change their behavior, not only knowing what the right thing to do is bit actually doing it, like washing hands, proper donning of gloves and gowns, or stopping antibiotic X on day seven because it's adequate treatment based on recent studies -- we encounter challenges. We must address how to cultivate healthcare professional  behavior changes that become automatic. But they also must stay mindful in order to consider these habits and why they must engage in proper practices."

Kaye continues, "Implementation science is about impacting behavior, where you make systems changes, things that systemize and obviate key steps or avoid unnecessary decision-making and when you can force systems to push providers in the right direction, that's always a plus. So, various aspects of implementation science, behavior change, process change at system levels, are some examples where we have learned a great deal, but in many ways, we are still at the toddler stage of this quality improvement venture, particularly around behavior modification of healthcare workers. I think there is a lot more that can be done in terms of optimizing process in healthcare systems to prevent infection and to prevent antibiotic and antimicrobial resistance."

In 2014, the President’s Council of Advisors on Science and Technology (PCAST) released a report to the President, "Combating Antibiotic Resistance." The report was released simultaneously with a National Strategy on Combating Antibiotic Resistant Bacteria as well as with a Presidential Executive Order, emphasizing to the Nation the importance of addressing this growing challenge. In late 2017, the World Health Organization (WHO) sounded the alarm that the world is running out of antibiotics with which to combat the growing threat of antimicrobial resistance. The WHO report, "Antibacterial Agents in Clinical Development: An Analysis of the Antibacterial Clinical Development Pipeline," explains that most of the drugs currently in the clinical pipeline are modifications of existing classes of antibiotics and are only short-term solutions. The report found very few potential treatment options for those antibiotic-resistant infections identified by WHO as posing the greatest threat to health. Earlier last year, WHO identified 12 classes of priority pathogens – some of them causing common infections such as pneumonia or urinary tract infections – that are increasingly resistant to existing antibiotics and urgently in need of new treatments.

The 2017 WHO report identifies 51 new antibiotics and biologicals in clinical development to treat priority antibiotic-resistant pathogens, as well as tuberculosis and Clostridium difficile. Among all these candidate medicines, however, only eight are classed by WHO as innovative treatments that will add value to the current antibiotic treatment arsenal. There is a serious lack of treatment options for multidrug- and extensively drug-resistant M. tuberculosis and gram-negative pathogens, including Acinetobacter and Enterobacteriaceae (such as Klebsiella and E. coli) which can cause severe and often deadly infections that pose a particular threat in hospitals and nursing homes.

While much work remains to be done, Kaye emphasizes that there is a glimmer of hope: "Antimicrobial stewardship is much more in the public vernacular these days, and both consumers and lawmakers are talking about it along with healthcare professionals and public health officials," he says. "it's good news that healthcare workers, and not just infectious disease physicians or pharmacists, are aware of this critical issue. There are still a few areas in which we have limitations; No. 1 being metrics -- how can we measure stewardship in a way that is generalizable across different types of hospitals, with different types of patients, that cater to different specialties? These metrics need to be better defined. Also, it is important to align national healthcare goals with stewardship efforts, to align what we think are critical issues with public policy, and with CMS as well as with existing political infrastructures to come up with what we think are good solid stewardship goals for hospitals to follow that will attack antimicrobial resistance. We are continuing to focus on having SHEA take more and more of a leadership role and be a vanguard in public policy as it relates to stewardship issues. SHEA partners with IDSA and other organizations, and together, we promote stewardship and drive policy. Unfortunately, given the complexities of U.S. healthcare, and given the fact that many healthcare workers are overburdened and don't have a lot of extra time, progress might be slower than we would like. It also takes financial incentives, policy requirements or accreditation requirements to move the needle, so to speak, to impact change in healthcare worker behavior in hospitals and other healthcare settings. I think the Joint Commission implementing antimicrobial stewardship standards, has been a critically important landmark in the past several months. I look forward to continuing to see stewardship grow in healthcare institutions of all sizes everywhere."

Janet Haas, PhD, RN, CIC, FSHEA, FAPIC, of Lenox Hospital in New York and president-elect of the Association for Professionals in Infection Control and Epidemiology (APIC), emphasizes the role that nurses and infection preventionists can play in antibiotic stewardship across the continuum of care. "That is something that people with expertise among our membership is thinking about deeply and trying to determine the best way that we can help in this very important work," she says. "Most likely that will be serving as a bridge to frontline healthcare providers and especially nursing staff who were under-appreciated in this role until that paper by Rita Olans and colleagues (Olans R, et al. Good Nursing Is Good Antibiotic Stewardship Am J Nurs. Vol. 117, No. 8. August 2017) said, 'Hey, nurses are pivotal to all of this, as they are the ones seeing these patients daily.'

However, many staff nurses are not familiar with the concept of antibiotic stewardship and so we are socializing that message and figuring out how we can help that practice. We want to ensure the communication among healthcare personnel about antibiotics in a very clear way so that the course duration isn't misunderstood during transfers of care, such in long-term care, for example, where it may not be clear to the receiving end what day the patient is on. We also want to get the word out to ambulatory-care sites about the true indications for starting patients on antibiotics. We want to work with the public so they can understand the ramifications of getting that course of antibiotics if they don't need it; clinicians who serve people in primary care are under enormous pressure to administer antibiotics, so we are trying to help with that communication. I think we have a unique role because we are seeing a patient not just on this unit or in this place, but having more of an overarching view, and so we as IPs are trying to make sure that people know what to do in the various care settings where antibiotics are being prescribed, and then helping to see how that moves across care for that patient. And recognizing when patients come back into a facility, that if they have had antibiotics they may be at a greater risk for C. difficile -- which, of course, is another priority around which we need to better work."

Outbreak Preparedness
Late last year, the Society for Healthcare Epidemiology of America (SHEA), with the support of the Centers for Disease Control and Prevention (CDC), issued a new expert guidance document for hospitals to use in preparing for and containing outbreaks. The guide was published in the journal Infection Control and Hospital Epidemiology.

"This guidance details the role of the healthcare epidemiologist as an expert and leader supporting hospitals in preparing for, stopping, and recovering from infectious diseases crises," says David Banach, MD, co-chair of the writing panel and assistant professor of medicine at the University of Connecticut and hospital epidemiologist at UConn Health. "Armed with the resources to develop and support key activities, healthcare epidemiologists can utilize their skills and expertise in investigation and response to infectious disease outbreaks within a hospital's incident command system."

SHEA and CDC collaborated in 2016 to form the Outbreak Response Training Program to guide healthcare epidemiologists in how to maximize their facilities' preparedness and response efforts to combat outbreaks such as Ebola, Zika, pandemic influenza, and other infectious diseases. The new document, "Outbreak Response and Incident Management: SHEA Guidance and Resources for Healthcare Epidemiologists in United States Acute-Care Hospitals," leads epidemiologists through how to apply, use, and interact with emergency response structures, groups, and frameworks from the institutional to the federal levels, and provides an overview of essential resources. The principles in the guidance are intended for acute-care hospitals, but may apply to other types of healthcare facilities, such as free-standing emergency departments and long-term care facilities.
According to the guidance document, during a crisis the epidemiologist provides medical and technical expertise and leads infection prevention and control efforts, coordinates with institutional stakeholders, and provides input into internal and external communications.
"We will always be faced with new and re-emerging pathogens," said Lynn Johnston, MD, co-chair of the writing panel and professor of medicine and infectious diseases at Dalhousie University, Halifax, Canada. "This guidance is part of an ongoing effort to develop tools and strategies to prevent and manage contagious diseases to ensure patient and public safety."

The document is part of a partnership between SHEA and CDC to prepare for emerging and re-emerging infections by providing training, educational resources, and expert guidance for dealing with outbreaks in healthcare facilities. The program is designed to train U.S. healthcare epidemiologists, who oversee infection control programs, to have the skills, abilities, and tools available to implement infection control practices and provide a leadership voice in responding to infectious threats. To operationalize the guidance, SHEA will conduct an outbreak response workshop in January, develop and post toolkits based on the recommendations, and provide online training modules and webinars.
While the world waits for the next pandemic, SHEA's Kaye emphasizes that there is much that can be done at home to prepare for an outbreak, large or small, including an outbreak of insidious influenza.

"No matter what else of going on with emerging and re-emerging pathogens, I always think about flu," says Kaye. "Influenza is something that healthcare providers must think about year-round, as mentally we must always be preparing for the next flu season.  Flu is a killer, and I feel it is our duty to get vaccinated to protect our patients. We know that Zika pops up, we had Ebola a few years back, and we never know what's going to hit next, but in general, there is preparedness work that can be done year-round that will pay dividends regardless of what the pathogen is. This preparedness work includes partnering with your public health department at the state or local level, conducting drills for different types of infectious threats, or seeing to stockpiles of personal protective equipment. By preparing for contagious outbreaks with pathogen x or y or maybe something like flu, it helps shore up general preparedness. Training is critically important, as is having a good communication flow within your institution, as well as between your facility and your state and local public health departments. Preparedness never ends, and it isn't outbreak- or pathogen-specific. Preparedness can be effective for all infections and improve infection prevention and control in general by reminding providers about proper practices. We never stop preparing because the next pandemic is around the corner. Having a plan is critical for protection and safety of patients as well as healthcare workers.

Cultivating a Culture of Patient Safety
Cultivating and maintaining an institutional safety culture is a significant underpinning of patient safety, emphasizes Amber Wood, MSN, RN, CNOR, CIC, a senior perioperative practice specialist with the Association for periOperative Registered Nurses (AORN). "The top issue that we have been working on at AORN is team communication and developing that patient safety culture," she says. "This kind of culture is essential to achieve successful outcomes, including the prevention of SSIs. Part of the patient safety culture includes team communication elements, including checklists, handover communications, briefings and debriefings, specific communication tools that can be implemented during the perioperative phase that can engage the team in conversation and part of supporting that patient safety culture and it's important for teams to be involved in the development of the tools and checklists and this is part of having high-reliability teams, so teams that are successful are continually evaluating the work that they are doing and the role of each team member on that team and what they are bringing to the table. Another element of this is team training; we recommend formal team training programs to use these tools and help improve communications."

Wood continues, "This concept can help prevent surgical site infections (SSIs) because facilities have created a culture in which people are free to speak up, and they are verifying that their evidence-based practices for infection prevention are being achieved. So, one example of this is ensuring the patient received his/her antibiotic preoperatively, which would be part of a preoperative checklist. Debriefing at the end of the surgery and ensuring that if this patient is at high risk for an SSI, we need to make sure we have passed off these communications for the next phase of care. Debriefing among the team and discussing how they could have done something much more efficiently in reducing the time the surgical site was open and thereby reduce the risk for an SSI. Or witnessing a break in sterile technique and feeling comfortable enough to speak up to any member of the team and say, 'You contaminated your glove' or 'You breached the sterile field,' and that provides a safer environment in which to facilitate patient safety."

Wood says she sees two trends in the SSI prevention arena: "The first is considering the role of the microbiome and antimicrobial stewardship when selecting interventions, such as antibiotic selection, testing the patient for staph colonization, considering decolonization protocols (whether with an ointment of with an antiseptic solution), looking at patient bathing and not just preoperatively but post-operatively as well, and how clean the patient is and considering the role their microbiome plays in the development of infection." She continues, "The other SSI prevention trend is looking at the patient in a more holistic way, looking at their recovery, so not isolating one element from another. For example, making sure they have good nutrition preoperatively and post-operatively to improve wound healing, which then reduces the risk of an infection developing. And mobilizing the patient early after surgery to get them moving, prevent pneumonia, get their body healing. Teaching the patient how to care for their wound. We think that the ERAS protocol -- standing for enhanced recovery after surgery -- is advancing in healthcare these days, with detailed protocols that address how to recover patients as quickly as possible, since quicker healing is less likely to be associated with post-surgical complications."

Wood says that in 2018, AORN will be issuing one new guideline and several updated guidelines. The new guideline, Guideline for Team Communication, provides instruction on cultivating and maintaining the aforementioned safety culture. The revised guidelines include updated guidance on patient positioning, medication safety, prevention of venous thromboembolism, medical device and product evaluation, as well as manual chemical high-level disinfection. "In this last revised guideline, we are emphasizing that manual high-level disinfection is not ideal, as there are human factors involved," Wood says. "Any time we can automate or use a mechanical process, that is ideal when the manufacturer's instructions for use (IFU) allow it. And regarding the hot topic of high-level disinfection versus sterilization of flexible endoscopes, it has been recommended that when a device is validated for sterilization, that it ought to be sterilized because that gives you a greater margin of safety over high-level disinfection that would still leave some microorganisms and spores on a device. Regardless of HLD or sterilization, we continue to emphasize the importance of effective cleaning first."

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