HAI Prevention Programs Require Better Adherence to Proven Strategies

When the Department of Health and Human Services (HHS) issued its “Action Plan To Prevent Healthcare-Associated Infections,” earlier this year, it not only cast new attention on this old problem, but it helped identify the key actions needed to achieve and sustain progress in protecting patients. While the field already had a number of guidance documents, the HHS plan adds to the knowledge base about four infections that account for approximately three-quarters of HAIs in acute-care hospitals: surgical site infections (SSIs), central line-associated bloodstream infections (CLABSIs), ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CAUTIs). These infections are exacerbated by the presence of infections due to Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA).

The take-away message of the HHS plan is simple and can be summarized as follows:

• Many HAIs are preventable.

• A systemic approach to reducing the transmission of disease can be more effective than disease-specific approaches.

• Developing and supporting basic and translational studies to address the gaps in the science in this field will allow generation of additional strategies to reduce the risks of HAI transmission.

• It will take a strong partnership between federal and local/state governments and communities to truly help prevent HAIs.

• The education of best practices for providers and other healthcare personnel is critical to prevent HAIs.

• Educating patients on HAIs and how to prevent them is a critical part of the effort.

• An informed media can help promote the education of the American public about the need to prevent HAIs and what HHS and its partners are doing.

• Preventive steps to control and prevent HAIs are cost-effective, save lives, and reduce disability for Americans.

Perhaps one of the most important points of the HHS plan is the call for a vastly improved research agenda relating to HAI prevention. The plan states, “Increased understanding of the basic science underlying HAIs and their associated pathogens will be critical for informing prevention efforts. A coordinated research agenda needs to be developed in order to strengthen the scientific understanding of these infections. Research into the epidemiology of HAIs needs to be broadened. Gaps in the existing epidemiologic knowledge base should be identified with corresponding research projects targeted to fill those gaps.”

The plan adds further that the effectiveness of current infection prevention and control practices in hospitals should be evaluated. HHS says new techniques to prevent HAIs must be identified and that “better implementation of existing practices is needed where the scientific basis for these practices already exists. Interventions that utilize technology to promote HAI prevention and provide clinical decision support, as well as the human and organizational factors affecting adoption of effective interventions in hospitals, need to be studied. Additionally, training grants for clinical HAI researchers could augment the resources addressing these issues. Specific projects for enhancing the implementation and impact of existing, evidence-based practices can then be identified, prioritized, and executed. Lastly, and perhaps most importantly, completely new and innovative approaches will be needed to combat current and emerging challenges related to these infections.”

When the HHS working group reviewed current infection prevention programs and processes, it identified these issues:

1. Adherence to current prevention recommendations has been suboptimal.

The HHS plan says that adherence to current prevention recommendations in healthcare settings has been generally suboptimal, even when knowledge of recommended practices is sufficient. Some studies have shown that simply increasing adherence to currently recommended practices can result in a dramatic reduction in infection rates for some infection types. The HHS plan says a better understanding of the barriers to adherence — and strategies to overcome those barriers — are needed to promote improvements such as the following:

• The use of technology to improve adherence

• Better understanding of human and organizational factors that affect adoption and implementation of effective strategies

• Standardized methods (i.e., performance methods) that are feasible, valid, and reliable for measuring and reporting compliance with broad-based HAI prevention practices that must be practiced consistently by a large number of healthcare personnel, such as compliance hand hygiene, isolation precautions and environmental cleaning practices, in order to prevent infections

2. Demonstrating preventability through multi-center demonstration projects has proven to be an effective strategy for influencing the adoption of recommended practices.

The HHS plan reports that projects involving large numbers of healthcare facilities working collaboratively to decrease HAIs by simultaneously implementing a multifaceted prevention program have been able to demonstrate, through standardized data collection, significant reductions in CLABSIs in ICUs. The HHS plan emphasizes that these projects have likely directly influenced practice by setting new expectations for prevention.

3. Multi-center collaborative trials to establish the efficacy of preventive interventions are needed.

In addition to multi-center demonstration projects designed to document preventability using current or existing prevention recommendations, the HHS plan says there is a need for additional multi-center collaborative trials that are carefully designed and conducted to establish the efficacy of new preventive interventions and further enhance understanding of the efficacy of existing interventions.

4. Limitations in current surveillance strategies exist and there is a need to use electronic data in measuring processes and outcomes.

The HHS plans asserts that a critical component of an effective prevention program is use of standardized process and outcome data as a means to inform those responsible for implementing the program and evaluate its impact, and adds, “Unfortunately, many of the current healthcare-associated infection surveillance strategies are labor intensive and subject to limitations as a result of poor inter-rater reliability in applying standard definitions and variable implementation of case-finding strategies.”

5. Additional research is necessary to strengthen the scientific basis for the acquisition of healthcare-associated pathogens.

The scientific basis for the acquisition (including basic pathogenesis, transmission and colonization) of numerous healthcare-associated pathogens is poorly understood, according to the HHS plan, which adds that more biologically plausible preventive measures may be derived from additional basic, epidemiological and translational research

Gaps in practice knowledge are addressed by the HHs plan, grouped by specific type of infection:

1. CLABSIs

• Biofilms and their relationship to the pathogenesis of device-associated infections

• The prevention of biofilm formation or disruption/removal of biofilms in situ

• Effective strategies and/or techniques for the early detection of CLABSI and for the differentiation of CLABSI from other bacteremias

• Strategies to inhibit or destroy biofilms as a means of preventing device-associated infections

• Use of antibiotic lock solutions

• Impact of daily chlorhexidine bathing on CLABSI rates,

• Impact of chlorhexidine-impregnated sponge dressings

• Utilization of antimicrobial-impregnated catheters

• Optimizing post-insertion catheter care

• Timely removal of catheters when no longer clinically necessary

2. SSIs

• Biofilms and their relationship to the pathogenesis of infections following procedures involving implantation of devices

• Prevention of biofilm formation or disruption/removal of biofilms in situ

• Post-operative risk factors

• Optimizing antimicrobial prophylaxis practices

• Pre-operative bathing with antiseptics

• Pre-operative screening for staphylococcal colonization and/or routine attempts to decolonize patients with antimicrobial agents prior to surgery

• Role of maintaining intra- and peri-operative normothermia

3. CAUTI

• Biofilms and their relationship to the pathogenesis of CAUTIs

• Prevention of biofilm formation or disruption/removal of biofilms in situ

• Effective strategies and/or techniques for the early detection of CAUTI

• Quantification of the contribution of UTI and bacteruria to antimicrobial use

• Role of urinary catheter systems as a reservoir for antimicrobial resistant bacteria and how different types of catheters affect the reservoir composition

• Quantification of unnecessary urinary catheter use

• Role of newer catheter materials and technology in prevention of CAUTI

• Appropriate catheter use in incontinent patients

• Appropriate use of urinary catheters to manage skin breakdown in incontinent patients or nursing home residents

• Role of antiseptics in preventing CAUTI

• Alternatives to indwelling urethral catheters and bag drainage

• Use of new prevention strategies in patients requiring chronic catheterization such as bacterial interference

4. VAP

• Gaps in knowledge about the pathogenesis of VAP lead to inconsistency of both definition as well as diagnosis of the syndrome

• Biofilms and their relationship to the pathogenesis of VAP

• Prevention of biofilm formation or disruption/removal of biofilms in situ

• Better understanding of the contribution of endotracheal tube composition to infection pathogenesis

• Poor understanding of the role of various host factors in the defense against VAP

• Evaluation of the effects of mucosal and pulmonary immunity on the prevention of VAP

• Effect of inflammatory lung injury on the susceptibility to VAP

• Lack of a clear understanding of the relative contributions of the large number of complex and confounding variables/risk factors that influence the development of VAP

• Need a better understanding of the role of broad-spectrum antimicrobials in the development of VAP caused by multiple-resistant pathogens

• Relationship of endotracheal tube-induced bacterial sinusitis to VAP

• Understanding the natural tension between the need for adequate nutrition and the increased risk for aspiration and VAP associated with enteral nutrition

• Role of oral decontamination

• Role of gastric decontamination

• Secretion management/role of subglottic suction

• Role of positioning the patient

• Degree to which less-invasive ventilatory support could reduce the need for positive pressure ventilation via endotrachael tube or tracheostomy and whether this could improve overall outcomes

• Role of antimicrobial impregnated endotrachael tubes

• Impact of internal ventilator filters and ventilator breathing circuit filters on the risk of VAP

• Impact of bundles for improving adherence

5. MRSA infection

• Effective vaccine target antigens

• Determinants of colonization/carriage (host, organism, environment)

• Host determinants in the development of invasive versus soft tissue disease

• Virulence facts associated with MRSA HAI

• Better understanding of colonization and transmission dynamics within the healthcare setting

• Patient characteristics that influence their risk of serving as a reservoir of transmission

• Patient characteristics that influence the risk of acquiring MRSA carriage

• Better understanding of the impact of community MRSA emergence on healthcare-associated MRSA infection

• Preventability of endemic MRSA colonization/infection

• Better understanding of the epidemiology of healthcare-associated MRSA infections that have their onset outside of hospitals

• Role of fomites in the healthcare-associated transmission of MRSA HAI

• Impact of suppressing or eradicating colonization for the purpose of either preventing infection in colonized individuals or preventing transmission to others

• Optimal role for active surveillance for detecting asymptomatic carriage

• Measurement of transmission

• Optimal approach to antibiotic-use controls

6. Clostridium difficile infection (CDI)

• Role of immunity in preventing CDI and the most effective vaccine strategies

• Presence of metronidazole resistance in C. difficile isolates

• Role of the gut flora

• Role of proctitis and/or nontoxigenic C. difficile in reestablishing gut flora ecology

• Basic biology of the sporulation and germination of C. difficile

• Roles of Toxin B and binary toxin in pathogenesis

• Better assessments of incidence/burden of CDI in the United States, including setting of onset and in relation to healthcare exposures

• Methodology for measuring transmission and burden of CDI in non-acute care settings

• Better understanding of the epidemiology of antimicrobial use in inpatient settings

• Role of asymptomatic carriers in healthcare transmission

• Role of C. difficile in neonatal/infant diarrhea

• Better understanding of the incubation period before CDI develops after C. difficile acquisition

• Relative importance of different sources of C. difficile transmission in the healthcare setting (e.g., environment versus healthcare workers) and in relation to CDI burden

• Better understanding of CDI in the community

• Impact of a C. difficile environmental cleaning bundle, role of sporicidal agents (e.g., bleach)

• Role of extending duration of contact precautions beyond duration of symptoms in reducing transmission of C. difficile in healthcare facilities

• Optimal measures to reduce unnecessary antimicrobial use

• Role of gastric acid suppression

To access the entire HHS Action Plan, visit: http://www.hhs.gov/ophs/initiatives/hai/infection.html

HAI Prevention Case Studies

Case Study 1

Clinicians at Jennie Edmundson Hospital (JEH) in Council Bluffs, Iowa, sought ways to reduce catheter-related bloodstream infections (CRBSIs) in its 13-bed intensive care unit (ICU). CRBSIs are potentially fatal, especially for critically ill ICU patients, and they can dramatically increase healthcare costs. Between 500 and 4,000 patients die annually due to bloodstream infections. The Centers for Medicare and Medicaid Services (CMS) estimates that a vascular catheter-associated infection can increase the cost of a hospital stay by more than $100,000 per patient.

Kari Love, RN, MSc, clinical quality specialist in infection prevention at JEH, observed the growing body of scientific evidence implicating mechanical valves and supporting split septum devices in correlation to CRBSI rates, and so Jennie Edmundson elected to convert to the use of a new, simpler design of spit-septum device in the ICU. Accordingly, JEH elected to study the impact of switching from complex mechanical valves, which can harbor bacteria that pose a risk to patients receiving intravenous therapy, to the BD Q-Syte™ Luer Access Split Septum as a method to potentially reduce CRBSI rates.

Under Love’s direction, nurse representatives from multiple departments and disciplines were involved in examining the impact of replacing the needleless mechanical valve which is the access port in a catheter for the administration of fluids, medication and blood.

While the IV catheter is needed to deliver treatment to the patient, the device itself becomes a “portal of entry” for bacteria to enter the bloodstream. Recent studies have indicated that the actual device may have an impact on infection rates. Love and her team conducted a retrospective review of the CRBSI rates in the adult medical ICU population at Jennie Edmundson. During the previous 10-month period prior to implementing the device change they found that there was an average infection rate of 3.045 per 1,000 catheter days (about three per month). Although this rate was below the benchmark reported by the National Healthcare Safety Network of the CDC, she considered it unacceptable. Using BD Q-Syte Devices, Love reduced the infection rate to zero throughout the eight-month period studied.

According to Love, “With the increasing prevalence of drug-resistant infections, it is encouraging to find simple ways to reduce risks to patients.”

Recognizing this significant achievement, Jennie Edmundson has rolled this program out to the remainder of the medical/surgical units and is evaluating the impact of this device in order to attain the goal of zero CRBSIs for all patients. Since implementing the Q-Syte Device house wide, the ICU rate remains at zero 19 months post implementation and the house wide rate has decrease to less than 1 percent, an 83 percent reduction.

Case Study 2

In 2005, a 500-bed hospital in the Midwest began a robust infection control initiative that has proven to be successful in reducing dangerous catheter-related bloodstream infections for patients, and thereby reducing unnecessary costs for the facility.

The protocol is largely based off of the central line bundle recommendations by the Institute for Healthcare Improvement (IHI) and the “Save That Line!” recommendations established by the Association for Vascular Access (AVA). Infection control measures are standardized for both central venous catheter and peripheral venous catheter insertions and include measures such as:

• Using proper hand hygiene. Everyone who touches the line must wash his or her hands with soap and water or an alcohol cleanser, even if gloves are worn.

• Using maximal sterile barrier precautions. The person who inserts the line should be in sterile clothing – wearing a mask, gloves and hair covering. In addition, full body drapes are recommended with use for central line insertions.

• Cleaning the patient’s skin with ChloraPrep (2 percent chlorhexidine/70 percent isopropyl alcohol) solution for 30 seconds.

• Ensuring patency of the device and prompt treatment of occlusions through flushing practices and treatment with thrombolytics.

• Daily review of line for infection and to determine necessity (rotate regularly).

To ensure that infection prevention practices were being used consistently across all staff, the hospital implemented a mandatory annual vascular access course for medical surgical residents and new employees and as part of an ongoing continuing education effort. The course focuses on infection prevention, including proper use of the central line bundle and optimizing barrier protection.

Rigorous surveillance efforts have been instrumental to the hospital’s success in reducing infections. As a policy, if any compliance issues are identified, education is readdressed on those subjects for all staff members. The hospital stands by its “zero tolerance” policy for infection prevention and emphasizes ownership and personal responsibility for all of its clinicians. As leaders in infection prevention, clinicians are encouraged to participate in conferences and help to educate other hospitals on infection prevention protocols.

As a direct result of these efforts, in 2008 there were only two infections (one associated with a central line and one associated with a peripheral line). The hospital addressed the peripheral venous catheter infection by ensuring that clinicians were using a 2 percent chlorhexidine/70 percent isopropyl alcohol solution for skin prep. In 2009, there has only been one infection to date.

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