Trends in Infection Prevention and Control: Experts Share Perspectives on Key Issues

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.

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 its difficult to get the CEO's attention when he or she is engaged with other issues. Its 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."

Pay for Performance & Infection Prevention

As of October 2008, the Centers for Medicare & Medicaid Services (CMS) stopped reimbursing for treatment of certain types of HAIs that have evidence-based prevention guidelines, including some surgical site infections, and panelists discussed how this has affected their institutions. Most saw this development as an opportunity to raise awareness and capture people's attention about HAIs.

"The effect is not all negative," Mitchell says. "There is a certain galvanizing quality to the challenge for us to focus on the HAI prevention arena because we can see directly how this is affecting our ability to fund our indigent care and other things we care about in this system. We are looking for ways to reduce costs like everybody else these days, and we see this as a tool that everyone can get behind. Our prevention and control efforts do have a demonstrable impact, and we can cost-reduce while we are delivering better quality, safer care. It has helped everyone understand that this is a good thing for our patients as well as our organization, so I see it as not quite as dark a tool as it has been made out to be."

"I don't know if the impact on reimbursement has really frightened any one particular organization," Murphy says. "In Pennsylvania, for example, there is a law that says a patient cannot pay for any adverse event, nor can an insurer pay for the treatment of an adverse event that occurs during a hospitalization. So payors are paying attention to this -- it's not just CMS, it's all reimbursement agents. It has brought people to the table that we didn't have before, such as the chief financial officer and the chief operating officer. What I find astounding and wonderful is that when they get to the table, they understand the clinical impact on patients, the societal impact on families and we start talking about these prevention measures and what is needed to support their implementation. I think they are happy to be part of that partnership that is doing better things for patients because they are feeling like part of the team now that is creating more reliable healthcare. So, the fear of revenue loss may have been what got them to the table, and of course keeping a healthy bottom line is their primary consideration, but once they start to learn what the clinicians know about preventing these infections, and the horror of the patients and the families who are living with them, I think it has done good things, even if it hasn't yet resulted in the level of financial penalty we thought it might."

Public Reporting

With required CLABSI reporting to NHSN launching this month, our panelists shared their perspectives on public reporting of infections.

"In the main hospital world, we really think this could be helpful because it puts a lot of additional pressure on all of us and our local and system hospital boards because none of those members want to be embarrassed by publicly reported rates that don't match up with the opinion we have of ourselves," Mitchell says. Our real problem is two-fold -- one is the accuracy of the data since so much of it is taken from administrative data sources and billing mechanisms, and that the processing that goes on is really very much a lag data presentation rather than anything that is up to date. Those are two things to fix before this is truly a tool which we can all live with and profit by." Mitchell adds, "I want to see us get better at this. We have introduced several software packages that will help our infection preventionists identify those that should be coded out as infections, and I think we are really working hard at making sure our coding is correct. But as long as the data on most public sites are a couple of years old, it really is very difficult for the public to understand what we are doing. I am hoping that ICD-10 helps us with driving toward more information in charts that will require better coding."

"One of the things I think is a challenge nationwide is there are still many hospitals that have not implemented an HAI reporting system, even though we have mandatory reporting requirements," says Shumaker. "I think another challenge is sufficient allocation of staff resources to be able to support this reporting. In ASCs especially, it is something that must be shored up, as it's being recommended that these centers have a designated infection prevention person, but at present many don't. So the reporting from the ambulatory arena has not been as good as it should be."

Reporting is fraught with challenges, our panelists point out. As Darouiche notes, "I like the stated objectives of public reporting, which would drive us to improve patient care. However, I am very opposed to how reporting is being done. For example, if we take SSI as an example, I can tell you that most reports of SSI rates do not adhere to the CDC definition of SSI. We know that a big portion of SSIs may not clinically manifest until the first or second week after surgery. What is being reported in some instances is the incidence of SSI either at the time of patient discharge from the hospital, which could be as short as a few hours or one day, or upon seeing the patient at his or her first clinical visit which could be as short as one to two weeks post-op. Another thing being done now is that the term 'SSI' is not necessarily mentioned; what is mentioned is that the skin looks inflamed, or that oral antibiotics were given to make sure the patient does not get infected. We know that is not valid. So I am discouraged by the fact that on a number of occasions, there is an element of hiding the data in order to feel good about the outcome." Edmiston says he agrees with Darouiche and adds, "A good example of the challenge of proper definitions is ventilator-associated pneumonia (VAP). If you have five pulmonologists on hand, every one of them would give you a different definition of VAP, and that's a real problem."

Edmiston says he likes the idea of increased transparency and says that surgeons are keeping their infection rates front of mind these days.

"What I have seen over the past three to four years is that surgeons are now reporting their own surgical outcomes," he says. "There was one surgeon who reported his post-op surgical wound infection rate in his group of about 24.5 percent over a three-year period. People might ask, 'Why would you ever report that?' But surgeons like to have good outcomes and when they don't, they are always searching for a reason why. And now we are seeing surgeons publish their own data in the surgical literature, looking at risk strategies and the rate of infection within their practice. I spend a lot of time reading the surgical literature, looking at what my colleagues are reporting and because of this environment of true transparency, you can run but you can't hide. I'm gleaning a lot of information from my surgical colleagues and the rates that they're reporting actually represent the iceberg. I think some of the rates reported under the old system are the tip of the iceberg."

Our panelists acknowledged the presence of "gamesmanship" that sometimes occurs in hospitals that are trying to massage their data for more positive outcomes.

"I actually do think there is gamesmanship in our institutions," says Murphy. "It takes very strong leadership in infection prevention -- and not just among the IPs but the hospital epidemiologists as well -- because the tendency is to explain away an infection. Rather, we need to have open conversations about the surveillance definition of an infection versus the clinical definition of an infection, even if we do or do not agree with those definitions. We explained to our surgeons that we are part of a national surveillance system and that they may be right in the fact that their patient may not clinically have an HAI but it meets the surveillance definition. And in order to participate in a system where we can benchmark, we need to stick to the surveillance definitions."

Murphy says that at her institution, routine data review meetings are held with chiefs of service in attendance, and recommends that whenever possible, other medical staff should be present to understand the definitions and the methodology that are being used in that organization, whether manual or electronic surveillance is being conducted, and what method for case finding is being used. "It's critical that everyone knows what the strict application of surveillance data definitions means, and that a review of the data against benchmarks is being conducted," Murphy says. "Have the medical staff, the physicians and the infection preventionists participate in performance improvement teams where they discuss the prevention measure and drill down on every case -- I find it is a wonderful learning experience for everyone."

Skin Antisepsis

Shifting to clinical issues impacting infection prevention, our panelists turn their focus to skin antisepsis.

"I continue to be amazed by how long it took us to realize the primary source of vascular catheter and post-op surgical site infection," says Darouiche. "if the primary source of organisms is the skin of the patient, why did it take us that long to establish a recommendation regardless of the antiseptic skin preparation used? For example, in 2002 when the CDC came out with its guidelines for the prevention of catheter-related infections, it specifically included recommendation of the use of a chlorhexidine gluconate (CHG)-based preparation to cleanse the skin at the site of the catheter insertion because there were a lot of emerging data supporting this practice. The primary objective of SCIP was to reduce infectious complications by about 25 percent within seven years. I am amazed by the fact that not a single SCIP measure actually addresses skin antisepsis. I believe we in the U.S. have been using what I would call suboptimal antiseptic skin preparation in at least three-quarters of surgeries for decades, without anybody actually saying that we need more recommendations about skin antisepsis -- and we need to do whatever it takes in terms of studies to determine what the optimal antiseptic skin preparation is. Maybe this is the reason why implementation of the SCIP measures has resulted in inconsistent reduction in infection rates. You see a number of articles that show a reduction of infections at certain hospitals yet more recently we see many more articles showing lack of consistent reduction on the rate of SSIs. We see articles coming from the same hospitals where one type of surgery using SCIP measures reduces the rate of infection, while another type of surgery using the same SCIP measures does not reduce the rate of infections. It's awkward as to why we waited that long to start focusing on optimal skin antisepsis for SSI as we have done for two decades with central line-associated bloodstream infections."

Edmiston says he agrees with Darouiche, and believes that the antiseptic agent of choice is CHG. He says that years ago especially in his institution's bariatric service, patients took preoperative showers. "We saw how beneficial that was, so we incorporated them into a number of surgical patient populations to the point that we want every elective patient to have the opportunity to take a pre-admission shower," he says. But Edmiston emphasizes that the pre-op bathing is to be done differently than the way it was analyzed by the Cochrane Collaborative, which saw no benefit in such a practice. We have suggested using a standardized, repetitive process of applying CHG either at home or in the healthcare environment to ensure having high, consistent concentrations of CHG on the skin -- concentrations that are anywhere from 40 to 300 times the inhibitory concentration required to kill skin staphylococci," Edmiston adds. "We published our first paper on this topic in 2008 in the Journal of the American College of Surgeons, and recently we published another paper that we feel completes the circle that when the patient comes in for pre-op antisepsis, they receive another CHG product, either a CHG aqueous product or in the case of our institution, they have the opportunity to be prepped with a 2 percent CHG/70 percent isopropyl alcohol. I think this represents state-of-the-art skin prep. While I do appreciate the fact that there are other preps out there, I think the data is pretty overwhelming in showing that you can achieve exceptional skin antisepsis with great persistence by using a CHG formulation."

Shumaker says she has experienced a great deal of resistance to pre-op bathing among outpatients and says it is an issue that must be resolved if infection rates are to be curbed. "At an ASC I opened in South Dakota, we had a lot of non-compliant patients, and their hygiene was not the best," she says. "We instructed them to bathe the night before surgery but they weren't all doing that. So we worked with infection prevention to send our patients information about the importance of pre-op bathing and packets of products, trying not to offend them. It's a huge challenge that we continue to have. I also worked at a large inner-city hospital where we had many patients coming in whose hygiene was less than desirable. They do not bathe and unless we start offering them a way to bathe before they come in, or just prior to surgery, I think we are going to continue to see problems with SSIs."

Mitchell reports that his institution has recently reached consensus among its large number of physicians about moving to a CHG product for all skin prep. "I think that will help us tremendously," he says, adding. "The places in which we have piloted this practice have had some pretty dramatic results. It's been a lot longer that we have been arguing for antisepsis it was 1847 when Semmelweiss figured out that a colleague who cut his finger after delivering children died of puerperal sepsis. To show you how hard it was to argue for hygienic practices, Semmelweiss ended up being placed in a mental institution. He died at the age of 47 by cutting his own finger and contracting a skin infection that progressed to sepsis, and he died in that mental institution. That's definitely a perspective on how far we've come and how far we've NOT come."

Guidelines: From Theory to Practice

Following both institutional and professional guidelines are important for infection prevention, so our panelists discussed the challenges they have encountered with translating these guidelines into clinical practice. Murphy says she was surprised to have received a random call recently from the Government Accountability Office (GAO) which was conducting a survey about the effectiveness of some of the national patient safety and infection prevention programs. "They brought up the idea of guidelines and the fact that they take too long to develop and update and that it's very hard to tease out the most important practices, so this is a good topic of focus," she says. "The CDC, working with the University of Pennsylvania, has done a fabulous job at streamlining the whole guideline development process, and then working with the professional societies on translating the 'must-dos' to frontline healthcare professionals. A guideline that is hundreds of pages long -- how can a busy healthcare professional have any sense of what is in that guideline and what their responsibility is in preventing that type of infection? So SHEA, IDSA, APIC, the Joint Commission and other partners created the compendium of strategies to prevent infection. And APIC has created many elimination guides. When the Institute for Healthcare Improvement (IHI) first started the concept of the "Lives" program, they did a phenomenal job of promoting the bundle concept. And the CUSP program, starting with the Michigan keystone project, produced tremendous evidence about the ability to eliminate CLABSIs. It's really about packaging the information and addressing the culture, the teamwork, the environment in which teams are responsible for implementing guidelines and how they have a responsibility to help each other do that."

Many quality improvement projects are including checklists as part of the intervention process, and no conversation about guidelines is complete without addressing the idea of checklists, and our panelists raised a few issues.

"I heard an interesting thing at a statewide conference in Pennsylvania," says Murphy. "Dr. Bob Wachter spoke about patient safety and commented about checklists. Although checklists have been a way to package the evidence-based measures that come from the many guidelines and standards, we must beware of checklist fatigue and bundle fatigue. If there are too many checklists, people will start to ignore them. And if you enable them with technology, as we have done in our organization, people become masters at how to jump past a particular screen or a group of fields so that they don't have to engage with every element." Murphy continues, "Unless you are innovative and get your checklists packaged with your central line kits, for example, how do the checklists get into electronic documentation so you can truly measure compliance with particular aspects of a bundle? Guidelines and standards must be built into effective workflows. Our organization has a committee comprised of members of IT, informatics, medicine, surgery, nursing, quality and safety, and infection prevention, which decides how to design the very best clinical practice around a particular area of care, and then enable it with technology, instead of just putting IT solutions on top of what are really bad work practices."

Mitchell says that Peter Pronovost's checklists work well from some clinical tasks, but notes, "We have discovered that checklist-completion compliance is different from task-completion compliance. We essentially use an observation system through wireless telemetry to monitor most of our procedures and ensure that we are actually complying with the checklists." Mitchell continues, "We have put checklist in our kits for central lines, etc. but the key for us is having an electronic observation function that covers 100 percent of our ICU beds. We have 400-plus ICU beds on an electronic system at a central headquarters that looks like an FAA tower. We monitor all compliance with the checklists for VAP and for central line insertion, so that compliance data is returned to the unit in real time. When we started it three years ago, people thought it was Big Brother, but now the staff sees it as a great help in keeping everyone on track. They have also seen infection rates go down."

Edmiston cautions that there is still too much lag time between theory and practice. "There is no doubt that an evidence-based guideline is going to drive patient improvement, but my concern with guidelines is the period of time it takes to put these guidelines together and their responsiveness to data," he says. "A good example is tight glycemic control, and now we are beginning to experience sentinel events. That was never the intent of putting together a risk reduction strategy that created these adverse events for patients. I'm not sure how to do it but there has to be some mechanism in place where as the evidence evolves, we evolve the guideline to optimize patient care."

Gaps in Knowledge

Infection preventionists face the challenge of staying abreast of newly published infection prevention data and how this data is used in decisions about what should become standard clinical practice. Our panelists address how product use is re-evaluated in light of new data. As the HHS Action Plan notes, " In addition to multicenter demonstration projects designed to document preventability using current or existing prevention recommendations, there is a need for additional multicenter collaborative trials that are carefully designed and conducted to establish the efficacy of new preventive interventions and further enhance our understanding of the efficacy of existing interventions."

"I believe that the reasons for the gaps between data and practice is that the data that could be generated regarding the measure for a process or for a product that either is too expensive to purchase or too impractical to implement," Darouiche says. "Glucose control, for example, is labor intensive and time-consuming, and it is not risk-free. The other reason has to do with how studies were conducted. What we usually like to do are randomized, controlled trials , and we like to change only one variable at a time. For instance, for the last study we did on skin antisepsis for prevention of SSIs, we looked at two preparations. We knew that there are major variations in each institution between surgeons as well as between different institutions with regard to other measures. There was a total of 10 different regimens used and we allowed every single one of them but we made sure each hospital had its own randomization schedule to make sure that within a participating hospital there was an equal number of patients who received certain antibiotic prophylaxis versus another, depending on what antiseptic preparation they used in the two groups. Likewise with pre-operative showering. We made sure that the results of the study would apply to a large sector of the population regardless of what other measures are being instituted. We did not want to do a study where antiseptic preparation A would be superior to antiseptic preparation B, only if the patients received a certain systemic antibiotic prophylaxis, because if had we done that, then people would suggest maybe this antiseptic preparation that you proved to be superior is really not superior had we used different systemic antibiotic prophylaxis. I think this has to do with the way studies are conducted that the end user can know that, regardless of what other measures are being utilized to prevent a particular infectious complication, the implementation of a new variable is going to have a consistent reduction in the rate of infection."

Mitchell explains that, "Management of healthcare is a tension between clinicians driving higher quality but oftentimes higher costs, and administrators who are trying to drive down costs and improve either profitability, or for non-profit organizations, accomplishing a mission statement. Until we have enough medical practitioners who understand how to read and evaluate the literature, who understand what arguments need to be made to impact the bottom line, and who can explain the effects from non-reimbursement, we will not make much progress against a strong and entrenched administration. Folks who are knowledgeable about this process must step into these roles so that they can influence hospital boards to adopt what may be more expensive measures -- on the face of it -- that are designed to help us take better care of our patients and get better clinical outcomes which are most often achievable in the long run."

As Shumaker notes, "I think if we can show empirical evidence when comparing what a surgical wound infection is costing our hospital in patient-days, looking at the overall effect and products that can help prevent this, then you have a value-based analysis to present to your hospital leadership. I don't think that's always done and I'm not so sure that clinicians are always very good at that. "

"The question always comes down to, how much evidence do you need?" Edmiston suggests. "I run into scenarios where there's one paper, a randomized, prospective medical trial in a first-tier journal that says a new intervention would be better than the past dogma, and the comment that I get from the administrator is that it is only one paper. At the same time, for example, there are probably 25 papers about a CHG-based catheter site dressing, and that particular product is probably not more than 25 percent of the U.S. market. Glenn is an administrator who is willing to stick his neck out and do a good thing. We don't have a lot of those folks around, and so it becomes very hard for infection preventionists to really drive some of these initiatives at a local level."

What is Preventable?

Our panelists also pondered the current controversy over which HAIs are preventable. The HHS Action Plan defines preventability as "the proportion of all cases of a certain HAI that can be demonstrated as possible to prevent through the careful and concerted implementation of current or existing recommendations and/or guidance."

"They are all preventable," Mitchell emphasizes, "we just haven't found the right means for certain sub-sections of patients. It's critical to understand that they all may be preventable in the long run but we don't understand how to do it yet on a number of very complicated cases. When you get as old as Chuck and me, you realize you were taught a lot of things that were unpreventable and necessary and a common occurrence in medicine -- it may not happen in the next couple of years but it will happen. "

Edmiston chimes in, "I think a good example of the standard of care in this country is a woman who has a mastectomy and is in need of breast reconstruction. If you look at the data on infection in that patient population, the papers will tell you it's between 16 percent and 20 percent. Let's take a woman with a double mastectomy as another example. That woman is going to lose a lot of vascularity; by the time the surgeon has handed the case off to the plastic surgeon you have anywhere between a three- to five-hour period that has elapsed. She gets her first dose of antibiotics from the general surgeon and may get another when the plastic surgeon comes on board, but by that time, she has lost vascularity so there may not be much tissue concentration for the antibiotic in the traumatized wound bed. Plus, she has been under anesthesia for 10 hours. So she may develop a post-op wound problem, which explains why the infection rate is quite high in that patient population. And as Glenn has correctly pointed out, where are the sentinel points that you begin to address to try to reduce the risk in that patient population? It's a very complex picture."

As Murphy notes, "I think when we say they are all preventable, I think we will always be challenged to care for patients who are compromised and very complex, as Chuck described. We have to get a commitment for more research dollars and more people to publish their experiences. We have seen so much published about CLABSI and I think everyone agrees these are among the most preventable types of infections. Harbarth published in 2003 in the Journal of Hospital Infection that 10 percent to 70 percent of HAIs were preventable with appropriate infection prevention measures, depending on the setting, the study design, your baseline infection rate and the type of infection. His conclusion was about 20 percent of all HAIs are probably preventable. If you search the literature and you are getting that kind of information, then for those of us out there pushing the envelope and saying we see many organizations that have been able to get to zero CLABSI -- I think it's tough to get the entire medical community behind this until we start seeing more evidence that is published and I think when you look at every type of infection and include everything -- C diff, it's a little tough to say that every one of them is preventable. We know that getting devices out is probably the best method of preventing infections for these patients. Sometimes it's that balance of is the ventilator or the line or the urinary catheter really necessary for this patient's wellbeing and their continued recovery. Because all devices aren't bad, it's the way they are managed and how long they are left in. I hope people will start to publish their experiences with SSIs that get to zero, many hospitals have published about their deep sternal wound infections going down and staying down. It's absolutely achievable. Is zero sustainable all the time for all patients for every type of infection in any setting? The answer is probably no, but when we focus on zero, every infection that occurs we will treat as a horrible event, a sentinel event that requires an almost immediate root cause analysis. "

And as Shumaker says, "I think what this group is saying that every effort has to be put forth to prevent and whatever measures we can use to prevent them and we have to take into consideration the challenges with age and concurrent disease and nutritional status and length of the operative procedure and damage to the tissue. Once we take those factors into consideration I think we could prevent infections in that population."

Facing the Future

What does the future hold for infection prevention and control? The HHS Action Plan asserts that infection preventionists must address the large knowledge gaps that exist in HAI prevention, and that these are, in part, "the result of barriers to new generation of knowledge that currently exit in U.S. healthcare." The HHS Action Plan also acknowledges, "While knowledge gaps do exist, there is much that has been accomplished." It says that the proposed research plans "have begun to identify the gaps in the existing knowledge base of current infection control practices in hospitals, a necessary first step in the process to develop a coordinated research agenda that will strengthen the science for infection control prevention practices in hospitals. It is critical that we understand why adherence to current HAI prevention recommendations has been suboptimal, that we fully understand the specific limitations that exist in current surveillance strategies, and that we have explored how electronic data can be used to measure process and outcomes."

Our panelists made the following suggestions for a focus for the future:

-- Pre-operative antisepsis

"I think every patient undergoing elective surgery should have the opportunity to either take a pre-admission shower using a standardized process," Edmiston says. "If the patient hasn't showered, they should do a pre-cleansing with a CHG product. I think there is now solid data showing this is a very effective risk reduction strategy. It's also a very inexpensive process relative to the other interventions that we have put into place."

-- Catheter-related infections

"The area that I think has not seen major progress in prevention is catheter-associated bloodstream infections," Darouiche says. "In the United States we insert about 30 million urinary catheters but we insert only 6 million venous catheters, and yet the amount of knowledge we have and our ability to prevent infections is much superior with central venous catheters than it is with urinary catheters. Part of that reason could be due to the high bacterial presence -- millions of CFUs in the catheterized bladder -- compared to having hundreds of thousands of CFUs on the skin around the site of the vascular catheter insertion. We have not done enough investigation that has produced meaningful data, and even today, about two and a half decades after the first antimicrobial catheter was tested here and in Europe, we do not know if they are effective against UTI and not just bacteriuria. We need to put more funds and divert more attention to catheter-related infections."

-- Crafting a national message of HAI prevention

"I think that a key issue is we need to focus on is a national message aimed at healthcare consumers and what they can do to help prevent infections -- preoperatively with the bathing, with the families washing their hands, with the good hygiene," says Shumaker. "Healthcare consumers are smarter, they search the Internet, and the problem is that they get a lot of bad information, so we need to provide reliable information. We like to sweep this topic under the rug, as no one wants to talk about infections." Edmiston concurs, saying, "Our institutions are very good at showcasing our latest surgical procedures or the newest scanning intervention, but you rarely see an article in a facility newsletter or magazine talking about infection prevention or the role of the infection preventionist to reduce risk. The reason for that is intrinsically, institutions don't like to admit that maybe they have infections. There is an old surgical adage that doctors who talk to their patients never get sued. And I agree that if we spent more time talking to consumers about what we are doing, -- because we spend a lot of time talking to each other about what we are doing instead -- we might be much better off in the long run."

-- Incentivizing HAI prevention

"A key issue is making sure that we have harnessed innovation and energy of all of the folks who work in the clinical environment, recognizing those folks and incentivizing those folks is really a key to releasing an incredible amount of energy and innovation," Mitchell says. "We recognize at least one hero among our hospital employees each board meeting and have them meet the board members and be thanked directly by the senior board members -- we make sure that happens so they understand that this is very important to key community and hospital leaders."

"We started the conversation on executive teams incentivized on the elimination of HAIs -- setting that target for zero and having the leadership responsible for the HAI prevention efforts in an organization," Murphy says. "I think we must continue to address the cultural problems that healthcare professionals face, such as speaking up when they see a lack of compliance with prevention measures, to address the power differentials, and to build evidence-based prevention measures into workflow processes and ensure that best practices and evidence-based guidelines are enabled with technology."

At the June 2008 meeting of the Healthcare Infection Control Practices Advisory Committee (HICPAC), the group was asked to prioritize the list of recommended clinical practices and develop a global top 10 list across the entire gamut of HAIs. Murphy says she heard Don Wright, MD, MPH, principal deputy assistant secretary for health at the HHS, speak about the national plan for elimination of HAIs. "He called it a draft list of the top 10 'must-dos' for HAI elimination, and that list touched on key issues such as hand hygiene, the prudent use of devices and reducing device use whenever possible, antibiotic stewardship, creating a culture of safety, and engaging leaders in the practice of infection prevention, and then using data to drive interventions down to the frontline. It's nice to know there is a national effort examining all of the guidelines and the evidence that has been published, determining the absolutes, or the interventions we must do that have been successful at reducing HAIs. I think as a nation we are in a much better place than we were in the past few years, as there has been an incredible change in the culture of safety across the country in making HAIs one of the top things on everyone's lists for elimination. And I think there will be more good news on the horizon."

The full report on this topic, sponsored by CareFusion, may be accessed HERE.

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