By Kelly M. Pyrek An increasingly complex
healthcare agenda, including tighter fiscal budgets, evolving technological
advancements, and higher patient acuity, is further complicating a challenging
to-do list for infection control practitioners (ICPs) already struggling with
increasing regulatory standards and antimicrobial-resistant or emerging
pathogens that are spreading with unprecedented speed and virulence. ICPs face
new levels of demands on their time and expertise as they look out for the
welfare of healthcare workers and patients alike.
The paper Chase
A Busy ICP's Top Agenda Items for 2006
By Kelly M. Pyrek
An increasingly complex healthcare agenda, including tighter fiscal budgets, evolving technological advancements, and higher patient acuity, is further complicating a challenging to-do list for infection control practitioners (ICPs) already struggling with increasing regulatory standards and antimicrobial-resistant or emerging pathogens that are spreading with unprecedented speed and virulence. ICPs face new levels of demands on their time and expertise as they look out for the welfare of healthcare workers and patients alike.
Infection Controls Purview is Expanding
In the 2001 white paper, Infection Control and Changing Healthcare Delivery Systems, expert William Jarvis documents the growing transition of healthcare delivery from hospital-based, acute-care facilities to outpatient, transitional care, long-term care, rehabilitative care, home, and private office settings, thus requiring stepped-up infection control and prevention efforts.
Jarvis writes, In the 1970s and 1980s, the acutecare facility was the center of the hospital infection and infection control universe. Most healthcare was delivered in the acute-care setting, and outpatient, long-term, and home care were relatively small, in number of facilities and patients. The growth of the U.S. gross domestic product (GDP) and the proportion spent on healthcare reflect change in healthcare delivery. From 1960 to 2000, the GDP grew nearly 15-fold ... at the same time, the proportion of the GDP expended on healthcare increased from 5.1 percent to 14 percent, a 41 percent increase. This growth, together with the introduction of the prospective payment plan based on diagnostic-related groups, led to marked changes in hospitalization.
From 1975 to 1995, the number of hospitals decreased from 7,126 to 6,291, the number of hospital beds decreased from 1.47 million to 1.08 million, patient admissions decreased by 5 percent, hospital stay decreased by 36 percent, the average length of patient stay decreased by 33 percent, and the number of inpatient surgical procedures decreased by 27 percent. These trends have resulted in fewer and smaller hospitals, more and larger intensive-care units, and greater severity of illness in the hospitalized population. At the same time, reports of nursing shortages and downsizing of infection control departments have been increasing, despite the fact that nearly 2 million HAIs occur each year. Thus, the challenge for infection control departments in acute-care settings will be to focus surveillance activities on populations at high risk, calculate risk-adjusted rates of hospital-acquired infection, and provide feedback to appropriate personnel so that integrated prevention programs can be implemented and interventions evaluated to ensure quality healthcare.1
Jarvis comments, Often infection control personnel are not aware of what populations of patients are being seen or what procedures are being performed in outpatient settings. Furthermore, no systems are in place to collect the needed numerators (infections or adverse events) and denominators (e.g., number of patients with central venous catheters being seen in the clinic) data. Calculating infection or adverse event rates in outpatients and reporting them to ambulatory care personnel will be useful for improving education programs for healthcare workers, as well as the quality of patient care.1
The Evolving Role and Responsibilities of the ICP
To meet this complex healthcare agenda, many ICPs are faced with evolving or increasing job responsibilities. In light of the aforementioned changing healthcare delivery statistics, Jarvis writes, Increasingly, infection control personnel have been expanding their activities to include prevention of infection and other adverse events in long-term care, home-care, and outpatient settings. If we are to prevent infections and other adverse events associated with the delivery of healthcare in the entire spectrum of healthcare settings, we will need to expand the infection control departments in all these settings. Jarvis adds, Because of their expertise in epidemiologic methods, infection control personnel can assist infection control, quality assurance, and medical-error reduction programs in all these healthcare system components.1
Indeed, many ICPs are adding risk management, occupational health, or any number of related activities to their job descriptions.
Jarvis believes that ICPs must expand their efforts to match the expansion of the healthcare delivery system. He notes, Enhanced administrative support for programs to prevent infections and medical errors will be needed if we are to reduce the risk of infection and other adverse events and improve the quality of care in the entire spectrum of healthcare delivery. Now, instead of the acute-care facility being the center of the infection control universe, the infection control department has become the center of the diverse healthcare delivery system.
Infection control departments will need to expand their surveillance of infections and adverse events, and their prevention efforts to all settings in which healthcare is delivered.1
The responsibilities of the ICP are numerous, and include:
- Ensure the facilitys regulatory compliance with imperatives such as Occupational Health and Safety Administration (OSHA)s Bloodborne Pathogens Standard, the Food and Drug Administration (FDA)s regulations on reprocessed medical devices, and recommendations and guidelines from the CDC on topics such as handwashing, post-exposure prophylaxis, prevention of surgical site infections, and disinfection and sterilization
- Ensure the facilitys compliance with state public health laws
- Review of standards from accreditation agencies such as JCAHO or regulatory bodies such as the OSHA to ensure compliance with requirements for accreditation or licensure
- Review of recommended guidelines issued by organizations such as APIC, AORN, the CDC, and the Society for Healthcare Epidemiology of America (SHEA)
- Surveillance for HAIs and comparison to rates collected by the CDCs National Nosocomial Infections Surveillance (NNIS) system
- Conduct investigations of outbreaks
- Perform communicable disease reporting, as outlined by state health departments and the CDC
- Plan and implement staff in-services on pertinent infection prevention and control issues such as handwashing and bloodborne pathogens, and maintain records
- Conduct ongoing review of written policies and procedures based on recognized guidelines and applicable laws and regulations
- Involvement in hospital infection control committees and product evaluation committees
- Consultation on patient-care or employee-health issues
The Importance of IC Programs
Dennis OLeary, president of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) addressed the importance of infection control and prevention in comments he delivered in November 2003 at an infection control conference addressing healthcare-acquired infections (HAIs). OLeary was discussing JCAHOs seventh National Patient Safety Goal, whose two requirements included that by Jan. 1, 2004, all accredited organizations must be in compliance with the CDCs latest handwashing guidelines (issued Ocotber 2003), and that all unanticipated deaths associated with HAIs must be managed as sentinel events (since one root cause of these sentinel events is inattention to handwashing).
In his comments, Leary underscored the need not only for effective infection control and prevention programs, but for organizational leadership that would support and promote an ICPs efforts. JCAHOs patient-safety goals put leaders of healthcare organizations on notice that they are responsible for the effectiveness of their infection control programs,
according to OLeary. If infectious problems arise in the organization and are not properly addressed, the accountability buck stops on the leaders desk. There is now even a separate standard which requires the allocation of sufficient resources to support the infection control program. We will be surveying this requirement closely. In addition, leaders are also responsible for assuring adequate staff training in infection control. Most are aware that in the resource-tight times that we live in, funds to support staff education and training are often the first to go. That is truly misguided priority-setting. Leaders also have the responsibility to communicate with and ensure engagement of all the parties in the organizations who have a role in infection control. That is essentially everybody. OLeary added that healthcare organizations will be expected to have adequate numbers of competent ICPs.
Making the Business Case for ICPs
With a birth in the 1950s and growth in the 1960s and 1970s (in 1970, fewer than 10 percent of U.S. hospitals had an infection control program but by 1976, more than 50 percent of U.S. hospitals had them), in the 1980s, hospital infection control programs underwent a midlife crisis, according to Karen Hoffmann, RN, MS, CIC, writing in the white paper, Developing an Infection Control Program.2 Hoffman explains, The cost value of infection control programs (e.g., surveillance) was questioned. Then in 1983, a combination of factors affecting healthcare impacted common infection control practice. The first was the adoption of a fixed-price prospective payment system based on diagnostic-related groups (DRGs), which resulted in widespread cost-containment initiatives to non-revenue producing hospital services. Infection control was often included. Quickly it was discovered that 56 percent of DRGs did not allow for any complications or co-morbidity. Further analysis demonstrated that only 5 percent of costs to treat nosocomial infections would be reimbursed to hospitals. The fallout from prospective payment meant sicker patients were admitted into hospitals since less ill patients were treated on an outpatient basis or discharged earliera trend in healthcare we continue to see today. The second and certainly most significant factor influencing infection control at the time was the advent of acquired immunodeficiency syndrome (AIDS). The human immunodeficiency virus (HIV) has taken an enormous toll in terms of loss of life and productivity. For infection control professionals (ICPs), HIV has been a challenge for education, risk reduction and resource utilization.2
In 1985, the Study of the Efficacy of Nosocomial Infection Control (SENIC) project was published, validating the cost-benefit of infection control programs. Hoffman reports that data collected in 1970 and 1976 to 1977 suggested that one-third of all nosocomial infections could be prevented if all the following were present:
- One ICP for every 250 beds
- An effective infection control physician
- A program reporting infection rates back to the surgeon and those clinically involved with the infection
- An organized hospital-wide surveillance system
Hoffman writes, Across the spectrum of todays healthcare, profits are decreasing. To keep healthcare systems viable, costs must be cut to increase the profit margin. Infection control programs need to demonstrate their value to their organizations. Therefore, the second goal should be cost control and reduction. Cost strategies may target products, injuries, or nosocomial infections. The ICP must examine clinical practices with unproven value for infection prevention and control in patients or staff. Activities that do not add value should be eliminated. ICPs should standardize product selection when at all possible. Cost savings and reductions should be integrated into reports: the goal is to balance quality and costs.
Hoffman continues, Significant trends in healthcare are occurring everyday including new medical procedures, new technology, and a shift from inpatient to outpatient care. Further changes in reimbursement and the push to reduce the cost of healthcare services with cuts in Medicaid/Medicare and managed-care reimbursements mean even less money is available for healthcare. Survival of infection control programs will depend on whether ICPs can efficiently demonstrate and communicate their value and provide competent and effective services. JCAHO standards have resulted in a dispersion of responsibility, but the ICP within the infection control program will remain the facilitator for the broad scope of practice to prevent and control infections throughout healthcare system.2
Jarvis writes, Infection control personnel play a critical role in preventing infections and medical errors. They conduct infection surveillance in acute-care facilities, apply standard definitions and surveillance protocols, calculate infection rates, report these data to essential personnel, implement prevention interventions, and evaluate their impact. Most importantly, as the Study of the Efficacy of Infection Control Programs (SENIC) has documented, the infection surveillance and prevention efforts of these infection control personnel are cost-effective.1
Kathleen Arias, MS, CIC, the current president- elect of APIC, says that in 2006, resource allocation and funding for infection control programs will be essential. We want to emphasize to ICPs that they must understand and promote the economics of their infection prevention programs, she says. ICPs must look at the economics associated with infection prevention and control programs in terms of how they can save lives, prevent morbidity and mortality, and generate financial savings.
Getting hospital administrators to look at the costs of the program and the associated cost saving, quality improvement efforts, and patient-safety efforts that a good infection control program can create, resource allocation will be less of a headache.
Top Infection Control-Related Issues for 2006
Avian Influenza and Healthcare Worker Immunization Just days after the Department of Health and Human Services (HHS) released in late October 2005 the HHS Pandemic Influenza Plan, a detailed guide for how the nations healthcare system can prepare and respond to an influenza pandemic, the Association for Professionals in Infection Control (APIC) applauded the components of the plan, including an emphasis on production and acquisition of vaccine and antivirals, as well as the commitment to global surveillance.
We have worked vigorously to encourage a comprehensive approach to pandemic and public health preparedness that will limit the potential human and economic loss, says Kathy Warye, executive director of APIC. This plan is an important first step and the appropriate level of attention. We encourage the President to sustain this heightened focus and work with state and local governments, the healthcare profession, private business, and the American public to resolve additional key issues. According to Warye, those issues include:
- Buy-in from state and local entities, with additional funds that would ensure a strengthening and not an erosion of the public health infrastructure
- The creation of surge capacity so that healthcare and public health infrastructures can meet the increased demand for qualified personnel, medical care, surveillance, and other activities in the event of a pandemic
- Adequate national levels of healthcare supplies and medical equipment, such as masks, gloves, gowns, and ventilators, to protect healthcare workers so that they can do their jobs
- Effectiveness and adequate supply of vaccine and antivirals
- Inclusion of a thorough pandemic pre-crisis communication plan
ICPs must also face the need for healthcare worker vaccination against influenza. In mid-November 2005, APICs board of directors, in recognizing the effect healthcare worker immunization has on reducing influenza outbreaks and associated complications, voted to endorse mandatory influenza vaccination for healthcare professionals who have direct contact with patients.
As stewards of patient safety, our nations healthcare professionals exemplify the axiom first do not harm, says APIC president Sue Sebazco, RN, BS, CIC. So it concerns APIC that a mere 36 percent of these professionals opt for vaccination. Even those healthcare facilities that promote immunization through aggressive voluntary campaigns show that 30 percent to 50 percent of healthcare workers remain unvaccinated, Sebazco adds. The facts prove that vaccination of healthcare professionals results in improved patient and employee safety and lessens the economic burden of influenza-related expenditures. It is time to do more to require healthcare professionals to be immunized against influenza annually.
Arias comments, Ive heard the pros and cons of mandatory HCW immunization; most people think its a great idea, and many are concerned about the timely delivery of vaccines and antivirals. Controversy ensues because some dont believe that a pandemic can occur, while others say its a doomsday scenario. I think we, as ICPs, must be somewhere in between, realizing that a pandemic is probably going to occur and preparing our facility for it as best s we can. We dont know if its next year or the year after, but eventually we will probably experience another pandemic. With so much global travel, avian influenza can spread quickly, like SARS did; its in one country one day and in another the next. So I think we must be realistic about addressing all of the issues that accompany a pandemic, such as the supply chain and its ability to provide much-needed items like masks and gowns. As soon as we have an outbreak, there will be hoarding of supplies; we have to make plans for that.
Mandatory Reporting of HAIs
Promising to be a big issue in 2006 is the adoption of mandatory infection reporting requirements at the state level, and further discussion of adoption at the federal level as well. In February 2005, the CDCs Healthcare Infection Control Practices Advisory Committee (HICPAC) issued recommendations addressing the public reporting of HAIs to provide direction and assistance to those states that have enacted or are considering legislation to require hospitals to make infection rate data available to consumers. The HICPAC guidance document recommends that any efforts to mandate public reporting ensure the use of established surveillance methods and experts in infection prevention to gather, interpret and report such information; the establishment of a multi-disciplinary advisory committee to provide oversight in the creation of any reporting system; the choice of appropriate process and outcome measures; and the provision of feedback to healthcare providers.
Arias says most ICPs now have a better understanding of the reporting requirements but may still be struggling with securing the additional resources that may be required for healthcare facilities to undertake public reporting. Patrick J. Brennan, MD, chair of HICPAC, had stated about the CDC guidelines, We didnt specifically address resources but it is an important issue. We do mention the necessity for ensuring adequate resources - we may need more infection control professionals and more information technology resources in order to accomplish this.
We support the idea of making meaningful information available to consumers, says Arias. We have dedicated our professional lives to preventing infections we just need to make sure that we do it right, so that patients have good, reliable information upon which to make sound decisions. APIC has been concerned about the possibility that each of the 50 states will adopt different reporting standards, something Warye has called a disservice to patients and healthcare institutions alike. APIC continues to push in 2006 for a national standard achieved through the consensus of stakeholders.
In November 2005, APIC pledged $25,000 toward an infections reporting template that can serve as a national standard. The group committed its support to the National Quality Forum (NQF), which will develop the standard over the next 12 to 15 months in an effort to formulate consensus standards for infection reporting via its formal Consensus Development Process. Last year, APICs board of directors called for a uniform method of collecting and reporting information on HAIs. In doing so, it supported NQFs mission to improve American healthcare through the endorsement of consensus-based national standards for measurement and public reporting of healthcare performance data.
The partnership with the National Quality Forum to assemble a consensus on requirements for mandatory reporting is a positive step forward, Arias says. We have been sending out a lot of information to the APIC membership on this, and Denise Graham has been very active in working with members in the states where legislation is being proposed.
We have been building discussion of mandatory reporting into nearly everything we do to get membership buy-in on the fact that this happening, and that it is something we need to support and be an integral part of developing.
Arias adds that there is an upside to the additional workload that mandatory reporting requires. I think we can use the fact that mandatory reporting is both important and required by law to make sure that infection control programs have the necessary resources they need, in terms of personnel, computer technology, administrative support, and budgetary wherewithal, to get the job done.
(MDROs) ICPs may be spending restless nights worrying about the onslaught of MDROs such as methicillin-resistant Staphylococcus aureus, but they should know that a major public health initiative has been created to battle MRSA. An interdisciplinary group of public health, industry, and infectious disease experts has united to form the MRSA Leadership Initiative, which will focus on global prevention and management of MRSA through development of public and professional awareness and education programs; clinical, epidemiological and outcomes research; and projects targeted toward prevention among high-risk patient populations.
This multi-year commitment will help get proven, life-saving improvement techniques put into action, says Denise Cardo, MD, director of the CDCs division of healthcare quality promotion. The MRSA Leadership Initiative includes experts in a variety of fields, including infectious diseases, nursing, long-term care, pharmacy, epidemiology, medical ethics, healthcare purchasers, payers, healthcare administration, public health, and health policy. Government, physician and patient groups also will be involved in developing and implementing programs.
MRSA incidence rates as a percentage of Staphylococcus aureus infections in many ICUs have increased from 2 percent to approximately 60 percent over the past 30 years. MRSA is now increasing, not only in the hospital setting, but also in communities around the United States and the world. A recent CDC study showed MRSA infections are now common outside the hospital setting and occur in otherwise healthy people. Specifically, 8 percent to 20 percent of all MRSA patient samples examined in the study were community strains.
Early identification of an MRSA infection is key to ensuring a patients successful treatment and reducing the risk of long-term complications of the infection, says John McGowan Jr., MD, a professor in the Department of Epidemiology at the Rollins School of Public Health at Emory University, and a member of the MRSA Leadership Advisory Group. The fact that these infections are increasingly contracted in the communities where we live and play, in addition to the hospital, means we must become more focused and vigilant in our efforts to prevent, properly diagnose and treat them.
To that end, Arias says APIC will place much greater emphasis on the word prevention when describing infection control duties. We dont do a good enough job promoting all the prevention efforts we do daily. So a lot of the material you will see coming out of APIC in 2006 will say infection prevention and control. Weve been preventing infections for years, but ICPs arent good at tooting their own horns. We must learn to let administrators and consumers know how effective our infection prevention and control programs are. Arias points to specific language addressing the importance of prevention efforts approved by the APIC board in its strategic plan called APIC Vision 2012: APIC will emphasize prevention and promote zero tolerance for HAIs and other adverse events. According to Arias, It doesnt mean you have to reach zero infections, just that you will not tolerate the occurrence of HAIs.
ICPs have been waiting for several years for the publication of the final isolation guidelines from the CDC. HICPAC has drafted guidelines for isolation precautions that were closed for comment in February 2005, and many hope that 2006 will be the magical year for their much-anticipated appearance. Arias believes some of the delay may have been triggered by an extended discussion of the definitions and characteristics of droplets and airborne spread of infectious pathogens.
Its been a real struggle with the respiratory portion of the draft guidelines, in terms of respirators and how to address infectious agents that are not quite droplet and not quite airborne, like SARS, Arias says. Nobody was really sure if SARS was spread by droplet method or if it was truly airborne; we later learned it appeared to be spread more efficiently than by droplet spread but is not truly airborne. Arias concedes that the profusion of guidelines can confuse ICPs. It can be quite overwhelming, especially for new ICPs. They receive pages and pages of information in their training programs, and they need to realize that this is very much a part of the job. They just have to keep up with it.
Arias continues, One of the things we have been trying to let new ICPs know is that APIC has a tremendous chapter network. People can use other ICPs as mentors. I tell new ICPs to introduce themselves to someone who is already in the field, especially someone who works in a similar healthcare organization, and work with them; this will help bring them up to speed. ICPs must also remember to share all of that information all of the regulations, requirements, and standards with others in their facility and in their community. The more they can set up collaborative networks in their own circles, the more people will realize that infection control is a pivotal piece of the puzzle.
1. Jarvis, W.R. Infection control and changing healthcare delivery systems. Emerg Infect Dis. 7(2), 2001.
2. Hoffman, K. Developing an infection control program Infection Control Today.