By Karin Lillis
It is estimated that U.S. healthcare institutions spend $9.8 billion annually treating healthcare-associated infections (HAIs). Ventilator-associated pneumonia (VAP), central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) rank among the top five most expensive HAIs (Zimlichman, 2013).
VAP and CLABSI are especially costly, accounting for 33.7 percent and 31.6 percent of the total cost hospitals spend treating HAIs. That translates to $3.3 billion that healthcare organizations nationwide spend treating cases of VAP, and nearly $3.1 billion for CLABSI. While the expense associated with treating CAUTIs is far lower than VAP and CLABSI, U.S. healthcare organizations still spend millions of dollars each year to treat these urinary tract infections (Zimlichman, 2013).
In January, the Centers for Disease Control and Prevention (CDC)’s National Health Safety Network (NHSN) published a report indicating that healthcare organizations are making significant headway against certain HAIs. Most notably, U.S. hospitals reported a 46 percent decrease in cases of CLABSI between 2008 and 2013, according to the HAI Progress Report. There was an uptick in the number of CAUTIs — 6 percent from 2008 to 2013 — but preliminary statistics from 2014 indicate those numbers are going down as well. The NHSN report did not address VAP (CDC, 2015).
“Many hospitals have focused on CLABSIs and all that time and attention has made a big impact," says Kelley Boston, MPH, CIC, an infection prevention consultant in San Antonio, Texas, and a member of APIC’s national communications committee. "We’ve nearly cut CLABSI rates in half. These types of infections are so devastating to patients, so expensive as healthcare costs. It’s not that healthcare institutions have let CAUTIs go — but the majority were focused on CLABSI and other high-mortality infections."
Of an estimated 2 million cases of HAIs annually, half are device-related — with CAUTI the most common cause, says Rabih O. Darouiche, MD, an infectious disease specialist and the program director for the Multidisciplinary Alliance Against Device-Related Infections (MAADRI). He also is the director of the Center for Prostheses Infection at Baylor College of Medicine. “Although CAUTIs are the most common infection, the infections with the highest mortality and morbidity are CLABSI and VAP.”
Central Line-Associated Bloodstream Infections
The Joint Commission estimates that there are a quarter-million cases of CLABSI in hospitals annually — around 80,000 of those on intensive care units. A central line-associated BSI can happen if the insertion site is not properly cleaned, and bacteria present on the skin travel with the needle into the blood vessel. The same can happen if that site is not kept clean and properly dressed: Bacteria can travel through the catheter and into the bloodstream. Contamination also can occur if the hub or caps are not cleaned properly, or if bacteria and biofilm build on the catheter walls. The most common causes of CLABSI are skin organisms, says Nichole Iovine, MD, PhD, an infectious disease specialist with University of Florida (UF) Health in Gainesville, Fla.
Additionally, patients who have experienced a prolonged hospital stay before the central line was placed — or those whose central line is in place for “prolonged duration” — face a higher risk of contracting CLABSI. Internal jugular or femoral catheterization (in adults) can also increase the chances of CLABSI occurring (Marschall, 2014).
But how does a healthcare institution combat CLABSI? General recommendations include establishing separate insertion and maintenance central line bundles, as well as maintaining a top-down accountability for HAIs and internal reporting processes that include senior and nursing leadership, as well as bedside staff (Marschall, 2014).
One hospital found success in implementing multidisciplinary, daily rounding on all patients who have central lines. Like cases of CAUTI and VAP, the rate of CLABSI is measured in reported incidents per 1,000 patient days.
About nine years ago, those rates were at a high of 5 CLABSIs per 1,000 patient days at UCSF Medical Center, San Francisco, says Amy Nichols, RN, MBA, CIC, director of hospital epidemiology and infection control. Each day, a clinical team — including the bedside nurse — visits every patient who has a central line and does a focused review of how to care for a central line, as well as one-to-one education and troubleshooting. Nichols says the hospital also introduced dedicated central line insertion and maintenance bundles. Virtually immediately, the rates of CLABSI dropped by more than half.
“Then our CLABSI rates stayed flat. We weren’t able to budge from that initial drop,” Nichols says. About a year ago, the hospital rolled out chlorhexidine bathing for its patients and finally reduced the CLABSI rate by another 24 percent. The rate of CLABSI, at present, is close to 1 but not yet below that benchmark. Without careful attention, Nichols says, these numbers can creep back up — something she and her colleagues are contending with at UCSF. “The biggest challenge is — once an institutions has made a good change in rates — other priorities begin to take staff attention away. These very basic strategies have been done painstakingly every day for every patient. We put a big push on this effort initially, so were focusing on getting our numbers below 1 incident per 1,000 patient days,” she says.
The driving force behind any of these strategies, she says, is feeding the data back to the bedside staff. “They need to know how their actions affect patient outcomes,” she says. The hospital’s device-related infection committee meets twice a month and reviews infection data — bedside nurses and patient care managers are part of that committee.
Most recently, the practice has led to a drastic decrease in the rate of CLABSI among pediatric hematology/oncology patients, Nichols says. Bedside nurses have taken to cleaning IV tubing and wiping down high-touch areas — like bedside tables and bed rails — once a shift. “We had a conversation over whether nurses should be doing that,” Nichols says, “but when it comes down to it, the bedside nurse is the last bastion of safety for the patient.
“There’s been a lovely evolution on that unit. The nurses have just enfolded those activities with doing the assessment of the patient at the beginning of the shift. As they’re wiping down a surface, they’re talking to the patients and the family. Right now, that’s the trial unit. In this fiscal year so far, we’ve had three months of zero CLABSI. You just do not see that in a pediatric hematology oncology unit.”
Catheter-Associated Urinary Tract Infections
CAUTIs account for around 4 in 10 of all HAIs — and 80 percent of these cases are caused by indwelling catheters (Foley catheters). Each day in the acute care setting, catheterized patients face a 3 percent to 7 percent chance of developing an associated UTI (WOCN). Darouiche estimates that between 400,000 and 500,000 cases of CAUTI occur annually among hospitalized patients in the U.S.
And the longer a catheter is left in place, the greater the patient’s risk of infection, explains Iovine. The risk also increases if the patient is immunocompromised, chronically ill, female or pregnant.
Catheter-associated urinary tract infections may occur if the urethral site is not adequately cleaned and bacteria slide into the bladder with the catheter. Or removing a catheter too soon and having to reinsert it can increase the chance of CAUTI. If the collection bag isn’t hung below bladder level — or there is a kink in the tubing where urine can accumulate — bacteria-filled urine can backwash into the bladder.
“Think about that part of the body. It’s not a sterile area,” Iovine says. “The clinician may try to use sterile technique to keep the insertion as clean as possible, but it doesn’t take a lot of bacteria to lead to a UTI — especially when you’re pushing a catheter through that space. The bacteria is now sitting in the bladder.”
The method and circumstances of the catheter insertion also can significantly impact the risk of a patient contracting a CAUTI, Iovine notes.
“For example, was it a prepared insertion following all prescribed hospital protocol — or was it a traumatic/emergency insertion after a car accident? Foley catheters inserted during an emergency situation are known to have higher rates of infections,” Iovine says. “You also need to consider who is placing the catheter. Was it a first-year resident, a urologist or an experienced nurse inserting the Foley?"
More infections are associated with indwelling catheter maintenance rather than insertion, Iovine explains. Special care must be taken to ensure the urethral area is cleaned before insertion and while the catheter is still in place.
A wide body of research supports the use of catheter-related insertion and maintenance protocol, as well as initiatives that include staff education and daily monitoring.
Research and programs in Michigan, for example, helped to reduce the rate of CAUTI, as well as the overall use of indwelling catheters (Lo 2014). Results included:
- A stringent policy and daily review of catheter necessity among emergency and internal medicine physicians resulted in far fewer indwelling catheters placed in patients — from 17.5 percent of patients to 6.6 percent.
- A statewide initiative sought to educate clinicians about “appropriate urinary catheter placement” and recommended daily assessment “of continuing catheter need during nursing rounds.”
Numerous studies have indicated that standardized bundles also can help decrease the risk of unnecessary catheter placement, as well as catheter-related UTIs (Lo 2014)
One of the biggest challenges healthcare institutions face, Darouiche says, is determining whether a UTI is truly catheter-associated or not. The NHSN's guidance for defining a catheter-associated UTI is very detailed (http://www.cdc.gov/nhsn/cms/), yet some healthcare organizations fail to differentiate between a UTI and one that is “a true clinical case of CAUTI,” Darouiche says.
There is generally a presence of bacteria in the urine of patients who have indwelling urinary catheters, Darouiche says, “but there is a lack of differentiation by astute healthcare providers between the microbiologic presence of bacteria in catheterized urine, compared to clinically diagnosing a case of CAUTI.” In turn, that causes the unnecessary introduction of antibiotics, Darouiche explains, resulting in a major increase in antibiotic resistance.
In diagnosing CAUTI, clinicians must focus on the clinical presentation as well as the presence of bacteria — does the urinalysis actually show evidence of inflammation and does the urine culture show an organism known to cause UTIs? “That is how you accurately diagnose a true clinical — without really relying on clinical presentation — suggests that most of these cases are misdiagnosed as being an infection that requires an antibiotic, he explains.
Catheterized urine, Darouiche says, is the “most important reservoir of antibiotic resistance. The elimination of the need to administer unnecessary antibiotics for treatment of bacteria is equally to — or even more important — as preventing CAUTI.”
“CAUTIs can be tricky problems to solve. It’s an easy solution to get the catheter out, and don’t culture unless the doctor suspects a UTI,” says APIC's Boston. “How do we make sure Foleys are used only in appropriate patients?” Often, infection is suspected and a culture ordered if the patient’s urine is cloudy, Boston says. “That’s an easy solution, but not necessarily the best.”
Additionally, localized signs — beyond a fever and a positive urine culture result -- may or may not be present, or may go unrecognized “because of patient comorbidity or inability to communicate due to illness or age. The most common clinical presentation is fever with a positive urine culture result, without other localized findings. However, given the high prevalence of bacteriuria in patients with an indwelling catheter in place, this definition lacks specificity” (Lo 2014).
VAP may affect as many as 28 percent of hospitalized, intubated patients (Halyard). On the extreme end, the mortality rate can climb as high as 30 percent, Darouiche says.
Oral bacteria are among the most common contributors to ventilator associated pneumonia. More than 60 percent of patients admitted to the ICU “have oral colonization with pathogens associated with VAP” (Halyard). Numerous leading regulatory and professional organizations —like the Centers for Disease Control and Prevention and the Association for Professionals in Infection Control and Epidemiology — recognize that comprehensive oral hygiene among intubated patients is crucial for preventing VAP.
Several factors contribute to the growth of oral bacteria (Halyard), including: Intubated patients typically experience “dry mouth,” which can lead to oral tissue inflammation and the growth of gram-negative bacteria. Plaque will begin to grow on teeth within 48 hours of intubation, if that patient has not received comprehensive oral care. And as dental plaque builds, the risk of pneumonia increases.
Additionally, when a patient is placed on a ventilator in an emergency setting — or that patient is immunocompromised — the risk of developing VAE is higher, Iovine says.
A decade ago at UCSF Medical Center in San Francisco, the VAP rate was “very, very high,” says Nichols. “There are two things that helped us move that needle downward.”
First, the hospital’s infection control and epidemiology team found that — when implemented as part of a ventilator bundle — oral care was crucial to driving down the rate of VAP. Second, respiratory therapist clean high touch surfaces on the ventilator at the beginning of each shift.
By drilling down further, Nichols and her colleagues found that the patients who drove the VAP rate were those who were taken off the unit for CT studies — more than 200 transfers a month. Ultimately, the hospital purchased portable CT equipment that can be brought to the appropriate unit when a patient needs a diagnostic test.
Iovine notes that there are barriers to accurately reporting cases of VAP to NHSN and other regulatory bodies. The CDC reporting requirements—in an effort to create more objective and expanded surveillance of ventilator-associated complications--now fold ventilator-associated pneumonia into a category called ventilator-associated events (VAE)—which include criteria for ventilator-associated conditions, infection-related ventilator, infection-related ventilator-associated complications, possible pneumonia, and probable pneumonia (Klompas, et al. 2014).
“A non-infectious example of VAE might be patient has increased oxygen requirement, so mix goes from 40 percent one day to 60 percent the next,” Iovine says. “It has nothing to do with infection but it could be that occurred because the patient has stiff or noncompliant lungs.”
“The rates you calculate end up being different and it can be hard to intervene. What you’re looking at three months ago isn’t the same as what you’re looking at now,” Iovine says. “Once the CDC stops changing its mind about it, then we can generate really long-term data.”
Until then, professional organizations like SHEA and IDSA advise, “Until studies of the best strategies to prevent all VAEs are published, the existing VAP prevention literature is the best available guide to improving outcomes for ventilated patients. Given the uncertainty surrounding the accuracy and reproducibility of VAP diagnoses, however, we prioritize VAP interventions that have been shown to improve objective outcomes, such as duration of mechanical ventilation, intensive care or hospital length of stay, mortality, and/or costs in randomized controlled trials. In addition, the potential benefits of different interventions are balanced against their feasibility, costs, and potential harm” (Klompas, et al. 2014).
Approaches to Driving Down HAIs
Generally, there are two approaches to driving down the rates of healthcare-associated infections — vertically and horizontally, says UF Health’s Iovine. “Under the vertical approach, you might focus on specific organisms — screening for MRSA or swabbing for VRE, for example. Under the horizontal approach, you would focus on, for instance, hand hygiene and antimicrobial management. There is some debate about whether a healthcare organization should focus on broad or specific. At UF Health, there is a more horizontal approach — what will impact organisms or outbreaks that have not yet arisen, or issues that exist but are not necessarily nationally reportable? For example, washing our hand will not only drop MRSA but will drop other organism’s infection rates as well.”
What works best, adds Darouiche, will vary among healthcare organizations. For example, a hospital may apply general infection prevention guidelines for a certain HAI, but then that facility will need to determine what practice works best in its individual setting. “Implement what we know works well in the prevention of infection and apply it in individual hospitals,” he says, “and determine on a local basis what approach — like a bundle or single intervention — does or does not work at that individual hospital. What works varies from one hospital to another and, in some cases, from one unit to another at the same facility. See how well it works for yourself, rather than just rely on what’s being published by other hospitals.”
The bottom line, Boston says, is a multidisciplinary approach. “It’s not just a problem for the doctor, infection preventionists or nurse. Organizations that are successful are not working in siloes. Organizations that can move rates and best protect patients have frontline and multidisciplinary engagements. The nurse, doctor, housekeeping, supply chain and infection prevention all have a piece of the puzzle,” she says.
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The U.S. Centers for Disease Control and Prevention’s National Health Safety Network: http://www.cdc.gov/nhsn. Specific reporting requirements for mandatory HAIs is available at (http://www.cdc.gov/nhsn/cms/).
The U.S. Centers for Disease Control and Prevention’s Healthcare Infection Control Practices Advisory Committee: http://www.cdc.gov/hicpac/.
The Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America’s Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: http://www.shea-online.org/PriorityTopics/CompendiumofStrategiestoPreventHAIs.aspx.
The Association for Professionals in Infection Control and Epidemiology’s scientific guidelines: http://www.apic.org/Professional-Practice/Scientific-guidelines.