By Kelly M. Pyrek
The move toward mandatory reporting of healthcare-acquired infections (HAIs)is just one way that transparency of healthcare delivery and increasedaccountability on the part of healthcare providers is being achieved. A numberof initiatives have been developed during the past few years that are pushingfor greater empowerment of healthcare workers (HCWs) and patients to preventHAIs, and for a much greater degree of intolerance of life-threateninginfections and adverse events in the nations 6,000-plus hospitals.
Surgical site infections (SSIs) account foras much as 16 percent of all HAIs, and among surgical patients, SSIs account forapproximately 40 percent of HAIs. And according to researchers,1 surgicalpatients who develop SSIs are twice as likely to die as other surgical patients.Recognizing the significant morbidity and mortality associated with SSIs, in1999 the Centers for Disease Control and Prevention (CDC) issued comprehensiveguidelines,2 and several years later, the Joint Commission on Accreditation ofHealthcare Organizations (JCAHO) included reducing the risk of HAIs (includingSSIs) in its 2005 National Patient Safety Goals. Galvanizing momentum andadvancing evidence-based practice have been a handful of organizations thatrecognize its time to translate theory into practice.
100,000 Lives Campaign
Preventing surgical site infections (SSIs) and deaths from SSIs by reliablyimplementing ideal perioperative care for all surgical patients is one of thegoals of the 100,000 Lives Campaign, an initiative of the non-profit Institutefor Healthcare Improvement (IHI) which is disseminating expert information andpowerful improvement tools throughout the healthcare system. This campaign hasenlisted 3,000-plus hospitals across the country in a commitment to implementchanges in care that have been proven to prevent avoidable deaths. The campaignis rooted in six interventions:
Central to the interventions are bundles which bring together scientificallygrounded concepts that are both necessary and sufficient to improve the clinicaloutcome of interest. The focus of measurement is the completion of the entirebundle as a single intervention, rather than completion of its individualcomponents.
(The bundles) are a real change in the way we approach infections, saysDon Goldmann, MD, senior vice president of the IHI, a member of the infectiousdiseases clinical staff at Childrens Hospital Boston, and professor ofimmunology and infectious diseases at Harvard School of Public Health. In thepast we have had a fair amount of evidence on what works, but we really didnthave a coordinated, rigorous approach to implementing that evidence-basedpractice. The infection control community was trying to advocate for infectioncontrol practices, but overall, there hasnt been that much of a sense ofurgency to prevent infections on the part of the healthcare stakeholders whocared for patients. That has changed.
Goldmann continues, The concept of bundles makes it an all-or-nothinghealthcare proposition, and it simplifies care. Clinical guidelines arenotoriously long and convoluted, containing many levels of evidence, and itdoesnt exactly give you a simple view of the imperatives contained therein.The bundles, however, select specific, evidence-based aspects of care and theysay to the healthcare provider, we are going to get this bundle 100 percentright. That is much easier to put into practice.
Goldmann explains that because the bundles are short, concise, and directpieces of guidance, corresponding compliance rates should be 100 percent becauseanything less is unacceptable.
Its like saying if we perform one aspect of hand hygiene well and weget 90 percent compliance, then we have done well. But your average patientdoesnt care if you got 1 out of 4 measures or 2 out of 4 measures right, theywant their healthcare providers to get all of the measures right the first time;there is no partial credit from the patients point of view. Once peopleunderstand the bundles concept, I have found remarkably little resistance to itin the end. They may look at it and say, this is impossible or this isvery difficult, but they certainly find it easier to deal with than a longclinical guideline, and they do understand the patients point of view that itis all or nothing and getting it partially right is not OK. Where it all works is in the attention to gettingeverything right, the multi-disciplinary approach, and daily vigilance as to howhealthcare can be improved. There is much less tolerance of infections,complications, and adverse events now.
The 100,000 Lives Campaign emphasizes that ideal perioperative care canprevent SSIs, and that care incorporates appropriate use of antibiotics,appropriate hair removal (avoidance of razors)2, perioperative glucosecontrol3-4, and perioperative normothermia.5
Any time you make an incision in the body, you create a pathway for germs,says David Classen, MD, vice president of the Health Delivery Services divisionof First Consulting Group in Long Beach, Calif. Its inevitable, so our jobis to push down the infection rate as far as possible and keep pushing.
Another goal of the 100,000 Lives Campaign is preventing central venouscatheter-related bloodstream infection (CRBSI). Consider these facts:6-8 48 percent of ICU patients have central venouscatheters, accounting for about 15 million central venous catheter days per yearin ICUs; there are approximately 5.3 CR-BSIs per 1,000 catheter-days in ICUs.;the attributable mortality for CR-BSIs is approximately 18 percent, so there areprobably about 14,000 deaths annually due to CR-BSIs in ICUs. CR-BSIs areaddressed in CDC guidelines,9 the Institute of Medicine,10 and by JCAHO in its2005 National Patient Safety Goals.
The central line bundle promulgated by the IHI is comprised of handhygiene, maximal barrier precautions, chlorhexidine skin antisepsis, optimalcatheter site selection, and daily review of line necessity with prompt removalof unnecessary lines. One study11 has shown that ICUs that have implementedmultifaceted interventions similar to the central line bundle have nearlyeliminated CR-BSIs.
Partners in Your Care Program
Empowerment is at the core of the Partners in Your Care program, a patient,family, and HCW program for monitoring hand hygiene compliance that wasdeveloped by Maryanne McGuckin, PhD, of the University of Pennsylvania. Patientsand families are requested to be partners in healthcare by asking all HCWs thathave direct contact with their family member patient, Did you wash/sanitizeyour hands? In addition, the patient is visited by a health educator within24 hours of admission to discuss the importance of hand hygiene by HCWs inpreventing HAIs, and receives a brochure discussing the hand-hygiene imperative.
The Partners in Your Care program provides the infection control practitioner(ICP) with an ongoing technique for hand hygiene, education, compliance withhand hygiene, and outcome monitoring through soap and hand-sanitizer usage.Following a simple formula, an ICP collects data on soap and handsanitizer usageand forwards it to the University of Pennsylvania to analyze. A confidentialreport showing handwashings per bed day, infection rates and/or endemic organismtrend is sent monthly to monitor the programs success.
Traditional educational hand-hygiene programs comprise in-services,behavioral modification/ intervention, and observational components. Experts saythat while these methods trigger initial success and improvement, they areshort-lived. Where Partners in Your Care differs is the focus on the patient,not the HCW, in that the patient becomes the intervention that changes HCWbehavior. McGuckin says that the program has been evaluated in the U.S. andEurope, showing a 35 percent to 60 percent increase in hand-hygiene compliance,and is the first behavioral program to show sustained compliance.12 McGuckin,who served on the 2002 CDC task force that developed hand hygiene guidelines forHCWs, created Partners in Your Care to help fight HAIs. The program, whichcombines monitoring and patient empowerment, is used in more than 300 hospitalsand has shown a mean improvement in hand hygiene compliance of 59 percent.
McGuckin also points to a recent survey that proves patients will takematters into their own hands, literally. Results from this University ofPennsylvania survey show if armed with the right information, patients arewilling to become a part of the solution, McGuckin says. Once we tell them that we welcome their reminders, patientswill become active members of their healthcare team by asking their HCWs to washtheir hands. The survey also signaled that patient empowerment plays anincreasingly important role in the HAI issue, with 4 in 5 consumers saying theywould ask hospital staff to wash their hands, if prompted to do so.
I think our survey has answered the question once and for all, abouthealthcare consumers willingness to be part of the hand-hygiene team,McGuckin says. I think the survey should put clinicians minds at ease thatit is all right to tell your patients to remind HCWs to sanitize their hands.HCWs say, We dont want to tell patients to remind us to wash our handsbecause they will think we have a problem at our hospital. Consumers/patientsdont feel that way. ICPs should say to their hospitals, Look, we shouldencourage patient empowerment because they are saying its OK to do so. Theliterature points to the fact that HCWs forget to wash their hands; if you tellthe patient its OK to ask, they will do it, and it will have a tremendousimpact on HAIs.
McGuckin continues, Study after study shows that no mater what you do interms of education, hand-hygiene compliance is short term and relativelyunsustainable. Current programs have about a 20 percent compliance rate. We mustchange the culture by involving the patient because the patient is the onlyconstant among many variables in the healthcare equation. In the eight years ofthe programs existence, we have a great deal of data showing sustained handhygiene compliance in the hospitals involved in the program. We now have morethan 400 hospitals supplying data, so we can tell what people are doing outthere, and the bottom line is once they involve the patient, they get to almost100 percent handhygiene compliance. McGuckin emphasizes that healthcare consumers in general are more observantof handhygiene practices, especially in a new age of mandatory reporting of HAIsin some states.
In the survey we asked consumers, the last time you were in the hospital,did you notice people putting on gloves instead of washing their hands, and 52percent said yes. The important message we should be giving hospitals is, guesswhat, our patients are noticing this. They will realize that gloves do notreplace handwashing. The foundation of preventing HAIs is hand hygiene.
Committee to Reduce Infection Deaths
The Committee to Reduce Infection Deaths (RID) is a nonprofit educationalorganization dedicated to providing hospital administrators, caregivers,insurers, and patients with the information they need to stop HAIs. Through RIDsrecent report, Unnecessary Deaths: The Human and Financial Costs of HospitalInfections, Betsy McCaughey, PhD, a health policy expert and chairman of RID,is calling upon the CDC and public health officials to do more to stopHAI-related deaths. The report, co-sponsored by the National Center for PolicyAnalysis, alerts the public to the grave financial and human consequences ofpoor infection control in U.S. hospitals and demonstrates that these infectionsare almost all preventable through improvements in hospital procedures andhygiene.
RIDs goals are to:
One out of every 20 patients gets an infection in the hospital, saysMcCaughey. Infections that have been nearly eradicated in some countries, such asmethicillin-resistant Staphylococcus aureus (MRSA), are raging throughhospitals. In the U.S., the danger is growing worse. Increasingly, hospitalinfections cannot be cured with commonly used antibiotics. These infections arealmost all preventable. Unnecessary Deaths documents the success of U.S.hospitals that have reduced infections by 85 percent or more in pilot programs.
McCaughey says standard precautions, as promulgated by the CDC, areinadequate, a stance long taken by infectious disease experts such as BarryFarr, MD, MSc, and others who advocate the use of contact precautions and activesurveillance. The CDC has delayed calling on all hospitals to institute therigorous precautions that are working in other countries and in the few U.S.hospitals that have tried them. Standard precautions are far less effective inpreventing HAIs. In 2003, the Society for Healthcare Epidemiologists ofAmerica (SHEA) warned that although hospitals have infection control programs,there is little evidence of control in most facilities.
Several years ago, SHEA issued important guidelines for preventing nosocomialtransmission of multidrug-resistant strains of Staphylococcus aureus and Enterococcus,essentially advocating for active surveillance cultures to identify thereservoir for spread of pathogens; engaging in rigorous hand hygiene practices;using barrier precautions for patients known or suspected to be colonized orinfected with resistant organisms; engaging in goods antibiotic stewardship tocurb resistance; and other measures, including proper environmental cleaning,and co-horting of equipment among colonized or infected patients.13
There are at least 50 studies demonstrating the effectiveness of theseprecautions, says Carlene Muto, MD, an epidemiologist at the University ofPittsburgh Medical Center, and not one study suggesting its possible tocontrol MRSA without them.
One study shows that MRSA spreads frompatient to patient 15 times as fast under standard precautions, as advocated bythe CDC, as under the more rigorous precautions advocated by SHEA.14
McCaughey emphasizes, We want patients to know there is a great deal theycan do to protect themselves from infection before they go into the hospital;one important part of the RID report is the list of steps patients can take toprotect themselves. The list is based on solid, peer-reviewed literature that isso seldom shared with patients. Another major thrust of the report is that theCDC should be doing more to encourage hospitals to put into place the morerigorous precautions that are proven successful in stopping the transmission ofbacteria from patient to patient.
McCaughey continues, If you stand in an ER and watch the doctors andnurses scrub and pull on their gloves, they have done what the CDC says isnecessary, but it is not enough to prevent infections because those sameclinicians reach up and open privacy curtains, which are laden with bacteria,and the gloves are contaminated before they ever touch the patient.
So hand hygiene is not enough. We need more effective training of HCWs aboutbetter precautions, because for the past 40 years, ever since the liberal use ofantibiotics replaced attention to hygiene, young HCWs in training have not beentaught to avoid contaminating their hands or gloves once they scrub. They havenot been taught to avoid leaning over a contaminated bedside and then carryingthat bacteria on their lab coats and scrubs to the next bedside. They haventbeen taught to clean their stethoscopes before putting them on a patient. Theyarent being taught about contact precautions.
McCaughey adds, We need evolved thought and leadership, and that is why Iput part of the blame on the CDC. As long as they continue to advocate only forstandard precautions, hospitals administrators will use that as an excuse not toimplement more rigorous precautions.
Mandatory Reporting Initiatives
In late January, the Association for Professionals in Infection Control andEpidemiology (APIC), the Infectious Diseases Society of America (IDSA), and SHEAreleased model legislation to assist patient safety initiatives by giving statelegislatures a template to use when adopting legislation for the collection andreporting of HAI rates.
Our organizations recognize the challenges to the states of publicreporting, says Michael L. Tapper, MD, chair of SHEAs Public Policy andGovernmental Affairs Committee. Sound science and appropriate methodologiesare integral to states successful institution of reporting requirements.
Currently, there is no uniform national standard for surveillance of HAIsor standardized systems for collecting and reporting these infections when theyoccur, says APIC president Kathleen Arias, MS, MT, SM, CIC. For the first time, states are armed with a tool to help craft legislationthat will result in useful data by which facilities can benchmark theirperformance.
The new model legislation was developed in response to a growing trend. Atleast six states now have laws mandating public reporting of infection rates,and one state mandates reporting infection rates to the state government. Similar proposals have been introduced in about 20 other states.
States need a good model on which to base their systems, says IDSApresident Martin J. Blaser, MD. Its important that public reporting bedone in a way that allows people to discern what the data actually mean, and howthe data can be used to prevent infections and improve patient care.
The model legislation aims to ensure that state reporting systems adhere torecommended practices that have been shown to reduce the risk of HAIs, protectthe confidentiality of medical records, and reflect the fact that someinstitutions treat more seriously ill patients.
People should be able to use this information to measure how wellinstitutions perform. The model legislation makes certain that state reporting systems are based onreliable data, says SHEA president Trish M. Perl, MD, MSc.
The aforementioned University of Pennsylvania study supports the idea thataccess to hospital infection-rate data will impact patients choices.According to the survey, 93 percent of consumers say knowing infection rates fora hospital or doctor would influence their selections, while 87 percent sayhigher-than-average infection rates would be a very important reason to avoid ahospital.
McGuckin says that mandatory reporting signals a return to the basic tenetsof infection control. I have been in infection control for 30 years and wedid surveillance back then. I think we have gotten away from it; all of a suddenICPs were saying, I dont have time for surveillance, I have to doprevention. The further away you get from surveillance, the less you want toreturn to it, but its essential. I think were getting back to basics now,and surveillance is what infection control is all about. If you dont knowwhere your problems are, you cant correct them. Its more fun to educateand give lectures than it is to do surveillance, but I am glad to see thatmandatory reporting is bringing us back to this critical tool.
Bringing it All Together
Goldmann believes that initiatives such as the 100,000 Lives Campaign workbecause they are voluntary, non-punitive approaches to empowerment of thepatient and the healthcare provider.
Patients are serving as sentinels in the night, reminding people to dowhat they are supposed to be doing; this has made care more patient-centered,he says. And HCWs are becoming more accountable. When you mobilize people toachieve a lofty aim, raise the bar on performance, and challenging the U.S. healthcare system to do even better, its amazing what can happen. A lot ofhealthcare stakeholders, who would really like to effect change, are encumberedby their own bureaucracy; something like the 100,000 Lives Campaign steps up the pace and allows themto change some of the old, lethargic processes they may have had; thegalvanizing of energy is important to the campaigns success.
Goldmann says that building on momentum is key. We always talk about ideasand execution; good ideas cant get started if there is no will to makeprogress, and if you dont execute, you dont make improvements. I think we need to pay more attention to behavioral issues; people dontfeel a sense of urgency if they are not enabled and if they feel there is noimpetus for change. So getting into peoples heads is one thing, but then youmust pay attention to performance barriers; if people dont feel they can make a difference, they will probably notperform. Goldmann continues, Its a bold leap.
Nobody said when we started this campaign that we knew how to help 3,000hospitals improve, and so its gratifying to see a great number of hospitalsable to make astonishing leaps in improvement. Like anything, success can beuneven, but the overall impact is great.
1. Kirkland KB, et al. The impact of surgical site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs.Infect Control Hosp Epidemiol. 1999;20:725-730.
2. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection, 1999.Infect Control Hosp Epidemiol. 1999;20:247-278.
3. Furnary AP, Zerr KJ, Grunkemeier GL, Starr Al. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures.Ann Thorac Surg. 1999;67:352-362.
4. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients.N Engl J Med. 2001;345:1359-1367.
5. Melling AC, Ali B, Scott EM, Leaper DJ. Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomized controlled trial.Lancet. 2001;358:876-880.
6. Pittet D, Tarara D, Wenzel RP. Nosocomial bloodstream infection in critically ill patients. Excess length of stay, extra costs, and attributable mortality.JAMA. 1994;271:1598-1601.
7. Saint S. Chapter 16. Prevention of intravascular catheter-related infection. Making healthcare safer: a critical analysis of patient safety practices. AHRQ evidence report, No. 43, July 20, 2001. www.ncbi.nlm.nih.gov/books
8. Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit.Crit Care Med. 2004;32:2014-2020.
9. O'Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections.MMWR Morb Mortal Wkly Rep. 2002;51(RR 10):1-29.
10. Adams K, Corrigan JM, eds. Priority areas for national action: transforming health care quality. Washington, D.C.: The National Academies Press, 2003.
11. Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit.Crit Care Med. 2004;32:2014-2020.
12. McGuckin M, Waterman R, et al. Patient education model for increasing handwashing compliance.Am J. Infect Control. 1999:27;309-314.
13. SHEA Guideline for Preventing Nosocomial Transmission of Multidrug-Resistant Strains ofStaphylococcus aureus and Enterococcus. Infect Control Hosp Epidemiol. 2003: vol. 24: pp. 362-386. See p.362.
14. Jernigan, J.A., Titus, M.G., Farr B.M., Groschel, D.H.M., Getchell-White, S.I., Effectiveness of contact isolation during a hospital outbreak of methicillin-resistantStaphylococcus aureus. Am J Epidemiol. (1996) Vol. 146, p. 496-504.