infection, prevention, and reporting...• concept of grouping key practices into a “bundle” •...

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WORKING TO PREVENT AND CONTROL INFECTIONS IN HEALTHCARE SETTINGSFOCUSED ON THE UTMOST QUALITY OF PATIENT CARE AND HEALTHCARE WORKER SAFETY

Infection, Prevention, and Reporting

Patrick J. Brennan, MDPresident

The Society for Healthcare Epidemiology of America

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Community-Associated and Healthcare-Associated Infections

• Community-associated = exposure and onset in community

• Healthcare-associated = exposure and onset in a healthcare setting

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What are the Germs that Cause Infection?

• Germs are microbes• Bacteria – free living, replicating life forms• Viruses – live and replicate inside cells• Others

• Patients carry germs • Patients acquire germs• Antibiotics can alter the types of germs we carry

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Many Different Types of Germs• Staphylococcus aureus (Staph)

• MRSA – comprises less than 10% of all infections• Skin germs• Intestinal germs• Respiratory germs

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Where do we Carry Germs?

germs

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How are Infections Established?

• Germs invade through an entry point• Break in the skin• Break in the mucous membranes• Natural ability to invade without breaks

• Procedures and devices create entry points• Urinary and bloodstream catheters

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Examples of Healthcare-Associated Infections

• “Central Line Associated Bloodstream Infection” in a trauma patient who had a central venous catheter placed under emergency circumstances• How did the germs get there?: from the patient’s

skin along the catheter into the blood• How might it have been prevented?: use of sterile

technique and full barriers during placement

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• “Ventilator Associated Pneumonia” in a patient resuscitated after near drowning in an icy river• How did the germs get there?: patient’s mouth and throat flora

aspirated during drowning or via ventilator tube

• How might it have been prevented?: elevation of the head of the bed, good oral care, avoidance of antacids

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• “Surgical Site Infection” of the sternum in a patient who had coronary bypass surgery • How did the germs get there?: from the patient’s

skin through the open incision• How might it have been prevented?: preoperative

antibiotics, avoidance of shaving surgical site, good blood sugar glucose control

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Swiss Cheese Model

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What Have we Done About Prevention?

• Historical context• Discovery

• 20th century programs• Hospital programmatic development• Federal support – NNIS• Healthcare Infection Control Practices Advisory Committee (HICPAC)

• Ongoing activities• Regulatory and accreditation requirements• NHSN• Professional Societies

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Discovery of Infection Prevention• Dates to 19th Century

• Semmelweis’ discovery of hand hygiene - 1847• Nightingale’s hospital practices – 1850s• Discovery of bacteria by Robert Koch - 1882

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Hospital Infection Prevention Programs• Developed in 1970s• NNIS established in 1980s• Study of the Efficacy of Nosocomial Infection

Control (SENIC) 1985• Multi-center study funded by CDC• Demonstrated benefit of infection prevention

• Programs• Staff• Established staffing ratios

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SENIC Study Results• Only one-third of infections deemed preventable• 5% of hospitalizations result in infection• Four common infections

• Urinary tract infections• Pneumonia• Surgical site infections (wound or organ space)• Bloodstream infections

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Research in Surveillance and Reporting

• Activities of Professional Societies –SHEA, APIC, IDSA

• Federal Activities• Creation of NNIS – 1980• Creation of HICPAC – 1990s

• Advisory group: evidence based guideline writing

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Risk Factors for Infection

• Patient Characteristics that make infection more likely• Extremes of age • Weak immune system • Poor nutrition• Diabetes (many germs like high sugar meals)• Organ injury or failure (smoker’s lungs; liver or kidney failure)• Loss of skin integrity

• Non-patient risk factors• Invasive procedures • Exposure to devices• Exposure to healthcare workers

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Are HAIs and Related Deaths Preventable?

• The million dollar question: If every preventive strategy is used every time, can we prevent all healthcare-associated infections?

• The answer: Probably not all of them

• The other answer: We should find out how many are preventable by using preventive strategies appropriately

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How to Prevent HAIs

• Eliminate or mitigate risk factors• Some risk factors can be reduced or eliminated• Procedures and processes can be controlled• Others are very difficult, if not impossible, to reduce at

the time of procedure or hospitalization

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How to Prevent HAIs

• The Basics• Hand Hygiene – wash hands before and after contact with the

patient and/or their environment• Maintain aseptic technique

• Do not break sterile field• Keep contaminated items separate from sterile items• Use barriers during CVC placement

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How to Prevent HAIs

• The Basics• Remove catheters and tubes as soon as they are no longer

needed• Evaluate need daily• Assess for early signs of infection

• Avoid placing devices if possible• Use transmission-based isolation precautions when necessary

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Risk Factors for HAIs• Related to the Procedure

• Procedure site• Bowel surgery risk > than knee surgery• CVC insertion into femoral vessel > than into subclavian

• Degree of bacterial contamination of site• Higher volume – e.g. perforated appendix• Low volume – e.g. bacteria that reside on patient’s skin,

intestines, etc. enter wound• Hair removal at surgical incision site using razor

• Creates small nicks for bacteria to hide

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Risk Factors for HAIs

• Related to the Operating Environment• Inadequate air circulation• Breaks in sterility of surgical field • Breaks in sterility of instruments• Improper sterilization of instruments

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Risk Factors for HAIs• Related to the Patient

• Underlying diseases• Diabetes – impairs healing, ability of immune cells to fight infection• Immunosuppression – cancer, HIV infection, autoimmune disorders• Obesity

• Age• Smoker• Hypothermia at time of surgery• Acuity of illness (i.e. shock)

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How to Prevent HAIs• The Procedure

• Clean procedure site with antiseptic using proper technique• Remove hair for surgery only if necessary and in those

instances, use clippers NO RAZORS• Control contamination of site

• Use of prophylactic antibiotics with surgery• Needs to be in the tissue at time of incision• Redose for prolonged procedures

• Minimize tissue destruction during surgery

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How to Prevent HAIs• The Operating Environment

• Have required number of air-exchanges• Laminar air flow• Avoid flash sterilization of instruments• Limit OR traffic

• OR personnel wear proper attire, perform surgical hand scrub

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How to Prevent HAIs• During Maintenance Phase

• Use aseptic technique to access device or catheter and to care for post-surgical wound

• Reduce potential for bacterial contamination• Perform oral care and routine suction of oral secretions

to reduce risk of bacterial aspiration in ventilated patients

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How to Prevent HAIs

• Control Patient Factors• Tight glucose control around surgery• Limit immunosuppression• Prevent perioperative hypothermia via warming of patient

during surgery• ? Prevent hypoxia (low tissue oxygenation)

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Use of “Bundles”• Concept of grouping key practices into a “bundle”

• Reduces HAIs – no single magic bullet for prevention – like active surveillance

• Increase adherence to all• Pick limited number of practices those with strongest evidence

and/or highest impact• Incorporated into process of care• Bundles derived from guidelines from HICPAC • Based on research from experts in SHEA, CDC, APIC, others

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Examples of Bundles

• For CVC Insertion• Hand Hygiene• Chlorhexidine to clean skin• Maximal Barrier Precautions

• Sterile cap, mask, gloves, gown• Large full-body drape over pt

• Subclavian insertion/avoidance of femoral insertion• Evaluate insertion site & need for CVC daily

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Map of Legislative Mandates for Public Reporting of HAIs

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Consequences of Public Reporting

• Presumed to motivate quality improvement• Patients, physicians, purchasers select high

quality physicians or institutions• Motivate physicians and institutions to compete on

quality• Value of public reporting of quality information has

not been demonstrated• May have unintended or negative consequences

• Also largely unexplored• e.g., Improper utilization of resources, adverse

patient selectionWerner RM, Asche DA. JAMA 2005;293:1239-44

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Factors to Consider in Public Reporting• Resource Needs

• ICP demand• Electronic surveillance systems• Need for support of federal resources• Diversion of care• Infrastructure support

• At NHSN• At Hospitals

• Best reporters may suffer• Impact of mandates – need for local judgment

• There are many issues other than MRSA

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The Public Perspective on Public Reporting

• PROS• Public can make its

own judgment• Public has a right to

know• Additional source of

information• Tools are

sophisticated• Providers respond

• CONS• Providers may avoid

sickest• Can be misinformed• Data may be skewed

Brennan TA et al. NEJM 2004;350:2409-12

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The Provider Perspective on Public Reporting

• PROS• Appear better than peers• Providers respond• No one uses them

• CONS• Administrative data has

flaws• Risk Adjustment may be

weak• Data may misinform• Best reporters suffer• Providers are most

reliable• No one uses them

Brennan TA et al. NEJM 2004;350:2409-12

infection, prevention, and reporting...• concept of grouping key practices into a “bundle” •...

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