Challenges for Infection Prevention in the 21st Century

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Challenges for Infection Prevention in the 21st
Century

• William A. Rutala, Ph.D., M.P.H.
• UNC Health Care and UNC School of Medicine,
  Chapel Hill, NC

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Disclosure

• This educational activity is brought to you, in
  part, by Advanced Sterilization Products (ASP)
  and Ethicon. The speaker receives an honorarium
  from ASP and Ethicon and must present information
  in compliance with FDA requirements applicable to
  ASP.

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CHALLENGES IN THE PREVENTION AND MANAGEMENT OF
HEALTHCARE-ASSOCIATED INFECTIONS

• Changing population of hospital patients
• Increased severity of illness
• Increased numbers of immunocompromised patients
• Shorter duration of hospitalization
• More and larger intensive care units
• Larger step-down units
• Growing frequency of antimicrobial-resistant
  pathogens
• Lack of compliance with hand hygiene and other
  infection preventive measures (e.g., endoscope)

4
CHALLENGES IN THE PREVENTION AND MANAGEMENT OF
HEALTHCARE-ASSOCIATED INFECTIONS

• Limited infection prevention resources
• Implementation of bundles demonstrated to reduce
  HAIs
• Public reporting of HAIs
• CMS non-reimbursement for HAIs
• Health insurance reimbursement tied to quality
  goals
• State and federal laws legislating care issues
• Influenza immunization for staff
• MRSA screening of patients and staff
• Greater emphasis on infection prevention by The
  Joint Commission

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HEALTHCARE SYSTEM OF THE PAST
Home Care
Outpatient/ Ambulatory Facility
Acute Care Facility
Long Term Care Facility
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CURRENT HEALTHCARE SYSTEM
Acute Care Facility
Home Care
Outpatient/ Ambulatory Facility
Long Term Care Facility
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HEALTHCARE-ASSOCIATED INFECTIONS IMPACT

• 1.7 million infections per year
• 98,987 deaths due to HAI
• Pneumonia 35,967
• Bloodstream 30,665
• Urinary tract 13,088
• SSI 8,205
• Other 11,062
• 6th leading cause of death (after heart disease,
  cancer, stroke, chronic lower respiratory
  diseases, and accidents)1

1 National Center for Health Statistics, 2004
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MORTALITY RATE OF COMMON HAIs
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INCREMENTAL HOSPITAL DAYSDUE TO COMMON INFECTIONS
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RATES OF HEALTHCARE-ASSOCIATED INFECTIONS PER
1,000 PATIENT DAYS
69 Increase
11
COST ESTIMATES FOR HEALTHCARE-ASSOCIATED
INFECTIONS (HAIs)
HAI Cost per HAI SE Range
Ventilator-associated pneumonia 25,072 4,132 8,682-31,316
Healthcare-associated bloodstream infections 23,242 5,184 6,908-37,260
Surgical site infections 10,443 3,249 2,527-29,367
Catheter-associated urinary tract infections 758 41 728-810
Anderson DJ, et al. ICHE 200728767-773 Costs
based on literature review 1985-2005 adjusted to
US 1995 dollars
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CHALLENGES IN THE PREVENTION AND MANAGEMENT OF
HEALTHCARE-ASSOCIATED INFECTIONS

• Changing population of hospital patients
• Increased severity of illness
• Increased numbers of immunocompromised patients
• Shorter duration of hospitalization
• More and larger intensive care units
• Larger step-down units
• Growing frequency of antimicrobial-resistant
  pathogens
• Lack of compliance with hand hygiene and other
  infection preventive measures (e.g., endoscope)

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HAZARDS IN THE ICU
Weinstein RA. Am J Med 199191(suppl 3B)180S
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PREVALENCE ICU (EUROPE)

• Study design Point prevalence rate
• 17 countries, 1447 ICUs, 10,038 patients
• Frequency of infections 4,501 (44.8)
• Community-acquired 1,876 (13.7)
• Hospital-acquired 975 (9.7)
• ICU-acquired 2,064 (20.6)
• Pneumonia 967 (46.9)
• Other lower respiratory tract 368 (17.8)
• Urinary tract 363 (17.6)
• Bloodstream 247 (12.0)

Vincent J-L, et al. JAMA 1995274639
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RISK FACTORS FOR ICU-ACQUIRED INFECTIONS
(95 CI)
(1.01-1.43)
(1.16-1.57)
(1.20-1.60)
(1.19-1.69)
(1.51-2.03)
(1.75-2.44)
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RISK FACTORS FOR ICU-ACQUIRED INFECTIONS
(95 CI)
(1.56-4.13)
(5.51-14.70)
(9.33-24.14)
(19.43-48.67)
(37.90-96.25)
(48.18-120.06)
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NOSOCOMIAL INFECTIONS IN THE UNITED STATES
Variable 1975 1995
Admissions 37,700,000 35,900,000
Patient-days 299,000,000 190,000,000
Average length of stay 7.9 5.3
Inpatient surgical procedures 18,300,000 13,300,000
Nosocomial infections 2,100,000 1,900,000
Incidence of nosocomial infections (number per 1000 patient-days) 7.2 9.8
Burke JP. NEJM 2003348651
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AGING POPULATION, US
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CANCER INCIDENCE DEATHS, 2006 (estimated)
American Cancer Society
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CHALLENGES IN THE PREVENTION AND MANAGEMENT OF
HEALTHCARE-ASSOCIATED INFECTIONS

• Changing population of hospital patients
• Increased severity of illness
• Increased numbers of immunocompromised patients
• Shorter duration of hospitalization
• More and larger intensive care units
• Larger step-down units
• Growing frequency of antimicrobial-resistant
  pathogens and emerging pathogen
• Lack of compliance with hand hygiene and other
  infection preventive measures (e.g., endoscope)

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Evolution of Antimicrobial Resistancein
Gram-positive Cocci
CA-MRSA
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UNITED STATES

• Enterobacter / Ceftazidime 21?19
• E. coli / ESBL phenotype 3?5
• E. coli / Ciprofloxacin 4?19
• Klebsiella / ESBL phenotype 6?15
• Klebsiella / Ciprofloxacin 4?13
• Klebsiella / Imipenem (?2 µg/ml) lt1?5 (3.7)

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UNITED STATES

• P. aeruginosa / Imipenem 9?8
• P. aeruginosa / Piperacillin-tazobactam 11?12
• P. aeruginosa / Ciprofloxacin 17?19
• Acinetobacter / Amikacin 11?16
• Acinetobacter / Ceftazidime 23?45
• Acinetobacter / Imipenem 3?7

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EMERGING INFECTIOUS AGENTS

• Current concerns
• Vancomycin resistant Staphylococcus aureus
• Multidrug resistant gram negative pathogens
• Clostridium difficile (strains that hyperproduce
  toxin)
• Norovirus
• Prions
• XDR-TB

• Future concerns but planning required
• Influenza pandemic (H5N1?)
• Bioterrorism
• Gene transfer
• Xenotransplantation

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EMERGING INFECTIOUS DISEASES RELEVANT TO THE
HOSPITAL

• 1977 (US) Legionnaires disease
• 1978 (US) Staphylococcal toxic shock syndrome
• 1996 (England ? US) Variant Creutzfeld-Jakob
  disease (vCJD)
• 2001 (US) - Anthrax (attack via letters)
• 2002 (US) Vancomycin-resistant S. aureus
• 2002 (Canada ? US) Hypervirulent C. difficile
• 2003 (China ? worldwide) - SARS
• 2003 (US) Monkeypox
• 2004 (Asia) Avian influenza (H5N1)
• 2006 (Worldwide) XDR-TB

HCWs at risk for infection
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RISKS FROM EMERGINGINFECTIOIUS DISEASES

• Person-to-person transmission
• Andes hanta virus
• Anthrax
• C. difficile
• Monkeypox
• Norovirus (G-II strain)
• Plague
• Rabies
• Smallpox
• Viral hemorrhagic fever

• Fomite transmission
• Anthrax
• C. difficile
• Norovirus
• Plague
• Q fever
• Smallpox
• Lab risk
• Q fever
• Monkeypox
• Smallpox

BT agent
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SARS
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Total SARS Cases and Healthcare Workers by
Country
HCW
Total No. SARS Cases
HCW
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CHALLENGES IN THE PREVENTION AND MANAGEMENT OF
HEALTHCARE-ASSOCIATED INFECTIONS

• Changing population of hospital patients
• Increased severity of illness
• Increased numbers of immunocompromised patients
• Shorter duration of hospitalization
• More and larger intensive care units
• Larger step-down units
• Growing frequency of antimicrobial-resistant
  pathogens
• Lack of compliance with hand hygiene and other
  infection preventive measures (e.g., endoscope)

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Lack of Compliance

• Hand Hygiene
• Endoscope reprocessing
• SSI

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ASSOCIATION BETWEEN HAND HYGIENE COMPLIANCE AND
HAI RATES
Author, year Setting Results
Casewell, 1977 Adult 1CU Reduction HAI due to Klebsiella
Maki, 1982 Adult 1CU Reduction HAI rates
Massanari, 1984 Adult 1CU Reduction HAI rates
Kohen, 1990 Adult 1CU Trend to improvement
Doebbeling, 1992 Adult 1CU Different rates of HAI between 2 agents
Webster, 1994 NICU Elimination of MRSA
Zafar, 1995 Newborn Elimination of MRSA
Larson, 2000 MICU/NICU 85 reduction VRE
Pittet, 2000 Hospitalwide Reduction HAI MRSA cross-transmission
HAI, healthcare-associated infections
Other infection control measures also
instituted
Boyce JM, Pitter D.
MMWR 200251(RR-16)
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How Is Our Track Record on Handwashingin
Healthcare Facilities?

• A review of 34 published studies of handwashing
  adherence among healthcare workers found that
  adherence rates varied from 5 to 81
• The average adherence rate was only 40

Average Handwashing Adherence of Personnel in 34
Studies
Average
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Hand Hygiene Adherence an Institutional Priority

• Multidisciplinary Program
• Administrative support (IOC, Executive Staff,
  Dept Heads)
• Monitor HCWs adherence to policy and provide
  staff with information about performance
• Provide HCWs with accessible hand hygiene (HH)
  products
• to include alcohol based hand rubs
• Education regarding types of activities that
  result in hand contamination and indications for
  hand hygiene
• Reminders in the workplace (e.g., posters)
• Considering ways to include HH in management
  standards (loss of hospital privileges, tickets
  for non-compliance, coffee coupons)

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UNC Hospitals Intensive Care Units Hand
Hygiene Compliance
Pocket-sized alcohol based gel available ?
Evaluated hand hygiene products ?
Leadership presentations Collected
baseline data ?

?
?
?
?
Implemented Infection Control Liaisons
Staff HH compliance added to patient
satisfaction survey
Began quarterly compliance reports to
ICUs Ongoing education
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GI ENDOSCOPES

• Widely used diagnostic and therapeutic procedure
• Endoscope contamination during use (109 in/105
  out)
• Semicritical items require high-level
  disinfection minimally
• Inappropriate cleaning and disinfection has lead
  to cross-transmission
• In the inanimate environment, although the
  incidence remains very low (35 cases of
  transmission from 1993-2002), endoscopes
  represent a risk of disease transmission

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Endoscope Reprocessing Current Status of
Cleaning and Disinfection

• Guidelines
• Society of Gastroenterology Nurses and
  Associates, 2000
• European Society of Gastrointestinal Endoscopy,
  2000
• British Society of Gastroenterology Endoscopy,
  1998
• Gastroenterological Society of Australia, 1999
• Gastroenterological Nurses Society of Australia,
  1999
• American Society for Gastrointestinal Endoscopy,
  2003
• Association for Professional in Infection Control
  and Epidemiology, 2000
• Multi-society Guideline for Reprocessing Flexible
  GI Endoscopes, 2003
• Centers for Disease Control and Prevention, 2004
  (in press)

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Endoscope Reprocessing, Worldwide

• Worldwide, endoscopy reprocessing varies greatly
• India, of 133 endoscopy centers, only 1/3
  performed even a minimum disinfection (1 glut
  for 2 min)
• Brazil, a high standard occur only
  exceptionally
• Western Europe, gt30 did not adequately disinfect
• Japan, found exceedingly poor disinfection
  protocols
• US, 25 of endoscopes revealed gt100,000 bacteria
• Schembre DB. Gastroint Endoscopy 200010215

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TRANSMISSION OF INFECTION

• Gastrointestinal endoscopy
• gt300 infections transmitted
• 70 agents Salmonella sp. and P. aeruginosa
• Clinical spectrum ranged from colonization to
  death (4)
• Number of reported infections is small,
  suggesting a very low incidence
• Endemic transmission may go unrecognized
• Bronchoscopy
• 90 infections transmitted
• M. tuberculosis, atypical Mycobacteria, P.
  aeruginosa
• Spach DH et al Ann Intern Med 1993 118117-128
  and Weber DJ et al Gastroint Dis 200287

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ENDOSCOPE INFECTIONS

• Infections traced to deficient practices
• Inadequate cleaning (clean all channels)
• Inappropriate/ineffective disinfection (time
  exposure, perfuse channels, test concentration)
• Failure to follow recommended disinfection
  practices (drying, contaminated water bottles,
  irrigating solutions)
• Flaws in design/manufacture of endoscopes or AERs

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ENDOSCOPE DISINFECTION

• CLEAN-mechanically cleaned with water and
  enzymatic detergent
• HLD/STERILIZE-immerse scope and perfuse
  HLD/sterilant through all channels for at least
  12-20 min
• RINSE-scope and channels rinsed with sterile,
  filtered or tap water followed by alcohol
• DRY-use forced air to dry insertion tube and
  channels
• STORE-prevent recontamination

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Surgical Site Infection

• SSIs third most common HAI, accounting for 14-23
  of HAIs
• Among surgical patients, SSIs were most common
  accounting for 40 of healthcare-associated
  infections
• 67 incisional infections (confined to incision)
• 33 organ/space infections
• Increase an average of 7 days to each
  hospitalization
• Increase gt10,000 (2005 ) to each
  hospitalization
• Appropriate preoperative administration of
  antibiotics and other prevention measures are
  effective in preventing infection

Surgical Site Infections. Available at
http//www.ihi.org/IHI/Topics/PatientSafety/Surgic
alSiteInfections/. Odom-Forren J. Nursing2006.
200636(6)58-63.
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Cost Estimates for Specific Healthcare-Associated
Infections
HAI type Weight-Adjusted Cost per HAI Mean SE Range of Published Estimates of Cost per HAI
VAP 25,072 4,132 8,682-31,316
BSI 23,242 5,184 6,908-37,260
SSI 10,443 3,249 2,527-29,367
CA-UTI 758 41 728-810
2005 US dollars Anderson DJ, et al. ICHE
200728767-773
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Clinical and Economic Impact
Procedure/Device Devices/yr Infections/yr Avg. cost Mortality
CARDIO CARDIO CARDIO CARDIO CARDIO
Heart valves 85,000 3,400 50,000 High
Vascular grafts 450,000 16,000 40,000 Moderate
Pacemaker/ICD 300,000 12,000 35,000 Moderate
LV assist dev. 700 280 50,000 High
NEURO NEURO NEURO NEURO NEURO
CNS shunt 40,000 2400 50,000 Moderate
Adapted from Darouiche RO. N Engl J Med.
20043501422-429. Darouiche RO. Clin Infec Dis.
2001381567-1572.
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Clinical and Economic Impact
Procedure/Device Devices/yr Infections/yr Avg. cost Mortality
ORTHOPEDIC ORTHOPEDIC ORTHOPEDIC ORTHOPEDIC ORTHOPEDIC
Joint prosthesis 600,000 12,000 30,000 Low
Fracture fixator 2,000,000 100,000 15,000 Low
PLASTIC PLASTIC PLASTIC PLASTIC PLASTIC
Breast implant 130,000 2600 20,000 Low
UROLOGICAL
Penile implant 15,000 450 35,000 Low
Adapted from Darouiche RO. N Engl J Med.
20043501422-429. Darouiche RO. Clin Infec Dis.
2001381567-1572.
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Surgical Site Infection

• Advances in infection control practices
• Improved operating room ventilation
• Sterilization methods
• Barriers
• Surgical technique
• Antimicrobial prophylaxis

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SSI Pathogenesis

• Risk of surgical site infections
• Dose of bacterial contamination x virulence
  (toxins)
• Resistance of the host

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SSI Primary Risk Factors

• Endogenous microorganisms
• Skin-dwelling microorganisms
• Most common source
• S aureus most common isolate
• Fecal flora (gnr) when incisions are near the
  perineum or groin
• Exogenous microorganisms
• Surgical personnel (members of surgical team)
• OR environment (including air)
• All tools, instruments, and materials (extremely
  rare)

Mangram AJ, et al. Infect Control Hosp Epidemiol.
199920(4)250-278.
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SSI CDC Guidelines
Patient characteristics
Preoperative issues
Intra-operative issues
Postoperative issues
Mangram AJ, et al. Infect Control Hosp Epidemiol.
199920(4)250-278.
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CDC Surgical Site Infection Prevention
Guidelines - 1999

• Category IA and IB
• No prior infections 15 air changes/hr in ORDo
  not shave in advance Keep OR doors closed
  Control glucose in D.M. pts Use sterile
  instrumentsStop tobacco use Wear a maskShower
  with antiseptic soap Cover hairPrep skin with
  approp. agent Wear sterile glovesSurgical team
  nails short Gentle tissue handlingSurgical team
  scrub hands DPC for heavily contaminated
• Exclude I/C surgical team wounds Give
  prophylactic antibiotics Closed suction drains
  (when used)Pos pressure ventilation in
  OR Sterile dressing x 24-48 hr SSI surveillance
  with feedback to surgeons

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Surgical Infection PreventionArch Surg
2005140174
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CHALLENGES IN THE PREVENTION AND MANAGEMENT OF
HEALTHCARE-ASSOCIATED INFECTIONS

• Limited infection prevention resources
• Implementation of bundles demonstrated to reduce
  HAIs
• Public reporting of HAIs
• CMS non-reimbursement for HAIs
• Health insurance reimbursement tied to quality
  goals
• State and federal laws legislating care issues
• Influenza immunization for staff
• MRSA screening of patients and staff
• Greater emphasis on infection prevention by The
  Joint Commission

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INCREASING DEMANDS ON ICPsWITH ACCOUNTABILITY

• Public expectation of 0 rate of
  healthcare-associated infections?
• Buy in by legislatures and CMS
• IC accountability and attention rich but resource
  poor

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ICP ACTIVITIES

• 1975 to 1990
• Surveillance
• Outbreak investigations
• Exposure evaluations
• Education
• JCAHO
• Policy development and review
• Sterilizer monitoring
• Dialysis water

• 1991 to 2003 (new)
• Targeted surveillance
• OSHA TB
• OSHA Bloodborne
• Molecular epidemiology
• MRSA, VRE
• BT preparedness
• Construction rounds

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ICP ACTIVITIES

• 2004 to 2008 (new)
• IHI bundles
• CMS core measures
• NSQUIP (VAs, others)
• NDNQI (ANA)
• Other CQI initiatives
• MRSA active surveillance
• Unannounced TJC visits
• Avian influenza preparedness
• Endoscope sampling

• Future
• Public health reporting
• Mandated influenza vaccine
• Mandated MRSA surveillance
• Cost analyses
• Comprehensive surveillance
• Transparency

58
CHALLENGES IN THE PREVENTION AND MANAGEMENT OF
HEALTHCARE-ASSOCIATED INFECTIONS

• Limited infection prevention resources
• Implementation of bundles demonstrated to reduce
  HAIs
• Public reporting of HAIs
• CMS non-reimbursement for HAIs
• Health insurance reimbursement tied to quality
  goals
• State and federal laws legislating care issues
• Influenza immunization for staff
• MRSA screening of patients and staff
• Greater emphasis on infection prevention by The
  Joint Commission

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Prevent Surgical Site InfectionsInstitute for
Healthcare Improvement

• Components or bundle if implemented reliably
  can eliminate SSIs
• Appropriate use of antibiotics
• Appropriate hair removal
• Maintenance of postoperative glucose control for
  major cardiac surgery patients
• Establishment of postoperative normothermia for
  colorectal surgery patients
• Bundle is a group of interventions related to a
  disease process that, when executed together
  result in better outcomes than when implemented
  individually.

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Institute for Healthcare ImprovementVAP AND
CA-BSI BUNDLES

• VAP Bundle
• Elevation of the head of the bed to between 30
  and 45 degrees
• Daily sedation vacation and daily assessment of
  readiness to extubate
• Peptic ulcer disease (PUD) prophylaxis
• Deep venous thrombosis (DVT) prophylaxis (unless
  contraindicated)

• CA-BSI
• Hand hygiene
• Maximal barrier precautions
• Chlorhexidine skin antisepsis
• Optimal catheter site selection, with subclavian
  vein as the preferred site for non-tunneled
  catheters
• Daily review of line necessity, with prompt
  removal of unnecessary lines

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University of North Carolina Health Care

• Ventilator-associated pneumonias
• Leads to an increased length of stay, 13 days
• Substantial cost to the healthcare institution,
  about 24,400
• Mortality about 30
• Catheter-related bloodstream infections
• Leads to an increased length of stay, 14 days
• Substantial cost to the healthcare institution,
  about 25,000 (not reimbursed by CMS, Oct 2008)
• Mortality about 20

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UNC Health Care ICUs Central Catheter-Associated
Bloodstream Infections
Medical Staff education ?
Dressing kit with Chloraprep ?
Custom insertion kits with antiseptic
catheters ?
Nursing education ?
IHI ?
Hospital Epidemiology Confidential Information
for CQI
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University of North Carolina Health CareHow We
Are Doing Overall VAPs
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CHALLENGES IN THE PREVENTION AND MANAGEMENT OF
HEALTHCARE-ASSOCIATED INFECTIONS

• Limited infection prevention resources
• Implementation of bundles demonstrated to reduce
  HAIs
• Public reporting of HAIs
• CMS non-reimbursement for HAIs
• Health insurance reimbursement tied to quality
  goals
• State and federal laws legislating care issues
• Influenza immunization for staff
• MRSA screening of patients and staff
• Greater emphasis on infection prevention by The
  Joint Commission

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PUBLIC REPORTING

• Who decides
• Legislature (with input from advocacy groups)
• Executive branch
• Independent commission (NC)
• Whats reported
• Specific infection rates (e.g., CR-BSI)
• All surveillance data?
• Who has access to the data
• Public health department
• Public

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CHALLENGES IN THE PREVENTION AND MANAGEMENT OF
HEALTHCARE-ASSOCIATED INFECTIONS

• Limited infection prevention resources
• Implementation of bundles demonstrated to reduce
  HAIs
• Public reporting of HAIs
• CMS non-reimbursement for HAIs
• Health insurance reimbursement tied to quality
  goals
• State and federal laws legislating care issues
• Influenza immunization for staff
• MRSA screening of patients and staff
• Greater emphasis on infection prevention by The
  Joint Commission

68
CMS Reimbursement Deniedfor Healthcare-Associated
Infections

• New CMS guidelines will deny reimbursement for
• Vascular catheter-associated infections
• Catheter-related UTIs
• Mediastinitis after CABG
• CMS is proposing to expand the list of conditions
  by 9 to include
• SSI following certain elective procedures
• Legionnaires disease
• Ventilator-associated pneumonia
• S. aureus septicemia
• Clostridium difficile associated disease

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CHALLENGES IN THE PREVENTION AND MANAGEMENT OF
HEALTHCARE-ASSOCIATED INFECTIONS

• Limited infection prevention resources
• Implementation of bundles demonstrated to reduce
  HAIs
• Public reporting of HAIs
• CMS non-reimbursement for HAIs
• Health insurance reimbursement tied to quality
  goals
• State and federal laws legislating care issues
• Influenza immunization for staff
• MRSA screening of patients and staff
• Greater emphasis on infection prevention by The
  Joint Commission

70
CHALLENGES IN THE PREVENTION AND MANAGEMENT OF
HEALTHCARE-ASSOCIATED INFECTIONS

• Health insurance reimbursement tied to meeting
  quality goals
• Incentive package would involve metrics that are
  clinically meaningful and measurable.
• Patient satisfaction
• Ventilator-associated pneumonia, target NHSN
• Central-line associated bacteremia, target NHSN
• Hand hygiene, compare to literature
• Prophylactic antibiotics within one hour of
  surgical incision

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Targeting ZeroD Murphy, APIC 2007

• Set goal at zero (BSI, VAP, SSI, MRSA)
• Strong leadership, MD support, Department
  champions
• Use the bundle approach to evidence-based
  prevention measures
• Real-time root-cause analysis when a HAI occurs
• Personalize HAIs (information about people not
  rates)
• Data shared relentlessly with staff, leadership
• Teamwork essential and team success celebrated
• Market the value of infection prevention to
  leadership

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University of North Carolina Health Care
73
CHALLENGES IN THE PREVENTION AND MANAGEMENT OF
HEALTHCARE-ASSOCIATED INFECTIONS

• Limited infection prevention resources
• Implementation of bundles demonstrated to reduce
  HAIs
• Public reporting of HAIs
• CMS non-reimbursement for HAIs
• Health insurance reimbursement tied to quality
  goals
• State and federal laws legislating care issues
• Influenza immunization for staff
• MRSA screening of patients and staff
• Greater emphasis on infection prevention by The
  Joint Commission

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MANAGEMENT OF MRSA IN HOSPITALSIMPACT OF MRSA

• 126,000 hospitalized patients infected annually
• 3.95 MRSA infections per 1,000 discharges
• gt5,000 deaths
• gt2.5 billion excess health care costs due to
  MRSA
• 9.1 days excess length of stay (LOS)
• gt20,000 in excess cost per case (range,
  7,000-32,000)
• 4 in excess in-hospital mortality

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MANAGEMENT OF MRSA IN HOSPITALS5 MILLION LIVES
CAMPAIGN (IHI)

• Improved hand hygiene
• Decontamination of the environment and equipment
• Active surveillance cultures for MRSA
  colonization
• 9.5 admission to UNCHC MICU colonized
• 6.5 admissions to UNCHC SICU colonized
• Contact isolation for infected and colonized
  patients
• Device bundles (Central Line and Ventilator
  Bundle)

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RATIONALE FOR SCREENING PATIENTS FOR MRSA

• Patients colonized or infected with MRSA
  represent the major reservoir of MRSA in
  healthcare settings
• 33 to 91 of colonized patients are NOT detected
  by routine clinical cultures
• Transmission of MRSA from non-isolated patients
  occurs 16 times more often than from isolated
  patients
• Impact of active surveillance cultures on MRSA
  acquisitions or infections
• 16/18 (89) published articles reported
  substantial reduction

77
CHALLENGES IN THE PREVENTION AND MANAGEMENT OF
HEALTHCARE-ASSOCIATED INFECTIONS

• Limited infection prevention resources
• Implementation of bundles demonstrated to reduce
  HAIs
• Public reporting of HAIs
• CMS non-reimbursement for HAIs
• Health insurance reimbursement tied to quality
  goals
• State and federal laws legislating care issues
• Influenza immunization for staff
• MRSA screening of patients and staff
• Greater emphasis on infection prevention by The
  Joint Commission

78
The Joint Commission2009 Chapter National
Patient Safety Goals

• Goal 7-reduce the risk of HAIs
• Compliance with WHO and CDC hand hygiene
• Implement evidence-based practices to prevent
  HAIs due to multiply drug-resistant organisms
• Implement evidence-based practices to prevent
  central-line associated bloodstream infections
• Implement best practices for preventing surgical
  site infections

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CONCLUSIONS

• Healthcare-associated infections are associated
  with significant patient morbidity and mortality
• Implementation of IHI bundles demonstrated to
  reduce VAP and CR-BSI infections
• Compliance with infection prevention
  recommendations needed to prevent HAIs
• New issues public reporting CMS
  non-reimbursement for HAIs National Patient
  Safety Goals (TJC) insurance reimbursement tied
  to quality goals

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CONCLUSIONS

• Current challenges
• Increased emphasis on preventing HAIs increased
  demands on ICP time
• Lack of compliance with hand hygiene and policies
• Institution of IHI bundles and other CQI
  activities
• Public reporting, mandated vaccines, mandated
  practices
• Multidrug pathogens VRSA, MDR-GNRs, XDR-TB
• Emerging pathogens C. difficile, norovirus
• Public desire for 0 rate of healthcare-associated
  infections

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CONCLUSIONS

• Future
• Gene therapy-genes introduced into human cells
• Xenotransplanation-organs from nonhuman species
  to human recipients emerged due to shortage of
  human organs
• Emerging pathogens?
• Influenza pandemic?
• Bioterrorism?

82
Thank you
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ACKNOWLEDGEMENTS

• Thanks to the following persons for slides
• David Weber
• Karen Hoffmann
• Jay Fishman
• Ron Jones
• Jason Stout