The Quality Colloquium

1
The Quality Colloquium

• August 22, 2004

2
Strategies for Reducing InfectionsThe Role of
the Patient Safety Officer

• Tammy Lundstrom, MD
• VP, Chief Quality and Safety Officer
• Detroit Medical Center

3
Infection Control in the Headlines

• Lax Procedures put Infants at High Risk Simple
  Actions by Hospital Workers, Such as Diligent
  Hand-washing, Could Cut the Number of Fatal
  Infections.

Chicago Tribune 2002
4
JCAHO Accreditation

• Revised IC standards
• Focus on traditional surveillance and quality
  improvement
• Focus on integration of Infection Control into
  Patient Safety Activities
• Surge Capacity
• HAI as Sentinel Event-consequences
• Root Cause Analysis (RCA)
• Failure Mode and Effects Analysis (FMEA)

5
CDC 7 Challenges

• Reduce Catheter-associated adverse events
• Reduce surgical adverse events
• Reduce mortality and hospitalizations due to
  respiratory infection in LTC
• Reduce antibiotic resistant infections
• Eliminate microbiology lab errors
• Eliminate occupational sharps injuries
• Active compliance with ACIP immunization
  recommendations

6
Historical Evolution

• 1940 First description IC Officer
• 1940-60 Penicillin and resistance
• 1970s SENIC study proves value
• 1980s Continued growth of epidemiology
• 1990s Expand role to non-acute settings
• 2000s Expand role to quality promotion across
  the healthcare delivery system

Lancet 1999 354 (Supp IV)25 Emerging
Infect Dis 2001 7 286-92, 363-66
7
Study of Efficacy of Nosocomial Infection Control
(SENIC)

• Hospitals with intensive surveillance and control
  programs had lower rates of nosocomial infections
• Recommended 1 FTE/250 beds
• OUTDATED!!!

8
Patterns of Healthcare Associated Infection (HAI)

• Endemic
• 90-95 of all HAI
• Epidemic
• 5-10 of all HAI
• Easier to demonstrate investigative techniques
• 114 investigations by CDC over a decade
• 6 National in scope (contaminated product/device)

Emerging Infect Dis 2001 7295-98 Seminars in
IC 2001 2 74-84 Infect Control 1985 6 233-36
9
Consequences

• 2 million HAI
• 90,000 deaths
• 4.5-5.7 billion/ year
• 25 in Intensive Care Units
• 70 involve organisms with resistance to one or
  more antibiotics

J. Burke. NEJM 2003 348 7 Emerging Infect
Dis 1998 4 416-20 Infect Control Hosp Epi 2001
22 708-14
10
US Data
Variable 1975 1995
admissions(106) 37.7 35.9
Pt Days(106) 299 190
Ave LOS 7.9 5.3
Inpt Surg(106) 18.3 13.3
NI (106) 2.1 1.9
NI/1000 pt days 7.2 9.8
J. Burke NEJM 2003
11
Decrease () in HAI in NNIS ICU1990-1999
Type ICU BSI VAP UTI
coronary 43 42 40
medical 44 56 46
surgical 31 38 30
pediatric 32 26 59
Emerging Infect Dis 2001 7 170-73
12
Why HAI May Increase

• Sicker patients
• More invasive procedures for longer duration
• Staff shortages
• Nursing
• Pharmacists
• Pharmacy Techs
• Radiology Techs

13
Why HAI May Increase

• Resistant Organisms
• 1990s P. aeruginosa
• 1990s VRE
• 2002 VRSA
• Emerging Infectious Disease
• 1980s HIV
• 1990s hantavirus
• 2000s SARS

14
Most Common Epidemiology Interventions

• Disseminate rates with benchmark data
• Develop multidisciplinary teams around issues
• Education
• Communication

Am J Infect Control 1999 27 221
15
Focus on Evidence-based Practices

• Handwashing
• Maximum barrier precautions for vascular device
  insertion
• Preoperative antimicrobial prophylaxis
• Appropriate antimicrobial use

16
Handwashing

• Compliance 16-81
• Nurses consistently better than physicians
• Waterless hand hygiene agents improve compliance
• Placement considerations

17
(No Transcript)
18
The Human Element in Hand Hygiene Adherence

• Of 34 studies evaluated by CDC/HICPAC average
  level of adherence by Health care personnel
• 40 (range 5-81)
• -overall physicians usually worst
• Why?
• Too busy not enough time
• Hand hygiene sinks or products inaccessible
• Skin irritation
• Hands dont appear visibly soiled
• Influence of opinion leaders

19
Antimicrobial Resistant OrganismsThe Scope of
the Problem

• Gram positive bacteria
• VRE
• Streptococcus pneumoniae
• Gram negative bacteria
• Pseudomonas
• Salmonella
• Fungi
• Fluconazole-resistant Candida albicans
• Viruses
• Multi-drug resistant HIV
• Acyclovir-resistant herpes

20
CDC Strategies to Decrease Antimicrobial
Resistance

• Vaccinate
• Remove invasive devices as soon as possible
• Culture (avoid empiric treatment)
• Treat with intent to eradicate infection
• Obtain expert advice on antibiotic selection
• Consult antibiograms

21
CDC Strategies to Decrease Antimicrobial
Resistance

• 7. Avoid unnecessary antibiotic use
• 8. Target the pathogen
• 9. Do NOT treat colonization
• 10. Stop empiric antibiotics quickly once it
  appears that bacterial infection is unlikely
• 11. Enforce good infection control practices

22
Factors Contributing to Antimicrobial Resistance
in Hospitals

• Serious illness
• Immunocompromised state
• Use of invasive procedures/devices
• Increasing introduction of resistant organisms
  from the community (Nursing home/hospital
  transfers)
• Ineffective infection control practices
• High antibiotic use per geographic area per unit
  of time

23
Risk Factors for Staphylococcus aureus with
Reduced Susceptibility to Vancomycin (MIC gt 4
ug/mL)

• 19 cases Adjusted OR (CI 95)
• Vancomycin (per week) 5.6 (2.2-14.3)
• in prior 1 month
• Previous MRSA culture 15.5 (1.8- 134.5)
• in prior 2nd or 3rd month
• Fridkin et al. Clin Infect Dis 2003 36429-39

24
Antibiotic ResistanceDo CDC Strategies Work?

• 50 ICUs from 20 hospitals
• Monitored vancomycin use
• Feedback of risk-adjusted comparison data
• Unit-specific interventions successfully
  decreased vancomycin use and VRE rates
• Fridkin et al. Emerging Infectious Disease 8(7)
  702-704 2002
• CDC 12 Steps to Prevent Antimicrobial Resistance
  Among Hospitalized Patients

25
(In)Appropriate Antimicrobial Use

• 2000 Patients visiting physician for cold or
  upper respiratory infection found
• 63 received an antibiotic
• 54 received a broad-spectrum antibiotic
• JAMA February 2003

26
(In)Appropriate Antimicrobial Use

• Survey of 4 US medical centers
• 424 physicians surveyed
• 85 thought resistance a national problem
• 55 thought resistance a problem for their
  patients
• Wester et al. IDSA abstract 529 1999

27
WHY?Human Factors

• Physician
• Considering individual patient, not public health
  implications
• Time pressure
• Defensive medicine
• More is better
• Patient
• Belief that antibiotics cure viral infections
• Wants something other than reassurance

28
Antibiotic ResistanceOutpatient Practices

• Successful strategies must account for human
  factors
• Physician
• Knowledge of local resistance rates
• Restricted formulary
• Cold packs
• Treatment guidelines
• Patient educational materials
• Preprinted order sets
• Patient
• Education

29
Expansion Beyond Acute Care

• Long term care
• 1.8 million in 16,500 LTCF
• Home care
• Home IV therapy 5 billion industry
• Estimated 20,000 provider agencies
• Rehabilitation
• Outpatient surgery
• 52 of hospital-based procedures
• 2.8 million outpatient procedures 1996
• Ambulatory care
• 80-90 of cancer care

CDC Draft Isolation Guidelines 2004 www.cdc.gov
30
Roles Beyond Traditional Infection Control

• Regulatory/Accreditation
• Design/Planning/Construction/Renovation
• Occupational Health
• Patient Safety/Quality
• Human Resources-Staffing
• Product Selection
• Media Relations
• Bioterrorism

31
The FutureTransition From

• Device associated infections to device associated
  complications
• Surgical site infections to surgical site
  complications
• Antimicrobial resistance to drug-related
  complications

Emerging Infect Dis 2001 7 363-66
32
Sources of Evidence-based Guidelines for
Epidemiology

• Centers for Disease Control and Prevention
• National Guidelines Clearinghouse
• Association for Professionals in Infection
  Control and Epidemiology
• Society for Healthcare Epidemiology of America
• Institute for Healthcare Improvement