The Ongoing Battle to Reduce Healthcare-associated Infections

By Jennifer Larson, contributor

February 25, 2014 - No one would dispute that healthcare-associated infections (HAIs) are both costly and deadly.

About two million HAIs occur each year in U.S. hospitals, resulting in as many as 90,000 deaths annually.

The cost estimates vary, but a September 2013 study published in JAMA Internal Medicine proposed that the total annual cost of five major HAIs was nearly $10 billion. (Central line-associated bloodstream infections, or CLABSIs, were the most expensive, with an average cost of nearly $46,000.)

Fortunately, HAIs are becoming less common than they once were.

“This is not a problem that is going to go away overnight, but I think enormous progress has been made,” said Katherine Kahn, MD, a researcher with the RAND Corporation and a professor of medicine at UCLA’s David Geffen School of Medicine.

“I do think we’re making progress,” said Pamela Owens, PhD, a researcher with the Agency for Healthcare Research and Quality (AHRQ) and a research assistant professor with Washington University School of Medicine. “I think there is much greater awareness of infections from health care acquired conditions than we had five years ago. That itself says a lot.”

And much of the credit can be given to a national action plan that was launched in 2009 with the goal of reducing common HAIs by significant margins, using evidence-based strategies and guidelines.

The action plan

In 2008, scientists, clinicians and public health leaders from a number of federal agencies joined together to establish a steering committee to coordinate HAI reduction efforts. In 2009, the steering committee released the National Action Plan to Prevent Health Care-Associated Infections, which called for significant reductions in costly HAIs.

“What was new and different about the action plan was a major effort to coordinate the activities that would be performed,” said Kahn, who led a project to assess the effectiveness of the plan. The efforts were recently published in a series of articles in the journal Medical Care.

She noted that the plan has accomplished several noteworthy achievements. It has highlighted the importance of developing an infrastructure to support the efforts, as well as creating a systematic approach for monitoring and measuring infection rates. It supported a more coordinated approach to research and the implementation of prevention practices.

The first phase of the plan focused on prevention in acute care hospitals. The plan set out nine five-year target goals for reducing the most common HAIs, including catheter-associated urinary tract infections (CAUTI), Clostridium difficile infections, central-line associated bloodstream infections (CLABSI), surgical site infections, MRSA infections, and ventilator-associated events.

As part of the plan, the AHRQ expanded a project called On the CUSP: Stop BSI that it began in 2008 to reduce CLABSIs. In 2007, it funded a second project to reduce CAUTIs , which expanded to become the national On the CUSP: Stop CAUTI effort in 2009. The programs both applied the Comprehensive Unit-based Safety Program (CUSP) model to the efforts.

“The efforts, regional as well as at a national level, have been very strong over the last few years,” said Sam Watson, executive director of the Michigan Health & Hospital Association Keystone Center for Patient Safety and Quality.

The center has long been in a leader in HAI reduction effort; it partnered with Johns Hopkins University and the Health Research & Educational Trust in 2003 to implement a program to reduce CLABSIs in the ICU that was the forerunner of the On the CUSP: Stop BSI project.

“We’ve learned a tremendous amount since those early days,” said Watson.

Infection prevention and reduction in ambulatory care settings

Despite the progress that has been made, there is still some way to go.

Much less data is available on HAIs in ambulatory surgery centers, said Owens, who is the lead author of a study in the February 19 issue of JAMA that is titled “Surgical Site Infections Following Ambulatory Surgery Procedures.”

But having this type of data may become increasingly important because, as the study notes, “the preponderance of surgical procedures are now performed in ambulatory settings.” In fact, they accounted for nearly 64% of all operations in 2010.

Surgical site infections in patients who just underwent surgery in an ambulatory care facility are relatively rare, if examining only the rates. This is good news, but the absolute numbers are still “substantial.” And the study’s authors wrote that prior studies have uncovered lapses in infection control practices at ambulatory surgery centers. Together, that shows a need for more attention to quality improvement efforts.

Fortunately for those who want to know more about infections on the ambulatory care side, the issue was specifically addressed in the national action plan’s second phase. After the first phase of the action plan was released, the steering committee expanded its focus to include the outpatient setting (and also the role of health care personnel).

“We will be paying more attention to the outpatient setting,” Owens predicted. “It’s an evolution, but there are things in place that make that easier from a data perspective.”

Five years later

Five years have passed since the U.S. Department of Health and Human Services (HHS) released the national action plan. What happens now?

“Moving forward, HHS leadership will need to decide how best to sustain the momentum achieved through the action plan to continue to reduce and, eventually, to eliminate HAIs,” wrote Kahn, et. al in “Lessons Learned and Future Directions,” published in a supplement to the February issue of the journal Medical Care. “Particular attention will need to be focused on securing the resources--both financial and nonfinancial--that are necessary to sustain progress.”

The cultural context must be kept at the forefront, too, Watson said. He noted that the CUSP model includes evidence-based interventions but also addresses the importance of the cultural context. And to be successful, future efforts to reduce infection need the support of a larger overall culture that prioritizes patient safety. That means that health care professionals must be attuned to the potential for risk at all times.

“That’s the frame that we have to move to, and I think we’re making gains in that,” he said.

Kahn noted that there is substantial evidence that many HAIs can be avoided. “We’re not in the position to do that just yet,” she said. “It is a goal that we should aspire for.”

“It used to be thought that these infections were inevitable, especially among sick people,” she continued. “But it turns out that many of these infections are preventable. We just have to change the way we implement some aspects of medical care.”

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