The Quality ColloquiumThe Quality Colloquium

August 22, 2004August 22, 2004

Strategies for Reducing Strategies for Reducing Infections:Infections:

The Role of the Patient Safety The Role of the Patient Safety OfficerOfficer

Tammy Lundstrom, MDTammy Lundstrom, MD

VP, Chief Quality and Safety OfficerVP, Chief Quality and Safety Officer

Detroit Medical CenterDetroit Medical Center

Infection Control in the Infection Control in the HeadlinesHeadlines

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

Chicago Tribune 2002

JCAHO AccreditationJCAHO Accreditation

Revised IC standardsRevised IC standards– Focus on traditional surveillance and quality Focus on traditional surveillance and quality

improvementimprovement– Focus on integration of Infection Control into Focus on integration of Infection Control into

Patient Safety ActivitiesPatient Safety Activities– Surge CapacitySurge Capacity

HAI as Sentinel Event-consequencesHAI as Sentinel Event-consequences– Root Cause Analysis (RCA)Root Cause Analysis (RCA)– Failure Mode and Effects Analysis (FMEA)Failure Mode and Effects Analysis (FMEA)

CDC 7 ChallengesCDC 7 Challenges

Reduce Catheter-associated adverse eventsReduce Catheter-associated adverse events Reduce surgical adverse eventsReduce surgical adverse events Reduce mortality and hospitalizations due to Reduce mortality and hospitalizations due to

respiratory infection in LTCrespiratory infection in LTC Reduce antibiotic resistant infectionsReduce antibiotic resistant infections Eliminate microbiology lab errorsEliminate microbiology lab errors Eliminate occupational sharps injuriesEliminate occupational sharps injuries Active compliance with ACIP immunization Active compliance with ACIP immunization

recommendationsrecommendations

Historical EvolutionHistorical Evolution

19401940 First description IC OfficerFirst description IC Officer1940-601940-60 Penicillin and resistancePenicillin and resistance1970’s1970’s SENIC study; proves valueSENIC study; proves value1980’s1980’s Continued growth of epidemiologyContinued growth of epidemiology1990’s1990’s Expand role to non-acute settingsExpand role to non-acute settings2000’s2000’s Expand role to “quality promotion Expand role to “quality promotion

across the healthcare delivery across the healthcare delivery system”system”

Lancet 1999; 354 (Supp IV):25 Emerging Infect Dis 2001; 7: 286-92, 363-66

Study of Efficacy of Nosocomial Study of Efficacy of Nosocomial Infection Control (SENIC)Infection Control (SENIC)

Hospitals with intensive surveillance and Hospitals with intensive surveillance and control programs had lower rates of control programs had lower rates of nosocomial infectionsnosocomial infections

Recommended 1 FTE/250 bedsRecommended 1 FTE/250 beds– OUTDATED!!!OUTDATED!!!

Patterns of Healthcare Associated Patterns of Healthcare Associated Infection (HAI)Infection (HAI)

EndemicEndemic

90-95% of all HAI90-95% of all HAI

EpidemicEpidemic

5-10% of all HAI5-10% of all HAI

Easier to demonstrate investigative techniquesEasier to demonstrate investigative techniques

114 investigations by CDC over a decade114 investigations by CDC over a decade

6 National in scope (contaminated product/device)6 National in scope (contaminated product/device)

Emerging Infect Dis 2001; 7:295-98 Seminars in IC 2001; 2: 74-84

Infect Control 1985; 6: 233-36

ConsequencesConsequences

2 million HAI2 million HAI

90,000 deaths90,000 deaths

$4.5-5.7 billion/ year$4.5-5.7 billion/ year

25% in Intensive Care Units25% in Intensive Care Units

70% involve organisms with resistance to one 70% involve organisms with resistance to one or more antibioticsor more antibiotics

J. Burke. NEJM 2003; 348: 7 Emerging Infect Dis 1998; 4: 416-20

Infect Control Hosp Epi 2001; 22: 708-14

US DataUS Data

VariableVariable 19751975 19951995

admissions(10admissions(1066)) 37.737.7 35.935.9

Pt Days(10Pt Days(1066)) 299299 190190

Ave LOSAve LOS 7.97.9 5.35.3

Inpt Surg(10Inpt Surg(1066)) 18.318.3 13.313.3

NI (10NI (1066)) 2.12.1 1.91.9

NI/1000 pt daysNI/1000 pt days 7.27.2 9.89.8

J. Burke NEJM 2003

Decrease (%) in HAI in NNIS Decrease (%) in HAI in NNIS ICUICU

1990-19991990-1999Type ICUType ICU BSIBSI VAPVAP UTIUTI

coronarycoronary 4343 4242 4040

medicalmedical 4444 5656 4646

surgicalsurgical 3131 3838 3030

pediatricpediatric 3232 2626 5959

Emerging Infect Dis 2001; 7: 170-73

Why HAI May IncreaseWhy HAI May Increase

Sicker patientsSicker patients More invasive procedures for longer More invasive procedures for longer

durationduration Staff shortagesStaff shortages

– NursingNursing– PharmacistsPharmacists– Pharmacy TechsPharmacy Techs– Radiology TechsRadiology Techs

Why HAI May IncreaseWhy HAI May Increase

Resistant OrganismsResistant Organisms– 1990’s1990’s P. aeruginosaP. aeruginosa– 1990’s1990’s VREVRE– 2002 2002 VRSAVRSA

Emerging Infectious DiseaseEmerging Infectious Disease– 1980’s1980’s HIVHIV– 1990’s1990’s hantavirushantavirus– 2000’s2000’s SARSSARS

Most Common Epidemiology Most Common Epidemiology InterventionsInterventions

Disseminate rates with benchmark dataDisseminate rates with benchmark data Develop multidisciplinary teams around Develop multidisciplinary teams around

issuesissues EducationEducation CommunicationCommunication

Am J Infect Control 1999; 27: 221

Focus on Evidence-based Focus on Evidence-based PracticesPractices

HandwashingHandwashing

Maximum barrier precautions for vascular Maximum barrier precautions for vascular device insertiondevice insertion

Preoperative antimicrobial prophylaxisPreoperative antimicrobial prophylaxis

Appropriate antimicrobial useAppropriate antimicrobial use

HandwashingHandwashing

Compliance 16-81%Compliance 16-81% Nurses consistently better than physiciansNurses consistently better than physicians Waterless hand hygiene agents improve Waterless hand hygiene agents improve

compliancecompliance– Placement considerationsPlacement considerations

Effect of Hand Hygiene on Resistant Organisms

Year Author Setting Impact on organisms

1982 Maki adult ICU decreased

1984 Massanari adult ICU decreased

1990 Simmons adult ICU no effect1992 Doebbeling adult ICU decreased with one versus

another hand hygiene product1994 Webster NICU MRSA eliminated

1999 Pittet hospital MRSA decreased

ICU = intensive care unit; NICU = neonatal ICU

MRSA = methicillin-resistant Staphylococcus aureus

12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

Step 12: Contain your contagion

Source: Pittet D: Emerg Infect Dis 2001;7:234-240

The Human Element in Hand Hygiene The Human Element in Hand Hygiene AdherenceAdherence

Of 34 studies evaluated by CDC/HICPAC average Of 34 studies evaluated by CDC/HICPAC average level of adherence by Health care personnel= level of adherence by Health care personnel= 40% (range 5-81%)40% (range 5-81%)

-overall physicians usually worst-overall physicians usually worst Why?Why?

– Too busy & not enough timeToo busy & not enough time– Hand hygiene sinks or products inaccessibleHand hygiene sinks or products inaccessible– Skin irritationSkin irritation– Hands don’t appear visibly soiledHands don’t appear visibly soiled– Influence of opinion leadersInfluence of opinion leaders

Gram positive bacteriaGram positive bacteria– VREVRE– Streptococcus pneumoniaeStreptococcus pneumoniae

Gram negative bacteriaGram negative bacteria– PseudomonasPseudomonas– SalmonellaSalmonella

FungiFungi– Fluconazole-resistant Candida albicansFluconazole-resistant Candida albicans

VirusesViruses– Multi-drug resistant HIVMulti-drug resistant HIV– Acyclovir-resistant herpesAcyclovir-resistant herpes

Antimicrobial Resistant OrganismsAntimicrobial Resistant OrganismsThe Scope of the ProblemThe Scope of the Problem

CDC Strategies to Decrease CDC Strategies to Decrease Antimicrobial ResistanceAntimicrobial Resistance

1.1. VaccinateVaccinate2.2. Remove invasive devices as soon as Remove invasive devices as soon as

possiblepossible3.3. Culture (avoid empiric treatment)Culture (avoid empiric treatment)4.4. Treat with intent to eradicate infectionTreat with intent to eradicate infection5.5. Obtain expert advice on antibiotic Obtain expert advice on antibiotic

selectionselection6.6. Consult antibiogramsConsult antibiograms

CDC Strategies to Decrease CDC Strategies to Decrease Antimicrobial ResistanceAntimicrobial Resistance

7. Avoid unnecessary antibiotic use7. Avoid unnecessary antibiotic use

8. Target the pathogen8. Target the pathogen

9. Do NOT treat colonization9. Do NOT treat colonization

10. Stop empiric antibiotics quickly once it 10. Stop empiric antibiotics quickly once it appears that bacterial infection is unlikelyappears that bacterial infection is unlikely

11. Enforce good infection control practices11. Enforce good infection control practices

Factors Contributing to Factors Contributing to Antimicrobial Resistance in Antimicrobial Resistance in

HospitalsHospitals Serious illnessSerious illness Immunocompromised stateImmunocompromised state Use of invasive procedures/devicesUse of invasive procedures/devices Increasing introduction of resistant organisms Increasing introduction of resistant organisms

from the community (Nursing home/hospital from the community (Nursing home/hospital transfers)transfers)

Ineffective infection control practicesIneffective infection control practices High antibiotic use per geographic area per unit of High antibiotic use per geographic area per unit of

timetime

Risk Factors for Risk Factors for Staphylococcus aureusStaphylococcus aureus with Reduced Susceptibility to with Reduced Susceptibility to

Vancomycin (MIC Vancomycin (MIC >> 4 ug/mL) 4 ug/mL)19 cases19 cases Adjusted OR (CI Adjusted OR (CI

95%)95%)

Vancomycin (per week) Vancomycin (per week) 5.6 (2.2-14.3)5.6 (2.2-14.3)

in prior 1 monthin prior 1 month

Previous MRSA culturePrevious MRSA culture 15.5 (1.8- 134.5)15.5 (1.8- 134.5)

in prior 2in prior 2ndnd or 3 or 3rdrd month month

Fridkin et al. Clin Infect Dis 2003; 36:429-39Fridkin et al. Clin Infect Dis 2003; 36:429-39

Antibiotic ResistanceAntibiotic ResistanceDo CDC Strategies Work?Do CDC Strategies Work?

50 ICUs from 20 hospitals50 ICUs from 20 hospitals Monitored vancomycin useMonitored vancomycin use Feedback of risk-adjusted comparison dataFeedback of risk-adjusted comparison data Unit-specific interventions successfully decreased Unit-specific interventions successfully decreased

vancomycin use and VRE ratesvancomycin use and VRE rates

Fridkin et al. Emerging Infectious Disease 8(7); 702-704 2002Fridkin et al. Emerging Infectious Disease 8(7); 702-704 2002

CDC 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized PatientsCDC 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Patients

(In)Appropriate Antimicrobial (In)Appropriate Antimicrobial UseUse

2000 Patients visiting physician for cold or 2000 Patients visiting physician for cold or upper respiratory infection found:upper respiratory infection found:

63% received an antibiotic63% received an antibiotic

54% received a broad-spectrum antibiotic54% received a broad-spectrum antibiotic

JAMA February 2003JAMA February 2003

(In)Appropriate Antimicrobial (In)Appropriate Antimicrobial UseUse

Survey of 4 US medical centersSurvey of 4 US medical centers424 physicians surveyed424 physicians surveyed

85% thought resistance a national problem85% thought resistance a national problem55% thought resistance a problem for their 55% thought resistance a problem for their

patientspatients

Wester et al. IDSA abstract 529 1999Wester et al. IDSA abstract 529 1999

WHY?WHY?Human FactorsHuman Factors

Physician:Physician:– Considering individual patient, not public Considering individual patient, not public

health implicationshealth implications– Time pressureTime pressure– Defensive medicineDefensive medicine– More is betterMore is better

Patient:Patient:– Belief that antibiotics cure viral infectionsBelief that antibiotics cure viral infections– Wants something other than reassuranceWants something other than reassurance

Antibiotic ResistanceAntibiotic ResistanceOutpatient PracticesOutpatient Practices

Successful strategies must account for human Successful strategies must account for human factors:factors:

Physician:Physician:– Knowledge of local resistance ratesKnowledge of local resistance rates– Restricted formularyRestricted formulary– ““Cold packs”Cold packs”– Treatment guidelinesTreatment guidelines– Patient educational materialsPatient educational materials– Preprinted order setsPreprinted order sets

Patient:Patient:– EducationEducation

Expansion Beyond Acute CareExpansion Beyond Acute Care

Long term careLong term care– 1.8 million in 16,500 LTCF1.8 million in 16,500 LTCF

Home careHome care– Home IV therapy $5 billion industryHome IV therapy $5 billion industry– Estimated 20,000 provider agenciesEstimated 20,000 provider agencies

RehabilitationRehabilitation Outpatient surgeryOutpatient surgery

– 52% of hospital-based procedures52% of hospital-based procedures– 2.8 million outpatient procedures 19962.8 million outpatient procedures 1996

Ambulatory careAmbulatory care– 80-90% of cancer care80-90% of cancer care

CDC Draft Isolation Guidelines 2004 www.cdc.gov

Roles Beyond Traditional Roles Beyond Traditional Infection ControlInfection Control

Regulatory/AccreditationRegulatory/Accreditation Design/Planning/Construction/RenovationDesign/Planning/Construction/Renovation Occupational HealthOccupational Health Patient Safety/QualityPatient Safety/Quality Human Resources-StaffingHuman Resources-Staffing Product SelectionProduct Selection Media Relations Media Relations BioterrorismBioterrorism

The FutureThe FutureTransition From:Transition From:

Device associated infections to device Device associated infections to device associated complicationsassociated complications

Surgical site infections to surgical site Surgical site infections to surgical site complicationscomplications

Antimicrobial resistance to drug-related Antimicrobial resistance to drug-related complicationscomplications

Emerging Infect Dis 2001; 7: 363-66

Sources of Evidence-based Sources of Evidence-based Guidelines for EpidemiologyGuidelines for Epidemiology

Centers for Disease Control and PreventionCenters for Disease Control and Prevention National Guidelines ClearinghouseNational Guidelines Clearinghouse Association for Professionals in Infection Association for Professionals in Infection

Control and EpidemiologyControl and Epidemiology Society for Healthcare Epidemiology of Society for Healthcare Epidemiology of

AmericaAmerica Institute for Healthcare ImprovementInstitute for Healthcare Improvement