Making Infection Prevention a Priority
Infection prevention is both a challenge and an urgent priority for healthcare organizations. As threats emerge, the latest research identifies—or disproves—new infection prevention strategies. Payers, meanwhile, are increasing the pressure on providers to prevent healthcare-acquired infections (HAIs).
Knocking Out HAIs
Over the past decade, the healthcare industry has made significant progress in preventing hospital-acquired infections. The biggest success story is a 50 percent reduction in central line-associated bloodstream infections (CLABSIs) between 2008 and 2014, according to the Centers for Disease Control and Prevention’s National and State Healthcare Associated Infections Progress Report, published in 2016 (www.cdc.gov/hai/pdfs/progress-report/hai-progress-report.pdf). Surgical site infections (SSIs) decreased 17 percent. Additionally, between 2011 and 2014, methicillin-resistant Staphylococcus aureus (MRSA) infections decreased 13 percent and Clostridium difficile (C-diff) infections were down 8 percent, as reported by the CDC.
Despite progress on the prevention front, HAIs still affect around one in 25 hospital patients on any given day and cost nearly $10 billion to treat annually, according to a 2013 study published in JAMA Internal Medicine. The study found that SSIs are the largest contributor to overall costs, followed by ventilator-associated pneumonia and CLABSIs.
Mitul Patel, M.D., an orthopedic surgeon at TriStar Summit Medical Center in Hermitage, Tennessee, says one of the most concerning outcomes after spinal fusion with hardware is a deep surgical site infection.
“Oftentimes, SSIs are associated with poor patient outcomes, including delayed wound healing and increased use of antibiotics, pain and lengths of stay,” he says. “And SSIs can lead to multiple major revision operations.”
What’s more, the financial cost to the patient, provider and payer increases significantly once a surgical site infection occurs. Patel estimates it can cost 3-4 times more than the index procedure once a surgical site infection occurs.
Payers, including the Centers for Medicare & Medicaid Services (CMS), have already begun penalizing hospitals for HAIs. In 2015, CMS levied a 1 percent penalty on nearly 800 hospitals—22 percent of applicable facilities—due to their poor performance in preventing HAIs. In FY 2017, as CMS raises the performance threshold, hospitals’ scores will have to be even better to avoid the penalty.
“These infections are extremely costly and they represent a growing economic burden for the American healthcare system,” Patel explains. “With new payment models emerging, avoiding potentially preventable and costly postoperative complications is extremely important.”
With an increasing focus on bundled episodes of care, complications following the index procedure, including infection, are typically not reimbursed. The financial burden of caring for the HAI is then on the provider.
“To avoid SSIs, it will become extremely important to stratify patients according to risk prior to surgery,” Patel says.
Attacking With Evidence-based Measures
Much of the recent drop in HAIs can be attributed to the bundling of various evidence-based interventions.
To prevent CLABSIs, evidence supports five different interventions: hand hygiene before catheter insertion; removing catheters when no longer needed; maximum sterile barrier precautions; chlorhexidine alcohol skin prep for insertion and maintenance; and chlorhexidine bathing of ICU patients over the age of two months.
- Diabetes and preoperative control of blood sugar levels
- Decreased immunity from certain medicines or medical conditions such as rheumatoid arthritis and cancer
- Previous history of infection
- Staphylococcus aureus colonization
- Certain skin conditions such as psoriasis
- Advanced age
- Complexity and invasiveness of procedure
- Amount of blood loss
- Procedure length
- Surgical technique and sterility
- Proper selection of antibiotics within one hour of surgery
- Proper preparation of skin prior to surgery
- Limiting traffic in the operating room
- Body temperature control
Bundling interventions becomes even more important in the prevention of SSIs, where a long list of risk factors puts patients at heightened risk—e.g., age, high blood sugar levels, susceptibility to certain medications or medical conditions, a high volume of blood loss, lengthy procedure time and, prior to surgery, inappropriate skin prep and/or dosing of antibiotics. (See sidebar for more factors.)
“The accurate identification of risk
factors is essential to developing strategies to reduce surgical site infections,” Patel says. “And, since many of the risk factors are directly related to the patient, optimizing patient health prior to surgery is becoming a major focus.”
Since 2005, the Surgical Care Improvement Project released a set of basic quality measures in hopes of reducing the incidence of SSIs. These include the timing and appropriate choice of antimicrobial prophylaxis, the avoidance of shaving hair at the surgical site, and both maintaining patient normothermia (normal body temperature) and controlling blood glucose levels during the perioperative period.
Healthcare organizations have more recently begun to take additional steps based on newer developments in infection prevention. For example, it is now standard practice to do preoperative nasal screening for MRSA. Based on the results of the nasal screening as well as other factors, surgeons are then able to administer appropriate antibiotic prophylaxis before and after surgery, including both nasal and skin treatments, Patel says. Increasingly common are other practices that include optimizing antibiotic prophylaxis dosing based on length of a procedure and the patient’s weight, and providing supplemental oxygen to patients during and after a surgical procedure. A 2014 study in the AORN Journal associates these steps with a 25 percent risk reduction for SSIs.
In terms of preventing joint infections, Patel is optimistic about the possibilities of nanotechnology and the introduction of antibiotic-coated implants. “These may aid in the prevention and early treatment of periprosthetic joint infections,” he says. “They may also help improve eradication rates.”
An important takeaway on these and other developments in infection prevention is that many of the clinical practices are still being refined. For example, chlorhexidine gluconate (CHG) bathing is recommended for critically ill patients and those undergoing cardiac surgery.
“Chlorhexidine is a broad-spectrum topical antimicrobial agent which, when used to bathe the skin, can decrease the bacterial burden and therefore reduce infections,” says Angie Mitchell, RN, director of nursing services and clinical lead of the infection prevention specialty committee at HealthTrust. Additional studies are being conducted confirming the appropriate use of CHG bathing and limiting the potential of antibiotic resistance.
Healthcare organizations are also relying on antimicrobial stewardship teams to guide the appropriate use of antimicrobial medications, in an effort to curb antibiotic-resistant infections. According to the CDC, at least 2 million people in the United States become infected with antibiotic-resistant bacteria each year, and at least 23,000 of them die as a direct result of these infections. The Joint Commission released a new standard related to antibiotic stewardship last year, and the CMS is working on a rule change that would require antibiotic stewardship as a condition of participation in Medicare and Medicaid.
Perfecting Hand Hygiene
Healthcare organizations continue to struggle with an infection prevention practice that dates back to the 19th century, and countless studies have found to be the easiest, least expensive and most important way to reduce HAIs—hand hygiene. On average, providers clean their hands less than half of the times they should, according to the CDC.
Historically, hand hygiene compliance initiatives involved visual observation, with clinicians employing a “secret shopper” approach to identifying and tracking infractions. Today, healthcare organizations are instead beginning to use technology to monitor compliance.
But there are drawbacks. One potential issue is whether the monitoring technology can be tricked into detecting compliance when hand-washing is in fact done incorrectly, such as when clinicians bump up against a sensor but don’t actually wash their hands. Another is whether the monitoring technology is compatible with current soap dispensers or if modifications will be necessary.
“Soap dispensers are not the easiest category to convert,” Mitchell says. “There’s sheer volume to contend with, and then potential wall repair once the new dispensers are in place.”
Not all monitoring technologies rely on soap dispensers, however. One from Biovigil Systems utilizes a smart badge worn by clinicians. When someone enters a patient room, the badge turns yellow and chirps to signal that hand hygiene is required. After the clinician washes her hands, she waves a hand over the badge. If the sensor detects alcohol, the light turns green. If not, it turns red.
HealthTrust is looking to expand its contract portfolio in the area of technology that is used to monitor hand hygiene. Last fall, its infection prevention specialty committee invited six suppliers to present their solutions—the first contract should be awarded in the spring of 2017.
“Unfortunately, these systems are expensive, and you can’t get reimbursed for hand hygiene compliance. But, with this type of technology available on contract, our members can at least initiate a program at a more appealing price point,” Mitchell adds.
Within the last year, HealthTrust added a new infection prevention category—UV disinfection services—proven effective in killing C-diff, MRSA and vancomycin-resistant Entereococcus on hospital room surfaces. For hospitals that can’t afford the capital outlay, Diamond Restorations can provide the workforce and equipment to disinfect rooms.
Fighting Back at the Front End
A year ago, the Zika virus was barely a blip on the radar; today, the mosquito-borne disease is one of more than 75 infectious diseases and conditions under active surveillance by the CDC. To date, there have been more than 4,000 confirmed cases in the United States. The majority of those cases are travel-related, including people (or their sexual partners) returning from affected areas. Although last November the World Health Organization declared Zika was no longer a global health emergency, that doesn’t make it—and other infectious diseases—any less of a priority for providers.
“Some of these diseases can spread so quickly that they can take off even before an outbreak is recognized and a plan is put into place,” Mitchell says.
So what can healthcare organizations do to protect their patients, workers and communities from the next outbreak? Practice the basics of infection prevention: Monitor infections through active surveillance, encourage vaccination for preventable diseases, and follow standard precautions such as washing hands, wearing gloves and asking patients the right questions on the front end to determine if they’re contagious.