The Quality Colloquium August 22, 2004

Strategies for Reducing Infections: The Role of the Patient Safety Officer Tammy Lundstrom, MD VP, Chief Quality and Safety Officer Detroit Medical Center

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

JCAHO Accreditation Revised IC standards 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 HAI as Sentinel Event-consequences –Root Cause Analysis (RCA) –Failure Mode and Effects Analysis (FMEA)

CDC 7 Challenges Reduce Catheter-associated adverse events Reduce Catheter-associated adverse events Reduce surgical adverse events Reduce surgical adverse events Reduce mortality and hospitalizations due to respiratory infection in LTC Reduce mortality and hospitalizations due to respiratory infection in LTC Reduce antibiotic resistant infections Reduce antibiotic resistant infections Eliminate microbiology lab errors Eliminate microbiology lab errors Eliminate occupational sharps injuries Eliminate occupational sharps injuries Active compliance with ACIP immunization recommendations Active compliance with ACIP immunization recommendations

Historical Evolution 1940First description IC Officer Penicillin and resistance 1970’sSENIC study; proves value 1980’sContinued growth of epidemiology 1990’sExpand role to non-acute settings 2000’sExpand role to “quality promotion across the healthcare delivery system” Lancet 1999; 354 (Supp IV):25 Emerging Infect Dis 2001; 7: ,

Study of Efficacy of Nosocomial Infection Control (SENIC) Hospitals with intensive surveillance and control programs had lower rates of nosocomial infections Hospitals with intensive surveillance and control programs had lower rates of nosocomial infections Recommended 1 FTE/250 beds Recommended 1 FTE/250 beds –OUTDATED!!!

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; 7: Seminars in IC 2001; 2: Infect Control 1985; 6:

Consequences 2 million HAI 90,000 deaths $ 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: Infect Control Hosp Epi 2001; 22:

US Data Variable admissions(10 6 ) Pt Days(10 6 ) Ave LOS Inpt Surg(10 6 ) NI (10 6 ) NI/1000 pt days J. Burke NEJM 2003

Decrease (%) in HAI in NNIS ICU Type ICU BSIVAPUTI coronary medical surgical pediatric Emerging Infect Dis 2001; 7:

Why HAI May Increase Sicker patients Sicker patients More invasive procedures for longer duration More invasive procedures for longer duration Staff shortages Staff shortages –Nursing –Pharmacists –Pharmacy Techs –Radiology Techs

Why HAI May Increase Resistant Organisms Resistant Organisms –1990’sP. aeruginosa –1990’sVRE –2002 VRSA Emerging Infectious Disease Emerging Infectious Disease –1980’sHIV –1990’shantavirus –2000’sSARS

Most Common Epidemiology Interventions Disseminate rates with benchmark data Disseminate rates with benchmark data Develop multidisciplinary teams around issues Develop multidisciplinary teams around issues Education Education Communication Communication Am J Infect Control 1999; 27: 221

Focus on Evidence-based Practices Handwashing Maximum barrier precautions for vascular device insertion Preoperative antimicrobial prophylaxis Appropriate antimicrobial use

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

The Human Element in Hand Hygiene Adherence The Human Element in Hand Hygiene Adherence Of 34 studies evaluated by CDC/HICPAC average level of adherence by Health care personnel= Of 34 studies evaluated by CDC/HICPAC average level of adherence by Health care personnel= 40% (range 5-81%) -overall physicians usually worst Why? Why? –Too busy & not enough time –Hand hygiene sinks or products inaccessible –Skin irritation –Hands don’t appear visibly soiled –Influence of opinion leaders

Gram positive bacteria Gram positive bacteria –VRE –Streptococcus pneumoniae Gram negative bacteria Gram negative bacteria –Pseudomonas –Salmonella Fungi Fungi –Fluconazole-resistant Candida albicans Viruses Viruses –Multi-drug resistant HIV –Acyclovir-resistant herpes Antimicrobial Resistant Organisms The Scope of the Problem

CDC Strategies to Decrease Antimicrobial Resistance 1. Vaccinate 2. Remove invasive devices as soon as possible 3. Culture (avoid empiric treatment) 4. Treat with intent to eradicate infection 5. Obtain expert advice on antibiotic selection 6. Consult antibiograms

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

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

Risk Factors for Staphylococcus aureus with Reduced Susceptibility to Vancomycin (MIC > 4 ug/mL) 19 cases Adjusted OR (CI 95%) Vancomycin (per week) 5.6 ( ) in prior 1 month Previous MRSA culture15.5 ( ) in prior 2 nd or 3 rd month Fridkin et al. Clin Infect Dis 2003; 36:429-39

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

(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

(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

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

Antibiotic Resistance Outpatient 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

Expansion Beyond Acute Care Long term care Long term care –1.8 million in 16,500 LTCF Home care Home care –Home IV therapy $5 billion industry –Estimated 20,000 provider agencies Rehabilitation Rehabilitation Outpatient surgery Outpatient surgery –52% of hospital-based procedures –2.8 million outpatient procedures 1996 Ambulatory care Ambulatory care –80-90% of cancer care CDC Draft Isolation Guidelines

Roles Beyond Traditional Infection Control Regulatory/Accreditation Regulatory/Accreditation Design/Planning/Construction/Renovation Design/Planning/Construction/Renovation Occupational Health Occupational Health Patient Safety/Quality Patient Safety/Quality Human Resources-Staffing Human Resources-Staffing Product Selection Product Selection Media Relations Media Relations Bioterrorism Bioterrorism

The Future Transition From: Device associated infections to device associated complications Device associated infections to device associated complications Surgical site infections to surgical site complications Surgical site infections to surgical site complications Antimicrobial resistance to drug-related complications Antimicrobial resistance to drug-related complications Emerging Infect Dis 2001; 7:

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