By Gary Evans, Executive Editor
Nobody said this was going to be easy. While much progress has been made, the unvarnished truth is that not one of the national health care associated infection (HAI) five-year reduction goals from 2009 to 2013 were met, the Centers for Disease Control and Prevention reports.1
An impressive 46% reduction in central line associated bloodstream infections (CLABSIs) came very close to the goal of 50% in the Department of Health and Human Services (HHS) National Action Plan to Prevent HAIs. Others lagged considerably, and catheter- associated urinary tract infections (CUATIs) – targeted for a 25% reduction over the period – actually increased by 6% from 2009-2013. “The HHS action plan that was developed in 2009 set forward some pretty ambitious national targets for a number of HAIs, including all of the ones covered in this report,” says Arjun Srinivasan, MD, associate director for HAI prevention in the CDC’s Division of Healthcare Quality Promotion. “We came together as a nation and as stakeholders and set some ambitious reduction targets. We didn’t make those targets for the 2013 data. We got really close with CLABSIs, not as close with some of the other ones. And I think it’s just an indication to us that there is certainly more to be done.”
The CDC progress report provides a snapshot of how individual states are doing on HAIs that hospitals are required to report to the agency’s National Healthcare Safety Network (NHSN): CLABSI, CAUTI, MRSA, Clostridium difficile, and surgical site infections (after colon surgery and abdominal hysterectomy).
“Infection preventionists can use this report to get a sense of where their hospital stands both in relation to others in the state and in the country with respect to how well they are doing at preventing infections,” Srinivasan says. “It can be used by IPs to draw attention to the importance of preventing HAIs and to help drive home the point that we are seeing some progress but we need to do more. We really need to be focusing our efforts on preventing those infections where we are not making much progress at all – like CAUTIs. And to focus more on those infections where we are only seeing a little bit of progress, like Clostridium difficile and MRSA bacteremias.”
New targets for 2020
The HHS plan will reset the baseline for targeted infections at the end this year, and the challenge picks up anew in 2016 with new HAI reduction goals set for 2020. The current national push toward antibiotic stewardship may be more favorably reflected in the 2016-2020 data, as prudent use of antimicrobials could particularly help reduce C. diff infections that emerge when antibiotics wipeout commensal bacteria in the gut. C. diff is another infection that has resisted reduction efforts, but the CDC report did cite some incremental progress with a 10% decrease in C. diff infections in acute care hospitals between 2011 and 2013.
“There has been a lot of emphasis on measures to directly prevent C. diff transmission like better environmental cleaning, adherence to isolation precautions and hand hygiene,” Srinivasan says. “And there has been an increasing focus recently on improving antibiotics use, so hopefully both of those factors are working in tandem to help address C. diff.”
The majority of C. difficile infections are developing in the community or are diagnosed in health care settings other than hospitals, the CDC report noted.
“That is something that we have been noticing for some time, and we think that outpatient antibiotic exposures are an important driver in these C. diff cases that are occurring outside of hospitals and nursing homes,” he says. “That’s just all the more reason to focus on improving antibiotic prescribing, not just in hospitals, nursing homes and other inpatient settings, but also in outpatient settings as well. We certainly know that exposure to antibiotics is the single most important factor in the development of C. diff. Antibiotics are prescribed for a lot of outpatient visits and we know that a lot of those antibiotics are unneeded.”
The glass half full
Despite the missed targets in 2013, there are other signs of progress in the current report, not the least of which is that all infections were reduced except CAUTIs. Early trends in 2014 are looking more favorable for that infection, and hospital onset MRSA bacteremia and C. diff declined 8% and 10% respectively between 2011 and 2013.
“I think it’s important to recognize that the glass is half full,” says Susan Dolan, RN, MS, CIC, president-elect of the Association of Professionals in Infection Control and Epidemiology (APIC). “[Think of all] the work that your facility and your staff have been putting forth to try to keep patients safe. It’s a journey that we are on and we have to continue to develop more knowledge as we go. We can’t rely on the status quo. I think that everybody realizes the germs and the resistance of these organisms is outpacing the development of countermeasures. That’s why the [infection control program] infrastructure has to become more robust and funded for us to try get ahead of these threats -- a [program] structure that will be long lasting and not just [designed] to deal with today’s problems.”
In that regard, the recent outbreak of Ebola in the U.S. focused unprecedented attention on infection control and occupational health that still resonates at many hospitals. Out of tragedy has come the teachable moment. Health care workers are suddenly more aware and attentive to infection prevention measures that protect them and their patients, says Dolan, hospital epidemiologist at Children’s Hospital Colorado in Aurora.
“It has given us a huge boost,” she says. “Our staff appreciates just some of the basic, standard personnel protective gear to wear when taking care of a patient who has a communicable disease or a drug resistant organism. Our programs are more robust perhaps than they have been in the past. I do think [Ebola] has given us a platform -- especially as it translates to isolation and PPE to prevent transmission.”
One thing Ebola revealed very quickly is that IPs have little surge capacity to take on additional training and education needed for an emerging pathogen. Thus a welcome trend in the CDC HAI report was the increasing use of “lab-identified” reports of HAIs, which can save IPs valuable time and labor. For the first time, the HAI progress report includes state-specific data about hospital lab-identified MRSA bacteremias and C. diff.
“These [HAI reports] come straight from the lab system into the NHSN,” Srinivasan says. “That is an exciting development for surveillance in health care. This is much less labor intensive for IPs because it is being done electronically. It is based on laboratory results that are reported and patient information that is taken out of electronic data systems. Hopefully this is the future of surveillance for HAIs. IPs won’t have to spend so much of their time doing surveillance, and can begin to shift their valuable time to prevention work. We would love to get to that day when we are doing surveillance for HAIs predominately if not exclusively through electronic records.”
At 140-pages replete with charts and graphs, the CDC progress report underscores the breadth of activity underway nationally to prevent hospital infections. “As an infection preventionist, first of all just take a look at it in its entirety and realize you are part of this national movement, this global movement, to try to decrease HAIs for our patients,” Dolan says. “We have a really important role in this. Then take a look at this and say where does my state fit in?”
There may be some statewide activities IPs are unaware of as well as the potential to link into national networks of specialty hospitals. “I work in a pediatric hospital and we have a pediatric collaborative around the country because some of our issues with these infections are a little different and some of the bundles [designed for adult patients] don’t work,” she says.
Attending a local APIC chapter meeting can ensure IPs are on top of community trends and aware of what their peers are reporting. “Learn what other people are doing and widen your networks to find out who your mentors and your peers are,” she says. “What are their rates compared to mine? Are they doing something different?”
CAUTIs get some respect
A lot of hospitals apparently need to do something different to prevent CAUTIs, the only HAI in the CDC report that actually increased after being targeted for reduction. There are several theories why, and one of them is the frank acknowledgement that for years CAUTIs have been seen as low-priority, easily treatable events – the so-called “Rodney Dangerfield” of infections. But a funny thing happened on the way to the post-antibiotic era. It turns out urinary tract infections trigger a large amount of antibiotic use, which in turn provides the selective pressure to spawn drug-resistant bacteria and C. diff.
“We know that in surveys antibiotics directed against UTIs as a group are often the most common or the second most common indication for the use of antibiotics,” Srinivasan says “So it always runs right up there with respiratory infections, which is another very common cause of antibiotic use. Certainly, if you look in most hospitals, giving antibiotics for UTIs is going to end up being in the top three to five reasons that antibiotics are prescribed.”
Urinary catheters have also been dubbed a “one-point restraint,” limiting patient movement, and raising the risk of pressure ulcers and other adverse events.
“Unfortunately, CAUTIs are not always an infection that people really focus on,” he says. “There is a sense sometimes that these are just very minor infections and are not infections that we really should invest effort into trying to prevent. I think there is general recognition now that is a shortsighted view.”
As more CAUTIs began to be reported to the NHSN, there may have also been a surveillance artifact effect as a historically under-reported infection surged to more accurate numbers. That could partially explain the 6% increase.
“We think that some of this is an artifact of very accurate reporting,” Srinivasan says. “That’s good -- we want the reporting to be accurate. It is encouraging as we look at the early data for 2014, we are beginning to see some suggestions that the trend might be reversing. We’ve got good reporting now — which made the rate go up – and we may be seeing that aggressive prevention is starting to have an impact.”
In addition, there has been a huge focus on CLABSI prevention the last few years, and it takes a while for a new mentality, a new safety culture target to set in at hospitals, Dolan says.
“That whole culture change takes time – it’s a process and it is not a quick process. Sometimes it can take a couple of years – depending on your type of facility -- for the culture to really be ingrained and hardwired in,” she says.
“So much emphasis has been put on CLABSIs — some institutions made a lot of effort on that and it got a lot of attention. But now that we have been able to get to a certain level with that, additional efforts can be focused on CAUTIs. Some of the prevention approaches are very similar: Number one, you don’t put the device in if you don’t need it; take the device out as soon as you can; and take good care of it while it is in.
CAUTIs are among the first HAIs that will be included in the CDC’s Targeted Assessment for Prevention (TAP) strategy.
The TAP strategy targets healthcare facilities and specific units within facilities with a disproportionate burden of CAUTIs, for example, so that gaps in infection prevention in the targeted locations can be addressed. The CDC is also developing tools to evaluate and address the gaps in infection prevention within targeted facilities.
“I’m quite excited to hear how that is going to play out,” Dolan says. “They can also look at high performers and say are they doing something above and beyond what the standard implementation bundles and processes are for this measure? What is it that might be unique that they’re doing? That could help [lower performers] and perhaps by doing so it may help administration and higher ups put more emphasis on the importance of resources for their infection prevention and control department.”
In addition, the recently revised compendium infection control guidelines on HAIs2 includes some new socio-adaptive and technical strategies on CAUTIs for infection preventionists to consider, including these common barriers and possible solutions:
- Lack of physician buy-in to CAUTI prevention practices: Possible solutions include finding a physician champion and providing physicians with feedback and data about urinary catheter use and monthly indwelling urinary catheter prevalence and CAUTI rates.
- Difficult to do education for nurses because of their inflexible schedules regarding overtime and non-patient care time: Possible solutions include bringing education to the bedside through unit competencies and talking with nurses one-to-one during point prevalence assessments.
- Physicians are resistant to having an automatic stop order for nurses to discontinue urinary catheter use: One solution could be to have nurses prompt physicians for DC order as an initial strategy to build rapport and to identify a physician champion who can serve as an advocate.
- Centers for Disease Control and Prevention. National and state healthcare associated infections progress report. Jan 2015: http://1.usa.gov/1yxD74k
- Lo E, Nicolle LE, Coffin SE, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Cont Hosp Epi 2014;35(5):464-479.