Infection prevention is everyone's business
Administration on hook for resources, staffing
The condensed guidelines in the recently issued compendium for six major infections emphasize administrative responsibility to provide the resources and infrastructure to make the prevention of health care-associated infections (HAIs) a reality. In this landmark new document at least, infection prevention really is everyone's business.
Just to be clear, the compendium is not a regulatory document and the recommendations are not required. However, The Joint Commission already is talking about turning selected recommendations into standards. Moreover, state and federal legislators have shown a continuing interest in turning perceived gold standards of infection prevention into laws. With all the clout behind this document, it becomes a new standard of care by default and an attractive target for future legislation. That gives the sections on infrastructure, staffing, and accountability a certain resonance beyond the typical plea for money to get things implemented.
"We have detailed sections on what kind of infrastructure you need, what kind of personnel to you need, what kind of information technology," said David Classen, MD, MS, co-author of the compendium and a consultant in infectious diseases at the University of Utah School of Medicine. "We know these are all challenges implementing the different recommendations. We actually go through the different levels of the organization. What is the responsibility of the CEO? What is the responsibility for the medical staff? What is the responsibility of practitioners?"
For example, on the section on catheter-associated urinary tract infections (CA-UTIs) — the most common HAI — the compendium states, "The hospital's chief executive officer and senior management are responsible for ensuring that the health care system supports an infection prevention and control program that effectively prevents CA-UTIs and the transmission of epidemiologically significant pathogens. Senior management is accountable for ensuring that an adequate number of trained personnel are assigned to the infection prevention and control program."1
Likewise, administration is held accountable for providing the infrastructure necessary to enact the strategies, with the compendium calling for — again in the CA-UTI section — "a system for documenting the following information in the patient record: indications for catheter insertion, date and time of catheter insertion, individual who inserted catheter, and date and time of catheter removal." Documentation should be accessible in the patient record and recorded in a standard format for data collection and quality improvement purposes, with electronic systems preferred, the guidelines state.
Similar language appears in each compendium section dealing with the other infections, with clinical staff also called out to be accountable. "Direct health care providers [such as physicians, nurses, aides, and therapists] and ancillary personnel [such as housekeeping and equipment-processing personnel] are responsible for ensuring that appropriate infection prevention and control practices are used at all times [including hand hygiene, standard and isolation precautions, cleaning and disinfection of equipment and the environment, aseptic technique when inserting and caring for urinary catheters, and daily assessment of whether an indwelling urinary catheter is medically indicated]," the document states.
Thus, infection prevention responsibilities are spread throughout the staff rather than dumped solely on IPs, who, of course, still are very much accountable to hold up their end of the bargain. "The person who manages the infection prevention and control program is responsible for ensuring that an active program to identify CA-UTIs is implemented, that data on CA-UTIs are analyzed and regularly provided to those who can use the information to improve the quality of care (e.g., unit staff, clinicians, and hospital administrators), and that evidence-based practices are incorporated into the program," the compendium states.
Though it reaches across all job titles, the compendium was designed in large part with IPs in mind, said Deborah S. Yokoe, MD, MPH co-author of the document and hospital epidemiologist at Brigham and Women's Hospital in Boston.
"These infection preventionists are my heroes and my role models," she said at a recent press conference on the compendium. "They are a group of individuals who are incredibly dedicated to the safety of our patients. They will often put in long and even uncompensated hours if they think there is something more they can do to protect our patients from infections. [We] tried to put these recommendations together using a format that is practical. We hope hospitals and very busy health care professionals like the infection preventionists that I work with can translate these infections into actual practice."
Each section has two levels of recommendations, with one level outlining basic practices and the second listing special measures if problems with the particular infection group continue. The latter group includes "strategies where the scientific evidence of their usefulness in all types of hospital settings isn't as strong as for the basic recommendations or where benefit has been most demonstrated during an outbreak-type of setting," Yokoe said. "One example of this is use of chlorhexidine bathing for intensive care unit patients."
The compendium is designed to provide clarity by clearing the thicket of strategies and recommendations from various sources, opening a path to implementation that more easily translates to day-to-day practice. "I am frustrated often in my practice at the University of Utah when we are [treating] complex patients and are faced with a bewildering set of recommendations from competing guidelines," Classen said. "As we build this compendium we were very driven by the idea that it really needed to be practical and implementation-focused."
Other novel aspects of the compendium include an effort to make the recommendations applicable to both children and adults, the inclusion of performance measures to assess effectiveness, and patient educational handouts. "One thing that I think that is unique is that we really emphasize the role of the patient and family," he said. "That is critical in any successful implementation approach and different from previous initiatives."(See patient handout.)
Some sacred cows also were driven to slaughter, as the compendium outlined infection prevention approaches that should not be done. "We did something else unique and unusual in those guidelines [by saying] here are recommendations that have been suggested in other guidelines that really shouldn't be done," Classen said. "We actually outlined the things that we thought the science did not justify."
For example, continuing with CA-UTIs, the compendium cites the following measures as ill-advised. (The ranking and evidence base are cited for each category.):
- Do not screen for asymptomatic bacteruria in catheterized patients (A-II). (Good evidence to support a recommendation for use. Evidence from ≥ 1 well-designed clinical trial, without randomization; from cohort or case-control analytic studies (preferably from >1 center); from multiple time series; or from dramatic results from uncontrolled experiments).
- Do not routinely use silver-coated or other antibacterial catheters (A-I). (Good evidence to support a recommendation for use. Evidence from ≥ 1 properly randomized, controlled trial.)
- Do not treat asymptomatic bacteruria in catheterized patients except before invasive urologic procedures (A-I).
- Avoid catheter irrigation (A-I).
- Do not perform continuous irrigation of the bladder with antimicrobials as a routine infection prevention measure.
- If obstruction is anticipated, closed continuous irrigation may be used to prevent it.
- To relieve obstruction due to clots, mucus, or other causes, an intermittent method of irrigation may be used.
- Do not use systemic antimicrobials routinely as prophylaxis (A-II).
- Do not change catheters routinely (A-III). (Good evidence to support a recommendation for use. Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.)
- Lo E, Nicolle L, Classen D, et al. SHEA/IDSA Practice recommendation strategies to prevent catheter-associated urinary tract infections in acute care hospitals. lnfect Control Hosp Epidemiol 2008; 29:S41-S50.