New IP guidelines on track to become standards
'A powerful expectation' that hospitals reduce HAIs
The Joint Commission has strongly endorsed recently issued compendium infection prevention guidelines, announcing that the condensed, actionable recommendations may become required as accreditation standards by 2010.
"In 2009, we will expect all hospitals to review their current practices and their risks and consider which of these [compendium] strategies they need to add," Robert Wise, MD, vice president for standards at The Joint Commission, said at an Oct. 8, 2008, press conference in Washington, DC. "Also in 2009, we will convene stakeholders, hospitals, experts in the field, consumers, and government officials to review the entire collection in the compendium to help determine which strategies should be immediately required as part of accreditation. In 2010, we will add these requirements to our accreditation standards. The Joint Commission will continue to create a powerful expectation to take on the problem of hospital infections."
Along with The Joint Commission, The Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals represents a two-year collaborative effort by the Society for Healthcare Epidemiology of America (SHEA); the Infectious Diseases Society of America; the American Hospital Association (AHA); and the Association for Professionals in Infection Control and Epidemiology (APIC). The compendium was published as a supplement to the October 2008 issue of the SHEA journal, Infection Control and Hospital Epidemiology.
The compendium is essentially a synthesis of established prevention guidelines to prevent Clostridium difficile, methicillin-resistant Staphylococcus aureus, central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CA-UTIs), surgical-site infections, and ventilator-associated pneumonia.
In that regard, many of the infections already have been targeted for prevention in the Joint Commission's recently finalized 2009 National Patient Safety Goals. Asked whether the compendium essentially mirrors the patient safety goals, Wise said the goals actually were based on the compendium. "The best strategies have never been in one place in an easy-to-use format as they are now," he said. "Immediately, we will join with our partners to rapidly disseminate these practices throughout the country."
Many hospitals already are following the measures recommended by the compendium but there are wide variations in practice even within institutions, he added. "The same hospital that does great at inserting central lines might do poorly at handling urinary catheters, not keeping track of who has them in and [whether] they are being checked daily to see whether they should be withdrawn," Wise said.
'A common playbook'
A key player in the process is the AHA, which can get the attention of hospital administrators and executives. "As of today, the nation's infection control team has a common playbook," said Rich Umbdenstock, AHA president and CEO. "As a partner to this group, the AHA is excited to offer these strategies to the field and will share this important work with our national hospitals through our multiple communications vehicles."
Indeed, having the AHA onboard is seen as a favorable sign that the guidelines actually will be clinically implemented.
"It has to start at the top," said Marsha Patrick, RN, MSN, CIC, an infection preventionist representing APIC at the press conference. "The C-suite sets the tone and I have certainly seen that during my career. We know the best practices, but we have to get them down to the bedside to each and every individual practitioner. Infection prevention efforts must be adequately resourced for us to make these kinds of changes and to be successful in our organizations. Our patients are counting on us."
Another driver in all this is the Centers for Medicare & Medicaid Services (CMS), which has reduced reimbursement for complications associated with two of the infections included in the compendium: CLABSI and CA-UTIs. "It's unfortunate that is has taken CMS threatening the withdrawal of reimbursement for some of these activities to get the attention at the C-suite level," Patrick said. "But, you know, it takes what it takes."
While there was reference to "federal partners" in the panel discussion, joining CMS on the conspicuously absent list was the Centers for Disease Control and Prevention. That immediately raised the question about possible confusion about standards of care, particularly if any CDC recommendations were at odds with those in the compendium. However, Patrick Brennan, MD, SHEA president and chair of the CDC's Healthcare Infection Control Practices Advisory Committee (HICPAC) — the gold standard for infection prevention recommendations — said that would not be a problem. "I don't have concerns about confusion about the standards given the collaborative nature of the process," he noted.
Indeed, an editorial accompanying the compendium publication was co-authored by Michael Bell, MD, a medical epidemiologist in the CDC division of health care quality promotion and the CDC's principal liaison with HICPAC.1 For all practical purposes, the editorial states that the compendium can be used as shorthand for the CDC's recommendations. "Although there is potential for variability among reviewers in their assessment of recommendation strength or evidence quality, this compendium represents an important tool that facilitates implementation of practices and procedures to prevent HAIs, complementing official Centers for Disease and Prevention guidelines," the editorial states.
Moreover, with CDC guidelines often stuck in the limbo of protracted government review, the compendium was actually used to provide updated CDC recommendations. "[T]he compendium delivers updated guidance in areas where official guidelines have revisions pending (e.g., surgical-site infection prevention and urinary tract infection prevention guidelines currently in preparation)," the editorial states. "The compendium published here is a concise, easily applied distillation of current guidelines for the prevention of HAIs that brings together recommendations from respected sources in a format suited to implementation in the clinical setting. . .
"As the CDC continues to produce official guidelines in collaboration with professional societies and academic partners, implementation tools such as this compendium will serve as a means to ensure that the best practices for infection prevention are successfully brought to the bedside."
Strong out of the gate
With a clear stamp of approval from the CDC and the promise of future enforcement by The Joint Commission, the compendium comes out of the gate about as strongly as any infection prevention initiative in recent memory. A new age of transparency, regulation, and consumer involvement is certainly pushing such action. Likewise, the ante has been upped by a new wave of clinicians who are showing that tools like simple checklists dramatically can reduce infections once considered inevitable. However, there is another factor that can scarcely be underestimated, the rise of multidrug-resistant and highly virulent strains of pathogens both in the hospital and community. Brennan recalled that he first saw the power of such bugs a decade ago when he lost a patient after a combination of infection and drug contraindications ruled out all available antibiotics.
"An attempt was made to drain the collection of infected fluid from the chest, but the patient died a few days later," he said. "For me this was an alarming and sentinel event. But imagine the feeling for the patient's family. A patient had acquired an infection in the hospital, and through a confluence of events had died without effective treatment as his doctors and nurses stood by helplessly. I didn't encounter such a situation again for a number of years, but now this scenario has become more commonplace. Extremely ill patients, limited therapeutic options, poor outcomes. Prevention is essential."
Given such consequences, the infection prevention community could ill afford to be seen as lost in a maze of its own making. However, a recent government report seemed to be suggesting just that in repeatedly noting that there are a staggering 1,200 individual infection prevention recommendations by the CDC to guide clinicians in protecting patients.2 "The report mentions that fact so often that it suggests disbelief that so many recommendations should be necessary to accomplish the task of prevention," Brennan said. "The number does not surprise us who deliver hospital care. The processes that simultaneously support patients and pose a hazard of infection are intricate and must be executed carefully. "
However, given the rising expectations by the public and even within the health care epidemiology community, it was time to err on the side of plain guidance rather than academic equivocation.
"We are now at an important intersection: the translation of public policy into health care reform," he said. "Our health care organizations need additional guidance, not about the knowledge but about the execution of HAI prevention measures. Too often where we fail is not in the knowledge, but in the execution. The compendium is intended to help organizations prioritize the myriad recommendations in order to focus their efforts to safely conduct these processes of care."
Patient advocate Victoria Nahum — who founded the Safe Care Campaign after the death of her son Josh due to an HAI — concurred. "We know the right way to proceed," she said. "It's going to take all of us together."
- Singh N, Brennan PJ, Bell M. Supplement Article: Editorial. Primum non nocere. Infect Control Hosp Epidemiol 2008; 29:S1-S2
- Government Accountability Office. Health care-associated infections in hospitals: Leadership needed from HHS to prioritize prevention practices and improve data on these infections. Report to the chairman, Committee on Oversight Government Reform, House of Representatives; March 2008. GAO-08-2839.