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Nosocomial infections: A thing of the past?

Nosocomial infections: A thing of the past?

CDC sets ambitious goal of eradication

In a dramatic departure from its traditional infection control philosophy, the Centers for Disease Control and Prevention is moving to a targeted, health care quality stance that ambitiously proposes to eliminate nosocomial infections from the health care system, Hospital Infection Control has learned.

The new mindset ushers in a "culture of accountability" at the CDC hospital infections program, which is being restructured and renamed the division of healthcare quality promotion (DHQP), says Julie Gerberding, MD, MPH, director of the division.

"Sometimes [eradicating infection] is in individual patient care decisions and sometimes it is an issue of the whole system of care," she tells HIC. "But if you don’t scrutinize the problem, you miss that opportunity. [For example], you work in a hospital, and your bloodstream infection rate is at the 10th percentile, and you are very happy about that. But nevertheless, you may still be missing prevention opportunities in that low — but nonzero — set of events that is occurring. So we want to encourage the concept that the default [setting] is that every infection is preventable until proven otherwise."

The time-honored perspective in infection control is that as much as a third of hospital-acquired infections are not preventable due to patient acuity, invasive devices, and other factors. But that view appears increasingly out of touch with a health care system facing disclosure of adverse events and reporting medical errors. Indeed, the CDC is discussing including bloodstream infections in patient-safety data collection systems and expects to receive a portion of any federal funding spurred by the nation’s patient safety movement. An emphasis on preventing infections and protecting patients must be done in a positive context, rather than as a medical error system that assigns blame, Gerberding emphasized. (See Q&A, p. 163.)

The restructuring of the CDC hospital infections program was outlined recently in Atlanta at a meeting of the Healthcare Infection Control Practices Advisory Committee (HICPAC). Under the umbrella goal of eliminating nosocomial infections, Gerberding cited seven specific targets for infection reduction and quality improvement. (See "Goals target catheters, surgery, and antibiotics".) "Elimination is a questionable word in a culture where we have always been told that some infections are expected," she conceded. Providing an example that underscored the shift in mindset, she reminded that groups such as Mothers Against Drunk Driving do not set rate reductions as their goal. "We don’t really talk about achieving a benchmark of drunk driving," Gerberding told the committee. "We say eliminate drunk driving. It is an unacceptable health hazard."

Indeed, diseases such as syphilis and tuberculosis have CDC program activities under way under a stated goal to eliminate the disease in the United States. "I don’t think anyone honestly believes that we would be able to entirely eradicate syphilis, but a comprehensive strategy has developed around that central goal," she says.

An infection by any other name

The CDC changes come with a new nomenclature that reflects both health care delivery changes and the program’s intent to move beyond purely infectious complications. Thus, in the outlined goals, surgical-site infections become "surgical adverse events" and infections linked to catheters now fall under "catheter-related complications." In an Orwellian twist to the semantical adjustments, the CDC wants to banish the word "nosocomial," even though the term for hospital-acquired infections has been ingrained in the literature of the field for three decades.

"We are trying to minimize the use of the term nosocomial whenever possible," Gerberding told HICPAC members. "In part, because of the changes in the delivery system, but also, in part, because we still are struggling to be more effective at communication. Many people still believe this is some kind of a sinus infection."

Indeed, the argument could be made that such a fate is deserved for a word that was popularized in part as a kind of obscure euphemism (e.g. collateral damage) to minimize the potential liability of infections acquired while under patient care. Regardless, the term has come to stand for onset of infection after admission (e.g., after 72 hours), with everything else generally considered a community-acquired infection. The CDC is shifting to a concept of health care-associated infections because the walls are coming down and infections are being acquired and transmitted across a health care continuum from the hospital, outpatient settings, and the community. Accordingly, the DHQP program is interested in communicating with a larger health care audience that would include hospital administrators, purchasers, microbiology lab workers, and employee health nurses.

ICPs not being left behind

While trying to broaden the influence of the program, Gerberding is wary of abandoning traditional core constituents such as infection control professionals and hospital epidemiologists. "The role of the ICP is absolutely key to this, and we look forward to learning from them about their views on what should be the highest priority for specific activities that need to be undertaken," she tells HIC. "We are also very interested to know what do they need from us, from administrators, or regulators to really effectively be able to do the things they want to do."

The CDC’s setting of specific goals might help ICPs prioritize their activities, "and give them some power," she says. "I don’t think the question is, Do we know what to do?’ The problem is many people are not empowered to do the right thing. They have priority systems imposed upon them from other sectors of the delivery system. So we’re hoping by really clearly defining what matters, we will be able to increase support for ICPs and epidemiologists to get their jobs done."

The new approach could be energizing to ICPs, says HICPAC member Marjorie Underwood, RN, BSN, CIC, infection control coordinator at Mount Diablo Medical Center in Concord, CA. "Setting very specific objectives, goals and targets like that, I think, invigorates people," she tells HIC. "It’s looking toward where we need to allocate our resources to get to the best result. I think those [goals] speak to some of the issues we are dealing with."

Concerning the overall goal of eliminating infections, Underwood noted that much the same idea was urged by keynote speaker Victoria Fraser, MD, in Minneapolis last year at the annual conference of the Association for Professionals in Infection Control and Epidemiology. (See HIC July 1999, pp. 85-88.) Fraser said ICPs should try to reduce endemic infection rates rather than be satisfied to be within national benchmark ranges.

"To continually strive to [make rates] lower and lower," Underwood says. "That has been the piece that has been missing. I think that this will excite people who are doing infection control."

But just how hard reducing infections will be — not to mention totally eliminating them — was brought home in HICPAC discussions about the cardinal infection control principle of hand washing. In drafting a new guideline for health care worker hand hygiene, HICPAC member John Boyce, MD, chief of the division of infectious diseases at the Hospital of Saint Raphael in New Haven, CT, recounted the miserable historical record of compliance with hand washing.

"Despite the fact that we have been telling people to wash their hands, in a variety of different settings, compliance has been basically terrible for decades and decades," he said.

Moreover, most of the efficacy data from soap manufactures are based on 30-second to one-minute hand washes, while studies show workers who do wash their hands do so for only about 15 seconds, he added. Reasons for noncompliance run the gamut from lack of time, inadequate sink access, and the development of dermatitis from frequent washing.

"I think if we continue to recommend hand washing for most patient care interactions, we are going to get the same amount of compliance that we have been getting," Boyce told HICPAC.

"We have to take a whole other look at what we are recommending. If hand washing is inaccessible, too irritating, and too time-consuming, we ought to consider recommending the use of alcohol hand rinses and gels as the predominant, favored way to clean the hands. . . . Maybe we should consider a whole shift in our atti- tude toward something that is easier and more accessible than hand washing," he added.

While concurring with Boyce’s concerns, Gerberding said that the CDC does not want to undermine its public education efforts for hand washing. "We have been very careful not to send the message to the general population that you have to use antiseptics in order to have clean hands," she said.

Other HICPAC members questioned whether workers would use the alcohol rubs with any greater degree, and reminded that it is hard to issue and enforce staff edicts during a nursing shortage.

But Boyce compared health care workers’ attitudes toward hand-washing compliance to the airline industry, asking what if mechanics only worked on planes as time allowed. "If you are going to run an airline, you have to make sure the planes can fly safely," he said. "Hospitals need to decide that this is an important safety issue."

They would have to indeed, if such a lofty goal as eliminating health care-associated infections is to be seriously undertaken.