87% of hospitals aren't following all practices to stop avoidable infections

Report's findings are 'alarming'

Patients, the press, and payers — all eyes are on the topic of hospital-acquired infections. Recently, the Centers for Medicare & Medicaid Services (CMS) announced that the Medicare program will no longer provide reimbursement for the additional costs incurred for these conditions.

Yet, surprisingly, 87% of 1,256 U.S. hospitals surveyed by the Washington, DC-based Leapfrog Group do not have all of the recommended policies in place to prevent many of the most common hospital-acquired infections.

As part of the Leapfrog Hospital Quality and Safety Survey, hospitals were asked about their practices related to the prevention of four common infections: aspiration and ventilator-associated pneumonia (38.5% of hospitals were in full compliance); central venous catheter-related bloodstream infection (35.4% of hospitals were in full compliance); surgical-site infection (32.3% were in full compliance); and influenza (30.7% were in full compliance).

The fact that 87% of hospitals surveyed are not taking the recommended steps to prevent deadly infections is "alarming," says Karen Linscott, Leapfrog's acting CEO. "All hospitals should be employing these basic infection avoidance protocols," says Linscott. "Leapfrog will continue to shine the light on how hospitals are doing on this front with new data each year."

The biggest challenge has been fully implementing recognized, standardized practices 100% of the time, says Thomas Talbot, MD, MPH, chief hospital epidemiologist at Vanderbilt University Medical Center in Nashville, TN.

"That means not only devising tools to use at the bedside at the time of the most critical impact, but also tracking those practices so we can give feedback to everybody," says Talbot. For example, you want to be able to tell staff that of all the central lines placed last month, how many were placed using appropriate precautions.

"Now we are getting to the point where we can tie that to our infections — and say, 'Where did we lapse in this group of people that had infections?'" says Talbot.

Here, organizations share their best strategies:

• Include infection control in your strategic plan.

Norwalk (CT) Hospital's strategic plan includes two initiatives that address infection prevention: "reduction of mortality and morbidity" and "excellent care for common conditions." The initiatives include Leapfrog recommendations for ventilator-associated pneumonia, central venous catheter bloodstream infections, and surgical-site infections. "The use of best practices has, in fact, reduced our rates of infection," says Claire Davis, vice president of quality. "Our board and senior leadership staff have endorsed these practices, resourced them, and track to ensure successful outcomes."

• Give prompt feedback.

Quality professionals at Vanderbilt are working with the hospital's informatics staff to automate its surveillance system, with the goal of being more transparent to clinicians and feeding data back to them as rapidly as possible.

For instance, a nurse will be able to see almost all of the data that are retrievable in the electronic record, and spot suspected ventilator-associated pneumonia. "They will be able to say, 'This is a new pneumonia' in fairly real-time," says Talbot. The next step is to be able to alert front-line clinicians and IT managers, and then tie the information to process measures, so problem areas can be targeted.

• Collaborate with infection control.

Now that quality and infection control have more clout, both should take full advantage by forming collaborative relationships, advises Talbot. "Previously, infection control would present their data and no one would necessarily pay much attention to it," he says. "But with the advent of the quality movement, that has really changed."

Initially, infection control looked at quality as "the new kid on the block," and didn't understand why another department was looking at infections when that was their role. "But once we got to know the new kid, we realized that what they were doing was different, but it really augmented what we had been doing," says Talbot. "Now we have our offices in the same suite as the quality group and we work very closely together. We are the content experts and they have ways to analyze data that are different than we traditionally used."

At Chapel Hill, NC-based UNC Health Care, the approach involves infection control professionals, quality professionals, medical and nursing staff, ancillary personnel, and administration, says David J. Weber, MD, MPH, medical director of the department of hospital epidemiology.

"Infection control meets regularly with CQI and QA personnel, participates in the monthly meeting of our Quality Council, and has a close working relationship with our chief of staff," he says.

At Oakland, CA-based Kaiser Permanente, quality, safety, and infection control leaders work together with front-line nurses and physicians to develop and implement plans, says Alide L. Chase, senior vice president for quality and service.

"A good working relationship with all health care workers and a very visible infection control program increases communication," says Chase. "This makes it more likely for all health care workers to report infection control issues, including infections."

• Identify post-discharge infections.

"We have one of the shortest lengths of stay in the country, so a lot of our infections occur after discharge," says Talbot. A patient may develop a peripherally inserted central catheter line infection, but is the cause due to the insertion of the line in Hospital A, the maintenance of the line when the patient went home for a week, or something that occurred when he or she went to Hospital B for an unrelated reason?

Infection control has partnered with Vanderbilt's case managers in each surgical group who field calls from each patient as they have problems. "They may know of potential infections that we never see on the radar," says Talbot. "We still would miss someone who went totally out of our system, but we are really trying to use a multipronged approach to pick these people up."

Tracking to find the source

One concern is the tendency to rationalize that an infection was due to another hospital or conduct "surveillance lite." "If you don't look too hard for infections, you won't find them," says Talbot. "That is why I'm an advocate for reporting and tracking adherence to process measures rather than outcomes."

If a hospital has data on each central line placed, such as what percentage had barrier precautions used, that a much stronger measure of quality than infection rates, since individual patients may be affected by morbidity that cannot totally be adjusted for, Talbot explains.

At University of California Irvine Medical Center, post-discharge infections are detected by screening lab results if the patient returns to the hospital or an ambulatory clinic, or through reporting between infection prevention professionals.

"Screening of lab results is routinely performed by infection prevention," says Linda L. Dickey, RN, MPH, CIC, manager of epidemiology and infection prevention. "However, any clinic, quality professional, or health care provider can call or e-mail to report a possible infection concern, particularly if there are concerns that may involve clusters of infection of the same type that are detected through routine chart review or a patient visit."

To gather data on patients who develop infections post-discharge at OSF Saint Francis Medical Center in Peoria, IL, infection control staff receive all inpatient and outpatient microbiology labs. "Cultures are reviewed daily, to determine if an outpatient who had a positive culture could have acquired the infection at our hospital," says Patricia Ham, RN, MS, CIC, manager of epidemiology, infection prevention and control.

Additionally, nurses conducting surveillance notify infection control of cases they have identified through review of patient charts in surgeon offices, says Ham.

At Norwalk, quality managers provide the infection control nurse with any cases identified via generic screening, occurrence reporting, patient complaints, and risk management data sources. "She may already know of many of these, but there are times, particularly with post-discharge complaints or risk contact, that a case of post-discharge infection may be identified that was not previously known," says Davis. "Likewise, infection control feeds data to quality as necessary."

Post-discharge infections also are identified via daily checks of culture results, checks of every readmission from a previous inpatient or outpatient procedure, and referral of cases from patient complaint and risk management mechanisms. "We also send a monthly fax to our surgeons with their patients from the previous month for them to check and let us know of any infections," says Davis.

At Mission Hospitals in Asheville, NC, post-discharge infections in the outpatient surgical center are tracked with a survey to the physician's office. "We have a 60% response rate," reports Tom Knoebber, director of performance improvement.

At Kaiser Permanente, an electronic health record system makes post-discharge "easy and very accurate," says Chase. "Our infection control professional can monitor patients electronically and review their post-discharge visit to determine if an infection developed," she says.

• Identify missed infections.

Through involvement with the Surgical Care Improvement Project (SCIP), the American College of Surgeons National Surgical Quality Improvement Program, incident reporting, and surveillance, Miami-based Baptist Health System has a number of ways to "catch" infections, says Jill M. Szymanski, RN, MS, CHE, CPHQ, manager of quality management.

"Our process also includes monitoring our patients concurrently. For example, we have a quality professional working with our infection control practitioners to review all coronary artery bypass graft surgeries throughout the patient's hospital stay," says Szymanski. "We have follow-up phone calls to the patients to determine if they have signs or symptoms of an infection."

If there is a concern with infections, then data are reviewed to determine if a trend exists. "We focus on the time of day of surgery, the surgeon, process issues, and the type of pathogen to see if there is a trend, then work together to improve then develop action plans when applicable," says Szymanski.

At University of California Irvine, infections missed by routine surveillance are identified when charts are reviewed for different purposes, such as the SCIP initiative. "Also, data are shared between infection prevention and the abstractor to help identify surgical-site infections," says Dickey.

At OSF St. Francis, the quality analysts who perform chart reviews notify infection control of any patients that they identify with an infection. "The infection control staff then review the case to determine if the infection was health care acquired," says Ham. To identify infections missed by routine surveillance, infection control "has a presence" on the nursing units, attends rounds, and talks with nurses, doctors, and case managers, adds Ham.

At Mission Hospitals, the performance improvement (PI) and infection control departments are working to automate data collection and surveillance. "We recently subscribed to a product that is intended to report positive cultures in real-time," says Knoebber. "Within PI, we are collecting data using a MIDAS interface. There is some duplication, but we will address this once everyone is up. We plan to add infections to our administrative dashboard and will track this monthly."

The task of identifying cases missed by routine surveillance currently falls primarily to the bedside nurse. "Our hope is through automated systems we can capture all positive test results and monitor trends," says Knoebber.

[For more information, contact:

Claire Davis, Vice President, Quality, Norwalk Hospital, 34 Maple St., Norwalk, CT 06856. Phone: (203) 852-2212. Fax: (203) 852-3436. E-mail: claire.davis@norwalkhealth.org.

Linda L. Dickey, RN, MPH, CIC, Manager, Epidemiology & Infection Prevention, University of California, Irvine Medical Center, 101 The City Drive, Rt. 171, Orange, CA 92868. Phone: (714) 456-5360. Fax: (714) 456-5367. E-mail: ldickey@hs.uci.edu.

Patricia Ham, RN, MS, CIC, Epidemiology, Infection Prevention & Control, OSF Saint Francis Medical Center, 530 NE Glen Oak, Peoria, IL 61637. Phone: (309) 655-4694. E-mail: Patricia.A.Ham@osfhealthcare.org

Tom Knoebber, Director, Performance Improvement, Mission Hospitals, 509 Biltmore Ave., Asheville, NC 28801. Phone: (828) 213-9194. E-mail: CIATXK@msj.org.

Thomas Talbot, MD, MPH, Chief Hospital Epidemiologist, Vanderbilt University Medical Center, A-2200 Medical Center North, 1161 21st Ave. S., Nashville, TN 37232. Phone: (615) 322-2035. E-mail: tom.talbot@vanderbilt.edu.]