“Right Sizing” National Initiatives to Reduce Healthcare Associated Infections Critical Access Hospitals

MHA Quality Improvement Showcase - 2011

Bonnie Barnard, MPH, CICHAI Prevention Initiative Coordinator

MTDPHHS

Federal Activities

State Activities

From: Cardo D, et. al., Moving toward elimination of healthcare-associated infections: A call to action; Infec Cont Hosp Epidemiol 31(11): 1101-1105, Nov 2010

Summary of Progress Toward the Nine National Targets for Elimination of Healthcare-Associated Infections, 2010

* 2009 or 2009-2010 is the baseline period. 

EIP is the CDC’s Emerging Infections Program; HCCUP is AHRQ’s Healthcare Cost and Utilization Project; NHSN is 

the CDC’s National Healthcare Safety Network; SCIP is surgical care improvement project

Metric Data Source National 5-year Prevention Target

On Track to Meet 2013 Targets?

Bloodstream infections NHSN 50% reduction Yes

Adherence to central-line insertion practices NHSN 100% adherence Data not yet available*

Clostridium difficile (hospitalizations) HCUP 30% reduction No

Clostridium difficile infections NHSN 30% reduction Data not yet available*

Urinary tract infections NHSN 25% reduction Data not yet available*

MRSA invasive infections (population) EIP 50% reduction Yes

MRSA bacteremia (hospital) NHSN 25% reduction Data not yet available*

Surgical site infections NHSN 25% reduction No

Surgical Care Improvement Project Measures SCIP 95% adherence Yes

*2009 or 2009-2010 is the baseline period.

EIP is the CDC’s Emerging Infections Program; HCCUP is AHRQ’s Healthcare Cost and Utilization Project; NHSN is the CDC’s National Healthcare

Safety Network; SCIP is surgical care improvement project.

Adherence to Evidence-Based Prevention Practices

PREVENTION OF CA-UTI

Why CA-UTI?

• Most common hospital-acquired infection: 40% of all HAIs> 1 million cases annually (hospitals & nursing

homes)• 12-25% of all hospitalized patients receive a

urinary catheter– Half of these found to not have valid indication

Potential Impact

• Increased length of stay 0.5 – 1 day• Estimated cost per case of CA-UTI ranges from

$500-$3,000• Cost to health care system up to $450 million

annually according to CMS• CA-UTI not documented as present on

admission can no longer code patient to higher reimbursement DRG for Medicare

Evidence-Based Guidelines

• APIC CA-UTI Elimination Guidewww.apic.org/CAUTIGuide

• SHEA-IDSA Compendiumhttp://www.shea-online.org/about/compendium.cfm

• CDC Guidelinehttp://www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html#

Evidence of Success

• Numerous published studies reporting reductions in CA-UTI rates of 48-81%– Use of reminders– Nurse-driven protocols– Reduction in duration of catheter days

“The duration of catheterization is the most important risk factor for development of infection.”

SHEA-IDSA Compendium, October 2008

Preventing CA-UTI

1. Avoid unnecessary urinary catheters2. Insert using aseptic technique3. Maintain catheters based on recommended

guidelines (daily care)4. Review catheter necessity daily and remove

promptly

1. Avoid unnecessary urinary catheters

• Studies:– 21% of catheters not indicated at insertion– 41-58% in place found to be unnecessary

• Catheters– Are uncomfortable for patients– Decrease mobility, which may impair recovery and

contribute to other complications (e.g., pressure ulcers, deep vein thrombosis)

Saint S, Lipsky BA. Preventing catheter-related bacteriuria: Should we? Can we? How? Arch Intern Med. 1999 Apr 26;159(8):800-808.

Jain P, Parada JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med. 1995;155:1425-1429.

Indications for Indwelling Urinary Catheters

Based on expert guidelines and published literature:• Perioperative use for selected surgical procedures• Urine output monitoring in critically ill patients• Management of acute urinary retention and urinary

obstruction• Assistance in pressure ulcer healing for incontinent patients • As an exception, at patient request to improve comfort (SHEA-

IDSA) or for comfort during end-of-life care (CDC)

Avoidance Strategies

• External condom catheters for appropriate male patients

• Intermittent catheterization multiple times per day

• Assessing urinary retention with bladder ultrasound

Changes to Avoid Unnecessary Catheters

• Develop criteria for appropriate insertion and verify prior to every insertion

• Empower nurses to contact physicians before insertion if criteria are not met

• Use a checklist of criteria – include this with the insertion kits

• Determine where most catheters are inserted (probably the ED) and start there

2. Insert urinary catheters using aseptic technique

• Utilize appropriate hand hygiene practice.

• Insert catheters using aseptic technique and sterile equipment, specifically using:– gloves, a drape, and sponges;– sterile or antiseptic solution for cleaning the urethral

meatus; and– single-use packet of sterile lubricant jelly for insertion.

• Use as small a catheter as possible that is consistent with proper drainage, to minimize urethral trauma.

3. Maintain catheters based on recommended guidelines

• Maintain a sterile, continuously closed drainage system.• Keep catheter properly secured to prevent movement and

urethral traction.• Keep collection bag below the level of the bladder at all times.• Maintain unobstructed urine flow.• Empty collection bag regularly, using a separate collecting

container for each patient, and avoid allowing the draining spigot to touch the collecting container.

• Maintain meatal care with routine hygiene (bathing).

• Determine need for continuation• Remove if not indicated• Possible strategies:

– Nursing assessments at every shift, with requirement to contact physician if criteria are not met

– Nursing protocols for removal of urinary catheters based on criteria– Automatic stop orders for 48 to 72 hours after insertion, continuation

only when indication is documented in renewal order– Reminders in patient records requiring physicians to document

indication for continuation of catheter

4. Daily review of necessity with prompt removal

Surgical Site Infections

Adherence to Evidence-Based Practices

Comprehensive HAI Prevention

• Early identification and containment or isolation– Sharing information– Resolving practice differences

• Hand hygiene– Unit based teams– Clear targets

• Environmental sanitation– Standardize P&P– Competencies

• Antibiotic stewardship– Laboratory, pharmacy and ID specialist roles

Strategies for Success

• Standardized prevention practices• Standardize products• Prevention practice component

documentation built into EMR• Feedback to staff on the front line

My 5 moments for HAND HYGIENE

Environmental Services as Driver for HAI Reduction

• Survival of organisms in the environment• High touch items– Bedrails, bedside tables, call buttons

• Standardize process– Room cleaning checklist– Room cleaning assessment

Case Study – Albany Memorial Hospitals

Other Topics of Interest

MDROs and Other “Buggers”

• MDROS– MRSA– VRE – vancomycin resistant enterococcus– ESBL - extended spectrium beta-lactamase producers– CRE / CRKP – carbapenemase resistant

enterobacteriaceae – Acinetobacter baumanii

• Clostridium difficile• GI viruses, e.g., Norovirus

An Outbreak of Hepatitis C Virus Infections among Outpatients at a Hematology/Oncology Clinic

Alexandre Macedo de Oliveira, MD, MSc; Kathryn L. White, RN, BSN; Dennis P. Leschinsky, BS; Brady D. Beecham, BS; Sara M. Vogt, PhD; Ronald L. Moolenaar, MD, MPH; Joseph F. Perz, DrPH; and Thomas J. Safranek, MD

Macedo de Oliveira et al., Annals of Internal Medicine, 2005, 142:898-902

• September 2002 – 4 patients recently diagnosed HCV infection reported to Nebraska Health Department– All regularly had cancer chemotherapy at one clinic

• Initial investigation identified infection control breach related to catheter flushing, prompting the notification of over 600 patients

• 99 clinic-acquired HCV infections were identified– All genotype 3a (uncommon in U.S.)– Transmission period: March 2000 – July 2001

Never Event:Nebraska Hepatitis C Outbreak

Never Event:Nebraska Hepatitis C Outbreak

• Nurse drew blood from indwelling IV catheter, then reused same syringe to perform saline flush – New syringe was used for each patient– Solution from 500cc bag used for multiple patients

• Clinic was independently owned and operated– No active infection control program

• Breaches never reported to state health department

• 2004 – Oncologist’s and RN’s licenses revoked

Growing Concern

• CDC and state and local health departments have investigated an increasing number of outbreaks– Unsafe injection practices– Other breaches in basic infection control– Detection is haphazard

• Outbreaks are occurring across the healthcare spectrum– Ambulatory, home and long-term care settings

• Infection control programs and oversight

Montana Pillar - Data For Action

Implementation of NHSN

Patient Safety Component

• Device-associated Module– Central line-associated bloodstream infection– Catheter-associated urinary tract infection– Ventilator-associated pneumonia– Dialysis incident

• Procedure-associated Module– Surgical site infection– Post-procedure pneumonia

• MDRO/CDAD Module– Infection vs LabID event reporting– Prevention Process Measures

National Healthcare Safety Network (NHSN)

• Voluntary, secure, internet-based surveillance system for patient and healthcare personnel safety– Healthcare-associated infection surveillance– Multi-drug resistant organisms surveillance– Healthcare influenza vaccination

• Managed by the CDC Division of Healthcare Quality Promotion

Healthcare Personnel Safety Component

• Blood and Body Fluid Exposures and Exposure Management– Events only or events + follow-up

• Influenza Vaccination and Exposure Management– Vaccination– Surveys– Post-exposure follow-up

Business Case for NHSN Use

• Standardized surveillance with consistent case definitions

• Data for state and local comparisons• Support for training and technical assistance• Detailed tables of instruction and data

collection forms

IPPS Rule – CMS Reporting

• CLABSI Reporting via NHSN – Jan 2011– Adult intensive care units– Pediatric intensive care unit– Neonatal intensive care unit (Level II/III and Level

III)• SSI Reporting via NHSN – Jan 2012– CABG, hip/knee prosthesis, colon surgery, vascular

NHSN Progress in Montana

• May 2010– Only 5 facilities participating at some level

• December 2010– 14 facilities participating!!• 11 IPPS• 3 CAH

• Outcomes vs process measurement• Standardize practices known to prevent HAIs• Standardize to surveillance definitions

CAH Issues

And let it be noted that there is no more delicate matter to take in hand, nor more dangerous to conduct, nor more doubtful in its success, than to set up as a leader in the introduction of changes. For he who innovates will have for his enemies all those who are well off under the existing order of things, and only lukewarm supporters in those who might be better off under the new.

- Niccolo Machiavelli, the Prince (1513)

Out of the Danger ZoneTMIT / safetyleaders.com

http://www.safetyleaders.org/discovery/dangerZone.jsp

http://haiprevention.hhs.mt.gov

Bonnie Barnard, MPH, CICHAI Prevention InitiativeMT DPHHS406.444.0274bbarnard@mt.govhttp://haiprevention.hhs.mt.gov