Focus Area 3: Prevent Healthcare-Associated Infections

Defining the problem

According to the federal Centers for Disease Control and Prevention (CDC), in 2002 there were an estimated 1.7 million Healthcare-Associated Infections and 99,000 deaths from those infections.45 A recent CDC report estimated the annual medical costs of Healthcare-Associated Infections in U.S. hospitals to be between $28 billion and $45 billion, adjusted to 2007 dollars.46

Since 2005, New York State Public Health Law § 2819 has required acute care hospitals to report selected hospital-acquired infections to NYSDOH. Reporting these infections allows NYSDOH to determine which hospitals need help to implement practices to decrease infection rates, and it allows hospitals themselves to identify areas of potential improvement. Also the general public can use publicly reported infection rates to help make decisions about where they will seek medical care.

Many Healthcare-Associated Infections are preventable. Since 2007, there has been a 41 percent reduction in central line associated bloodstream infections (CLABSIs), in NYS intensive care units; this means 669 fewer infections, and between 80 and 167 fewer deaths in 2011 than there would have been had the 2007 rates persisted. Additionally, the reduction in CLABSI rates resulted in savings of $12 billion to 48 million from 2008-2011. Similarly, there has been a 13 percent reduction in surgical site infections (SSIs) in certain selected procedures (colon, hip replacement, and coronary artery bypass graft) since 2007, which has resulted in reduced morbidity and mortality, and savings of $9 million to $27 million. Clostridium difficile infection (CDI) rates were publicly reported for the first time in 2010. The 2011 rates did not show a decrease yet, although the interpretation of the data is complicated by the fact that many hospitals have switched to more sensitive testing methods that would be expected to identify more infections.

Currently, Healthcare-Associated Infections of concern at the national level include Clostridium difficile infections, multidrug-resistant organisms (MDROs), CLABSIs, catheter-associated urinary tract infections (CAUTIs), SSIs and ventilator-associated conditions. NYS hospitals have been reducing SSIs for several years; it is unclear how much additional improvement is feasible for currently reported procedures. Ventilator-associated conditions, such as pneumonia, are difficult to measure because of challenges related to definitions and diagnosis. Therefore, the goals of this Action Plan will focus on CDIs, MDROs, and device-associated infections (CLABSIs and CAUTIs).

In 2011, there were more than 10,300 hospital-onset CDIs in New York State. Assuming an attributable mortality rate of approximately 10 percent,47 more than 1,000 patients who developed CDI, while hospitalized, hospitalized, died from CDI in 2011. A reduction of these infections by 30 percent over five years is closely aligned with the U.S. Department of Health and Human Services (HHS) Action Plan,48 and would result in 600 fewer infections and 60 lives saved in the first year. Additionally, there were almost 3,000 CDIs, occurred shortly after hospital admissions. Because it is difficult to determine whether these infections were acquired during the hospital admissions or from other exposures, a lesser reduction, such as 15 percent, would be more feasible.

There are few data on rates of infection from MDROs in NYS hospitals. The Federal Centers for Medicare and Medicaid Services (CMS) has requested that hospitals report methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections as part of reimbursement incentives, which means data from NYS hospitals for this particular MDRO will soon be available. The HHS Action Plan48 called for a 25 percent reduction in this type of infection from 2009-2013; however, data from NYS hospitals are not available for that time-period. Because some MRSA bloodstream infections are associated with CLABSIs, and CLABSI rates have markedly decreased in NYS over the past four years, it is unclear whether a 25 percent reduction is feasible in the future. Therefore, a ten percent reduction was chosen as the NYS goal.

There is no mandated surveillance of gram-negative MDROs in NYS hospitals. These infections include organisms for which treatment options are extremely limited, such as cephalosporin- or carbapenem resistant Klebsiella species and carbapenem resistant E.coli. Because baseline rates are not known, it is not possible to define an appropriate reduction; surveillance must be instituted first.

NYS hospitals are making good progress in decreasing CLABSIs in intensive care unit (ICU) patients. The problem of CLABSIs outside ICUs is starting to be addressed through Partnership for Patients, a program funded by the Affordable Care Act in which HHS works with public or private partners, such as hospitals and hospital associations, to improve the quality and safety of health care. The Partnership for Patients' goal is to reduce CLABSIs by 50 percent, a reasonable objective for NYS non-ICU settings. Regarding CAUTIs, hospitals are reporting ICU CAUTIs to CMS, and non-ICU CAUTIs are being addressed by Partnership for Patients with a goal of a 40 percent reduction. CAUTIs may be reduced either by reducing usage of catheters or by reducing rates in catheterized patients. Non-ICU areas are the focus of this objective because there may be a greater potential for reductions because this is a new area of focus.

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Goals and Objectives for Action

Goal #1: Reduce Clostridium difficile (C. difficile) infections (CDIs)

Objective 1.1: (Core Tracking Indicator):
By December 31, 2017, reduce hospital-onset CDIs by 30% to 5.94 new cases per 10,000 patient days.
(Baseline: 8.48 new cases per 10,000 patient days; Year: 2011; Data Source: National Healthcare Safety Network (NHSN))
Objective 1.2: (Core Tracking Indicator):
By December 31, 2017, reduce community-onset health care facility-associated CDIs by 15 percent to 2.05 new cases per 10,000 patient days.(Baseline: 2.41 new cases per 10,000 patient days; Year: 2011; Data Source: NHSN)

Goal #2: Reduce infections caused by multidrug-resistant organisms.

Objective 2.1:
By December 31, 2017, reduce hospital-onset methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections by 10%. (Baseline: Not available; Data Source: NHSN)
Objective 2.2:
By December 31, 2017, institute surveillance of hospital-onset multidrug-resistant Gram-negative bacterial infections and decrease infection rates.
(Baseline: Not available; Data Source: NHSN)

Goal #3: Reduce device-associated infections.

Objective 3.1:
By December 31, 2017, reduce non-ICU central line-associated blood stream infections (CLABSIs) by 50%.
(Baseline: Not available; Data Source: NHSN)
Objective 3.2:
By December 31, 2017, reduce non-ICU catheter-associated urinary tract infections (CAUTIs) by 40%. (Baseline: Not available; Data Source: NHSN)

Focus Area 3: Prevent Healthcare-Associated Infections - Interventions and Activities by Sector

Changes can be made across all sectors to improve health outcomes for people with health care associated infections. Below are evidence-based and best-practice examples of how your sector can make a difference.

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Healthcare Delivery System

Goal #1: Reduce C. difficile infections (CDIs).
  • Educate patients and visitors about the importance of handwashing.
  • Encourage patients to speak up about health care personnel's handwashing.
  • Institute formal quality improvement programs to reduce infections.
  • Offer training on CDI prevention for health care personnel.
  • Ensure adequate cleaning and disinfection of patient care rooms and medical equipment.
  • Dedicate medical equipment to individual patients with CDIs when possible.
  • Consider using sporicidal disinfectants in health care facilities when possible.
  • Use hypochlorite-based disinfectants where endemic rates are high.
  • Place patients with CDIs in private rooms when possible or cohort CDI patients.
  • Monitor and enforce hand hygiene and contact precaution adherence by health care personnel.
  • Ensure health care personnel wear gowns and gloves when entering rooms of patients with CDIs.
  • Continue contact precautions at least until diarrhea ceases in patients with CDIs.
  • Use laboratory testing methods with high sensitivity to detect CDIs.
  • Institute antimicrobial stewardship programs that might decrease patients' exposure to antibiotics.
  • Where feasible, incorporate building design elements that may reduce transmission of CDIs, such as private rooms and private bathrooms.
  • Ensure administrative support and commitment of resources to C. difficile prevention efforts.

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Goal #2: Reduce infections caused by multidrug-resistant organisms (MDROs).
  • Ensure that sinks and alcohol-based hand rub are readily available for patients, visitors and health care personnel.
  • Implement focused educational efforts for hospital staff to improve their understanding of MDRO transmission.
  • Institute formal quality improvement programs to reduce infections.
  • Educate environmental services staff about MDROs and the importance of disinfection.
  • Keep health care personnel informed about changes in MDRO transmission rates.
  • Provide reports to clinicians summarizing the prevalence of resistance among clinical isolates by disseminating anti-biograms.
  • Institute observation and feedback programs to educate health care personnel about hand hygiene adherence and isolation precautions.
  • Institute management protocols of vascular and urinary catheters and the prevention of respiratory infections in ventilated patients.
  • Place colonized or MDRO-infected patients in private rooms whenever possible.
  • Monitor and enforce hand hygiene and adherence to isolation precautions.
  • Monitor adherence to environmental cleaning and disinfection protocols.
  • Use tiered or stepwise implementation of aggressive measures to control MDRO outbreaks.
  • In outbreak situations, consider use of molecular techniques to verify and understand transmission, and monitor interventions.
  • Consider the use of active surveillance cultures to detect patients colonized with MDROs.
  • Ensure administrative support and commitment of resources to MDRO prevention efforts.
  • Implement computer alerts to ensure colonized or MDRO-infected patients are identified rapidly.
  • Institute antimicrobial stewardship programs that might decrease patients' exposure to antibiotics and reduce or slow the development of resistance.
  • Implement surveillance for MDROs, using CDC's National Healthcare Safety Network to define the baseline and detect changes.
  • Institute increased cleaning and disinfection of frequently touched surfaces.
  • Maintain adequate staffing levels for the acuity of care.

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Goal #3: Reduce device-associated infections.
  • Educate health care personnel about indications for central venous catheter use and the procedures for insertion and maintenance.
  • Ensure that appropriate hand hygiene is performed before central venous catheter insertion and maintenance, and provide immediate feedback if appropriate hand hygiene is not performed.
  • Provide recurrent education to staff on proper insertion and maintenance practices for urinary catheters.
  • Institute formal quality improvement programs to reduce infections.
  • Provide feedback to personnel on the proportion of urinary catheters meeting usage indications and proper maintenance.
  • Ensure that personnel inserting or caring for central venous catheters adhere to insertion and maintenance procedures.
  • In adults, avoid use of the femoral vein whenever possible.
  • Assess the need daily for central venous catheters and remove them once their use is not essential.
  • Use maximal sterile barrier precautions when inserting central venous catheters.
  • Use chlorhexidine with alcohol to prepare skin before central venous catheter insertion if there are no contraindications.
  • Consider using chlorhexidine for daily skin cleansing.
  • If CLABSI rates are not decreasing despite comprehensive interventions, consider use of antimicrobial or antiseptic impregnated catheters and cuffs.
  • Avoid use of urinary catheters for incontinence.
  • If CAUTI rates are not decreasing despite interventions, consider use of antimicrobial or antiseptic impregnated catheters.
  • Assess the need daily for urinary catheters and remove them once they are no longer needed.
  • Use checklists and bundles to improve adherence to central venous catheter best practices.
  • Ensure staff have the authority to stop non-emergent central venous catheter insertions if proper protocols are not followed.
  • Encourage nursing staff to notify physicians when central venous catheters are no longer necessary.
  • Monitor adherence to indications for urinary catheter use.
  • Monitor appropriate removal of urinary catheter postoperatively, preferably within 24 hours.

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Interventions and Activities by Sector

Media

Goal #1:
Reduce C. difficile infections.
  • Publicize the dangers of overuse and improper use of antibiotics; advise patients to take antibiotics only as prescribed by a physician.

Academia

Goal #1:
Reduce C. difficile infections.
  • Offer training on CDI prevention.
Goal #2:
Reduce infections caused by MDROs.
  • During outbreaks, consider use of molecular techniques to verify and understand transmission.

Other Governmental Agencies

Goal #1:
Reduce C. difficile infections.
  • Ensure adequate resources for hospitals' infection prevention efforts.
Goal #2:
Reduce infections caused by MDROs.
  • Ensure adequate reimbursement for hospitals' infection prevention efforts.
  • Improved education and better availability of health insurance may improve overall health and decrease the need for extensive outpatient care or hospitalizations, thereby reducing the opportunities for healthcare associated infections to occur.
Goal #3:
Reduce device-associated infections.
  • Ensure adequate resources for hospitals' infection prevention efforts.
  • Improve education and make health insurance readily available to improve overall health and decrease the need for extensive outpatient care or hospitalizations, which would reducing the chances for Healthcare-Associated Infections to occur.

Governmental (G) and Non-Governmental (NG) Public Health

Goal #1:
Reduce C. difficile infections.
  • Offer training on CDI prevention.
Goal #2:
Reduce infections caused by MDROs.
  • Implement focused educational efforts for health care personnel to improve understanding of MDRO transmission.
  • Use tiered or stepwise implementation of aggressive measures to control outbreaks of MDROs.
  • During outbreaks, consider use of molecular techniques to verify and understand transmission.

Policymakers and Elected Officials

Goal #1:
Reduce C. difficile infections.
  • Improve education and make health insurance readily available to decrease need for extensive outpatient care or hospitalizations, reducing chances for these infections to occur.
Goal #2:
Reduce infections caused by MDROs.
  • Improve education and make health insurance readily available to decrease need for extensive outpatient care or hospitalizations, reducing chances for these infections to occur.
Goal #3:
Reduce device-associated infections.
  • Ensure adequate resources for hospitals' infection prevention efforts.
  • Improve education and make health insurance readily available to decrease need for extensive outpatient care or hospitalizations, reducing the chances for these infections to occur.

Philanthropy

Goal #1:
Reduce C. difficile infections.
  • Offer training on CDI prevention.

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