Healthcare-Associated Infections: The Bottom Line

1. Healthcare-Associated Infections: The Bottom Line Insert LOGO

2. DISCLAIMER This document was developed by the Surveillance Subcommittee (SS) of the Arizona Healthcare-Associated Infection (HAI) Advisory Committee. SS is a multidisciplinary committee representing various healthcare disciplines working to define and categorize the strength of evidence for preventing healthcare-associated infections. Their work was guided by the best available evidence at the time this document was created.

3. SBAR Approach • Situation: One in 20 hospitalized patients in US acquire an HAI while receiving medical or surgical treatment. Limited resources for infection prevention hamper HAI prevention and elimination efforts. • Background: With the burden of HAI disease increasing and new CMS non-reimbursement/ value based purchasing (VBP) policies, there is now a need for change.

4. SBAR Approach • Assessment: Accurate and timely information is needed to monitor and implement HAI intervention strategies. Collecting, analyzing and reporting data into CDC/NHSN, to fulfill CMS mandatory requirements, require technical and personnel resources which are limited. • Recommendations: Allocate resources to support infection prevention and patient safety. Implement evidence based practice and foster a culture of infection prevention.

5. Acronyms • Healthcare Associated Infections (HAI) • Value Based Purchasing (VBP) • Surgical Care Improvement Project (SCIP) • Surgical Site Infection (SSI) • Central Line-Associated Bloodstream Infection (CLABSI) • Ventilator-associated Event/Pneumonia (VAE/VAP) • Catheter-associated Urinary Tract Infections (CAUTIs) • Clostridium difficile Infection (CDI) • National Healthcare Safety Network (NHSN) • Multidrug-Resistant Organism (MDRO)

6. The HAI Problem • HAIs add billions of dollars to U.S. health care costs • In 2002, 1.7 million hospital-associated infections contributed to 99,000 deaths • The Harbarth study concluded that approximately 20 percent of all HAIs are probably preventable based on current medical practice and technology Harbarth S, Sax H, Gastmeier P. The preventable proportion of nosocomial infections: an overview of published reports. J Hosp Infect 2003;54:258-266. Centers for Disease Control and Prevention: Press Release, March 2000. Available at: http://www.cdc.gov/od/oc/media/pressrel/r2k0306b.htm Klevens et al. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. Public Health Reports. March-April 2007. Volume 122.

7. HAI Impact • The health and safety of your patients! • Direct medical costs • Indirect costs • Reimbursement • Public awareness factor • Liability/litigation • Accreditation and licensing factors

8. Impact of HAI • Central line-associated blood-stream infections (CLABSI) $36,441 • Surgical site infection (SSI) $25,546 • Ventilator-associated pneumonia (VAP/VAE) $9,969 • Catheter-associated urinary tract infections (CAUTI) $1,006 http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf

9. Age-Adjusted Death Rate* for Enterocolitis Due to C. difficile 2.5 Male Female 2.0 White Black Entire US population 1.5 Rate 1.0 0.5 0 1999 2000 2001 2002 2003 2004 2005 2006 Year *Per 100,000 US standard population Heron et al. Natl Vital Stat Rep 2009;57(14). Available at http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf

10. Outcomes of C. difficile Infections • Excess costs • $2,380 to $3,240 per index hospitalization • $3,797 to $7,179 inpatient costs over 180 days of follow-up • Other outcomes • 2.8 days attributable excess length of stay • 19.3% attributable readmission (180 days) • 5.7% attributable mortality (180 days) • More likely to be discharged to long-term care • DubberkeER, et al. Clin Infect Dis. 2008;46:497-504. • Dubberke ER, et al. 17th Annual Meeting of The Society for Healthcare Epidemiology of America (SHEA), April 14-17, 2007; Baltimore, MD. • Unpublished data.

11. Hospital Charges for C. difficile Hospital Discharge Database

12. National Data:Summary of HAI Cost • Annual direct medical costs of HAI to U.S. hospitals • $28.4 to $33.8 billion (after adjusting to 2007 dollars using the CPI for all urban consumers) • $35.7 to $45 billion (after adjusting to 2007 dollars using the CPI for inpatient hospital services) Scott RD. The Direct Medical costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. CDC March 2009

13. What HAI Prevention Saves • Benefits of prevention • $5.7 to $6.8 billion (20 percent of infections preventable, CPI for all urban consumers) • $25.0 to $31.5 billion (70 percent of infections preventable, CPI for inpatient hospital services) CPI = Consumer Price Index

14. The Bottom Line: HAI Prevention Needs to Start at the Frontlines • Executive support • Resource allocation • Technology transfer • Personnel resources • Succession planning • Shared resources including DE, DA • Collaborative relationships (HSAG, HRET-HEN, APIC, Skilled nursing facilities, health departments) • Participation with collaborative performance improvement efforts • Reward and acknowledge performance improvement efforts

15. The Bottom Line: HAI Prevention Needs to Start at the Frontlines • Surveillance • Activities result in improved patient safety • Electronic technology for data retrieval and data transfer to NHSN • Implementation science • Process for sustaining improvement efforts require resources • Reinforce “ no shortcuts” for evidence based initiatives • Make change manageable = One person, one process at a time • Improvement is cyclical, forecast for future needs

16. Recommendations:What Should Be Done to Correct the Problem? • Support Infection Prevention program • Electronic Surveillance System • Adequate staffing for surveillance activities • Real Time Reporting to Units • Rounding

17. Recommendations • Implement house-wide device-related infection prevention bundle • Integrate “bundle” elements into electronic medical record • Checkbox for reason for device • Only include Reasons that are Evidence Based • Daily reminder to physicians to discontinue/continue indwelling catheter

18. Recommendations • Support multi-disciplinary rounding • Support multi-disciplinary device-related infection team • CLABSI team, VAP team, CAUTI team • Support antibiotic stewardship programs • Support Just Culture environment • Non compliance is reckless behavior

19. Questions? For more information about this topic, please visit: • www.cdc.gov/hai/ • www.azdhs.gov/phs/oids/hai/Surveillance.htm • www.wearepublichealth.org