The health care community and the general public have come to the realization that health care acquired infections (HAI), and their associated burden of increased mortality, morbidity, and expense, are needless and preventable. While past focus has been on strategies that emphasize monitoring and feedback as a way of improving compliance with established best practices, the spread of H1N1 put an increased level of attention on care delivery processes that can be implemented to keep patients safe from the transmission of infection, despite the increased patient loads anticipated as a result of the pandemic.
There is no doubt that health care presents a high-risk environment for our patients. While The Joint Commission (TJC) attempts to measure the extent of the problem through its infection-related sentinel event data, the Institute for Healthcare Improvement (IHI) and the Agency for Healthcare Research and Quality (AHRQ) are helping to establish benchmarks and publish evidence-based practices and reports of clinical outcomes and effectiveness. Despite the information available on infection control best practices, the situation remains depressing. Estimates by the Centers for Disease Control and Prevention (CDC) put nosocomial infections at 10% of all hospitalized patients each year, which works out to approximately 2,000,000 patients and adds $6.5 billion in increased care costs.1 Of course, respiratory care practitioners are most familiar with ventilator-associated pneumonia (VAP) and the significant costs directly attributable to this HAI, including needless patient death.2,3 A recent study on the economic burden of VAP found that this HAI generates an increased cost of approximately $35,000 per patient mainly due to increased need for respiratory therapy services, longer intubation times, and increased ICU lengths of stay.4
The increasing burden of health care costs is a major contributor to the budget deficit in the United States. As an incentive for health care facilities to eliminate the costs associated with HAI, the Deficit Reduction Act of 2005 requires the Administrator of the Centers for Medicare and Medicaid Services (CMS) to identify conditions that could reasonably have been prevented through the application of evidence-based guidelines. Inpatient prospective payment system (IPPS) hospitals are required to screen patients on admission, and no additional reimbursement is given to offset the cost of care for select conditions if they were not present at the time of the patient’s admission to the facility. The point of the legislation is to encourage the health care facility to “prevent an adverse event and improve the reliability of care it is giving.”5
So what is the solution? What are the most effective methods for decreasing the rate of HAI? Prevention of HAI will be achieved through a combination of emerging technologies, reporting, benchmarking/feedback, and “returning to basics.” The quotation marks are deliberate because we still have not managed to get those basics right to begin with. For example, there is still a lack of compliance with hand hygiene standards despite all the available evidence, so any talk about a “return to basics” is a bit misleading. And the recommendations are changing as additional evidence about better ways to do things is developed.
The complex health care environment lends itself to instrument reprocessing errors and environmental infection control lapses, but the use of new technologies may present a solution for minimizing the transmission of infections. An invisible fluorescent dye has been developed that can be used to train staff to do a better job cleaning the hospital environment. The dye is sprayed on all surfaces in the environment before the housekeeping staff performs a thorough cleaning. Once the cleaning is completed, a fluorescent light is used to make the remaining dye glow and highlights the areas that are still contaminated, including bathroom light switches, door knobs, telephones, nurse call lights, and grab rails. The feedback from this information increases the awareness of the housekeeping staff and encourages them to do a better job. Other emerging technologies include a shower-sized cubicle with a fogging mechanism inside that can disinfect difficult to clean equipment, and a machine that uses hydrogen peroxide vapor to “fog” a patient’s room and disinfect hard to clean equipment.6
Several companies have made new advances in the world of endotracheal tubes with thin-walled polyurethane cuffs that are designed to decrease “micro-aspiration” and reduce both early and late onset of VAP when compared with traditional tubes with PVC cuffs.7 Another newer innovation is the use of silver-coated tubes to reduce VAP. At present, the costs of these tubes are significantly higher than those of standard tubes, and implementation would require a risk/benefit analysis that considers both the dollar costs and patient lives lost to VAP.
BENCHMARKING AND FEEDBACK
Data can have motivational power to change practices and improve the public image of health care because low infection rates boost consumer confidence. Development of benchmarks is essential to improving practice, and while reporting infection rates to NNIS (CDC’s National Nosocomial Infections Surveillance System) is currently voluntary, 25 states have passed laws requiring hospitals to publicly report rates of common infections. Additionally, several software products are available to provide tracking of hospital admissions, discharges, transfers, and laboratory results. The programs identify spikes in infection rates sooner than is possible using a manual system. At least one product will also isolate the spike to a specific hospital unit so that timely dissemination of the data with physicians and staff can be accomplished and actions to correct an outbreak can be quickly implemented.6 Once again, a cost/benefit analysis can be done to determine how many lives and dollars could be saved by reducing the infection rate at any given facility.
BACK TO BASICS
There was a time when patients were given a daily bath, and there is recent research that supports a daily bath using a mild antibacterial soap, such as chlorhexidine gluconate, to reduce bloodstream infections. And there is nothing better for increasing accuracy and safety than a checklist to make sure that each step in the process has been completed. One study found that using a checklist lowers the rate of bloodstream infections by 66%, because every indwelling catheter is evaluated each shift for continuing necessity and is pulled as soon as it isn’t needed.8
There are times when a physician inserting a central line is too busy to wait for sterile drapes or a surgical mask before starting the procedure and puts the patient at risk because of impatience. If the supplies are immediately available, however, the excuse that “the patient can’t wait” isn’t valid. Procedure kits are a great way to ensure that practitioners have all necessary supplies in one place so nothing is left out or forgotten. There are also newer bedside diagnostic kits that can be used to identify infected patients in hours rather than days, which allows for timelier treatment.9
All RCPs are familiar with the recommendations in the ventilator bundle. Oral care is a big piece of VAP prevention, and there are several products on the market designed to facilitate easy oral care. However, an expensive prepackaged kit is not necessary to achieve good oral care; you just have to have staff committed to doing a good job. Routine brushing of the teeth and tongue with a regular toothbrush and toothpaste, followed by antibacterial mouthwash, can contribute to a significantly lower VAP rate.9
Finally, the single most important thing we can do to prevent the spread of infection and protect ourselves and our patients is to practice good hand hygiene. According to the IHI, occupational skin diseases are the second most common type of occupational disease and “hand hygiene in health care settings is key to protecting patients and personnel against possibly pathogenic microorganisms.” Estimates are that one third of all HAIs are preventable and hand hygiene plays a crucial role in this prevention.10
Soap and water can attack the skin’s protective acid mantle and wash away skin lipids, which is the reason alcohol-based hand rubs are currently considered the gold standard. Further, because most clinical situations do not result in gross contamination of the hands, an alcohol-based hand rub should be used to decontaminate the hands instead of soap and water. During a major campaign introducing an alcohol-based hand rub, compliance increased from 48% to 66%. In the same time period, the rate of HAIs was reduced by 41% and the rate of MRSA by 57%.10
The IHI has determined that there are three elements of hand hygiene: hand washing (washing hands with water and plain soap), hand antisepsis (rubbing hands with an alcohol-based product or washing hands with water and antimicrobial soap), and skin care (prevention of skin-stressing activities and use of hospital-approved skin care cream/lotion). It has also developed specific indications for when each element of hand hygiene should be performed.
There are so many benefits to good hand hygiene that it is hard to understand why health care workers still struggle with compliance. Elaine Larson, editor of the American Journal of Infection Control, says, “We expect the public to understand how important our work is and why we have a ‘legitimate’ excuse for deficient practices, and, yet, we would not tolerate a mechanic who was too busy to assemble the car engine correctly or the pilot too busy or distracted to ensure that all systems are functioning before a flight.”10
OTHER WAYS TO MINIMIZE RISK
Another way to minimize the spread of infection is to follow expert guidelines. The latest recommendations from the World Health Organization will not come as a surprise to anyone, since they include standard droplet precautions at all times; personal protective equipment, including particulate respirators for high-risk aerosol-generating procedures; and strict compliance with isolation precautions.11
Mandatory vaccination for influenza has been recommended for all health care workers by the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP) since 1986. Despite outcry from many workers opposed to this recommendation, many health care facilities have made influenza vaccination mandatory in an effort to protect not only health care workers from contracting influenza, but also to minimize the spread of infection in the hospital between patients. The CDC reports that only 64.3% of health care workers were vaccinated against seasonal or H1N1 influenza as of January 2010, so there is much room for improvement. The CDC states that “health care administrators should consider influenza vaccination coverage among employees an important measure of patient safety and make appropriate efforts to increase coverage in future seasons.”12
EDUCATION AND AWARENESS CAMPAIGNS
Rigorous programs are necessary to educate employees and increase their awareness of the rationale behind infection control standards and gain their buy-in for new processes and best practices. Most health care workers are very compliant when they realize that compliance does improve patient outcomes. Simply making the information available is not enough; there must be programs in place to check for understanding and compliance with the guidelines. Direct monitoring of individual employee performance ensures processes are correctly followed and provides proof that a positive change has been achieved.
Once the data is gathered, it must be shared with the individual employees; feedback is essential to ensure that staff remain aware of their performance and know that the requirement is not going away. One-on-one counseling for those who need it is appropriate, but an even better way to ensure that good performance continues is to reward compliant staff to enhance their motivation to continue to do a good job. Rewards can include paid CE hours, pins, gift cards, or recognition certificates given at public ceremonies.
Health care facilities are dangerous places for patients due to exposure to disease, poor staff adherence to infection control practices, and lack of staff knowledge and training. Implementation of evidence-based infection control standards can minimize risks and provide protection to patients. Effective methods for preventing health care acquired infections include use of emerging technologies to reduce transmission of infections; rigorous use of the basics in infection control practices; and reporting, benchmarking, and feedback to staff to improve compliance with effective infection control processes.
Cheryl Hoerr, MBA, RRT, CPFT, FAARC, is director, Respiratory Therapy and Sleep Center, Phelps County Regional Medical Center, Rolla, Mo. For further information, contact [email protected].
- Scott D. The direct medical costs of healthcare associated infections in U.S. hospitals and the benefits of prevention. Available at: www.cdc.gov/ncidod/dhqp/hai.html. Accessed May 10, 2010.
- CDC. Guidelines for Preventing Healthcare-Associated Pneumonia, 2003. Recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR. 2004; 53(RR-3):1-36.
- Chastre J, Fagon J. Ventilator–associated pneumonia. Am J Respir Crit Care Med. 2002; 165:867-903.
- Restrepo M, Anzueta A, Arroliga AC, et al. Economic burden of ventilator-associated pneumonia based on total resource utilization. Infect Control Hosp Epidemiol. 2010;3:509-15.
- Centers for Medicare and Medicaid Services. Hospital-acquired conditions (present on admission indicators). Available at: www.cms.gov/HospitalAcqCond/. Accessed May 10, 2010.
- Simon S. Ten steps to preventing infection in hospitals. Wall Street Journal. October 10, 2009.
- Leonardo L, Lecuona M, Jinenez A, Mota ML, Sierra A. Influence of an endotracheal tube with polyurethane cuff and subglottic secretion drainage on pneumonia. Am J Respir Crit Care Med. 2007;176:1079-83.
- Pronovost P, Needham D, Berenholz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-32.
- Pear S, Stoessel K, Shoemake S. The role of oral care in the prevention of hospital-acquired pneumonia. Independent study guide. Kimberly-Clark Health Care Education.
- How-to Guide: Improving Hand Hygiene. Institute for Healthcare Improvement. Available at: www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Tools/HowtoGuideImprovingHandHygiene.htm. Accessed May 10, 2010.
- World Health Organization. Clinical management of human infection with pandemic (H1N1) 2009: revised guidelines. Available at: www.who.int/csr/resources/publications/swineflu/clinical_management_h1n1.pdf. Accessed May 10, 2010.
- Centers for Disease Control and Prevention, Mortality and Morbidity Weekly Report. Interim results: influenza A (H1N1) 2009 monovalent and seasonal influenza vaccination coverage among health-care personnel—United States, August 2009-January 2010. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm5912a1.htm. Accessed May 10, 2010.