Looking to gut HAIs by 2020, HHS has given hospitals aggressive goals on HAI reduction
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June 1, 2018
The Department of Health and Human Services (HHS) has given hospitals aggressive goals on HAI reduction. By 2020, the department wants CAUTI rates to be cut 50% in acute care hospitals, long-term care facilities, and ambulatory surgical centers.
Sue Dill Calloway, RN, Esq., AD, BA, BSN, MSN, JD, CPHRM, CCMSCP, president of Patient Safety and Healthcare Consulting and Education, says the HHS goals are pretty ambitious, particularly considering some of their previous results.
The first step, Calloway says, is for hospitals to commit to HAI prevention training. That requires special emphasis on educating staff working on the frontlines of care.
“When my sister was in [the hospital], I saw [staff] do some really bad dressing changes,” she says. “I saw them not washing their hands. When my sister had a wound infection, they didn’t culture it or notify the infection preventionist. They took an off-label saline flush and put it on there. And there was a fresh patient coming from postop into that room.”
HAI training requires many different competencies, she says, including hand hygiene, proper antibiotic usage, and the correct way of handling IVs and catheters. While conducting this kind of training may sound like a drain on resources, she points to a number of free toolkits and resources that organizations can take advantage of.
Two key providers of free HAI prevention guidance and training are the Centers for Disease Control and Prevention (CDC) and the Institute for Healthcare Improvement (IHI). The CDC website offers several worksheets, checklists, and free webinars on HAI reduction and antimicrobial stewardship. Meanwhile, the IHI has several HAI reduction toolkits and how-to guides covering hand washing, CAUTIs, SSI, CLABSI, and MRSA.
The main issue with these resources, she says, is that most people aren’t aware that they exist.
“The CDC in April 2011 put out this amazing document on reducing infections and found a lot of hospitals didn’t even use it,” says Calloway. “It was a great resource that tells you how to put a peripheral line, mid-line, central line. It told you how often to change the dressing, how often to change the tubing. But I did a number of web-based programs — none of them were well attended — and we would ask people, ‘Do you know this document? Do you use this document?’ They would say, ‘No.’ ”
She says this lack of awareness of HAI resources has even come to the attention of CMS, who even mentioned in its list of proposed changes that many outpatient facilities were unaware that there was a CDC infection control checklist for them.
An increasing challenge in treating infections is the alarming rise in antimicrobial resistance. In just the U.S., antibiotic-resistant diseases result in 2 million illnesses and 23,000 deaths annually. This is due to the rampant misuse of antibiotics, with nearly 50% of all prescriptions given needlessly or inappropriately. What’s more, 60% of U.S. hospitals didn’t have antimicrobial stewardship programs (ASP) that met all seven components of the CDC stewardship guidelines. Several of the HHS’ HAI rates are directly tied to antibiotic resistance and misuse, such as MRSA and C. diff infections.
Jennifer Pisano, MD, is medical director of the ASP at the University of Chicago Medicine and Biological Sciences. While implementing a working ASP is a big job, she says it’s still something that hospitals should be able to accomplish.
"I would highly recommend reaching out to like institutions to discuss their plans for antimicrobial stewardship and what has worked [or] not worked at their institution," Pisano says. "Every institution is different, but it is invaluable to discuss with institutions that are similar to your own and the challenges that they have faced; you may not have to reinvent the wheel at your home institution. I learn new things all of the time from creative, energetic stewardship champions who are building programs in many different settings."
She recommends facilities look at the CDC’s Core Elements of Hospital Antimicrobial Stewardship Programs and accompanying checklist. She also notes that the guidelines for implementing an ASP were updated in April and are available on the Infectious Diseases Society of America website and through CDC.gov. The CDC site includes education materials and guidance for both patients and providers on how to reduce inappropriate antibiotic prescribing and establish a measurement framework. The CDC website also has links to examples of existing ASPs at facilities across the country.
The requirement represents a huge opportunity to reduce HAIs, Calloway says, though people should temper their expectations.
“I just don’t know if it will be as great as they would like to see,” she says. “If you look at their 2020 target of 30%, right now in a regular hospital they think that 50% of their antibiotic use is unnecessary, and in the outpatient setting it’s 30%. If we can reduce a lot of unnecessary antibiotic usage, we will drive the C. diff rate down. I’m not a magician with a crystal ball and I think it’ll go in the right way. But 30% still seems ambitious to me.”
Employ an infection preventionist
The importance of an infection preventionist in HAI prevention can’t be stressed enough, says Calloway. Hospitals should pick a qualified leader for their infection prevention and control program and the antibiotic stewardship program respectively.
An effective ASP requires both an infection control expert and a pharmacist to be involved, she says. And there’s a business case to be made for having the hospital board, CEO, and chief nursing officer to make sure they have someone who can do those things, she says.
As an example, Calloway points to a Nevada hospital she visited for work. Nevada passed a law a few years ago requiring that for every 100 beds, there must be one full-time employee with infection preventionist training. The hospital in question had around 212 beds, and when the law passed, it went from having two infection preventionists to three. Calloway remembers the conversation she had with one of the hospital’s staff.
“She said, ‘We reduced our CAUTI rate by 50% in six months. We reduced our central line infections to 0%. Because we just didn’t have enough staff to go and train everybody and put it up on every unit how many days have we had since an infection to make sure we did QAPI. And we had the check-off list on like and keystone projects, and when you did all that and made sure that we had gotten to the operating room to tell the anesthesiologist that you need to use a checklist, you wouldn’t believe what we did with one extra set of hands.”
So, part of the battle is getting administration to understand that if it wants to reduce HAIs, Calloway says, it must be sure there are enough hours and qualified infection preventionists to get stuff done. However, smaller facilities might have trouble finding someone on staff with the prerequisite infection control background.
“I was just talking to a hospital yesterday,” she says. “They said, ‘Sue, we don’t have anybody with that expertise. We have a pharmacist, but he’s not here all that often. How do we implement an ASP?’ My concern is how do critical access hospitals do that unless we have some nice resource come out that tells them in a more descriptive manner how they’re going to have to implement an ASP?”
To get the C. diff and the SSI numbers down, says Calloway, an effort needs to be made to make sure there are enough qualified IC preventionists to meet the demand.
“We need to develop more user-friendly guides on how smaller hospitals and critical access hospitals are going to meet these guidelines,” she says. “Because it’s going to be hard for them. [If] they don’t have a physician who can lead their ASP — and it’ll be a requirement to have a program and follow the core elements — how are they going to do that?”
Pisano says when finding people within your organization to lead your ASP, the most important thing is to select someone with energy and interest in filling the role.
“Hospitalists and intensivists are really nice groups of people if there hasn't already been somebody willing to identify themselves as wanting to be part of the [ASP],” she says. “That can be really helpful if their work is already multi-system. They’re working with lots of consultants, a lot of physicians, with the neurologists, and a myriad of specialty groups, and they already have relationships with them in place. [That] will help you get a look into how the frontline prescribers are using their antibiotics, what issues they're having, and how to implement change.”