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The Quality Colloquium

The Quality Colloquium. August 22, 2004. Strategies for Reducing Infections: The Role of the Patient Safety Officer. Tammy Lundstrom, MD VP, Chief Quality and Safety Officer Detroit Medical Center. Infection Control in the Headlines.

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The Quality Colloquium

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  1. The Quality Colloquium August 22, 2004

  2. Strategies for Reducing Infections:The Role of the Patient Safety Officer Tammy Lundstrom, MD VP, Chief Quality and Safety Officer Detroit Medical Center

  3. Infection Control in the Headlines “Lax Procedures put Infants at High Risk; Simple Actions by Hospital Workers, Such as Diligent Hand-washing, Could Cut the Number of Fatal Infections.” Chicago Tribune 2002

  4. JCAHO Accreditation • Revised IC standards • Focus on traditional surveillance and quality improvement • Focus on integration of Infection Control into Patient Safety Activities • Surge Capacity • HAI as Sentinel Event-consequences • Root Cause Analysis (RCA) • Failure Mode and Effects Analysis (FMEA)

  5. CDC 7 Challenges • Reduce Catheter-associated adverse events • Reduce surgical adverse events • Reduce mortality and hospitalizations due to respiratory infection in LTC • Reduce antibiotic resistant infections • Eliminate microbiology lab errors • Eliminate occupational sharps injuries • Active compliance with ACIP immunization recommendations

  6. Historical Evolution 1940 First description IC Officer 1940-60 Penicillin and resistance 1970’s SENIC study; proves value 1980’s Continued growth of epidemiology 1990’s Expand role to non-acute settings 2000’s Expand role to “quality promotion across the healthcare delivery system” Lancet 1999; 354 (Supp IV):25 Emerging Infect Dis 2001; 7: 286-92, 363-66

  7. Study of Efficacy of Nosocomial Infection Control (SENIC) • Hospitals with intensive surveillance and control programs had lower rates of nosocomial infections • Recommended 1 FTE/250 beds • OUTDATED!!!

  8. Patterns of Healthcare Associated Infection (HAI) Endemic 90-95% of all HAI Epidemic 5-10% of all HAI Easier to demonstrate investigative techniques 114 investigations by CDC over a decade 6 National in scope (contaminated product/device) Emerging Infect Dis 2001; 7:295-98 Seminars in IC 2001; 2: 74-84 Infect Control 1985; 6: 233-36

  9. Consequences 2 million HAI 90,000 deaths $4.5-5.7 billion/ year 25% in Intensive Care Units 70% involve organisms with resistance to one or more antibiotics J. Burke. NEJM 2003; 348: 7 Emerging Infect Dis 1998; 4: 416-20 Infect Control Hosp Epi 2001; 22: 708-14

  10. US Data J. Burke NEJM 2003

  11. Decrease (%) in HAI in NNIS ICU1990-1999 Emerging Infect Dis 2001; 7: 170-73

  12. Why HAI May Increase • Sicker patients • More invasive procedures for longer duration • Staff shortages • Nursing • Pharmacists • Pharmacy Techs • Radiology Techs

  13. Why HAI May Increase • Resistant Organisms • 1990’s P. aeruginosa • 1990’s VRE • 2002 VRSA • Emerging Infectious Disease • 1980’s HIV • 1990’s hantavirus • 2000’s SARS

  14. Most Common Epidemiology Interventions • Disseminate rates with benchmark data • Develop multidisciplinary teams around issues • Education • Communication Am J Infect Control 1999; 27: 221

  15. Focus on Evidence-based Practices Handwashing Maximum barrier precautions for vascular device insertion Preoperative antimicrobial prophylaxis Appropriate antimicrobial use

  16. Handwashing • Compliance 16-81% • Nurses consistently better than physicians • Waterless hand hygiene agents improve compliance • Placement considerations

  17. The Human Element in Hand Hygiene Adherence • Of 34 studies evaluated by CDC/HICPAC average level of adherence by Health care personnel= 40% (range 5-81%) -overall physicians usually worst • Why? • Too busy & not enough time • Hand hygiene sinks or products inaccessible • Skin irritation • Hands don’t appear visibly soiled • Influence of opinion leaders

  18. Antimicrobial Resistant OrganismsThe Scope of the Problem • Gram positive bacteria • VRE • Streptococcus pneumoniae • Gram negative bacteria • Pseudomonas • Salmonella • Fungi • Fluconazole-resistant Candida albicans • Viruses • Multi-drug resistant HIV • Acyclovir-resistant herpes

  19. CDC Strategies to Decrease Antimicrobial Resistance • Vaccinate • Remove invasive devices as soon as possible • Culture (avoid empiric treatment) • Treat with intent to eradicate infection • Obtain expert advice on antibiotic selection • Consult antibiograms

  20. CDC Strategies to Decrease Antimicrobial Resistance 7. Avoid unnecessary antibiotic use 8. Target the pathogen 9. Do NOT treat colonization 10. Stop empiric antibiotics quickly once it appears that bacterial infection is unlikely 11. Enforce good infection control practices

  21. Factors Contributing to Antimicrobial Resistance in Hospitals • Serious illness • Immunocompromised state • Use of invasive procedures/devices • Increasing introduction of resistant organisms from the community (Nursing home/hospital transfers) • Ineffective infection control practices • High antibiotic use per geographic area per unit of time

  22. Risk Factors for Staphylococcus aureus with Reduced Susceptibility to Vancomycin (MIC > 4 ug/mL) 19 cases Adjusted OR (CI 95%) Vancomycin (per week) 5.6 (2.2-14.3) in prior 1 month Previous MRSA culture 15.5 (1.8- 134.5) in prior 2nd or 3rd month Fridkin et al. Clin Infect Dis 2003; 36:429-39

  23. Antibiotic ResistanceDo CDC Strategies Work? 50 ICUs from 20 hospitals • Monitored vancomycin use • Feedback of risk-adjusted comparison data • Unit-specific interventions successfully decreased vancomycin use and VRE rates • Fridkin et al. Emerging Infectious Disease 8(7); 702-704 2002 • CDC 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Patients

  24. (In)Appropriate Antimicrobial Use 2000 Patients visiting physician for cold or upper respiratory infection found: 63% received an antibiotic 54% received a broad-spectrum antibiotic JAMA February 2003

  25. (In)Appropriate Antimicrobial Use Survey of 4 US medical centers 424 physicians surveyed 85% thought resistance a national problem 55% thought resistance a problem for their patients Wester et al. IDSA abstract 529 1999

  26. WHY?Human Factors • Physician: • Considering individual patient, not public health implications • Time pressure • Defensive medicine • More is better • Patient: • Belief that antibiotics cure viral infections • Wants something other than reassurance

  27. Antibiotic ResistanceOutpatient Practices Successful strategies must account for human factors: Physician: • Knowledge of local resistance rates • Restricted formulary • “Cold packs” • Treatment guidelines • Patient educational materials • Preprinted order sets Patient: • Education

  28. Expansion Beyond Acute Care • Long term care • 1.8 million in 16,500 LTCF • Home care • Home IV therapy $5 billion industry • Estimated 20,000 provider agencies • Rehabilitation • Outpatient surgery • 52% of hospital-based procedures • 2.8 million outpatient procedures 1996 • Ambulatory care • 80-90% of cancer care CDC Draft Isolation Guidelines 2004 www.cdc.gov

  29. Roles Beyond Traditional Infection Control • Regulatory/Accreditation • Design/Planning/Construction/Renovation • Occupational Health • Patient Safety/Quality • Human Resources-Staffing • Product Selection • Media Relations • Bioterrorism

  30. The FutureTransition From: • Device associated infections to device associated complications • Surgical site infections to surgical site complications • Antimicrobial resistance to drug-related complications Emerging Infect Dis 2001; 7: 363-66

  31. Sources of Evidence-based Guidelines for Epidemiology • Centers for Disease Control and Prevention • National Guidelines Clearinghouse • Association for Professionals in Infection Control and Epidemiology • Society for Healthcare Epidemiology of America • Institute for Healthcare Improvement

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