Background
Health care–associated infections (HAIs) are likely the most common complication of hospital care. According to the Centers for Disease Control and Prevention (CDC), approximately 1 in 20 hospitalized patients falls victim to an HAI, leading to nearly 100,000 deaths per year. Such infections were long accepted by clinicians as an inevitable hazard of hospitalization. However, relatively simple measures can prevent the majority of common HAIs, and as a result, hospitals and providers are under intense pressure to reduce the burden of these infections.
Four specific infections together account for more than 80% of all HAIs:
- Surgical site infections (SSI)
- Catheter-associated urinary tract infections (CAUTI)
- Central venous catheter–related bloodstream infections (CRBSI)
- Ventilator-associated pneumonia (VAP)
In addition, infections caused by Clostridium difficile (a bacteria which causes severe diarrhea after exposure to antibiotics) are rapidly becoming more common in hospitals. Preventing the transmission of Clostridium difficile and antibiotic-resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) is therefore an increasing focus of attention.
Preventive Measures
Strategies to prevent infections from C. difficile primarily involve limiting antibiotic use, which is the major precipitant of these infections, and preventing patient-to-patient transmission of the bacteria through isolation procedures and clinicians' hand hygiene. Prevention of transmission of antibiotic-resistant bacteria can follow similar principles.
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Table. Specific Measures for Prevention of Health Care–Associated Infections Recommended by the Centers for Disease Control and Prevention
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Health Care–Associated Infection
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Preventive Measure
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Definition
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All health care–associated infections
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Hand hygiene
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Washing hands before and after each patient contact
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Central venous catheter–related bloodstream infections (CRBSI)
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Maximal sterile barrier precautions
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Use aseptic technique including the use of a cap, mask, sterile gown, sterile gloves, and a large sterile sheet for the insertion of all central venous catheters (CVCs)
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Chlorhexidine skin antisepsis
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Use 2% chlorhexidine gluconate solution for skin sterilization at the CVC insertion site
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Appropriate insertion site selection
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Avoid femoral site for nonemergency CVC insertion
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Prompt removal of unnecessary catheters
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Removal of CVC that is no longer essential for care
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Surgical site infection (SSI)
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Appropriate use of perioperative antibiotics
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Administration of appropriate prophylactic antibiotic, generally begun within 1 hour before skin incision and discontinued within 24 hours
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Avoidance of shaving of the operative site
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Use clippers or other methods for hair removal in the area of skin incision(s)
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Perioperative glucose control
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Maintenance of blood glucose less than 150 mg/dL during postoperative period (tighter control may be more beneficial in specific patient populations)
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Ventilator-associated pneumonia (VAP)
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Semirecumbent positioning
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Elevation of the head of the bed to more than 30 degrees for all mechanically ventilated patients
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Daily assessment of readiness for weaning
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Minimize duration of mechanical ventilation by minimizing sedative administration (including daily "sedation holidays") and/or using protocolized weaning
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Catheter-associated urinary tract infection (CAUTI)
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Aseptic insertion and catheter care
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Use of skin antisepsis at insertion and proper aseptic technique for maintenance of catheter and drainage bag; use of closed urinary drainage system
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Prompt removal of unnecessary catheters
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Removal of urinary catheter when no longer essential for care
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(From: Ranji SR, Shetty K, Posley KA, et al. Prevention of healthcare-associated infections. In: Shojania KG, McDonald KM, Wachter RM, Owens DK, eds. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Technical Review 9. Rockville, MD: Agency for Healthcare Research and Quality; 2007. AHRQ Publication No. 04-0051-6.)
Evidence of Effectiveness
Some of the most prominent successes in the patient safety field have been achieved in the area of HAI prevention. The landmark Keystone ICU project nearly eliminated CRBSI in intensive care units (ICUs) throughout Michigan, an achievement that has been sustained over time. While the checklist that powered the intervention has garnered considerable publicity, in-depth analysis of the project identified other equally important components (such as improving safety culture). An AHRQ-sponsored initiative that extended the Keystone ICU project nationwide has also achieved dramatic reductions in CRBSI rates.
Reduced infection rates have been demonstrated for other specific HAI following implementation of the preventive measures described in the Table, and improved hand hygiene rates have been associated with lower overall HAI rates. However, despite knowledge of effective strategies to prevent HAI, clinician adherence to these measures has long been suboptimal. Even the seemingly simple act of handwashing is routinely ignored by both physicians and nurses. More complex interventions are also not used routinely, and institutional policies on HAI prevention vary widely. Thus, current research focuses on methods of effectively implementing preventive strategies and encouraging clinicians to use these methods for all patients.
Current Context
The large burden of disease posed by HAIs has resulted in considerable regulatory attention. The Centers for Medicare and Medicaid Services (CMS) has not reimbursed hospitals for the costs of care associated with certain HAIs, including SSI, CRBSI, and CAUTI, since 2008. Reducing the risk of HAI is one of The Joint Commission's National Patient Safety Goals (NPSGs). The NPSG specifically requires adherence to hand hygiene practices and also considers death or serious disability due to HAI to be a sentinel event. Appropriate hand hygiene, influenza vaccination for health care workers, and prevention of VAP, CRBSI, and SSI are among the National Quality Forum's 30 "Safe Practices for Better Healthcare."
Public reporting of hospital-specific HAI rates is also being more widely utilized as a means of monitoring hospital quality of care. Currently, 20 states mandate reporting of HAI rates, and CMS publicly reports certain HAI rates on its Hospital Compare Web site. One important challenge in using public reporting and payment policies to catalyze efforts to decrease HAIs is that the definitions are complex and may be subject to interpretation. In this, as well as in other types of preventable adverse events, the adoption of standard, auditable definitions will be crucial in creating a fair playing field that is not subject to "gaming." Early studies of CMS's HAI reimbursement policy indicate that, perhaps due to these issues, the effect has been smaller than originally anticipated.