Infections that patients acquire during the course of receiving

1. Trends and Strategies for Prevention of
Healthcare-Associated Infections
Alice Guh, MD, MPH
Division of Healthcare Quality Promotion
Centers for Disease Control and Prevention

2. Healthcare-Associated Infections
(HAIs)
 Definition: Infections that patients
acquire during the course of receiving
treatment for other conditions within a
healthcare setting
 Healthcare settings:
– Hospitals: acute care facilities, critical
access hospitals
– Long term care facilities (LTCF)
– Outpatient settings: dialysis centers,
ambulatory surgical centers,
physician’s offices

3. She was progressing in the neonatal intensive
care unit until she developed a bloodstream
infection related to her umbilical catheter.
Your baby was born prematurely.

4. The surgery goes well
but he later dies in a
nursing home of a
MRSA wound infection
that developed after
surgery.
Your father has open heart surgery.

5. She has lived with this unbearable
infection through 6 months of relapses.
Your sister contracts Clostridium
difficile after giving birth.

6. Your mother is being treated for cancer
 And now has to fight two diseases because she
got Hepatitis C from an unsafe injection

7. HAI Burden
What is Known: Acute Care Settings
 1.7 million infections (5% of all admissions)
– Most (1.3 million) were outside of ICUs
 $28–33 billion in excess costs
 99,000 associated deaths
 Most common type of infections:
– Bloodstream infections (BSI)
– Urinary tract infections
– Pneumonia
– Surgical site infections
Klevens, et al. Pub Health Rep 2007;122:160-6

8. Estimated Annual Hospital Cost of HAI
by Site of Infection
Major Site of Infection Total
infections
Hospital Cost
per
Infection
(2002 $)
Total annual
hospital cost
(in millions $)
Deaths
Per year
Surgical Site Infection 290,485 $25,546 7,421 13,088
Central line associated-
Bloodstream Infection 248,678 $36,441 9,062 30,665
Ventilator-associated
Pneumonia 250,205 $9,969 2,494 35,967
Catheter associated-
Urinary Tract Infection 561,667 $1,006 565 8,205
Roberts RR, et al Clin Infect Dis 2003;36:1424-32.

9. Social Costs of HAIs

10. Emerging Threats in Healthcare

11. Clostridium difficile: “Deadly Superbug”

12. McDonald LC, et al. Emerg Infect Dis. 2006;12(3):409-15
National Estimates of U.S. Short-Stay
Hospital Discharges with C. difficile

13. Tranquil Gardens
Nursing Home
Home
Care
Acute Care Facility
Outpatient/
Ambulatory
Facility
Long Term Care
Facility
The Healthcare System 
More than Just Hospitals

14. HAI Burden Outside of Acute Care
 We know much less about this
 What we have learned to date:
HAIs are a substantial problem
outside of acute care settings

15. HAIs in LTCF
 1.7 million beds with 2.5 million
residents / yr1
 1/3 of long-term care residents affected
by respiratory disease outbreaks2
 Veterans Healthcare data3
– 133 nursing homes; 11,475 residents
– HAI prevalence: 5.2%
– Indwelling medical device: 25% of all
residents
1 NCHS, 2009 2Loeb, CMAJ, 2006 3Tsan, AJIC, 2008

16. Growth in Outpatient Care
 Shift in healthcare delivery from acute care
settings to ambulatory care, long term care
and free standing specialty care sites
 Dialysis Centers
– 2008: 4,950 (72% increase since 1996)
 Ambulatory Surgical Centers
– 2009: 5175 (240% increase since 1996)
 Approximately 1.2 billion outpatient visits / yr

17. Surgical Procedures Moving from
Inpatient to Outpatient Setting
0
10
20
30
40
50
60
1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005*
Source: Avalere Health analysis of Verispan’s Diagnostic Imaging Center Profiling
Solution, 2004, and American Hospital Association Annual Survey data for community
hospitals, 1981-2004.
*2005 values are estimates.
All Outpatient
Settings
Hospital Inpatient
Procedures
(millions)

18. Healthcare-associated Outbreak
Investigations by Healthcare Setting,
2004-2008
n = 47, as of April 2008
Increasing number of
outbreaks associated with
outpatient care
• Wide range of settings
(e.g., ambulatory
surgery, cancer clinics,
pain medicine, dialysis,
long-term care,
physician offices)
• Unsafe injections,
foundation of basic safe
care practices lacking Hospital (27)
Outpatient Setting (12)
LTCF (3)
Community (5)

19. TRANSMISSION OF BLOODBORNE PATHOGENS VIA
CONTAMINATED EQUIPMENT OR MEDICATIONS
SOURCE
Infectious person,
e.g. chronic, acute
CASE
Susceptible,
non-immune person
CONTAMINATED
EQUIPMENT OR
MEDICATION OR
HANDS

20.  33 outbreaks in 15 states
– Outpatient clinics, n=12
– Dialysis centers, n=6
– Long term care, n=15
Thompson et al. Ann Intern Med. 2009;150:33-39.

21. Viral Hepatitis Outbreaks - Outpatient Settings
State Setting Year Type
NY Private MD office 2001 HCV
NY Private MD office 2001 HBV
NE Oncology clinic 2002 HCV
OK Pain remediation clinic 2002 HBV+HCV
NY Endoscopy clinic 2002 HCV
CA Pain remediation clinic 2003 HCV
MD Nuclear imaging 2004 HCV
FL Chelation therapy 2005 HBV
CA Alternative medicine infusion 2005 HCV
NY Endoscopy/surgery clinics 2006 HBV+HCV
NY Anesthesiologist office 2007 HCV
NV Endoscopy clinic 2008 HCV
NC Cardiology clinic 2008 HCV
NJ Oncology clinic 2009 HBV
Thompson et al. Ann Intern Med. 2009;150:33-39.

22. Ongoing Threat to Patient Safety
 Continued outbreaks associated with unsafe injections and other
breakdowns in basic infection control
 Large public health patient notifications advising testing for
hepatitis B virus, hepatitis C virus, and HIV

23. Infection Control in Outpatient Settings
 Sub-optimal infection control
infrastructure and oversight
 Approximately 50% of ambulatory
surgical centers (ASC) surveyed by CMS
and CDC had serious, noncompliance
with the Medicare ASC health and safety
standards
– 28% had unsafe injection practices

24. A Collaborative Approach to
Preventing HAIs

25. State of Prevention
Knowledge and Science
 Evidence-based prevention
recommendations
– Major device and procedure associated
HAIs (CLABSI, VAP, CAUTI, SSI)
– Prevention of pathogen transmission
(MRSA, C. difficile)
 Suboptimal adherence to key prevention
recommendations

26. Current State of Affairs
 Hand hygiene compliance for healthcare
worker: 40-50%
 Compliance with timing of surgical
prophylaxis was ~40%1
 Many facilities have yet to implement
proven prevention measures:
– Bloodstream infections
– Urinary tract infections
2005 Data from Surgical Care Improvement Project

27. What’s Been Missing in the Past to
Promote HAI Prevention?
 Robust data on HAI Prevention
 Focused attention of policymakers on
HAI prevention
 Incentives / disincentives to promote
systems change for sustainable HAI
prevention
 Framework to extend local / regional
successes across the nation

28. What’s Been Missing in the Past to
Promote HAI Prevention?
 Robust data on HAI Prevention
 Focused attention of policymakers on
HAI prevention
 Incentives / disincentives to promote
systems change for sustainable HAI
prevention
 Framework to extend local / regional
successes across the nation

29. Preventability of Infections
 Study on the Efficacy of Nosocomial
Infection Control (SENIC)
– 6% of all HAIs preventable with minimal
infection control efforts
– 32% preventable with “well organized
and highly effective infection control
programs”
 20-70% of infections are preventable1
1J Hosp Infection 2003;54:258

30. Estimates of preventable infections, deaths, and
costs based on existing published literature
$166-$345
2–4
75–157
26%–54%
SSI
$115-$1,820
2–9
95–388
17%–69%
CAUTI
$2,200-3,300
14–20
95–138
38%–55%
VAP
$960-$18,200
6-20
45-164
18%–66%
CLABSI
Cost avoided
(millions of 2009
dollars)
Preventable
deaths
(thousands)
Preventable
infections
(thousands)
Preventable
fraction
Infection
type
Source: Umschied, C. University of Pennsylvania. Presentation at HICPAC, March 2009
Estimates of Preventable
Infections, Deaths, and Costs

31. Trends in MRSA Bloodstream Infections by
ICU Type, NHSN hospitals, 1997-2007
• Estimated 7000
BSIs prevented
• 1800 lives saved
• $50-180 M in
costs averted
annually

32.  Significant reductions:
– Surgical site infections
– Unplanned return to OR
– All complications
– Deaths
Haynes AB, et al. NEJM 2009;360:491-9.

33. What’s Been Missing in the Past to
Promote HAI Prevention?
 Robust data on HAI Prevention
 Focused attention of policymakers on
HAI prevention
 Incentives / disincentives to promote
systems change for sustainable HAI
prevention
 Framework to extend local / regional
successes across the nation

34. IL
Sept-
2008
NY
Jan-2007
MS
OR
Jan-
2009
ID
MT
NV
May- 2009
AZ
CO
Jan-2008
NM
OK
Jul-2008
MO
AR
TX
August- 2009
LA
ND
SD
IA
NE
KY
ME
NJ Jan-2009
MD Jul-2008
TN
Jan-
2008
WY
MI
SC
Jul-
2007
FL
HI
AK
MA Jul-2008
VT
Feb-
2007
WA
Jul-2008
CA
Jan-2008
WI
PA
Feb-
2008
VA
Jul-2008
NH Jan-2009
AL GA
UT
KS
MN
OH
NC
RI
DE Feb-2008
WV
Jul -
2009
IN
CT Jan-2008
State Legislative Activity for HAIs
(as of October 6, 2009)
Month –
Year =
Date mandatory
reporting using
NHSN
implemented
Mandates public reporting of infection rates
Mandates reporting only to state government Mandatory data collection,
Voluntary reporting
States with study laws
States with no legislation
Mandates public reporting using NHSN

36. HHS Steering Committee:
HAI Prevention
 Charge: Develop an Action Plan to reduce, prevent,
and ultimately eliminate HAIs
 Plan will:
– Establish national goals for reducing HAIs
– Include short- and long-term benchmarks
– Outline opportunities for collaboration with external
stakeholders
– Coordinate and leverage HHS resources to accelerate
and maximize impact

37. HHS Action Plan: Tier One Priorities
HAI Priority Areas
 Catheter-associated
urinary tract infection
 Central line-associated
blood stream infection
 Surgical site infection
 Ventilator-associated
pneumonia
 MRSA
 Clostridium difficile
Implementation Focus
 Hospitals*
*Tier Two will address
other types of
healthcare facilities

38. What’s Been Missing in the Past
to Promote HAI Prevention?
 Robust data on HAI Prevention
 Focused attention of policymakers on
HAI prevention
 Incentives / disincentives to promote
systems change for sustainable HAI
prevention
 Framework to extend local / regional
successes across the nation

39. Centers for Medicare and
Medicaid Services
 October 2008
 Non-payment rules for “Never events”
– Preventable conditions acquired
during patient’s hospital stay
– Includes HAIs

40. Federal Funding for HAI
Prevention
 American Recovery and Reinvestment
Act of 2009 (ARRA)
– Allocated funding to states for HAI
prevention
 FY 2009 Omnibus Bill
– States to develop HAI prevention plans
to be consistent with HHS Action Plan

41. What’s Been Missing in the Past
to Promote HAI Prevention?
 Robust data on HAI Prevention
 Focused attention of policymakers on
HAI prevention
 Incentives / disincentives to promote
systems change for sustainable HAI
prevention
 Framework to extend local / regional
successes across the nation

42. Tranquil Gardens
Nursing Home
Home
Care
Acute Care Facility
Outpatient/
Ambulatory
Facility
Long Term Care
Facility
Increasing Needs and Opportunities for Public
Health Approach Across the Continuum of Care
State Health
Departments

43. A New Paradigm: Central Role of
State Health Departments
 Expanding state public health workforce
to make progress toward HAI prevention
 Create and expand state-based HAI
prevention collaboratives
 Sustainable statewide efforts will
contribute to national healthcare
improvement efforts

44. A New Model For Prevention:
Prevention Collaboratives
 Experience is showing that multi-facility
collaborative projects are the gold
standard in HAI prevention
 Many “change methods” that have
demonstrated success:
– Comprehensive Unit-based Patient
Safety Program (CUSP)
– Positive deviance
– Six-sigma

45. Basics of a Prevention Collaborative
 Group of healthcare facilities engaged in
a common effort to reduce HAIs
 Members use a common approach
 Discuss progress regularly and share
lessons learned in real time

46. What is the Minimum Size of a
Prevention Collaborative?
 2 or more facilities working together
meaningfully
 Ideal size multi-factorial
– Specific subject or targeted HAI
– Type of healthcare facilities
– Available resources
– More “cutting edge” ─ smaller number
– More established “change packages” can
be quite large
– Level of enthusiasm

47. Prevention Strategies
 Supplemental
Strategies
– Some scientific
evidence
– Variable levels of
feasibility
 Core Strategies
– High levels of
scientific evidence
– Demonstrated
feasibility

48. Regional Prevention Collaboratives
Examples of Success
0
2
4
6
8
10
0 18
ICUs at 103 Michigan
hospitals, 18 months
BSIs/1,000
catheter
days
Months
Pittsburgh Regional
Healthcare Initiative Michigan Keystone Initiative
Pronovost P. New Engl J Med 2006;355:2725-32.
Muto C, et al. MMWR 2005;54:1013-16
Overall rate reduction of 68%
Overall rate
reduction of 66%

49. Lessons Learned from
Pittsburgh and Michigan Experience
 Decreases in BSI rates in hospital ICUs
of varying types
 Prevention practices utilized during
these interventions were not novel
 Practical strategies identified that can
be successful across many facilities

50. If Expanded Nationally….
 66% reduction of BSIs would
translate into:
– 180,000 fewer BSIs
– 20,000 fewer BSI-associated deaths
– $4–6 billion in healthcare cost
savings

51. Strengths of a Collaborative
 Opportunities to share experiences on
what works and does not work
 Ability to get advice from others who
are working on the same project
 Peer pressure is also a motivator

52. Common Elements for
Successful Infection Prevention
 Simple
 Patient-centered, integrated with care
 Evidence-based recommendations
 Part of a “package” for prevention
 Engaging and empowering clinicians
 Protocols and systems in place
 Standardized ways for recording information about
infections (e.g., NHSN)
 Regular feed-back of information to providers
 Changing to a pro-safety culture
 Leadership support
Sources: Muto et al, MMWR, Oct 14 2005; Pronovost et al, NEJM 2006

53. Other Key Factors in
Prioritizing Interventions
 Burden of the HAI
– Cost
– Clinical outcomes
 Preventability
– Are there interventions that are known
to work?
– What is the likely return on prevention
investment?

54. Next Steps Towards Elimination
 Prevention of CLABSIs in ICU settings
remains important, BUT….
– These are a small fraction of all of the HAIs
– They likely represent “low-hanging” fruit
 Given our goal of eliminating HAIs, we need
to “move higher up the tree”
 Prevention collaborations create
opportunities to do this

55. Next Steps Towards Elimination
 Expand to other settings (CLABSI in non-ICU
settings)
 Expand to other types of infection (CAUTI,
C. difficile, etc.)
 Expand success to new problem pathogens
(multi-drug resistant organisms)
 Expand efforts in outpatient infection control

56. ICU
VA Pittsburgh
Hospital-
wide
VA Pittsburgh
VA Pilot
• 17 hospitals,
multiple states
Maryland
Initiative
• 15 hospitals
Unit
Facility
Region
National
Local
National VA
Initiative
• 150 hospitals
• nationwide
CMS
•9th Scope of Work
National
RWJ Initiative
• 6 hospitals, 4 states
Expansion of Local Prevention Success in
One State to Across the Nation
>60% Reduction in MRSA

57. The findings and conclusions are those of the
presenter and do not necessarily represent the view
of the Centers for Disease Control and Prevention.
Thank you
AGUH@CDC.GOV