The Case for “Reasonably Preventing” Healthcare-Associated Infections

There have been many studies demonstrating the costs  - both in terms of patient suffering and associated interventions – of healthcare-associated infections (HAIs).  The most famous of these  was the 1999 Institute of Medicine’s “To Err is Human, ” an astounding report describing the evidence of HAIs as a component of patient safety errors. Since that time, numerous evidence-based guidelines by the CDC, APIC, SHEA and AHRQ among others have attempted to provide strategies to prevent infections in the most common HAI’s: catheter-associated bloodstream infections (CA-BSIs), ventilator-associated pneumonia (VAP), catheter-associated urinary tract infections (CA-UTIs), and surgical site infections (SSIs).

HAI elimination is a top priority for the federal government.  In 2008, the U.S. Department of Health and Human Services (HHS) promoted the Action Plan to Prevent Healthcare-Associated Infections, which outlines national goals for prevention and key actions for achieving them. In 2009, a second action plan was introduced to Ambulatory Surgery Centers, primarly for the prevention of SSI.  In October 2008, the Centers for Medicare and Medicaid Services (CMS) stopped its reimbursement of five conditions they deemed “reasonably preventable” – three of which were HAIs, specifically CA-BSI, SSI and CA-UTI. VAP is to be added to the list in 2011.

So what makes an infection “reasonably preventable” ?  A new study by Umscheid, et al asserts that as many as 65% to 70% of cases of CA-BSI and CA-UTI, and 55% of VAP and SSI, may be preventable with current evidence-based strategies. In otherwords, there are many processes that are logical and when incorporated into the care of the patient will prevent most  infections. These include education of healthcare workers regarding these strategies, hand hygiene, the proper use of aseptic technique during the insertion and care of catheters and during surgical procedures, timely withdrawal of catheters and breathing tubes, and the proper use of antibiotics.

One of the most important tools in preventing HAIs is the use of surveillance – tracking the rates of infection in patients during and after their healthcare stay, and reporting these numbers to the National Healthcare Safety Network. The NHSN is a voluntary, secure, internet-based surveillance system managed by the Division of Healthcare Quality Promotion (DHQP) at CDC that is open to all types of healthcare facilities in the United States, including acute care hospitals, long term acute care hospitals, psychiatric hospitals, rehabilitation hospitals, outpatient dialysis centers, ambulatory surgery centers, and long term care facilities.   If all healthcare facilities participated, we would have a greater understanding of the processes that need improvement, and how the use of preventative measures impact rates of infection. To learn more about the benefits of NHSN participation, visit http://blogs.cdc.gov/safehealthcare/.

There are those who point out that HAIs are not 100% preventable, even with the inclusion of evidence-based practice.  Of course, there is always the aspect of human nature: despite training and checklists, things will not be done perfectly every time.  Interventions can be costly for hospitals on tight budgets, and there are not enough Infection Preventionists to educate staff and keep up with surveillance. And most importantly, there are some patient populations who are inherently at greater risk for infection, regardless of how hard caregivers may try.  But naysayers are missing the point.  The implementation of evidence-based strategies across the board at hospitals, skilled nursing centers and ambulatory surgery centers will save the lives of tens of thousands, and prevent hundreds of thousands of HAIs.  Saving lives, while saving costs.  Thats a win-win situation.

For evidence-based training of healthcare professionals in the prevention of Central Line-Associated Bloodstream Infections, Ventilator-Associated Pneumonia, Surgical Site Infections, and Catheter-Associated Urinary Tract Infections, please visit www.envisioninc.net.  For a link to the study “Estimating the Proportion of Healthcare-Associated Infections That Are Reasonably Preventable and the Related Mortality and Costs” by Umsheid et al, visit www.jstor.org/pss/10.1086/657912