Reducing HAIs: Effective Change Strategies (Text Version)

On September 27, 2010, Anthony Harris made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (1.6 MB).  

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Slide 1

Reducing HAIs: Effective Change Strategies

Anthony Harris MD, MPH
Professor
Acting Medical Director of Infection Control
Head Division of Genomic Epidemiology and Clinical Outcomes
University of Maryland School of Medicine

Slide 2

Who am I: what am I and what am I not qualified to talk about?

Slide 3

Outline of talk

• Discussion of important healthcare-associated infection (HAIs).
• Science of how to decrease HAIs.
• Epidemiological issues of HAIs research.
• Barriers to implementation and maintenance:
  • Illustrative examples

Slide 4

Outline of talk

• Discussion of important healthcare-associated infection (HAIs)
• Science of how to decrease HAIs
• Epidemiological issues of HAI research
• Barriers to implementation and maintenance
  • Illustrative examples

Slide 5

• HAIs:
  • Central-line associated bacteremias
  • Ventilator-associated pneumonia
  • Surgical-site infection
  • Catheter-associated urinary tract infection

Slide 6

Importance of HAIs

• 1 of every 10-20 patients hospitalized in the United States develops a healthcare-associated infection.

Image: An individual with an IV inserted is shown.

Slide 7

Importance of HAIs

• The U.S. Centers for Disease Control and Prevention estimates that nearly 2 million patients (5%-10% of hospitalized patients) experience an HAI each year.
• These infections lead to almost 100,000 deaths and $28-$33 billion in extra costs.

Slide 8

Cost of HAIs

Infection type	Attributable costs	Excess length of stay
Ventilator-associated pneumonia	$22,875 ($9,986-$54,503)	9.6 (7.4-11.5)
CLABSI	$18,432 ($3,592-$34,410)	12 (4.5-19.6)
Catheter-associated urinary tract infection	$1,257 ($804-$1,710)

Eber MR, Arch Intern Med 2010;170:347

Slide 9

 

Outline of talk

• Discussion of important healthcare-associated infection (HAIs)
• Science of how to decrease HAIs
• Epidemiological issues of HAI research
• Barriers to implementation and maintenance
  • Illustrative examples

Slide 10

 

I am a hospital epidemiologist, infection preventionist, or hospital administrator with an HAI problem what literature should I look at that shows what interventions may work?

Slide 11

 

Infection Prevention Goals

Improving Health and Patient Safety by reducing risk of Infection

Image: 5 cartoon people holding the text "Patient Safety" above their heads is shown.

Slide 12

 

• SHEA guidelines
• Centers for Disease Control and Prevention
• HICPAC guidelines
• IDSA
• APIC
• HHS

Slide 13

 

SHEA guidelines

• To assist acute care hospitals in focusing and prioritizing efforts to implement evidence-based practices for prevention of HAIs, the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America Standards and Practice Guidelines Committee appointed a task force to create a concise compendium of recommendations for the prevention of common HAIs.

http://www.shea-online.org/about/compendium.cfm

Slide 14

 

CLBSI

Image: An IV is shown surrounded by ovals containing the following text:

1. Skin Organisms

• Endogenous
  • Skin flora
• Extrinsic
  • HCW hands
  • Contaminated disinfectant

2. Contaminated Catheter Hub

• Endogenous
  • Skin flora
• Extrinsic
  • HCW hands

3. Contaminated Infusate

• Extrinsic
  • Fluid
  • Medication
• Intrinsic
  • Manufacturer

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CLABSI: Effective interventions

• At insertion:
  • Use a catheter checklist to ensure adherence to infection prevention practices at the time of central venous catheter insertion.
  • Perform hand hygiene before catheter insertion or manipulation.
  • Avoid the femoral vein.
  • Use an all-inclusive catheter cart or kit.
  • Use maximal sterile barrier precautions during central venous catheter insertion.
  • Use a chlorhexidine-based antiseptic for skin preparation.

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CLABSI: Effective interventions

• After insertion:
  • Disinfect catheter hubs, needleless connectors, and injection ports before accessing the catheter.
  • Remove nonessential catheters.

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Effective interventions in difficult situations

• Bathe ICU patients with a chlorhexidine preparation on a daily basis.
• Use antimicrobial-impregnated central venous catheters.
• Use chlorhexidine-containing sponge dressings for central venous catheters.
• Use antimicrobial locks for central venous catheters.

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VAP: Effective interventions

• Implement policies and practices for disinfection, sterilization, and maintenance of respiratory equipment.
• Ensure that all patients are maintained in a semi-recumbent position.
• Perform regular antiseptic oral care in accordance with product guidelines.
• Provide easy access to noninvasive ventilation equipment and use weaning protocols.

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UTI: Effective interventions

• Provide and implement written guidelines for catheter use, insertion, and maintenance.
• Ensure that only trained personnel insert urinary catheters.
• Ensure that supplies necessary for aseptic-technique catheter insertion are available.
• Implement a system for documenting: indications for catheter insertion, date and time of catheter insertion, individual who inserted catheter, and date and time of catheter removal.

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SSI: Effective interventions

• Administer antimicrobial prophylaxis.
• Do not remove hair at the operative site unless the presence of hair will interfere with the operation.
• Do not use razors.
• Control blood glucose level during the immediate postoperative period for patients undergoing cardiac surgery.
• Measure and provide feedback to providers on the rates of compliance with the above process measures.

Slide 21

 

Outline of talk

• Discussion of important healthcare-associated infection (HAIs)
• Science of how to decrease HAIs.
• Epidemiological issues of HAI research
• Barriers to implementation and maintenance
  • Illustrative examples

Slide 22

 

Image: A cartoon of a doctor's office is shown. The patient is Kermit the Frog and the doctor is holding up an X-Ray showing the bones of a human hand inside Kermit's puppet body. The doctor is speaking: "Have a seat, Kermit. What I'm about to tell you might come as a big shock..."

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Epidemiological barriers

• Too few randomized clinical trials.
• Few to no cluster randomized trials in infection control.
• Sub-optimal quasi experimental studies.

Slide 24

 

Definition

• Q: What is a quasi-experimental study?
• A: Study that aims to evaluate interventions but does not utilize a randomized control group.

Slide 25

 

Image: A flow cart showing the Overview of Clinical Research model. A yes or no answer to the initial question, "Did investigator assign exposures?" leads to "Experimental Study" (Yes) or "Observational Study" (No). Under "Experimental Study," the next question "Random allocation?" leads to "Randomised controlled trial" (Yes) or "Non-randomised controlled trial" (No). Under "Observational Study," the next question "Comparison group?" leads to "Analytical study" (Yes) or "Descriptive study" (No). Under "Analytical study," the question "Direction" leads to three options: Cohort study (Exposure → Outcome), Case control study (Exposure ← Outcome), or Cross-sectional study (Exposure and outcome at the same time).

From Grimes and Schultz, Lancet 2002;359:57-61.

Slide 26

 

Textbooks

Shadish et al. Experimental and Quasi-experimental Designs. Houghton Mifflin Co; 2001.
Cook and Campbell. Quasi-experimentation: Design and Analysis Issues for Field Settings. Houghton Mifflin Co; 1979.

Images: The covers of the two textbooks are shown.

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Types of QE Studies

1. Quasi-experimental designs without control groups.
2. Quasi-experimental designs that use control groups but no pretest.
3. Quasi-experimental designs that use control groups and pretests.
4. Interrupted time-series designs.

Harris AD. The use and interpretation of quasi-experimental studies in infectious diseases. Clin Infect Dis 38:1586-91. 2004.

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Hierarchy of QE Designs

1. Quasi-experimental designs without control groups
2. The one-group pretest-posttest design: O1 X O2
3. The one-group pretest-posttest design using a double pretest: O1 O2 X O3
4. The one-group pretest-posttest design using a nonequivalent dependent variable: (O1a, O1b) X (O2a, O2b)
5. The removed-treatment design: O1 X O2 O3 removeX O4
6. The repeated-treatment design: O1 X O2 removeX O3 X O4

O = observational measurement; X = intervention under study. Time moves from left to right.

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Systematic Review ID Literature (cont)

• 73 articles used quasi-experimental designs in infection control and/or antibiotic resistance studies in 4 journals over a 2 year period.
• Few studies used higher-level quasi-experimental design:
  • Only 16% used a control group.

Harris et al. Clin Infect Dis 2005;41:77-82.

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Future Quasi-experimental Studies Should Include...

• Use of standard nomenclature.
• Choice of "higher level" studies if possible.
  • Add control group, multiple measurements.
• Discussion of why the specific study design and analysis was chosen.
• Discussion of particular study limitations.
• Collaboration with statisticians to improve analysis

Stone SP, The Orion Statement. J Antimicrob Chemother 2007 May;59:833.

Slide 31

 

Outline of talk

• Discussion of important healthcare-associated infection (HAIs)
• Science of how to decrease HAIS
• Epidemiological issues of HAI research
• Barriers to implementation and maintenance
  • Illustrative examples

Slide 32

 

Images: A doctor is shown on the left, and the MHA Keystone Center for Patient Safety & Quality logo is shown on the right.

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• In the day-to-day world certain issues arise:
  • How do you sustain an intervention?
  • How do you get ground-level buy in?
  • How do you deal with the powerful naysayers?
  • What logistical issues arise?
  • How do you stay on top of all the logistical issues?

Slide 34

 

Resources for affecting health behavior

• Health Behavior and Health Education
  • Karen Glanz, Barbara K. Rimer and K. Viswanath
  • 3rd edition 2002

Image: The cover of the book, Health Behavior and Health Education, is shown.

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Resources for affecting health behavior: Positive deviance

• In healthcare-associated infections, leaders such as Dr. B Doebbeling are using techniques such as integrated lean and positive deviance.
• Marsh et. al, The Power of Positive Deviance. BMJ 2004:13;329:1177.

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Six sigma

• Assessing the evidence of six sigma and lean in the health care industry.
  • DelliFraine JL Qual Manag Health Care 2010;19:211.

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Illustrative example: Hand Hygiene

• Literature has consistently shown hand hygiene levels to be below 60%.
• Numerous interventions work but only temporarily.
• Yet, JCAHO during their audits aims for 100% levels.

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Illustrative example: CLABSI checklists

• Fear of places in reporting what happens at the ground level:
  • Difficulty empowering nurses.
  • Difficulty in getting CEO/CMO buy-in.
  • Powerful naysayers in the ICU.

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I Can Prevent HAIs!

Images: A photograph of 4 doctors is shown to the left, and a hand with the thumb upraised is shown on the right.

Slide 40

 

Illustrative example: CLABSI

• This all leads to:
  • Signing the checklist and not being there to supervise.
  • Checklist indicating that all was done properly when many aspects were not.
• Constant need to monitor what is going right and what is going wrong.

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Conclusions

• HAIs can be reduced.
• Level of science needs to be improved to determine which interventions are optimal.
• Maintenance and sustainability of successful interventions is a difficult process.