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Surely those statisticians would have been quite troubled to learn that while Methicillin-resistant staphylococcus aureus (MRSA) accounted for just 2 percent of hospital staph infections in 1974, that number has been steamrolling at a steady pace, accounting for 22 percent of staph infections by 1995 and 63 percent by 2004. And its not just staph infections that are causing problems.

Certainly 30 years ago no one could have imagined the intensity of the aggressive diseases that would test the capabilities of today’s infection control practitioner (ICP) or the complexity of the requirements for modern infection prevention and control programs. 

Suzanne Pear, RN, Ph.D, CIC, associate director of infection prevention practices, Kimberly-Clark Health Care, spent three decades working for the Department of Veterans Affairs Medical Center - 10 years as a staff med/surg nurse, then 20 in infection control. She’s seen a lot during that time.

"I came into infection control right on the cusp of major changes," she noted. "It was during the heightened concern about HIV, the initial development of universal precautions, and then the evolution into standard precautions. I saw all of that evolution of practice, the recognition by CDC that really the focus of universal precautions was too narrow and they needed to expand it to all patients and all situations and not just bloodborne pathogens."

Pear recalled that the main focus of many of the original infection control programs was surgical site infections (SSIs), "because those infections are so obvious and so devastating." 

Of course that focal point today has expanded to include so many different areas of infection prevention. For example, many hospitals are concentrated on, and are showing great success with, the intervention bundles recommended by the Institute for Healthcare Improvement’s (IHI) "100,000 Lives Campaign" and now the "5 Million Lives Campaign".

The IHI interventions are based on guidelines from the Centers for Disease Control and Prevention (CDC). But with the growing number of healthcare acquired infections (HAIs), smarter and more resistant bacteria, and sicker and sicker patients, it’s more important than ever for the practitioner to return to the basic protocols that have been proven to reduce infection rates.

"IHI has really been able to put the marketing message behind [the evidence], to put it together in an easy-to-use, easy-to-implement, ‘getting started’ type of concept," said Matt Moore, senior marketing manager, venous access for Arrow International. "They can break it down into manageable pieces and by doing that, it helps everyone understand the value of doing it, the impact they can make. It empowers people to get involved. And ultimately what they’re showing is that it’s sustainable, which is the exciting part of it. I think behaviors are actually changing which is the thing that was missing for so long."

"In the last five years, the IHI has done more to revolutionize healthcare than anything I can think of," agreed Pear. "We’re all on this bandwagon. This is infection control’s day in the sun."

Springboarding off of the IHI campaigns, many companies are offering "bundled" products to correspond with the recommended intervention bundles. For example, Arrow International offers its Maximal Barrier Precautions Central Venous Access kit, an integrated system for combating the five sources of catheter-related bloodstream infection (CRBSI), which now includes Hi-Lite Orange Tinted ChloraPrep as well as protective gear and upgraded sharps safety devices.

"The concept of bundling is that you want to make everything very accessible; you want to remove those barriers for non-compliance," said Moore. "All of these things being at the same place at the same time so that they can be implemented in a very consistent way, really reinforces that theme of bundles."

Other companies are also offering products that help to make it easier to implement IHI interventions. For example, Kimberly-Clark Health Care offers a system of solutions designed to prevent SSI and ventilator-associated pneumonia (VAP). Among offerings from Cardinal Health is the Convertors Line Insertion Draping system that helps ensure maximum barrier precautions even if only one nurse is present.

3M Health Care, with 50 years of experience in developing products for the OR environment, has a variety of products designed to help reduce the risk of SSIs. For example, the company was instrumental in pioneering the use of clippers to eliminate shaving. The 3M DuraPrep Surgical Solution Patient Preoperative Skin Preparation meets criteria for surgical skin prep and enhances drape adhesion, so that when used in combination with the 3M Ioban 2 Antimicrobial Incise Drape, it helps to create a sterile field and minimize the risk of infection.

3M is also introducing a new diagnostic test that will help clinicians in detecting carriers of MRSA much faster. "3M is developing and commercializing rapid diagnostic product solutions for the detection of key infectious pathogens, including MRSA and other treatment-resistant microbes," said Sue Wasserman, infection prevention marketing manager. "We recently introduced the 3M BacLite Rapid MRSA Test in Europe and plan to introduce the test in the U.S. next year. This test can effectively and reliably detect the presence or absence of MRSA in high risk patients in 5 hours, whereas with the current culture method, results can take 48 hours."

Added Cathy Bartz, asepsis technical services, 3M,"What the physician wants to do is to detect whether the individual is a MRSA carrier prior to surgical procedures. Because if it’s known that the individual is a carrier of MRSA, then the physician can take appropriate actions that should contribute to decreasing the patient’s risk of surgical site infection,"

Sandel Medical is a company that was founded on the principals brought to light in the 1999 Institute of Medicine report, the initial driver for the IHI campaigns. "Here we are almost 10 years after the IOM report, and basically there’s been no change. I’m surprised people aren’t more outraged than they are across the country. It’s our medical tsunami that’s happening – 200,000 people die each year. The only difference between the tragedy of the tsunami two years ago and now, is that 200,000 people died in one day, and we spread it out over the course of a year," said Brian Mach, COO, Sandel Medical.

Sandel is introducing a new sponge counter product for the OR that drapes over an existing basin ring stand. It’s designed to be a simple, cost-effective solution to keeping tabs on sponges, as well as reduce the risk of injuries due to repetitive bending and stooping by the circulating nurse.

Also coming down the pipeline from Kimberly-Clark Health Care is an all-in-one Personal Protective Equipment (PPE) dispenser. The Kimberly-Clark PPE Dispensing System makes gloves, gowns, masks and hand sanitizer readily accessible, promoting compliance to infection control best practices. The System helps eliminate cross-contamination by using spring-assisted dispensing for gloves and standard procedure masks. Sterling Nitrile and Purple Nitrile gloves are dispensed cuff first and FluidShield masks are oriented to reduce fingerprints on visors.

Obviously this is just a sampling of products available to help ICPs reduce infection rates.

"We are no longer looking at products in isolation, but rather how they work together as a system," said 3M’s Wasserman. "One of the things that we see changing in the last decade, is the shift in focus from looking at an individual product performance to really looking at that whole issue of human factors. It’s all about helping the healthcare workers to know how to use the products, know how to really be compliant with what’s necessary in order to get the outcome. There is probably not a magic bullet in a certain product or technology, but it’s really about educating the team so that they work together to minimize the errors that are often just related to human nature, human behavior."

"What you’re seeing is a combination of medical science and behavioral science coming together," said Pear of the evolution of infection prevention product development. Drawing from her experience practicing infection control at the VA, Pear added, "A big part of infection prevention and control is basically dealing with people. I used to say, ‘I do a lot of talking about infection control, but the bedside providers are the ones who actually do infection control.’"

"As I’ve matured in my practice I’ve come to understand that it’s basically the old ‘shoe-leather’ infection prevention specialist – the one who goes out there, who’s relating well to his/her colleagues at the bedside, who can impress upon these colleagues the criticality of what they’re doing in terms of outcomes – who is successful in reducing infection rates," continued Pear.

"It’s really important when you look at IHI successes that the majority of that appears to come from the real behavioral changes that are associated with it," said Arrow’s Moore.

"There is no quick fix to any of the IHI prevention strategies," emphasized Pear. "It takes a number of strategies performed reliably, consistently for there to be true house-wide improvement in patient care. Someone might consider hand hygiene simple, but it certainly hasn’t been easy to implement reliable hand hygiene compliance. And I think this is true with any of the other strategies that you look at."

Gordon LaFortune, president, infection prevention, Cardinal Health Inc., noted that "Clinicians are often blamed for improper hand hygiene and not following established protocols. One of the major issues is the need to find innovative solutions to address the underlying reasons that protocols are not always followed. There is a great need for the ability to quickly and efficiently access real-time information to address infection control issues. People, processes, information and products are all interconnected in the infection control equation. We will be able to find solutions when all of these factors are taken into consideration."

Fortunately, just as the demands on infection control are reaching their breaking point, assistance in the form of electronic infection surveillance and analysis is gaining headway – something the ICPs of 1977 could only dream about.

Programs such as Cardinal Health’s MedMined, Premier SafetySurveillor and TheraDoc are just some of the new automated technologies that can give ICPs real-time data access and reporting capabilities that were never before possible.

"Thirty years ago, the majority of your day was spent in a paper chase of chart abstraction, chart review, and data analysis, which left little time for teaching and interventions," said G.T. LaBorde, vice president of operations for MedMined, Cardinal Health. "Now technology can do all of the data crunching. It can identify who has infections that were likely acquired in the hospital; it can identify patterns of those events; it automatically tells you where there are opportunities for improvement."

Floyd Eisenberg, MD, Mph, senior physician consultant with Siemens Medical Solutions, is an infectious disease physician who has concurrently managed Infection Control Departments in three hospitals during his career, and who, incidentally, is celebrating his own 30^th anniversary of graduating from medical school. He recalled, "I remember when this was all paper-based and maybe we would throw [the data] in Excel...It took a lot of work." He added, "Automated surveillance can revolutionize and take advantage of the detailed work that is being done and expand on it."

Siemens Medical Solutions Sorian solution incorporates a workflow engine that connects real-time human interactions with enterprise data transactions to help healthcare organizations bring new levels of automation to their current processes and to make meaningful improvements to the processes themselves (e.g., initiation of and removal from isolation.) In addition, Sorian’s Embedded Analytics provides immediate access to essential information that enables organizations to track performance and affect process change where needed, such as infection risk data and associated factors or root causes such as particular patient populations, physician practices or patient units.

"The vision and intent is to be able to look at your performance over time, say month-to-month to see what you’ve done and how it was improved, in what locations or under what services," said Eisenberg. "Where’s the best practice so everyone else can emulate it?"

Stan Pestotnik, president and CEO of TheraDoc, indicated that the time factor remains a challenge. "Manual surveillance and reporting take up so much of an ICP’s time that they must reduce the scope of their practice and even then they don’t have sufficient time to be on the floors to affect the needed prevention and control interventions for patients, educate clinicians and monitor compliance measures. They are so busy hunting and gathering information and preparing reports that they can’t get to those activities that will really make a quality and safety difference for the patients." He notes that TheraDoc can save up to 50 percent of surveillance time spent at the desk. "Less desk time means more availability for prevention and control interventions on the floor."

Pushing paper is a major problem, too, according to Dan Peterson MD, Mph, VP and medical director, Premier. "It’s a poor use of human intelligence to have ICPs looking through hundreds of pages of lab reports trying to figure out patterns." Peterson previously spent eight years at the CDC and was active in setting up the electronic surveillance for reportable diseases, then started Cereplex, which was recently acquired by Premier. He described SafetySurveillor as "surveillance on steroids", adding that "The first thing it does is increase the breadth of surveillance…now you can go hospital-wide."

Explained LaBorde: "[Initially] the infection control community realized that they didn’t have the resources to manually identify every single infection that was acquired in the hospital with something back then called house-wide surveillance. They realized that they spent all of their time trying to compute one number, one statistic for the hospital that wasn’t terribly actionable. So they gave up on that and for many years now the community has practiced something called ‘targeted surveillance’. They said, ‘let’s only try to identify those infections that are related to an invasive device such as a ventilator, central line, or urinary catheter. And in many cases let’s limit ourselves to only certain units like the critical care units.’"

LaBorde suggested that it is precisely this targeted surveillance approach that has mistakenly led many C-suite hospital executives to believe that their infection rates aren’t nearly as high as they really are. "I participated in panels of CFOs and CEOs from some of the biggest healthcare systems in the country. When I ask them what percentage of their patients do they think acquired infections (the national age on that is about 5.5 percent), their answers ranged from 0.6 percent to 1.7 percent. What they’ve done is taken the manual, targeted surveillance methodology that’s not designed to capture every infection and then assumed that’s it."

Automated surveillance can significantly improve the ICP workflow. "It provides a framework for focused action by the ICP,’ said Peterson of Premier SafetySurveillor. "It organizes the workflow and documentation so the ICP can be more efficient."

"Thirty years ago, ICPs were working in a silo and responding either because there was a crisis or an outbreak. They now have the tools, the ability and the time to get out in front of the problem, and do more teaching, training, rounding and pushing the infection control agenda," said Peterson.

"If you ask me what’s different 30 years ago versus now, it’s that ICPs have that power. They have the power to comprehensively use technology to monitor the hospital and figure out where they should be targeting their efforts," said LaBorde.

If it’s known that infection prevention programs, products and protocols are effective, not to mention good for the patient, why aren’t they practiced more consistently and more reliably? The answer is multi-fold, but it starts with a lack of understanding about the true nature of how infections impact the hospital’s bottom line and the importance of sound practices.

"Infection control influence historically has been sort of a thorn in the side [of hospital administration]," said Arrow’s Moore. "It’s been in that group in the hospital that’s always been an advocate for the patient, and for reducing risk, and for being a good steward of the drugs that were used and those types of things. But they have not necessarily been resourced appropriately nor have they really had the marketing tools available to them to really get people’s attention and to ultimately change behavior."

Pestotnik concurred that ICPs have been short-shrifted over the years. "Many organizations have done without funding, personnel, tools and technology for so long that an attitude of ‘good enough’ has developed," he said. "Despite the protests of ICPs, and even if it is not the best solution available, hospitals continue to struggle forward. Any money to get any tool is welcomed thinking that it is ‘better than nothing’. Those signing the checks for systems are still focused on how cheaply compliance can be accomplished. The component that is often missed is: what is the real goal (reducing HAI) and how is it going to return to the hospital enhanced clinical and financial outcomes. Many ICPs continue to fight to have their voice heard in the process."

Healthcare facilities may need to re-examine ICP services as a cost. "Most CEOs look at infection control as a cost center rather than a revenue generator," said Pear. "But infection prevention is the most cost-effective expenditure you can make."

Compounding the problem, explained LaBorde, "Most CEOs and CFOs don’t have the ability to tie [infection risk data] to their own financial data in an efficient way. We recently looked at about 2.5 million admissions across about 100 hospitals. What we found is that patients that get infections are so unprofitable that the relatively small percent, 4.5 percent of patients, that acquire an infection in the hospital, accounts for 92 percent of the net operating losses of hospitals on their inpatient population. It represents a big drag on their operating margins, because the patients are staying longer, they’re primarily Medicare patients that are getting infections, and the extra cost of treating them is very poorly reimbursed."

And the reimbursement issue is likely to become even more costly for hospitals in relation to their infection rates as CMS is expected to redefine parameters for reimbursement for care associated with HAIs. "If hospitals no longer get reimbursed for complications related to infections, that will have them thinking very hard about, ‘what can we do to reduce them?’", said Don Bauman, regional vice president, Premier.

"The landscape of infection control has also changed in terms of the number and types of groups calling for better, safer care for patients," said Pestotnik. "The Leapfrog Group, IOM, JCAHO, CMS, other federal and state agencies, and consumer advocacy groups are all pushing for published data on outcomes, complications and quality data for the consumer, so that consumers can make informed choices about their care and where to receive it."

As mandatory reporting looms for many states, the spotlight on infection control grows even brighter. "There is a lot of support right now for reporting different infection rates and outcomes, and a hospital’s reputation being built on, how do they stack up versus other healthcare facilities in minimizing these infections," said 3M’s Wasserman. "I think maybe 30 years ago, there wouldn’t have been so much open documentation of that information. If nothing else, bringing it out in the open, so there’s an awareness of the need to work on lowering infection rates, that’s a very progressive outlook."

Pear emphasized that success emerges from leadership. "A top-down approach is often required to make changes in local situations," she said. "Often times the changes, however critical they may be, are very difficult to put into effect, without pressure from either national organizations or national leaders."

One new tool for making the business case for infection prevention, the Association for Professionals in Infection Control and Epidemiology (APIC) recently issued a white paper, titled "Dispelling the Myths: The True Cost of Healthcare-Associated Infections", which was designed as a call to action for "hospital executives nationwide to develop a deeper understanding of the economic impact infections play on both patient safety and bottom line outcomes", according to the organization. (See http://www.apic.org/Content/NavigationMenu/
PracticeGuidance/Reports/hai_whitepaper.pdf).

Peterson noted that the much publicized successes of the IHI bundle interventions are driving changes in the way infection prevention is viewed. "It’s one thing to realize the cost of infections, but if you don’t think you can change that, then they’re just costs. Now with the IHI bundles, people realize that we can really impact infection rates."

Premier’s SafetySurveillor system is able to tie into the hospital’s cost accounting system to provide in-depth analysis of how much infections are costing them and how much they’re saving with SafetySurveillor. It could also provide input regarding the cost effectiveness of implementing infection prevention products and interventions.

"There is a resistance to paying more money for products and services that clearly drive benefit," said Cardinal’s LaFortune. "Decisions need to be based not on price but on the broader benefit to the quality of care delivered. While the industry needs to do a better job of providing evidence that their claims are well founded, buyers must be willing to spend more to get an improved outcome."

Countering economic arguments can be simple. "Administration is saying, ‘we don’t have the money for a new safety product’. So it comes down to justifying it and putting a business case together," said Sandel’s Mach.

"ICPs have been empowered because of all of this information that’s now available, to be much more on the front line of the financial improvement of the hospital, not to mention the overall clinical impact that they can have by really understanding the problem, documenting it, analyzing it, implementing changes like bundles, or introduction of new products, or whatever the case may be," said Moore. "They have a lot more credibility because of this awareness of the risk and the unnecessary nature of the risk."

C-suite office-holders just need to put this in perspective. "If executives and administrators of hospitals realize that it’s a big issue for their own facility, and you have the technologies that get clinicians and ICPs in the right place at the right time with the right information to change people’s behavior, then that’s when you have a powerful opportunity to improve care," said LaBorde.