"I would say that infection prevention efforts in the U.S. are definitely improving – but those efforts are not improving everywhere," Warye observed. Describing infection prevention efforts across the U.S. as somewhat "spotty," she noted, "Some institutions are doing a fabulous job in creating significant reductions, particularly in central line associated bloodstream infections, surgical site infections and even in some of the more difficult infections like ventilator-associated pneumonia. There are a number of examples where institutions have used a systems-based approach to the reduction of central line associated bloodstream infections and have held at zero for months, and sometimes even a couple of years.

"But even with those types of successes only about 25 percent of American institutions are using this approach," conceded Warye. "So that’s very problematic. APIC is currently involved in a project to try to determine why. What are the barriers that are preventing hospitals from implementing such procedures that are clearly proven, evidence-based, and will help not only protect patients but also improve the bottom line?"

According to Warye, financial roadblocks are common. "Many infection prevention departments are still severely under resourced," she said. "They are still considered to some degree a cost center. I think that many executives still are not aware of the vast sums that healthcare associated infections cost them that are avoidable."

Even though CMS reimbursement changes and other government initiatives have helped turn focus towards the financial impact of healthcare-associated infections (HAIs), many facilities have yet to adequately shore up funding to acceptable levels.

"We know for example, during the economic downturn of last year, 41 percent of our members had resources cut. And what we’re hearing is, in most cases, those resources have not returned even though the economy has improved and the healthcare economy has improved. To me this is really a fundamental disconnect in the orientation of some healthcare executives. I realize they have many competing priorities, but we really need to elevate this," emphasized Warye.

Barriers aside, new infection prevention success stories come to light everyday, and those that are reaching goals of zero for various HAIs have a few things in common, explained Warye.

"In the institutions that have seen real success around reduction of infections, two things are consistent across the board. One is commitment on the part of top leadership – both clinical and administrative – visible, vocal, consistent support for infection prevention and control. Culture starts at the top. And [second is] adequately resourced departments and interventions," she said.

Ecolab’s EnCompass Environmental Hygiene Program can help improve cleaning outcomes

Naturally the technical element of having infection prevention bundles and evidence-based processes in place is irrefutable. "That’s almost the easier part," acknowledged Warye. "The bundles exist. We’re still working on the resources and the clinical and administrative support."

Warye also credited technological developments, such as antimicrobial-impregnated and silver-coated products as well as rapid diagnostics, with advancing infection prevention efforts.

To help aid infection preventionists in making a business case for additional resources at their facilities, APIC recently provided members with a free "IP Program Evaluation Tool" (available at www.apic.org/Content/
NavigationMenu/Links/Publications/APICNews/
IP_Program_Evaluatio.htm).

"It’s a comprehensive analysis of the variables in your institution that underlie the type of resources that you should have," described Warye. Beyond a simplistic ratio of "X" number of infection preventionists to "X" number of beds, "this tool takes you through a variety of elements," she said. "For example, what does your patient population look like? What type of services do you provide? Do you have an emergency room? How many ICUs do you have? Do you have long term care coming into your facility? What are your personnel demographics? Do you have surveillance technology? (which is absolutely an enabler.) What kind of performance improvement initiatives are you attempting to manage? [It also provides] an analysis of the job functions in infection prevention and control."

Using this data, the decision support tool then provides recommendations that can be translated into a report or a request for additional resources with management.

Commenting on a recent report from AHRQ that cast a rather gloomy outlook on infection prevention efforts¹, Warye stated, "I think there are a couple of things that are important to know about that report that I don’t think came out in the messaging so that you can appropriately put it into context. First, it was using 2005-2008 data. And a lot of the efforts I’ve described to undertake reduction in HAIs were really just getting underway in that time frame, and I don’t think the results were nearly as dramatic as they have been in the last year to 18 months."

"The second thing is that they used administrative data. That’s coding data as opposed to epidemiologic surveillance data," she added, noting that the Medicare data that is available to AHRQ is likely to be reflective of a more problematic patient population that may inherently be more susceptible to infections than the overall patient population.

"There are three studies in the scientific literature that are very consistent in their conclusions that administrative coding data tends to over-represent the number of infections^2-4," offered Warye. "One report that appeared in AJIC⁴ several years ago indicated that the administrative coding data is really a very poor tool to identify infections [due to low sensitivity issues, etc.]"

Comparatively, for a better reflection of current outcomes, in late May, the Centers for Disease Control and Prevention released the "First State-Specific Healthcare-Associated Infections Summary Data Report⁵," showing that U.S. healthcare facilities have reduced the rate of central-line associated bloodstream infections by a commendable 18 percent.

The report compares national and state data from January to June 2009 with national data from 2006 to 2008, and uses surveillance data collected through the CDC’s National Healthcare Safety Network (NHSN), which APIC describes as being "epidemiologically sound."

"We see everyday, institutions making great strides in lowering rates and holding those rates," concluded Warye.

Irena B. Kenneley, PhD, APRN-BC, CIC, assistant professor of nursing at the Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, and a spokesperson for APIC, helped interpret the results of APIC’s "2010 Clostridium difficile Pace of Progress Survey⁶," an online poll of infection preventionists across the U.S.

The survey showed an overall increase in infection prevention measures aimed at C. diff, with 53 percent of the nearly 1,800 respondents adopting measures in the last 18 months to prevent and control the spread of C. diff infection (CDI).

Underscoring the increasing prevalence of CDI, a study presented at the Fifth Decennial International Conference on Healthcare-Associated Infections 2010, found C. diff to be more common than MRSA in Southeast community hospitals. The study showed that healthcare-associated CDI occurs almost as often as healthcare-associated bloodstream infections and combined device-related infections.

Kenneley discussed the challenges associated with controlling the spread of C. diff and additional details of the survey results.

"With C. difficile, this is happening in older patients; they’re not always conscious, and the type of diarrhea that occurs with this organism is profuse and it’s very difficult to clean up," she said. "The C. diff bacteria forms what’s known as a spore, and that spore can live in the environment, theoretically for up to 100 years."

Further, because certain antibiotics destroy normal bowel flora and pre-dispose patients to C. diff, inappropriate or unnecessary antibiotic therapy is another accomplice in acquiring the infection and ultimately the spread of CDI. (Indeed, APIC’s C. diff survey showed that many respondents’ hospitals lack an antibiotic stewardship program.)

Just as patients infected with MRSA should be placed in contact isolation, patients exhibiting symptoms associated with C. diff should be immediately tested and placed under contact precautions as soon as a diagnosis is made.

Hand hygiene is another key measure to CDI prevention, and the CDC generally recommends that healthcare workers use soap and water to wash spores from their hands versus alcohol hand rubs, noted Kenneley, adding, "Many of the hospitals that responded to the survey did have a specific policy for hand hygiene for C. diff patients, and that generally was hand washing. However, the CDC has also come out and said that whether it be hand washing or an alcohol rub if you do some sort of hand hygiene, the evidence suggests it will help regardless."

Monitoring for hand hygiene compliance is equally important, and in particular unannounced hand hygiene observations tend to provide the most objective measure. "When people know you’re watching them they act differently," said Kenneley. She pointed to recommendations from the World Health Organization (WHO) to use as a standardized guideline for monitoring hand hygiene in an institutional setting.

Contaminated surfaces have been implicated time and again in the spread of CDI and other resistant organisms, therefore environmental cleaning protocols should also be a high priority.

Observed Linda Homan, RN, CIC, senior manager of clinical and professional services for Ecolab Healthcare, "Infection prevention and control programs have traditionally focused on hand hygiene and targeted measures to reduce healthcare-associated infections such as ventilator-associated pneumonia and surgical site infection. However, numerous studies have shown that patient rooms are not well cleaned and contaminated patient rooms increase pathogen transmission risk, but that cleaning can be programmatically improved which can decrease patients’ acquisition of pathogens such as MRSA, VRE and C. difficile. Given the success of other interventions, it just makes sense for providers to apply the same best practices that have been used in infection control to the processes in environmental services."

Specifically because C. diff produces spores, the CDC recommends sodium hypochlorite, or bleach solution to clean surfaces contaminated with C. diff. The majority of APIC survey respondents (84 percent) reported using bleach to clean rooms with C. diff-infected patients, although in varying degrees – from using bleach during outbreaks only, to daily/discharge cleaning and a small percentage using bleach for all room disinfection all the time (7 percent).

High-touch objects are obviously the most critical to properly clean and Kenneley noted that APIC’s "Guide to the Elimination of Clostridium difficile in Healthcare Settings⁷" contains checklists on what housekeeping should clean, and where and how they should be trained.

According to APIC’s C. diff survey, while environmental cleaning efforts have increased (86 percent have increased emphasis on environmental cleaning and decontamination practices during the past 18 months), monitoring efforts have not kept pace. Instead, nearly 7 in 10 respondents relied only on visual observation of the room and cleaning practices to determine effectiveness.

Questioned Kenneley, "What is that, the ‘white glove’ test? How are you observing how well a room is cleaned after a terminal cleaning, for example? I just find that to be very subjective. I think it’s very important to keep in mind, that just observing how clean the environment is, is not sufficient, and that some of the newer technology to assess whether the room is clean or not is more optimal than the white glove test."

Agreed Homan, "Environmental services has traditionally measured cleanliness in terms of visual inspection—are the walls free of spots? Is the floor shiny? With the increasing evidence of environmental transmission of pathogens, there is now an emphasis on reducing the bioburden in patient care areas and objectively measuring cleaning outcomes.

"Often environmental services faces high turnover, staff who are under significant time pressure and who may only have limited training," continued Homan. "They also may not have objective measures of cleanliness. The success of any program requires a continuous improvement loop of proper training, objective outcome monitoring and performance feedback. This shift in thinking requires collaboration between environmental services and infection prevention. We’ve seen the most success in organizations whose environmental services and infection prevention departments work together to monitor, evaluate and improve the cleanliness of the environment."

References: 

1. Agency for Healthcare Research and Quality, “2009 National Healthcare Quality Report and National Healthcare Disparities Report”, March 2010. http://www.ahrq.gov/qual/qrdr09.htm 

2. Sherman E, Heydon K, et al. Administrative Data Fail to Accurately Identify Cases of Healthcare-Associated Infection. Infection Control and Hospital Epidemiology 2006; 27.4: 332-37. 

3. Jhung  M, Banerjee, S. Administrative Coding Data and Health Care–Associated Infections. Healthcare Epidemiology; 2009: 49:949-55.

4. Stevenson  K, Khan Y, Dickman J, et al.  Administrative coding data, compared with CDC/NHSN criteria, are poor indicators of health care-associated infections. American Journal of Infection Control 2008; 36:155-64.  

5. “First State-Specific Healthcare-Associated Infections Summary Data Report,” CDC’s National Healthcare Safety Network (NHSN) January-June, 2009. http://www.cdc.gov/hai/pdfs/stateplans/SIR_05_25_2010.pdf  

6. Association for Professionals in Infection Control and Epidemiology, “2010 Clostridium difficile Pace of Progress Survey,” May 2010. http://www.apic.org/AM/Template.cfm?Section=Featured_News_and_Events&TEMPLATE=/
CM/ContentDisplay.cfm&CONTENTID=15653 

7. Association for Professionals in Infection Control and Epidemiology, “Guide to the Elimination of Clostridium difficile in Healthcare Settings.” http://www.apic.org/AM/Template.cfm?Section=APIC_Elimination_Guides
&Template=/CM/HTMLDisplay.cfm&ContentID=15643
 

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