SYMPOSIUM
Prevention of health care-associated infections in an era of public reporting
BY CHETAN JINADATHA, MD, AND EDWARD J. SEPTIMUS, MD
Health care-associated infections (HAIs) are a leading cause of wasted health care dollars, and prevention of HAIs is a quintessential pillar of pa- tient safety and satisfaction. Cathe- ter-associated urinary tract infections, central line-associated blood stream infections, ventilator-associated pneu- monias, surgical site infections, and Clostridium difficile infections are the important HAIs seen in U.S. hospitals. C. difficile infections are an emerging threat to modern health care systems, attributed to antibiotic overuse and re- sistance. Combined payment bundle in- creases the pressure on hospitals to take ownership of hip and knee replacement surgery patients. Health care facilities are heavily penalized for HAIs by the Centers for Medicare & Medicaid Ser- vices, not to mention the potential for negative publicity with public reporting. The role of initiatives such as preven- tion bundles, decolonization, antibiotic stewardship, and no-touch disinfection are emerging, but proper hand hygiene still remains the most important step in preventing HAIs.
BACKGROUND
Health care-associated infections (HAIs) are a significant burden on modern health care systems. HAIs represent a large consumption of scarce resources.1
most commonly reported HAIs are pneumonia (22 percent), surgical-site infections (22 percent), and gastroin- testinal infections (17 percent). Clos- tridium difficile was the most com- monly reported organism, causing 12 percent of HAIs. Device-associated infections account for 25 percent of HAIs.4
lococcus aureus (MRSA), in particular, is known as one of the most common causes of ventilator-associated pneu- monia, bloodstream infection associ- ated with central venous catheters, and surgical-site infections.1,4 Other HAIs have also been known to arise as a result of exposure to surgical procedures, ongoing hemo- dialysis, and residence in long-term care facilities, in addition to shared risk factors with MRSA.5
HAIs result
in longer length of stay (LOS; 21.9 vs. 5.0 days), higher 30-day readmission rates (31.3 percent vs. 6.3 percent), and greater mortality (9.1 percent vs 1.7 percent) compared with patients without an HAI.6
conditions reduction measures, CMS can penalize hospitals for excessive rates of HAI; the bottom 25th percen- tile of hospitals can lose 1 percent to 2 percent of their total payment from CMS. Nonpayment for HAIs and resul- tant penalties could lead to closure of low-performing hospitals. There is a renewed interest even among civilian hospitals in adapting and implement- ing novel ways to decrease HAIs.10-12 HAIs can be broadly classified into
Methicillin-resistant Staphy-
device-related and non-device-related infections. The common device-relat- ed infections are catheter-associat- ed urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), and ventilator- associated pneumonia (VAP). The common non-device-related infec- tions are surgical site infections (SSIs) and Clostridium difficile infections (CDIs). A significant number of these HAIs are preventable using evidence- based strategies such as prevention bundles.13
The other HAIs that are not
classified in any of the aforementioned conditions are health care-associated Legionnaires’ disease, norovirus, and respiratory viruses, which are not dis- cussed in this article.
CATHETER-ASSOCIATED URINARY TRACT INFECTIONS
The various path- In the United States,
about 1.7 million HAIs occur each year, accounting for up to $9.7 billion annu- ally in additional health care costs and approximately 99,000 deaths.2,3 HAIs are of clinical relevance in
patients who have in one way or an- other been entangled in any of the numerous pathways of HAIs. The
42 TEXAS MEDICINE February 2017
ways to infection for HAIs are numer- ous but frequently include contamina- tion of the hands of health care work- ers due to inadequate hand hygiene practices or inadequate cleaning of environmental surfaces. This makes potential risk factors limitless in a hospital environment and makes it consequently difficult to establish ef- fective interventions.7-9 The Affordable Care Act authorizes
payers such as the Centers for Medi- care & Medicaid Services (CMS) to re- duce payment to hospitals for HAIs. As a part of their value-based purchasing measures and health care-associated
CAUTIs are one of the most common hospital-associated infections, ac- counting for approximately 15 percent to 20 percent of all HAIs.4
The cath-
eter most commonly associated with HAIs is the indwelling urinary cathe- ter. Approximately one in five patients is subjected to an indwelling urinary catheter at some point during a hos- pital stay.4
Major differences exist be-
tween what the Infectious Diseases Society of America (IDSA) defines as CAUTI and the definition used by the U.S. Centers for Disease Control and Prevention’s (CDC’s) National Health- care Safety Network (NHSN) surveil- lance. Infection preventionists use the latter to report to NHSN as a part of their CMS reporting requirement.14,15 The costs associated with taking care
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