Commentary — February 2017
Tex Med. 2017;113(2):15-16.
By Charles J. Lerner, MD, and Jane D. Siegel, MD
Physicians have been trained to find the causes of medical problems, and that includes health care-associated infections (HAIs). Strong evidence suggests it's no longer acceptable to say a patient became infected because he or she was in a high-risk group or was just so sick that infection was expected.
In 2002, the U.S. Centers for Disease Control and Prevention (CDC) estimated 1.7 million patients annually developed HAIs. There were an estimated 99,000 deaths associated with those infections, according to a study published in Public Health Reports in 2007.
In 2011, the annual burden of HAIs in U.S. acute care hospitals was 722,000, and 75,000 of those patients died. CDC data show decreases in HAI rates and associated death rates as health facilities consistently implement effective evidence-based, bundled practices for prevention of device-related infections and surgical site infections. HAI prevention is now a key component of patient safety programs.
We must have no tolerance for failing to follow established best practices. In our personal experience treating adults and children, several large hospital intensive care units (ICUs) have, with process improvement, dramatically reduced central line-associated bloodstream infection (CLABSI) rates, making a CLABSI a rare event. At least one of these ICUs hasn't had a CLABSI in more than two years.
Each CLABSI is now approached with a formal root cause analysis to see if anything could have been done differently to prevent the infection. Data from 2014 show the number of HAIs in long-term acute care hospitals is also decreasing.
These lessons from well-designed studies have led to zero tolerance for HAIs:
- Most HAIs are preventable.
- Hand hygiene before and after contact with patients and items and surfaces in their immediate environment saves lives.
- HAIs in all facilities where health care is delivered contribute to adverse patient outcomes, and most are preventable.
- Prevention of HAIs requires a multidisciplinary approach that uses root cause analysis and the implementation of optimal prevention bundles (combination of several evidence-based practices) with audits and feedback to assure consistent practice, especially within specialized high-risk populations.
- Limiting the use of medical devices to only necessary indications rather than convenience leads to improved patient outcomes and reduced HAI rates.
- In the absence of an outbreak, a horizontal approach that includes preventive practices, such as hand hygiene, standard precautions, and reduced use of devices for all patients is more effective than a vertical approach based on active surveillance cultures for a specific organism and contact precautions when that organism is present. A commentary accompanying the "Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2014 Updates," published in Infection Control and Hospital Epidemiology, discusses how the horizontal approach targets prevention of infections caused by a broad spectrum of infectious agents.
- A guideline for implementing an antimicrobial stewardship program published last year in Clinical Infectious Diseases states the two key components of any HAI prevention program in all health care delivery sites are infection prevention and control to reduce the risk of transmission and antimicrobial stewardship to reduce emergence of untreatable multidrug-resistant infections. Guidance states every prescriber must use antibiotics only when indicated for treatment of bacterial infections and assure the right drug for the right bug for the right duration.
- Surgeons must know their surgical site infection rates and work toward reduction.
What does this mean for us in practice? It means prevention of HAIs is now everyone's responsibility and no longer the sole responsibility of the infection preventionist in acute care hospitals. For physicians and surgeons, an area of great impact is an awareness of established, evidence-based guidelines to use medical devices and antimicrobial agents judiciously.
We must welcome reminders from our coworkers when we have forgotten to observe hand hygiene or proper isolation precautions and embrace the alerts in electronic health records that guide us to make more prudent antibiotic choices. Communication among all subspecialists and primary care physicians and surgeons is necessary so we are all working toward the same goal, using the same principles. We must remember each of us has the opportunity with every health care encounter to contribute to HAI prevention and improve patient safety.
Charles J. Lerner, MD, is a hospital epidemiologist in private practice in San Antonio.
Jane D. Siegel, MD, is a pediatric infectious disease physician and has served as the medical director of the Corpus Christi State Supported Living Center for Adults with Intellectual and Developmental Disabilities.