Background

Health care–associated infections (HAIs) are the most common complication of hospital care. According to the Centers for Disease Control and Prevention (CDC), nearly 1.7 million HAIs occur yearly, leading to approximately 99,000 deaths every year. Such infections were long accepted by clinicians as an inevitable hazard of hospitalization. However, recent efforts have demonstrated that relatively simple measures can prevent the majority of common HAIs, and as a result, hospitals and providers are under intense pressure to reduce the burden of these infections.

Four specific infections together account for more than 80% of all HAIs:

• Surgical site infections (SSI) 
• Catheter-associated urinary tract infections (CAUTI) 
• Central venous catheter–related bloodstream infections (CRBSI) 
• Ventilator-associated pneumonia (VAP)

These infections are especially common in intensive care unit (ICU) patients, and consequently, much recent work has focused on preventing HAIs in the ICU setting. In addition, preventing the transmission of antibiotic-resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) has become increasingly important.

Preventive Measures

Effective measures exist to prevent the most common HAIs. The Table shows the strategies currently recommended by the CDC for prevention of SSI, CAUTI, CRBSI, and VAP.

Table. Specific Measures for Prevention of Health Care–Associated Infections Recommended by the Centers for Disease Control and Prevention
Health Care–Associated Infection	Preventive Measure	Definition
All health care–associated infections	Hand hygiene	Washing hands before and after each patient contact
Central venous catheter–related bloodstream infections (CRBSI)	Maximal sterile barrier precautions	Use aseptic technique including the use of a cap, mask, sterile gown, sterile gloves, and a large sterile sheet for the insertion of all central venous catheters (CVCs)
	Chlorhexidine skin antisepsis	Use 2% chlorhexidine gluconate solution for skin sterilization at the CVC insertion site
	Appropriate insertion site selection	Avoid femoral site for nonemergency CVC insertion
	Prompt removal of unnecessary catheters	Removal of CVC that is no longer essential for care
Surgical site infection (SSI)	Appropriate use of perioperative antibiotics	Administration of appropriate prophylactic antibiotic, generally begun within 1 hour before skin incision and discontinued within 24 hours
	Avoidance of shaving of the operative site	Use clippers or other methods for hair removal in the area of skin incision(s)
	Perioperative glucose control	Maintenance of blood glucose less than 150 mg/dL during postoperative period (tighter control may be more beneficial in specific patient populations)
Ventilator-associated pneumonia (VAP)	Semirecumbent positioning	Elevation of the head of the bed to more than 30 degrees for all mechanically ventilated patients
	Daily assessment of readiness for weaning	Minimize duration of mechanical ventilation by minimizing sedative administration (including daily "sedation holidays") and/or using protocolized weaning
Catheter-associated urinary tract infection (CAUTI)	Aseptic insertion and catheter care	Use of skin antisepsis at insertion and proper aseptic technique for maintenance of catheter and drainage bag; use of closed urinary drainage system
	Prompt removal of unnecessary catheters	Removal of urinary catheter when no longer essential for care

(From: Ranji SR, Shetty K, Posley KA, et al. Prevention of healthcare-associated infections. In: Shojania KG, McDonald KM, Wachter RM, Owens DK, eds. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Technical Review 9. Rockville, MD: Agency for Healthcare Research and Quality; 2007. AHRQ Publication No. 04-0051-6.)
 
Evidence of Effectiveness

Reduced infection rates have been demonstrated following implementation of the preventive measures described in the Table, particularly for SSI and CRBSI. However, despite knowledge of effective strategies to prevent HAI, clinician adherence to these measures has long been suboptimal. Even the seemingly simple act of handwashing is routinely ignored by both physicians and nurses. More complex interventions are also not used routinely, and institutional policies on HAI prevention vary widely. Thus, recent research has focused on methods of effectively implementing preventive strategies and encouraging clinician use of these methods for all patients. A major success in this area was achieved in Michigan's "Keystone ICU" project, where implementation of a checklist for CVC insertion nearly eliminated CRBSI in ICUs throughout the state. The checklist mandated use of all of the above preventive practices before a CVC could be inserted and empowered nurses to stop physicians from performing the procedure if the checklist was not completed. The Institute for Healthcare Improvement promotes the concept of "bundles" of preventive strategies, emphasizing that the likelihood of successful prevention goes up when all of the recommended strategies are implemented.

Current Context

Reducing the risk of HAI is one of the Joint Commission's 2007 National Patient Safety Goals (NPSGs). The NPSG specifically requires adherence to hand hygiene practices and also considers death or serious disability due to HAI to be a sentinel event. Appropriate hand hygiene, influenza vaccination for health care workers, and prevention of VAP, CRBSI, and SSI are among the National Quality Forum's 30 "Safe Practices for Better Healthcare." The Institute for Healthcare Improvement's ongoing "5 Million Lives" campaign seeks to implement specific preventive measures for CRBSI, VAP, and SSI and to reduce infections due to methicillin-resistant Staphylococcus aureus (MRSA).

The large burden of disease posed by HAIs has resulted in considerable regulatory attention. The Centers for Medicare and Medicaid Services recently announced that they will not reimburse hospitals for the costs of care associated with certain HAIs, including SSI, CRBSI, and CAUTI. Public reporting of hospital-specific HAI rates is being widely discussed as a means of monitoring hospital quality of care. Currently, 20 states mandate reporting of HAI rates, and legislation supporting public reporting has been considered in nearly all US states.

One important challenge in using public reporting and payment policies to catalyze efforts to decrease HAIs is that the definitions are complex and may be subject to interpretation. For example, the utility of VAP as a quality measure is hampered by the lack of standardized diagnostic criteria. In this, as well as in other types of preventable adverse events, the adoption of standard, auditable definitions will be crucial in creating a fair playing field that is not subject to "gaming."