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Health Care-Associated Infections
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Background

Health care–associated infections (HAIs) are likely the most common complication of hospital care. According to the Centers for Disease Control and Prevention (CDC), approximately 1 in 20 hospitalized patients falls victim to an HAI, leading to nearly 100,000 deaths per year. Such infections were long accepted by clinicians as an inevitable hazard of hospitalization. However, 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)

In addition, infections caused by Clostridium difficile (a bacteria which causes severe diarrhea after exposure to antibiotics) are rapidly becoming more common in hospitals. Preventing the transmission of Clostridium difficile and antibiotic-resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) is therefore an increasing focus of attention.

Preventive Measures

Strategies to prevent infections from C. difficile primarily involve limiting antibiotic use, which is the major precipitant of these infections, and preventing patient-to-patient transmission of the bacteria through isolation procedures and clinicians' hand hygiene. Prevention of transmission of antibiotic-resistant bacteria can follow similar principles.

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

Some of the most prominent successes in the patient safety field have been achieved in the area of HAI prevention. The landmark Keystone ICU project nearly eliminated CRBSI in intensive care units (ICUs) throughout Michigan, an achievement that has been sustained over time. While the checklist that powered the intervention has garnered considerable publicity, in-depth analysis of the project identified other equally important components (such as improving safety culture). An AHRQ-sponsored initiative that extended the Keystone ICU project nationwide has also achieved dramatic reductions in CRBSI rates.

Reduced infection rates have been demonstrated for other specific HAI following implementation of the preventive measures described in the Table, and improved hand hygiene rates have been associated with lower overall HAI rates. 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, current research focuses on methods of effectively implementing preventive strategies and encouraging clinicians to use these methods for all patients.

Current Context

The large burden of disease posed by HAIs has resulted in considerable regulatory attention. The Centers for Medicare and Medicaid Services (CMS) has not reimbursed hospitals for the costs of care associated with certain HAIs, including SSI, CRBSI, and CAUTI, since 2008. Reducing the risk of HAI is one of The Joint Commission's 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."

Public reporting of hospital-specific HAI rates is also being more widely utilized as a means of monitoring hospital quality of care. Currently, 20 states mandate reporting of HAI rates, and CMS publicly reports certain HAI rates on its Hospital Compare Web site. 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. 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." Early studies of CMS's HAI reimbursement policy indicate that, perhaps due to these issues, the effect has been smaller than originally anticipated.

 
What's New in Health Care-Associated Infections on AHRQ PSNet
STUDY
Identifying critically ill patients at risk for inappropriate antibiotic therapy: a pilot study of a point-of-care decision support alert.
Micek ST, Heard KM, Gowan M, Kollef MH. Crit Care Med. 2014;42:1832-1838.
BOOK/REPORT
Advances in the Prevention and Control of HAIs.
Battles JB, Cleeman JI, Kahn KL, Weinberg DA, eds. Rockville, MD: Agency for Healthcare Research and Quality; June 2014. AHRQ Publication No. 14-0003.
STUDY
Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle.
Sacks GD, Diggs BS, Hadjizacharia P, Green D, Salim A, Malinoski DJ. Am J Surg. 2014;207:817-823.
MULTI-USE WEBSITE
Applying High Reliability Principles to Infection Prevention and Control in Long Term Care.
Oakbrook Terrace, IL: Joint Commission; 2014.
REVIEW
Strategies to enhance adoption of ventilator-associated pneumonia prevention interventions: a systematic literature review.
Goutier JM, Holzmueller CG, Edwards KC, Klompas M, Speck K, Berenholtz SM. Infect Control Hosp Epidemiol. 2014;35:998-1005.
ORGANIZATIONAL POLICY/GUIDELINES
Strategies to prevent healthcare-associated infections through hand hygiene.
Ellingson K, Haas JP, Aiello AE, et al. Infect Control Hosp Epidemiol. 2014;35:937-960.
TOOLS/TOOLKIT
Antimicrobial Stewardship Toolkit.
Chicago, IL: American Hospital Association Physician Leadership Forum; July 2014.
 
Editor's Picks for Health Care-Associated Infections
From AHRQ WebM&M
Connie's Story: A Nurse's Personal Experience with MRSA.
AHRQ WebM&M [serial online]. April 2008
Methicillin-Resistant Staphylococcus aureus.
Gary A. Noskin, MD. AHRQ WebM&M [serial online]. April 2008
Environmental Safety in the OR.
Darren R. Linkin, MD; Ebbing Lautenbach, MD, MPH, MSCE. AHRQ WebM&M [serial online]. Febuary 2004
 
From AHRQ PSNet
JOURNAL ARTICLE
An intervention to decrease catheter-related bloodstream infections in the ICU. Classic icon
Pronovost P, Needham D, Berenholtz S, et al. N Engl J Med. 2006;355:2725-2732.
Safety of patients isolated for infection control. Classic icon
Stelfox HT, Bates DW, Redelmeier DA. JAMA. 2003;290:1899-1905.
Methicillin-resistant Staphylococcus aureus central line–associated bloodstream infections in US intensive care units, 1997-2007.
Burton DC, Edwards JR, Horan TC, Jernigan JA, Fridkin SK. JAMA. 2009;301:727-736.
Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections. Classic icon
Jain R, Kralovic SM, Evans ME, et al. N Engl J Med. 2011;364:1419-1430.
The effect of hospital-acquired Clostridium difficile infection on in-hospital mortality. Classic icon
Oake N, Taljaard M, van Walraven C, Wilson K, Roth V, Forster AJ. Arch Intern Med. 2010;170:1804-1810.
The wisdom and justice of not paying for "preventable complications." Classic icon
Pronovost PJ, Goeschel CA, Wachter RM. JAMA. 2008;299:2197-2199.
WEB RESOURCE
National Patient Safety Goals.
Oakbrook Terrace, IL: The Joint Commission; 2013.
PreventInfection.org.
Association for Professionals in Infection Control and Epidemiology.
BOOK/REPORT
Better: A Surgeon's Notes on Performance.
Gawande A. New York, NY: Metropolitan Books; 2007. ISBN: 0805082115.
TOOLS/TOOLKIT
10 Patient Safety Tips for Hospitals. Classic icon
Rockville, MD: Agency for Healthcare Research and Quality; Revised December 2009. AHRQ Publication No. 10-M008.
Preventing Infections in the Hospital—What You As a Patient Can Do.
Chicago, IL: National Patient Safety Foundation.
NEWSPAPER/MAGAZINE ARTICLE
The checklist. Classic icon
Gawande A. The New Yorker. December 10, 2007;83:86-95.
LEGISLATION/REGULATION
A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals. Classic icon
Yokoe DS, Mermel LA, Anderson DJ, et al. Infect Control Hosp Epidemiol. 2008;29:901-994.
 
Last Updated: October 2012