Improving Patient Safety Through Infection Control: A New Healthcare Imperative, DC Classen

Tags: Control Hosp Epidemiol, National Quality Forum, Clin Infect Dis, prevention, Staphylococcus aureus, infection control, Healthcare Infection Control Practices Advisory Committee, intensive care units, Healthcare Epidemiology, intensive care unit, recommendations, healthcare-associated infections, nosocomial infection, methicillin-resistant Staphylococcus aureus, Joint Public Policy Committee, nosocomial infections, surgical site infection, C. difficile, Society for Healthcare Epidemiology of America, urinary tract infection, acute care hospitals, Duke University Medical Center, Hackensack University Medical Center, bloodstream infections, Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, urinary tract infections, National Voluntary Consensus Standards, The Joint Commission, methicillin resistant Staphylococcus aureus, Washington, DC, Ann Intern Med, National, National Healthcare Safety Network, Acute Care Hospitals Deverick J. Anderson, Periodic Health Examination, S51 infection control and hospital epidemiology, Clin Perform Qual Health Care, Urinary catheter, Lucet J. Duration, educational program, Intensive Care, Kluytmans J. Performance, Gatermann S. Qualitative, active surveillance, surveillance, Infection control guidelines, David Classen, care facility, Washington University School of Medicine, Patient Safety, risk factors, Harvard Medical School, Sanjay Saint, MD, Rush University Medical Center, Clostridium difficile infection, Clostridium difficile, healthcare facilities, the University of Utah, Westin La Paloma Resort, Medical University of South Carolina, University of Manitoba, University of Michigan Medical School, Institute for Healthcare Improvement, National Academy Press, hand hygiene, National Academies Press, Infection Control and Epidemiology, Hospital Infection Control Practices Advisory Committee, Warren Alpert Medical School of Brown University, risk factor, Loyola University Chicago Stritch School of Medicine, The Canadian Hospital Epidemiology Committee, University of Pennsylvania, Johns Hopkins Medical Institutions and University, Canadian Infectious Diseases Society, Hospital Quality Initiative
Content: June 1­3, 2009 · Westin La Paloma Resort · Tucson, Arizona Improving Patient Safety Through Infection Control: A New Healthcare Imperative Presented by: Dr. David C. Classen MD, MS Vice President, CSC Dr. David C. Classen MD, M.S. is Associate Professor of Medicine at the University of Utah and Consultant in Infectious Diseases, and a Senior Partner at CSC, leading CSC's clinical excellence, safety, and quality of healthcare initiatives. He co-chairs the National Quality Forum's Patient Safety Common Formats Expert Panel, having also co-chaired the NQF Patient Safety Taxonomy Steering Committee. Dr. Classen is well known for his research in the use of trigger tools, and is a developer of the "Trigger Tool Methodology" at IHI used for the improved detection of adverse events ­ currently used by more than 150 healthcare organizations throughout the US and Europe. Dr. Classen will present Improving Patient Safety Through Infection Control: A New Healthcare Imperative at 9:30 am during Tuesdays general session. He will also co-present Trigger Tools -- A Best Practice Model for Successful Process Improvement at a 1:00 pm breakout session on Tuesday.
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S81 infection control and hospital epidemiology october 2008, vol. 29, supplement 1 supplement article: shea/idsa practice recommendation Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals Erik R. Dubberke, MD; Dale N. Gerding, MD; David Classen, MD, MS; Kathleen M. Arias, MS, CIC; Kelly Podgorny, RN, MS, CPHQ; Deverick J. Anderson, MD, MPH; Helen Burstin, MD; David P. Calfee, MD, MS; Susan E. Coffin, MD, MPH; Victoria Fraser, MD; Frances A. Griffin, RRT, MPA; Peter Gross, MD; Keith S. Kaye, MD; Michael Klompas, MD; Evelyn Lo, MD; Jonas Marschall, MD; Leonard A. Mermel, DO, ScM; Lindsay Nicolle, MD; David A. Pegues, MD; Trish M. Perl, MD; Sanjay Saint, MD; Cassandra D. Salgado, MD, MS; Robert A. Weinstein, MD; Robert Wise, MD; Deborah S. Yokoe, MD, MPH
purpose Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their Clostridium difficile infection (CDI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America "Compendium of Strategies to Prevent Healthcare-Associated Infections" Executive Summary and Introduction and accompanying editorial for additional discussion. section 1: rationale and statements of concern 1. Increasing rates of CDI C. difficile now rivals methicillin-resistant Staphylococcus aureus (MRSA) as the most common organism to cause healthcare-associated infections in the United States.1 a. In the United States, the proportion of hospital discharges in which the patient received the International Classification of Diseases, Ninth Revision discharge diagnosis code for CDI more than doubled between 2000 and 2003,1
and CDI rates continued to increase in 2004 and 2005 (L. C. McDonald, MD, personal communication, July 2007). These increases have been seen in pediatric and adult populations, but elderly individuals have been disproportionately affected.1 CDI incidence has also increased in Canada and Europe.2-4 b. There have been numerous reports of an increase in CDI severity.2-6 c. Most reports of increases in the incidence and severity of CDI have been associated with the BI/NAP1/027 strain of C. difficile.2-6 This strain produces more toxins A and B in vitro than do many other strains of C. difficile, produces a third toxin (binary toxin), and is highly resistant to fluoroquinolones. 2. Outcomes associated with CDI CDI is associated with increased lengths of hospital stay, costs, morbidity, and mortality among adult patients. Data on the changing epidemiology of CDI in pediatric patients are limited and are confounded by the prevalence of asymptomatic carriage of C. difficile among children younger than 12 months of age.7,8 a. CDI increases mean length of hospital stay from 2.6 days to 4.5 days.9,10
From the Washington University School of Medicine, St. Louis, Missouri (E.R.D., V.F., J.M.); the Loyola University Chicago Stritch School of Medicine (D.N.G.), the Stroger (Cook County) Hospital and the Rush University Medical Center (R.A.W.), Chicago, the Joint Commission, Oakbrook Terrace (K.P., R.W.), and the Hines Veterans Affairs Medical Center, Hines (D.N.G.), Illinois; the University of Utah, Salt Lake City (D.C.); the Association for Professionals in Infection Control and Epidemiology (K.M.A.) and the National Quality Forum (H.B.), Washington, D.C.; the Duke University Medical Center, Durham, North Carolina (D.J.A., K.S.K.); the Mount Sinai School of Medicine, New York, New York (D.P.C.); the Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania (S.E.C.); the Institute for Healthcare Improvement, Cambridge (F.A.G.), and the Brigham and Women's Hospital and Harvard Medical School, Boston (M.K., D.S.Y.), Massachusetts; the Hackensack University Medical Center, Hackensack (P.G.), and the University of Medicine and Dentistry­New Jersey Medical School, Newark (P.G.), New Jersey; the Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island (L.A.M.); the David Geffen School of Medicine at the University of California, Los Angeles (D.A.P.); the Johns Hopkins Medical Institutions and University, Baltimore, Maryland (T.M.P.); the Ann Arbor Veterans Affairs Medical Center and the University of Michigan Medical School, Ann Arbor, Michigan (S.S.); the Medical University of South Carolina, Charleston (C.D.S.); and the University of Manitoba, Winnipeg, Canada (E.L., L.N.). Accepted May 27, 2008; electronically published September 16, 2008. Infect Control Hosp Epidemiol 2008; 29:S81­S92 2008 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2008/2910S1-0009$15.00. DOI: 10.1086/591065
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b. Attributable costs of inpatient CDI have been estimated to be $2,470-$3,669 per episode. Attributable inpatient costs during the 6 months after CDI diagnosis are $5,042-$7,179.10,11 US hospital costs for CDI management have been estimated to be $3.2 billion per year.12 c. Patients with CDI were almost twice as likely to be discharged to a long-term care facility than were propensity score­matched control individuals.9 d. CDI has recently been associated with an attributable mortality rate of 6.9% at 30 days after diagnosis and 16.7% at 1 year.3,4,9 3. Changing risk factors and possible decrease in CDI treatment response rates a. Fluoroquinolones, previously infrequently associated with CDI, have been found to be one of the primary predisposing antimicrobials in recent studies.3,6,13,14 i. Virtually every antibiotic has been associated with CDI. Cephalosporins, ampicillin, and clindamycin remain important predisposing antibiotics. b. Gastric acid suppression has been recognized as a risk factor for CDI in some studies.14,15 i. Some studies suggest that the association between gastric acid suppression and CDI are related to other important risk factors, such as severity of illness and age.14,16 ii. Gastric acid suppression may be an important risk factor for CDI outside of healthcare facilities.15 c. Several studies suggest that rates of response to treatment of CDI with metronidazole are declining; these studies include a randomized, prospective, blinded, and severity-stratified study that demonstrated statistically superior rates of response to vancomycin treatment for severe disease but not for mild disease, compared with metronidazole treatment.17-19 section 2: strategies to detect cdi 1. Surveillance definitions Definitions for CDI surveillance in the United States and Europe have recently been published.20,21 a. In the United Kingdom, all cases of CDI in patients older than 65 years of age have been reported to the healthcare-associated infection surveillance system for National Health Service Acute Trusts in England since January 2004.22 Reporting for all CDI cases in patients older than 2 years of age started in April 2007.23 b. The Canadian Hospital Epidemiology Committee, a joint initiative of the Canadian Infectious Diseases Society and the Canadian Nosocomial Infection Surveillance Program, used a standard definition for CDI surveillance to track nosocomial CDI over a 4-month period in 1997 and after 2005 in healthcare facilities across Canada24 (M. Miller, MD, personal communication, December 2007). c. Data are lacking to determine the ideal definition for
healthcare-associated CDI. However, this is a minor limitation in light of the need for a standardized surveillance definition for CDI. The following information focuses on the definitions for CDI surveillance in the United States and Europe.20,21 i. A CDI case is defined as a case of diarrhea or toxic megacolon without other known etiology that meets 1 or more of the following criteria: (1) the stool sample yields a positive result of a laboratory assay for C. difficile toxin A and/or B, or a toxin-producing C. difficile organism is detected in the stool sample by culture or other means; (2) pseudomembranous colitis is seen on endoscopic examination or surgery; and (3) pseudomembranous colitis is seen on histopathological examination. ii. Several CDI definitions are proposed, including community-associated CDI; community-onset, healthcare facility­associated CDI; and recurrent CDI. Healthcare facilities should track at least healthcare facility­ onset, healthcare facility­associated CDI (Table 1).20,21 iii. Surveillance for CDI is limited by the use of non­ culture-based methods to diagnose CDI, such as stool toxin assays, which have lower sensitivity than does C. difficile stool culture.20-22,24-27 2. Identifying patients with CDI Positive results of diarrheal stool tests for toxigenic C. difficile or its toxins are the most common methods used to identify patients with CDI.20-22,24 a. Positive results of diarrheal stool tests should automatically be sent to infection prevention and control professionals and to clinicians caring for the patient. b. Only diarrheal stools should be tested for C. difficile or its toxins. A positive result of a test for toxigenic C. difficile and/or its toxins in a patient with diarrhea is considered to be diagnostic for CDI. However, some centers permit C. difficile testing of nondiarrheal stools. In such cases, review of patient records is required to ensure that the patient has symptoms consistent with CDI. i. Because of the high prevalence of asymptomatic carriage of toxigenic C. difficile among infants younger than 1 year of age, testing should be conducted only for infants with diarrhea along with investigation of alternative causes of diarrhea.7,8 Detection of C. difficile toxin should not be assumed to be causative of diarrhea in these infants, although infants older than 6 months of age who are colonized have been shown to have a higher frequency of all-cause diarrhea than do noncolonized infants.28,29 c. A minority of patients have CDI diagnosed by visualization of pseudomembranes by endoscopy and/or histopathologic analysis, without positive stool test results. 3. Methods for surveillance of CDI a. Conducting CDI surveillance to determine CDI rates provides a measure to determine the burden of CDI at a
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table 1. Clostridium difficile Infection (CDI) Surveillance Definitions
CDI case type
Definition
Healthcare facility onset, healthcare facility associated Community onset, healthcare facility associated Community associated Indeterminate onset Unknown Recurrent
Symptom onset 148 h after admission to a healthcare facility Symptom onset in the community or X48 h after admis- sion, provided that symptom onset was !4 weeks after the last discharge from a healthcare facility Symptom onset in the community or X48 h after admission to a healthcare facility, provided that symptom onset was 112 weeks after the last discharge from a healthcare facility Case does not fit any of the above criteria for an exposure setting (eg, onset in the community 14 weeks but !12 weeks after the last discharge from a healthcare facility) Exposure setting cannot be determined, because of a lack of available data Episode occurred X8 weeks after the onset of a previous episode, provided that CDI symptoms from the earlier episode resolved
note. Definitions are from McDonald et al.20 and Kuijper et al.21 When laboratory-based reporting of symptoms is used, the date and time of stool specimen collection can be used as a surrogate for symptom onset. If data on the time a patient was admitted (in addition to date) and/or the time stool was collected for testing are not available, CDI can be considered to be healthcare facility onset if stool is positive for toxigenic C. difficile or a C. difficile toxin after the third calendar day after hospital admission, where the first day is the day of admission (ie, a patient admitted on Monday with stool first positive for C. difficile toxin on Thursday or later is considered to have healthcare facility­onset CDI).
healthcare facility. These data are also used to assess the efficacy of interventions to prevent CDI. When they are reported back to healthcare providers and hospital administrators, CDI rates can be applied as a tool to improve adherence to CDI Preventive Measures. b. Surveillance can be performed on specific wards or units and/or at the level of the entire healthcare facility. c. Laboratories performing C. difficile testing should report results to infection prevention and control professionals daily. The CDI rate can be expressed as the number of CDI case patients per 10,000 patient-days. i. This rate is calculated as follows: (number of case patients/number of patient-days per reporting period) # 10,000 p rate per 10,000 patient-days.19 ii. To convert the rate per 10,000 patient-days to the rate per 1,000 patient-days, divide the rate by 10 (conversely, to convert a rate from 1,000 patient-days to 10,000 patient-days, multiply the rate by 10). d. Because of a lack of published data on CDI surveillance using similar case-finding methods and surveillance definitions, specific definitions for what constitutes an "outbreak" or "hyperendemic" rate cannot be provided at this time. i. An outbreak can be defined as an increase in CDI rate in time and/or space believed to be greater than that expected by chance alone. ii. A hyperendemic rate can be defined as a persistently elevated CDI rate compared with past rates or compared with rates in other, similar healthcare facilities.
section 3: strategies to prevent cdi 1. Existing guidelines and recommendations a. Published guidelines for the management of CDI are few, and only some address CDI prevention.22,25-27 i. Most data published on CDI prevention are from before-after studies conducted in response to outbreaks. Often, several concomitant interventions are performed, making it difficult to determine the relative importance of one intervention compared with another. Before-after studies are also limited by time-related biases that are difficult to adjust for in the absence of a control group or properly conducted analyses, such as interrupted time series analysis.30,31 However, 2 recent studies have used these techniques, demonstrating the importance of antimicrobial stewardship and its role in preventing CDI.31,32 b. Less is known about the mechanisms and prevention of C. difficile transmission, compared with other antimicrobial-resistant gram-positive organisms, such as MRSA and vancomycin-resistant enterococcus (VRE). Although these 3 organisms have many common epidemiologic characteristics, C. difficile and VRE, in particular, share risk factors for transmission.33 The major difference among these 3 organisms is that C. difficile forms spores, whereas the other 2 do not. The formation of spores has novel (as yet unknown) implications for methods of hand hygiene and environmental disinfection, because C. difficile spores are resistant to the bactericidal effects of alcohol and most hospital disinfectants.
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c. General strategies to prevent CDI, per previously published guidelines,22,24-27 include the following: i. Methods of reducing the risk of CDI if the organism is encountered by the patient (a) Follow antimicrobial usage restriction and stewardship guidelines. ii. Methods of preventing the patient from being exposed to C. difficile (disinfection and barrier methods) (a) Avoid the use of electronic thermometers; the handles become contaminated with C. difficile. (b) Use dedicated patient care items and equipment; if items must be shared, clean and disinfect the equipment between patients. (c) Use full barrier precautions (gowns and gloves) for contact with patients with CDI and for contact with their body substances and environment (contact precautions). (d) Place patients with CDI in private rooms, if available; give isolation preference to patients with fecal incontinence if room availability is limited. (e) Perform meticulous hand hygiene based on Centers for Disease Control and Prevention or World Health Organization guidelines before and after entering the room of a patient with CDI, with soap and water or an alcohol-based hand-hygiene product (in routine settings or settings of endemicity). Perform hand hygiene with soap and water preferentially, instead of alcohol hand hygiene products, after caring for a patient with CDI in outbreak settings or settings of hyperendemicity. Ensure that proper hand-hygiene techniques are used when hand washing with soap and water is employed.34 (f) Perform environmental decontamination of rooms housing patients with CDI, using sodium hypochlorite (household bleach) diluted 1 : 10 with water, in an outbreak setting or setting of hyperendemicity. (g) Educate healthcare personnel and hospital administration about the clinical features, transmission, and epidemiology of CDI. d. Other important principles to be aware of when caring for patients with CDI include the following:22,25-27 i. Perform testing for C. difficile only on unformed diarrheal stools (toxin testing of formed stool is strongly discouraged). ii. Do not give prophylactic antimicrobial CDI therapy (eg, with metronidazole or vancomycin) to patients at high risk for CDI. iii. Do not treat or attempt to decolonize asymptomatic C. difficile carriers. Antimicrobial therapy is not effective for decolonization. iv. Do not conduct repeated testing for C. difficile if a patient has had a stool sample positive for C. difficile, unless symptoms resolved with treatment and then re-
turned after treatment (ie, do not perform test of cure in patients successfully treated for CDI). 2. Infrastructure requirements a. Trained infection prevention and control personnel i. Infection prevention and control personnel must have knowledge about risk factors for and methods to prevent CDI. They must also be trained in how to determine when a case of CDI is healthcare associated and how to calculate CDI rates.20,21 b. Method to identify patients with CDI i. Infection prevention and control personnel must be able to identify patients with CDI as soon as possible after their condition is diagnosed. This is necessary to ensure that patients are placed under contact precautions in a timely fashion. These data can also be used to calculate CDI rates. c. Ability to place patients with CDI under contact precautions i. Contact precautions require the ability to place pa- tients in a private room (preferably) or to cohort patients with CDI, as well as to place materials necessary for compliance with contact precautions (eg, gowns and gloves) in an easily accessible space outside of the patient's room. ii. Place a sign indicating that the patient is under contact precautions outside of the patient's room. iii. If there is a limited number of single-bed rooms, patients with stool incontinence should preferentially be placed in these rooms. iv. If it is necessary to cohort patients, cohort patients who are colonized or infected with the same organism(s) (eg, do not cohort patients with CDI who are discordant in their VRE or MRSA colonization status). v. Have systems in place to facilitate communication among infection prevention and control, admitting, nursing, and housekeeping departments and develop contingency plans for conditions of limited bed availability. d. Provide educational materials for patients, family members, and healthcare personnel that include explanations of CDI, why contact precautions are necessary, and the importance of hand hygiene. e. Provide adequate resources and training for housekeeping personnel to ensure proper cleaning of rooms. 3. Initiating a CDI prevention program a. Pilot test the intervention in 1 patient care location to assess efficacy. i. Perform CDI surveillance to determine locations where CDI rates are highest. ii. Initiate the prevention program where there is a high concentration of patients at risk for CDI, such as an intensive care unit or an oncology ward. iii. Start in 1 patient care location.
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(a) Identify opportunities to improve the system for identifying patients with CDI. (b) Identify opportunities to improve the process for placing patients with CDI under contact precautions and to minimize problems for family members, visitors, and healthcare personnel. iv. Obtain the support of hospital administration and local physician and nursing leadership before starting the program. b. Use process and outcome measures to determine whether the intervention is effective. c. Replicate the CDI infection prevention and control program in other patient care areas when it is determined that the systems developed are effective. section 4: recommendations for implementing prevention and monitoring strategies Recommendations for preventing and monitoring CDI are summarized in the following section. They are designed to assist acute care hospitals in prioritizing and implementing their CDI prevention efforts. Criteria for grading the strength of recommendation and quality of evidence are described in Table 2. I. Basic practices for prevention and monitoring of CDI: recommended for all acute care hospitals A. Components of a CDI prevention program 1. Use contact precautions for infected patients, with a single-patient room preferred (A-II for hand hygiene, A-I for gloves, B-III for gowns, and B-III for single-patient room).22,25-27 a. Place patients with CDI under contact precautions to help reduce patient-to-patient spread of the organism. i. Place patients in private rooms when available.
ii. Don gown and gloves on entry to the patient's room. (a) Gloves should be changed immediately if visibly soiled and after touching or handling surfaces or materials contaminated with feces. iii. Remove gown and gloves before exiting the room. iv. Conduct Centers for Disease Control and Prevention­ or World Health Organization­compliant hand hygiene on exiting the patient's room. v. Cohorting patients with CDI is acceptable when single, private rooms are not available. (a) Place patients with stool incontinence preferentially in private rooms. (b) Do not cohort patients who have discordant status of infection or colonization with other epidemiologically important organisms (eg, VRE and MRSA). (c) Remove gowns and gloves and perform hand hygiene when moving from one patient to another. b. Ensure that adequate supplies for contact precautions are readily available. i. Management leaders are responsible to ensure that necessary barrier-equipment supplies (eg, gowns and gloves) and hand-hygiene products are readily available. ii. Assign responsibility for monitoring the availability and restocking of supplies to specific healthcare personnel. c. Criteria for discontinuing contact precautions i. The Centers for Disease Control and Prevention currently recommends contact precautions for the duration of illness when caring for patients with CDI.36 Some experts recommend continuing contact precautions for at least 48 hours after diarrhea resolves. Areas of controversy include the following: (a) Asymptomatically colonized patients (including, in many cases, those successfully treated for CDI)
table 2. Strength of Recommendation and Quality of Evidence
Category/grade
Definition
Strength of recommendation A B C Quality of evidence I II III
Good evidence to support a recommendation for use Moderate evidence to support a recommendation for use Poor evidence to support a recommendation Evidence from x1 properly randomized, controlled trial Evidence from x1 well-designed clinical trial, without randomization; from cohort or case-control analytic studies (preferably from 11 center); from multiple time series; or from dramatic results from uncontrolled experiments Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
note. Adapted from the Canadian Task Force on the Periodic Health Examination.35
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continue to shed C. difficile spores, but the number of spores and degree of contamination is not as great as for patients with active CDI. There are currently no data to support isolation of these asymptomatic patients.37-39 (b) Prolonging the duration of contact isolation for patients with CDI is recommended when CDI is not effectively controlled by the use of basic practices (see below: II. Special Approaches for the Prevention of CDI). Similarly, there are no data to indicate the efficacy of this practice at this time. 2. Ensure cleaning and disinfection of equipment and the environment (B-III for equipment and B-II for the environment). a. C. difficile spores contaminate the environment in which patients are housed and the equipment used to care for them.26,27,37-39 This includes the following: i. Furnishings in the room, including over-bed tables, bed rails, furniture, sinks, floors, commodes, and toilets ii. Patient care equipment that directly touches patients, such as thermometers, stethoscopes, and blood pressure cuffs iii. "High-touch" (ie, frequently touched) surfaces, such as door knobs and intravenous fluid pumps b. C. difficile appears to contaminate very few surfaces outside patient rooms.37 c. Contaminated surfaces and equipment are potential reservoirs for transmission of C. difficile. i. Recent guidelines have outlined environmental disinfection protocols.40 There are no US Environmental Protection Agency­registered products specific for inactivating C. difficile spores. Data are conflicting as to whether inactivation of spores is necessary to prevent C. difficile transmission, especially in a setting of endemicity. ii. Facilities should consider using a 1 : 10 dilution of sodium hypochlorite (household bleach) for environmental disinfection in outbreak settings and settings of hyperendemicity in conjunction with other infection prevention and control measures (see below: II. Special Approaches for the Prevention of CDI). The bleach solution should have a contact time of at least 10 minutes.41 d. Develop and implement protocols for disinfection of equipment and the environment. i. On a routine basis, assess adherence to protocols and the adequacy of cleaning. ii. Assess the adequacy of cleaning before changing to a new cleaning product (eg, bleach). If cleaning is not adequate, address this before changing products (see below: II. Special Approaches for the Prevention of CDI). iii. Because of the high turnover of housekeeping personnel, educate personnel on proper cleaning technique frequently. Ensure that education is provided in the personnel's native language.
e. Dedicate noncritical patient care items, such as blood pressure cuffs, stethoscopes, and thermometers, to a single patient with CDI. i. When this is not possible, ensure adequate cleaning and disinfection of shared items between patient encounters. Ensure that the manufacturers' recommendations for contact time of disinfectants are followed. 3. Implement a laboratory-based alert system to provide immediate notification to infection prevention and control personnel and clinical personnel about patients with newly diagnosed CDI (B-III). a. To place patients with CDI under contact precautions in a timely manner, it is important that an alert system be developed between the laboratory and both infection prevention and control personnel and clinical personnel caring for the patient. This alert system should immediately notify infection prevention and control and clinical personnel when a patient has newly diagnosed CDI. b. There are a variety of methods by which this information can be transmitted, but some options include fax alerts, phone call and pager alerts, or automated secure electronic alerts. i. The alert system should not rely on fax transmissions alone, because there may be delays from the time the transmission is received to the time it is seen by an appropriate healthcare provider. c. Alert patient care areas of positive test results immediately, so that these patients can be placed under contact precautions. d. When a patient has active CDI, communicate the CDI status when transferring the patient to another healthcare facility, so that appropriate precautions can be implemented at the accepting facility. 4. Conduct CDI surveillance and analyze and report CDI data (B-III). a. At a minimum, calculate healthcare facility­onset, healthcare facility­associated CDI rates at the unit/ward and organizational levels (Table 1).20,21 b. Provide CDI data and other CDI prevention process and outcome measures to key stakeholders, including senior leadership, physicians, nursing staff, and other clinicians. c. Provide the process and outcome measures outlined in the "performance measures" section below to appropriate hospital staff and administrators on a regular basis. The frequency with which these data are provided will depend on the hospital's existing reporting structure and the type of data collected. These data can be added to routine quality assessment and performance improvement reports. 5. Educate healthcare personnel, housekeeping personnel, and hospital administration about CDI (B-III).
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a. Include risk factors, routes of transmission, local CDI epidemiology, patient outcomes and treatment, and prevention measures (including Centers for Disease Control and Prevention and World Health Organization recommendations regarding proper hand hygiene, contact precautions, and management of multidrug-resistant organisms).34,42,43 6. Educate patients and their families about CDI, as appropriate (B-III). a. Although often not considered part of a program to reduce transmission of multidrug-resistant organisms, proper education may help to alleviate patient fears regarding being placed in isolation.44 i. Include information about anticipated questions: general information about CDI, colonization versus infection, the hospital's CDI prevention program, the components of and rationale for contact precautions, and the risk of transmission to family and visitors while in the hospital and after discharge. Helpful materials might include patient education sheets in appropriate language(s) and the use of patient education channels, Web sites, or VHS tapes and DVDs.
agement are responsible for ensuring that the healthcare system supports an infection prevention and control program that effectively prevents CDI and the transmission of epidemiologically significant pathogens. 2. Senior management is accountable for ensuring that an adequate number of trained personnel are assigned to the infection prevention and control program. 3. Senior management is accountable for ensuring that healthcare personnel, including licensed and nonlicensed personnel, are competent to perform their job responsibilities. 4. Direct healthcare providers (such as physicians, nurses, aides, and therapists) and ancillary personnel (such as housekeeping and equipment-processing personnel) are responsible for ensuring that appropriate infection prevention and control practices are used at all times (including hand hygiene, standard and isolation precautions, and cleaning and disinfection of equipment and the environment). 5. Hospital and unit leaders are responsible for holding personnel accountable for their actions.
7. Measure compliance with Centers for Disease Control and Prevention or World Health Organization hand-hygiene and contact precaution recommendations (B-III). a. Patient-to-patient transmission of C. difficile is thought to occur primarily through transient contamination of the hands of healthcare personnel with spores. b. Glove use when caring for patients with CDI or touching surfaces in their rooms has been shown to be effective at preventing the transmission of C. difficile. c. Hand-hygiene practices in compliance with Centers for Disease Control and Prevention or World Health Organization guidelines are critical to C. difficile control and prevention. Evidence-based recommendations for implementation and assessment of hand-hygiene programs in healthcare settings have been published.34 i. Area of controversy: There are concerns regarding reliance on alcohol-based hand-hygiene products, because alcohol is not sporicidal. Conversely, hand washing with soap and water is associated with much lower compliance. In settings where CDI is endemic, it appears the potential decrease in efficacy of alcohol-based hand-hygiene products for removing spores, compared with hand washing, may be offset by the increase in handhygiene adherence with alcohol-based hand-hygiene products, if contact precautions are followed (ie, if gloves and gowns are worn) when caring for patients with CDI.45 B. Accountability 1. The hospital's chief executive officer and senior man-
6. The person who manages the infection prevention and control program is responsible for ensuring that an active program to identify CDI is implemented, that data on CDI are analyzed and regularly provided to those who can use the information to improve the quality of care (eg, unit staff, clinicians, and hospital administrators), and that evidencebased practices are incorporated into the program. 7. Personnel responsible for healthcare personnel and patient education are accountable for ensuring that appropriate training and educational programs to prevent CDI are developed and provided to personnel, patients, and families. 8. Personnel from the infection prevention and control program, the laboratory, and information technology departments are responsible for ensuring that systems are in place to support the surveillance program. II. Special approaches for the prevention of CDI Perform a CDI risk assessment. These special approaches are recommended for use in locations and/or populations within the hospital that have unacceptably high CDI rates despite implementation of the basic CDI prevention strategies listed above. There are several unresolved issues regarding CDI prevention. This is apparent when reviewing the rankings of each recommendation on the basis of the quality of the data to support it. As a result, implementation of the recommendations beyond the basic practices to prevent CDI should be individualized at each healthcare facility. One may consider a "tiered" approach in which recommendations are instituted
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individually or in groups; additional "tiers" are added if CDI rates do not improve, with implementation of basic practices as the first tier. A. Approaches to minimize C. difficile transmission by healthcare personnel 1. Intensify the assessment of compliance with process measures (B-III). a. Contact precautions: Gowns and gloves should be worn by all healthcare personnel who enter the rooms of patients under contact precautions. b. Hand hygiene: Hand hygiene should be performed on entry and exit from patient rooms. When hand washing is performed, determine whether proper techniques are being used (eg, hand washing for at least 15 seconds).34 c. If hand-hygiene compliance or techniques are not adequate, conduct interventions to improve hand-hygiene compliance and techniques. 2. Perform hand hygiene with soap and water as the preferred method before exiting the room of a patient with CDI (B-III). a. Ensure proper hand-hygiene technique when using soap and water.34 b. Be aware that hand-hygiene adherence may decrease when soap and water is the preferred method. i. Additional education may be necessary to remind healthcare workers that alcohol-based hand-hygiene products are superior to hand washing for non­sporeforming organisms (eg, MRSA). 3. Place patients with diarrhea under contact precautions while C. difficile test results are pending (B-III). a. To decrease transmission, it is essential to place symptomatic patients under contact precautions as soon as diarrhea symptoms are recognized. b. If the results of C. difficile testing are negative, the patient has a low pretest probability of CDI, and the patient is continent of stool, contact precautions can be discontinued. i. Because of concerns about the low sensitivity of enzyme immunoassays, clinical suspicion of CDI should outweigh negative test results for patients with a high pretest probability of having CDI. 4. Prolong the duration of contact precautions after the patient becomes asymptomatic until hospital discharge (BIII). a. Patients may still shed C. difficile in their stool after diarrhea resolves.46-48 B. Approaches to minimize CDI transmission from the environment 1. Assess the adequacy of room cleaning (B-III).
a. If room cleaning practices are deemed to be inadequate, focus on improving room cleaning techniques. b. Important issues to address include proper dilution of cleaning products, adequacy of cleaning technique, cleaning "high-touch" surfaces, frequency of changing rags/ mop water, and moving from "clean" areas to "dirty" areas. i. Create a checklist based on cleaning protocols and perform observations to monitor cleaning practice. ii. Environmental culture for C. difficile is difficult to perform and requires specialized media; therefore, it is not routinely recommended.49 c. Consider environmental decontamination with sodium hypochlorite if room cleaning is deemed to be adequate but there is ongoing CDI transmission (see below). 2. Use sodium hypochlorite (bleach)­containing cleaning agents for environmental cleaning. Implement a system to coordinate with the housekeeping department if it is determined that sodium hypochlorite is needed for environmental disinfection (B-II). a. Area of controversy: Data on the ability of diluted sodium hypochlorite or other sporicidal agents used for environmental decontamination to control CDI have not been consistent. However, a beneficial effect has been reported when bleach has been used in outbreak settings or settings of hyperendemicity, typically in conjunction with other enhanced CDI control measures.40,50-53 b. When diluted sodium hypochlorite is instituted for environmental decontamination, it is necessary to coordinate activities with housekeeping staff. i. Clinical, infection prevention and control, and housekeeping staff will need to determine the location, type, and frequency of diluted sodium hypochlorite use. For instance: (a) All rooms, only rooms of patients with CDI, or outside of patient rooms? (b) Daily cleaning or terminal cleaning only when the patient is discharged or transferred? c. When diluted sodium hypochlorite is used, it is important to address the following issues: i. Avoid toxicity to patients and staff and damage to equipment and the environment from bleach use. Sodium hypochlorite can be corrosive and irritating to patients, housekeeping staff, and other healthcare personnel. ii. The sodium hypochlorite solution must be mixed fresh daily. d. When sodium hypochlorite will be used only in the rooms of patients with CDI, a system will need to be created to identify these patients to the housekeeping staff. C. Approaches to reduce the risk of CDI acquisition 1. Initiate an antimicrobial stewardship program (AII).22,25-27,32,54,55
strategies for prevention of cdi S89
a. Assess the appropriateness of antimicrobial prescribing practices. i. Restrict antimicrobials that are strongly associated with CDI and promote appropriate antimicrobial use. III. Approaches that should not be considered a routine part of CDI prevention 1. Do not test patients without signs or symptoms of CDI for C. difficile (B-II). a. C. difficile toxin tests have been studied in patients with symptoms of CDI and a high pretest probability of having CDI. A positive C. difficile toxin test result for a patient without symptoms has a high probability of being a false-positive result. i. Only stool culture for C. difficile has been confirmed to identify patients with asymptomatic C. difficile colonization. The sensitivity, specificity, and negative and positive prediction values of antigen and toxin assays are unknown for asymptomatic patients. b. Obtaining stool specimens requires nursing time to collect and laboratory technician time to perform the test and report results. c. A positive toxin test result for an asymptomatic patient may result in the initiation of unnecessary treatment for CDI, which may increase the patient's risk of developing CDI in the future.56 d. Do not place patients with asymptomatic C. difficile colonization under contact precautions. i. Area of controversy: Previous research has demonstrated that asymptomatically colonized patients can be a source of transmission of C. difficile and that patients can remain colonized after symptoms cease.38,39,47-49 However, asymptomatically colonized patients are less likely than symptomatic patients to contaminate their surrounding environment or serve as a source of transmission. In some settings, the duration of contact precautions can be extended if there is concern that asymptomatically colonized patients represent a significant source of potential C. difficile exposure. e. Do not attempt to decolonize asymptomatic patients, because this has not been effective and may increase the patient's risk of developing CDI in the future.56 2. Do not repeat C. difficile testing at the end of successful therapy for a patient recently treated for CDI (B-III). a. A positive test result may result in unnecessary prolongation of contact precautions and CDI treatment. i. In some settings, contact precautions may be extended until hospital discharge after symptom resolution (see above). However, there are insufficient data to recommend extending the duration of contact precautions on the basis of whether C. difficile or its toxins can be detected in the patient's stool.
b. A positive test result at the end of therapy does not predict who will develop a recurrence or relapse.48 c. Repeated C. difficile testing does not provide any useful clinical information but requires nursing time to collect the specimen and laboratory technician time to perform the test and report results.48 IV. Unresolved issues 1. Use of gowns and gloves by family members and other visitors a. The utility of requiring family members and other visitors to wear gowns and gloves to prevent C. difficile transmission is unknown.57 The risk that family members and other visitors will transmit C. difficile between patients is likely to be related to the degree of contact the visitor has with the patient and the patient's environment, whether the visitor performs hand hygiene, and the degree of interaction the visitor has with other patients. At a minimum, family members and other visitors should be instructed to perform hand hygiene whenever entering or leaving the patient's room. 2. Standing orders or nurse-driven protocols to test all patients with diarrhea for C. difficile a. Nurses frequently know, before the treating physician does, when a patient has diarrhea 3. Admitting-based alert systems that notify infection prevention and control and clinical personnel about readmitted or transferred patients with a history of CDI a. This information can be integrated into a computerized database used during admission and registration or a separate electronic or paper-based database. i. If an alert system is implemented, patients with a history of CDI should be placed under contact precautions if they are readmitted only if they have symptoms consistent with CDI at admission. Asymptomatic patients with a history of CDI do not require contact precautions. ii. The duration that the alert should remain active is unknown. Nearly all cases of recurrent CDI occur within 90 days after the last episode. On the basis of this fact, it is reasonable to discontinue the alert 90 days after the last episode of CDI. However, healthcare facilities may not be aware of recurrent episodes of CDI that are diagnosed and managed in outpatient settings, so an arbitrary cutoff based on the last known episode of CDI may inadvertently remove patients with ongoing recurrent CDI. 4. Ongoing assessment of CDI knowledge and intensified CDI education among healthcare personnel a. Re-educate staff if prior CDI training occurred more
S90 infection control and hospital epidemiology october 2008, vol. 29, supplement 1
than 12 months earlier or if overall knowledge is deemed to be inadequate. i. Include housekeeping personnel in educational efforts. 5. Restricting the use of gastric acid suppressants14,16 section 5: performance measures I. Internal reporting These performance measures are intended to support internal hospital quality improvement efforts and do not necessarily address external reporting needs. The process and outcome measures suggested here are derived from published guidelines, other relevant literature, and the opinions of the authors. Report process and outcome measures to senior hospital leadership, nursing leadership, and clinicians who care for patients at risk for CDI. A. Process measures 1. Compliance with hand-hygiene guidelines a. Preferred measure for hand-hygiene compliance i. Numerator: number of observed proper hand-hygiene episodes performed by healthcare personnel. ii. Denominator: total number of observed opportunities for hand hygiene. iii. Multiply by 100 so that the measure is expressed as a percentage. b. If hand hygiene with soap and water is the preferred method of hand hygiene when caring for patients with CDI, also assess proper hand washing techniques (minimum duration of 15 seconds). i. Numerator: number of proper hand washing episodes with proper technique. ii. Denominator: total number of hand washing episodes observed. iii. Multiply by 100 so that the measure is expressed as a percentage. 2. Compliance with contact precautions a. Preferred measure of contact precautions compliance i. Numerator: number of observed patient care episodes in which contact precautions are appropriately implemented. ii. Denominator: number of observed patient care episodes in which contact precautions are indicated. iii. Multiply by 100 so that the measure is expressed as a percentage. 3. Compliance with environmental cleaning a. One specific measure of compliance for use in all hospitals cannot be recommended. However, many hos-
pitals use checklists and environmental rounds to assess the cleaning process and cleanliness of equipment and the environment (see above). B. Outcome measures Perform ongoing measurement of the incidence density of CDI to permit longitudinal assessment of the processes of care. 1. CDI rates should be calculated according to the recently published recommendations and as described above.20,22 a. See Table 1 for case definitions. i. Numerator: number of CDI cases in the population being monitored (the specific cases included in the numerator depends on the definition used; see Table 1). ii. Denominator: total number of patient-days in the population being monitored. iii. Multiply by 10,000 so that measure is expressed as number of cases per 10,000 patient-days. b. To convert the rate per 10,000 patient-days to 1,000 patient-days, divide the rate by 10 (conversely, to convert a rate from 1,000 patient-days to 10,000 patient-days, multiply the rate by 10). II. External reporting There are many challenges in providing useful information to consumers and other stakeholders while preventing unintended adverse consequences of public reporting of healthcare-associated infections.58 Recommendations for public reporting of healthcare-associated infections have been provided by the Hospital Infection Control Practices Advisory Committee,59 the Healthcare-Associated Infection Working Group of the Joint public policy Committee,60 and the National Quality Forum.61 Given the absence until recently of standardized CDI surveillance definitions and the difficulties in ascertaining the specific time and location of C. difficile acquisition, specific recommendations for external reporting of CDI rates cannot be made at this time. A. State and local requirements 1. Hospitals in states that have mandatory reporting requirements for CDI must collect and report the data required by the state. 2. For information on local requirements, check with your state or local health department. B. External quality initiatives 1. Hospitals that participate in external quality initiatives must collect and report the data if required by the initiative.
strategies for prevention of cdi S91
acknowledgments For Potential Conflicts of Interest statements and information on financial support, please see the Acknowledgments in the Executive Summary, on page S20 of this supplement. Address reprint requests to the Reprints Coordinator, University of Chicago Press, 1427 E. 60th St., Chicago, IL 60637 ([email protected]) or contact the journal office ([email protected]). references 1. McDonald LC, Owings M, Jernigan DB. Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2003. Emerg Infect Dis 2006; 12:409-415. 2. Kuijper EJ, Coignard B, Tull P. Emergence of Clostridium difficile-associated disease in North America and Europe. Clin Microbiol Infect 2006; 12(Suppl 6):2-18. 3. Loo VG, Poirier L, Miller MA, et al. A predominantly clonal multiinstitutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med 2005; 353:2442-2449. 4. Pepin J, Valiquette L, Cossette B. Mortality attributable to nosocomial Clostridium difficile-associated disease during an epidemic caused by a hypervirulent strain in Quebec. CMAJ 2005; 173:1037-1042. 5. McDonald LC, Killgore GE, Thompson A, et al. An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med 2005; 353:24332441. 6. Muto CA, Pokrywka M, Shutt K, et al. A large outbreak of Clostridium difficile-associated disease with an unexpected proportion of deaths and colectomies at a teaching hospital following increased fluoroquinolone use. Infect Control Hosp Epidemiol 2005; 26:273-280. 7. Jarvis WR, Feldman RA. Clostridium difficile and gastroenteritis: how strong is the association in children? Pediatr Infect Dis 1984; 3:4-6. 8. Welch DF, Marks MI. Is Clostridium difficile pathogenic in infants? J Pediatr 1982; 100:393-395. 9. Dubberke ER, Reske KA, Butler AM, et al. Attributable outcomes of Clostridium difficile-associated disease in non-surgical patients. Emerg Infect Dis (in press). 10. Kyne L, Hamel MB, Polavaram R, Kelly CP. Health care costs and mortality associated with nosocomial diarrhea due to Clostridium difficile. Clin Infect Dis 2002; 34:346-353. 11. Dubberke ER, Reske KA, Olsen MA, McDonald LC, Fraser VJ. Short and long term attributable cost of Clostridium difficile­associated disease in non-surgical patients. Clin Infect Dis 2008; 46:497-504. 12. O'Brien JA, Lahue BJ, Caro JJ, Davidson DM. The emerging infectious challenge of Clostridium difficile­associated disease in Massachusetts hospitals: clinical and economic consequences. Infect Control Hosp Epidemiol 2007; 28:1219-1227. 13. Dubberke ER, Reske KA, Yan Y, Olsen MA, McDonald LC, Fraser VJ. Clostridium difficile­associated disease in a setting of endemicity: identification of novel risk factors. Clin Infect Dis 2007; 45:1543-1549. 14. Pepin J, Saheb N, Coulombe MA, et al. Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile­associated diarrhea: a Cohort study during an epidemic in Quebec. Clin Infect Dis 2005; 41:1254-1260. 15. Dial S, Delaney JA, Barkun AN, Suissa S. Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile-associated disease. JAMA 2005; 294:2989-2995. 16. Beaulieu M, Williamson D, Pichette G, Lachaine J. Risk of Clostridium difficile­associated disease among patients receiving proton-pump inhibitors in a Quebec medical intensive care unit. Infect Control Hosp Epidemiol 2007; 28:1305-1307. 17. Musher DM, Aslam S, Logan N, et al. Relatively poor outcome after treatment of Clostridium difficile colitis with metronidazole. Clin Infect Dis 2005; 40:1586-1590.
18. Pepin J, Alary ME, Valiquette L, et al. Increasing risk of relapse after treatment of Clostridium difficile colitis in Quebec, Canada. Clin Infect Dis 2005; 40:1591-1597. 19. Zar FA, Bakkanagari SR, Moorthi KM, Davis MB. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile­ associated diarrhea, stratified by disease severity. Clin Infect Dis 2007; 45:302-307. 20. McDonald LC, Coignard B, Dubberke E, Song X, Horan T, Kutty PK. Recommendations for surveillance of Clostridium difficile­associated disease. Infect Control Hosp Epidemiol 2007; 28:140-145. 21. Kuijper EJ, Coignard B, Tull P, ESCMID Study Group for Clostridium difficile; EU Member States; European Centre for Disease Prevention and Control. Emergence of Clostridium difficile-associated disease in North America and Europe. Clin Microbiol Infect 2006; (Suppl 6):2-18. 22. National Clostridium difficile Standards Group. National Clostridium difficile Standards Group: report to the Department of Health. J Hosp Infect 2004; 56(Suppl 1):1-38. 23. United Kingdom Department of Health. Changes to the mandatory healthcare associated infection surveillance system for Clostridium difficile associated diarrhea from April 2007. Available at: http://www.dh.gov.uk/ en/Publicationsandstatistics/Lettersandcirculars/Professionalletters/ Chiefmedicalofficerletters/DH_073767. Accessed November 28, 2007. 24. Miller MA, Hyland M, Ofner-Agostini M, Gourdeau M, Ishak M. Morbidity, mortality, and healthcare burden of nosocomial Clostridium difficile-associated diarrhea in Canadian hospitals. Infect Control Hosp Epidemiol 2002; 23:137-140. 25. Fekety R. Guidelines for the diagnosis and management of Clostridium difficile-associated diarrhea and colitis. American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol 1997; 92: 739-750. 26. Gerding DN, Johnson S, Peterson LR, Mulligan ME, Silva J Jr. Clostridium difficile-associated diarrhea and colitis. Infect Control Hosp Epidemiol 1995; 16:459-477. 27. Simor AE, Bradley SF, Strausbaugh LJ, Crossley K, Nicolle LE. Clostridium difficile in long-term-care facilities for the elderly. Infect Control Hosp Epidemiol 2002; 23:696-703. 28. Tullus K, Aronsson B, Marcus S, Mollby R. Intestinal colonization with Clostridium difficile in infants up to 18 months of age. Eur J Clin Microbiol Infect Dis 1989; 8:390-393. 29. Merida V, Moerman J, Colaert J, Lemmens P, Vandepitte J. Significance of Clostridium difficile and its cytotoxin in children. Eur J Pediatr 1986; 144:494-496. 30. Harris AD, Bradham DD, Baumgarten M, Zuckerman IH, Fink JC, Perencevich EN. The use and interpretation of quasi-experimental studies in infectious diseases. Clin Infect Dis 2004; 38:1586-1591. 31. Stone SP, Cooper BS, Kibbler CC, et al. The ORION statement: guidelines for transparent reporting of outbreak reports and intervention studies of nosocomial infection. J Antimicrob Chemother 2007; 59:833-840. 32. Fowler S, Webber A, Cooper BS, et al. Successful use of feedback to improve antibiotic prescribing and reduce Clostridium difficile infection: a controlled interrupted time series. J Antimicrob Chemother 2007; 59: 990-995. 33. Shadel BN, Puzniak LA, Gillespie KN, Lawrence SJ, Kollef M, Mundy LM. Surveillance for vancomycin-resistant enterococci: type, rates, costs, and implications. Infect Control Hosp Epidemiol 2006; 27:1068-1075. 34. Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep 2002; 51:1-45, quiz. 35. Canadian Task Force on the Periodic Health Examination. The periodic health examination. Can Med Assoc J 1979; 121:1193-1254. 36. Centers for Disease Control and Prevention. C. difficile frequently asked questions information for healthcare providers. 2005. Available at: http:
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//www.cdc.gov/ncidod/dhqp/id_CdiffFAQ_HCP.html. Accessed August 18, 2007. 37. Dubberke ER, Reske KA, Noble-Wang J, et al. Prevalence of Clostridium difficile environmental contamination and strain variability in multiple health care facilities. Am J Infect Control 2007; 35:315-318. 38. Johnson S, Clabots CR, Linn FV, Olson MM, Peterson LR, Gerding DN. Nosocomial Clostridium difficile colonisation and disease. Lancet 1990; 336:97-100. 39. McFarland LV, Mulligan ME, Kwok RY, Stamm WE. Nosocomial acquisition of Clostridium difficile infection. N Engl J Med 1989; 320:204210. 40. Sehulster L, Chinn RY. Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep 2003; 52:1-42. 41. Perez J, Springthorpe VS, Sattar SA. Activity of selected oxidizing microbicides against the spores of Clostridium difficile: relevance to environmental control. Am J Infect Control 2005; 33:320-325. 42. Garner JS. Guideline for isolation precautions in hospitals. The Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1996; 17:53-80. 43. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. June 2007. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf. Accessed December 13, 2007. 44. Lewis AM, Gammon J, Hosein I. The pros and cons of isolation and containment. J Hosp Infect 1999; 43:19-23. 45. Boyce JM, Ligi C, Kohan C, Dumigan D, Havill NL. Lack of association between the increased incidence of Clostridium difficile­associated disease and the increasing use of alcohol-based hand rubs. Infect Control Hosp Epidemiol 2006; 27:479-483. 46. Riggs MM, Sethi AK, Zabarsky TF, Eckstein EC, Jump RL, Donskey CJ. Asymptomatic carriers are a potential source of transmission of epidemic and nonepidemic Clostridium difficile strains among long-term care facility residents. Clin Infect Dis 2007; 45:992-998. 47. Wenisch C, Parschalk B, HasenhuЁndl M, Hirschl AM, Graninger W. Comparison of vancomycin, teicoplanin, metronidazole, and fusidic acid for the treatment of Clostridium difficile­associated diarrhea. Clin Infect Dis 1996; 22:813-818. 48. Surawicz CM, McFarland LV, Greenberg RN, et al. The search for a better treatment for recurrent Clostridium difficile disease: use of highdose vancomycin combined with Saccharomyces boulardii. Clin Infect Dis 2000; 31:1012-1017. 49. Wilcox MH, Fawley WN, Parnell P. Value of lysozyme agar incorporation
and alkaline thioglycollate exposure for the environmental recovery of Clostridium difficile. J Hosp Infect 2000; 44:65-69. 50. Kaatz GW, Gitlin SD, Schaberg DR, et al. Acquisition of Clostridium difficile from the hospital environment. Am J Epidemiol 1988; 127:12891294. 51. Wilcox MH, Fawley WN, Wigglesworth N, et al. Comparison of the effect of detergent versus hypochlorite cleaning on environmental contamination and incidence of Clostridium difficile infection. J Hosp Infect 2003; 54:109-114. 52. Mayfield JL, Leet T, Miller J, Mundy LM. Environmental control to reduce transmission of Clostridium difficile. Clin Infect Dis 2000; 31:9951000. 53. McDonald LC. Confronting Clostridium difficile in inpatient healthcare facilities. Clin Infect Dis 2007; 45:1274-1276. 54. Valiquette L, Cossette B, Garant MP, Diab H, Pepin J. Impact of reduction in the use of high-risk antibiotics on the course of an epidemic of Clostridium difficile­associated disease caused by the hypervirulent NAP1/027 strain. Clin Infect Dis 2007; 45:S112-S121. 55. Pear SM, Williamson TH, Bettin KM, Gerding DN, Galgiani JN. Decrease in nosocomial Clostridium difficile­associated diarrhea by restricting clindamycin use. Ann Intern Med 1994; 120:272-277. 56. Johnson S, Homann SR, Bettin KM, et al. Treatment of asymptomatic Clostridium difficile carriers (fecal excretors) with vancomycin or metronidazole: a randomized, placebo-controlled trial. Ann Intern Med 1992; 117:297-302. 57. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Healthcare Infection Control Practices Advisory Committee. Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings 2007. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf. Accessed January 15, 2008. 58. Wong ES, Rupp ME, Mermel L, et al. Public disclosure of healthcareassociated infections: the role of the Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol 2005; 26:210-212. 59. McKibben L, Horan TC, Tokars JI, et al. Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 2005; 26:580-587. 60. Healthcare-Associated Infection Working Group of the Joint Public Policy Committee. Essentials of public reporting of healthcare-associated infections: a tool kit. January 2007. Available at: http://www.cdc.gov/ ncidod/dhqp/pdf/ar/06_107498_Essentials_Tool_Kit.pdf. Accessed April 6, 2007. 61. The National Quality Forum. National voluntary consensus standards, endorsed November 15, 2007. Available at: http://www.qualityforum.org/ pdf/news/lsCSACMeasures.pdf. Accessed December 20, 2007.
S41 infection control and hospital epidemiology october 2008, vol. 29, supplement 1 supplement article: shea/idsa practice recommendation Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals Evelyn Lo, MD; Lindsay Nicolle, MD; David Classen, MD, MS; Kathleen M. Arias, MS, CIC; Kelly Podgorny, RN, MS, CPHQ; Deverick J. Anderson, MD, MPH; Helen Burstin, MD; David P. Calfee, MD, MS; Susan E. Coffin, MD, MPH; Erik R. Dubberke, MD; Victoria Fraser, MD; Dale N. Gerding, MD; Frances A. Griffin, RRT, MPA; Peter Gross, MD; Keith S. Kaye, MD; Michael Klompas, MD; Jonas Marschall, MD; Leonard A. Mermel, DO, ScM; David A. Pegues, MD; Trish M. Perl, MD; Sanjay Saint, MD; Cassandra D. Salgado, MD, MS; Robert A. Weinstein, MD; Robert Wise, MD; Deborah S. Yokoe, MD, MPH
purpose Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their catheter-associated urinary tract infection (CAUTI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America "Compendium of Strategies to Prevent Healthcare-Associated Infections" Executive Summary and Introduction and accompanying editorial for additional discussion. section 1: rationale and statements of concern 1. Burden of CAUTIs a. Urinary tract infection is the most common hospital- acquired infection; 80% of these infections are attributable to an indwelling urethral catheter.1 b. Twelve to sixteen percent of hospital inpatients will have a urinary catheter at some time during their hospital stay.2
c. The daily risk of acquisition of urinary infection varies from 3% to 7% when an indwelling urethral catheter remains in situ. 2. Outcomes associated with CAUTI a. Urinary tract infection is the most important adverse outcome of urinary catheter use. Bacteremia and sepsis may occur in a small proportion of infected patients.3,4 b. Morbidity attributable to any single episode of catheterization is limited,3 but the high frequency of catheter use in hospitalized patients means that the cumulative burden of CAUTI is substantial.1,5,6 c. Catheter use is also associated with negative outcomes other than infection, including nonbacterial urethral inflammation,7 urethral strictures,8 and mechanical trauma. 3. Risk factors for development of CAUTI a. The duration of catheterization is the most important risk factor for development of infection.1,9-11 Limiting catheter use and, when a catheter is indicated, minimizing the duration the catheter remains in situ are primary strategies for CAUTI prevention. b. Additional risk factors include female sex, older age, and not maintaining a closed drainage system.
From the University of Manitoba, Winnipeg, Canada (E.L., L.N.); the University of Utah, Salt Lake City (D.C.); the Association for Professionals in Infection Control and Epidemiology (K.M.A.) and the National Quality Forum (H.B.), Washington, D.C.; the Joint Commission, Oakbrook Terrace (K.P., R.W.), the Loyola University Chicago Stritch School of Medicine (D.N.G.) and the Stroger (Cook County) Hospital and Rush University Medical Center (R.A.W.), Chicago, and the Hines Veterans Affairs Medical Center, Hines (D.N.G.), Illinois; the Duke University Medical Center, Durham, North Carolina (D.J.A., K.S.K.); the Mount Sinai School of Medicine, New York, New York (D.P.C.); the Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania (S.E.C.); the Washington University School of Medicine, St. Louis, Missouri (E.R.D., V.F., J.M.); the Institute for Healthcare Improvement, Cambridge (F.A.G.), and Brigham and Women's Hospital and Harvard Medical School, Boston (D.S.Y., M.K.), Massachusetts; the Hackensack University Medical Center, Hackensack (P.G.), and the University of Medicine and Dentistry­New Jersey Medical School, Newark (P.G.), New Jersey; the Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island (L.A.M.); the David Geffen School of Medicine at the University of California, Los Angeles (D.A.P.); the Johns Hopkins Medical Institutions and University, Baltimore, Maryland (T.M.P.); the Ann Arbor Veterans Affairs Medical Center and the University of Michigan Medical School, Ann Arbor, Michigan (S.S.); the Medical University of South Carolina, Charleston (C.D.S.). Accepted May 27, 2008; electronically published September 16, 2008. Infect Control Hosp Epidemiol 2008; 29:S41­S50 2008 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2008/2910S1-0006$15.00. DOI: 10.1086/591066
S42 infection control and hospital epidemiology october 2008, vol. 29, supplement 1
table 1. Summary of Recommendations From Published Guidelines for Prevention of Infections Associated With Short-Term Indwelling Urethral Catheters
Recommendation
NHS Epic 1 Project (2001)
CDC (1981) [19]
[20]
NHS Epic 2 Project (2007) [21]
Ensure documentation of catheter insertion
ND
Y
Y
Ensure that trained personnel insert catheter
Y
Y
Y
Train patients and family
ND
ND
Y
Practice hand hygiene
Y
Y
Y
Evaluate necessity of catheterization
Y
Y
Y
Evaluate alternative methods
Y
Y
Y
Review ongoing need regularly
ND
Y
Y
Select catheter material
ND
U
U
Use smallest-gauge catheter possible
Y
Y
Y
Use aseptic technique/sterile equipment
Y
Y
Y
Use barrier precautions for insertion
Y
ND
ND
Perform antiseptic cleaning of meatus
Y
N
N
Use closed drainage system
Y
Y
Y
Obtain urine samples aseptically
Y
Y
Y
Replace system if a break in asepsis occurs
Y
ND
ND
Do not change catheter routinely
Y
Y
Y
Perform routine hygiene for meatal care
Y
Y
Y
Avoid irrigation
Y
Y
Y
Cohort patients
Y
ND
ND
Ensure compliance with training
ND
ND
ND
Ensure compliance with control measures
ND
ND
ND
Ensure compliance with catheter removal
ND
ND
ND
Monitor rates of CAUTI and bacteremia
ND
ND
ND
note. CAUTI, catheter-associated urinary tract infection; CDC, US Centers for Disease Control and Prevention; N, no (not recommended); ND, not discussed; NHS, UK National Health Service; U, unresolved (choice left to clinical experience and patient factors); Y, yes (recommended).
4. Reservoir for transmission a. The drainage bag of the bacteriuric patient is a res- ervoir for organisms that may contaminate the environment and be transmitted to other patients.12 b. Outbreaks of infection with resistant gram-negative organisms attributable to bacteriuria in catheterized patients have been reported.12-15 section 2: strategies to detect cauti 1. Surveillance definitions a. The National Healthcare Safety Network definition of symptomatic nosocomial urinary tract infection16,17 is commonly used but can be difficult to apply to patients with indwelling catheters. Localizing signs and symptoms may not be present with a catheter in situ or may not be recognized because of patient comorbidity.3,18 b. The most common clinical presentation is fever with positive urine culture results, without other localizing findings. However, given the high prevalence of bacteriuria in patients with an indwelling catheter, this definition lacks specificity. 2. Methods for surveillance of CAUTI a. Surveillance programs that monitor urine culture re- sults through the microbiology laboratory are generally
used to detect patients with potential urinary tract infections. Patients with positive urine culture results are then evaluated for the presence of an indwelling urinary catheter and a CAUTI defined using surveillance criteria. i. Infection in patients with an indwelling urinary catheter is usually asymptomatic.3 ii. Microbiological diagnosis usually requires the growth of at least 105 cfu/mL of an organism from a urine specimen collected aseptically from the catheter. Lower quantitative counts may be consistent with bacteriuria in some patients or may predict subsequent development of higher quantitative counts.18 section 3: strategies to prevent cauti 1. Existing guidelines and recommendations (see Table 1) a. In 1981, the Centers for Disease Control and Pre- vention published guidelines for the prevention of catheterassociated urinary tract infections.19 These guidelines provide recommendations for catheter use, catheter insertion, catheter care, placement of catheterized patients, and bacteriologic monitoring. The guidelines are currently being updated for the first time since 1981. b. In 2001, the Department of Health in Great Britain
strategies for prevention of cauti S43
published guidelines for preventing infections associated with the insertion and maintenance of short-term indwelling urinary catheters in acute care;20 these guidelines were updated in 2006.21 2. Updated relevant literature a. Cochrane reviews i. Comprehensive Cochrane reviews with meta-analysis evaluating interventions to prevent complications of the use of short-term indwelling urinary catheters have recently been published.22-27 Consistent observations include the limited number of studies addressing any specific question, small study numbers, low quality of most studies, and heterogeneity in results, particularly when morbidity is addressed. b. Alternatives to an indwelling urethral catheter i. A prospective, randomized comparative trial reported that the use of external condom catheter drainage for men compared with a short-term indwelling urethral catheter reduced acquisition of bacteriuria and adverse outcomes and was more acceptable to the patient.28 ii. A randomized study reported that in-and-out catheterization was as effective as the use of an indwelling catheter for management of postoperative retention.29 iii. Some studies have reported fewer complications with use of a suprapubic catheter, but the surgical procedure required to insert the suprapubic catheter is associated with additional risks. A randomized, controlled trial comparing suprapubic and urethral catheterization for men undergoing elective laparotomy reported a similar incidence of urinary infection in the 2 groups.30 Current evidence is not sufficient to support the routine use of a suprapubic catheter for short-term catheterization to prevent symptomatic urinary infection or other complications.22,23 c. Catheter materials i. Reviews and meta-analyses of silver-coated and other antibacterial urinary catheters consistently conclude that evidence does not support a recommendation for the uniform use of such devices.26,31,32 ii. Silver-alloy catheters may decrease bacteriuria but have not been shown to decrease symptomatic infection or other undesirable outcomes.31,32 (a) Some of the variability in outcomes reported in trials of silver catheters may be related to whether the comparator catheter is silicone or latex.33 (b) A recent prospective crossover study comparing a silver-alloy, silicone-based hydrogel­coated catheter with a silicone-based hydrogel­coated catheter reported no difference in symptomatic or asymptomatic infection or in bloodstream infections attributable to a urinary source.34 d. Limiting the duration of catheterization i. Indwelling urethral catheters are frequently used
when not indicated or, if indicated, remain in situ longer than necessary.35-37 ii. Optimal approaches to limit catheter use and duration may be dependent on facility characteristics. Approaches reported to be effective include the following: (a) Implementing procedure-specific guidelines for postoperative catheter removal38 (b) Providing guidelines to manage postoperative retention, which may include the use of bladder scanners39 (c) Providing reminders to physicians to review the need for continued catheterization and to remove catheters promptly when they are no longer indicated40-42 (d) Development of care plans directing nurse removal of catheters for patients who meet prespecified criteria43 e. Surveillance i. Providing feedback on unit-specific urinary Infection rates to nursing and healthcare staff has been effective in decreasing infection rates.44,45 section 4: recommendations for implementing prevention and monitoring strategies Recommendations for preventing and monitoring CAUTI19-21 are summarized in the following section. They are designed to assist acute care hospitals in prioritizing and implementing their CAUTI prevention efforts. Criteria for grading the strength of recommendation and quality of evidence are described in Table 2. I. Basic practices for prevention and monitoring of CAUTI: recommended for all acute care hospitals A. Appropriate infrastructure for preventing CAUTI 1. Provide and implement written guidelines for catheter use, insertion, and maintenance (A-II). a. Develop and implement facility criteria for acceptable indications for the use of indwelling urinary catheters. b. Indications for the use of indwelling urethral catheters are limited and include the following:35,47 i. Perioperative use for selected surgical procedures ii. Urine output monitoring in critically ill patients iii. Management of acute urinary retention and urinary obstruction iv. Assistance in pressure ulcer healing for incontinent residents v. As an exception, at patient request to improve comfort 2. Ensure that only trained, dedicated personnel insert urinary catheters (B-III).
S44 infection control and hospital epidemiology october 2008, vol. 29, supplement 1
table 2. Strength of Recommendation and Quality of Evidence
Category/grade
Definition
Strength of recommendation A B C Quality of evidence I II III
Good evidence to support a recommendation for use Moderate evidence to support a recommendation for use Poor evidence to support a recommendation Evidence from x1 properly randomized, controlled trial Evidence from x1 well-designed clinical trial, without randomization; from cohort or case-control analytic studies (preferably from 11 center); from multiple time series; or from dramatic results from uncontrolled experiments Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
note. Adapted from the Canadian Task Force on the Periodic Health Examination.46
3. Ensure that supplies necessary for aseptic-technique catheter insertion are available (A-III). 4. Implement a system for documenting the following information in the patient record: indications for catheter insertion, date and time of catheter insertion, individual who inserted catheter, and date and time of catheter removal (AIII). a. Include documentation in nursing flow sheet, nursing notes, or physician orders. i. Documentation should be accessible in the patient record and recorded in a standard format for data collection and quality improvement purposes. b. Electronic documentation that is searchable is preferred, if available. 5. Ensure that there are sufficient trained personnel and technology resources to support surveillance of catheter use and outcomes (A-III).
a. The percentage of patients with an indwelling urinary catheter inserted during hospitalization b. The percentage of catheter use with accepted indications c. Duration of indwelling catheter use 6. Use surveillance methods for case finding that are appropriate for the institution and are documented to be valid (A-III). C. Education and training 1. Educate healthcare personnel involved in the insertion, care, and maintenance of urinary catheters about CAUTI prevention, including alternatives to indwelling catheters and procedures for catheter insertion, management, and removal (A-III). D. Appropriate technique for catheter insertion
B. Surveillance of CAUTI 1. Identify the patient groups or units in which to conduct surveillance, on the basis of risk assessment, considering the frequency of catheter use and the potential risk factors (eg, types of surgery, obstetrics, and critical care) (B-III). 2. Use standardized criteria to identify patients who have a CAUTI (numerator data) (A-II). 3. Collect information on catheter-days (denominator data) for all patients in the patient groups or units being monitored (A-II).
1. Insert urinary catheters only when necessary for patient care and leave them in place only as long as indications persist (A-II). 2. Consider other methods for management, including condom catheters or in-and-out catheterization, when appropriate (A-I). 3. Practice hand hygiene (in accordance with Centers for Disease Control and Prevention or World Health Organization guidelines) immediately before insertion of the catheter and before and after any manipulation of the catheter site or apparatus (A-III).
4. Calculate CAUTI rates for target populations (A-II). 5. Measure the use of indwelling urinary catheters (B-II), including the following:
4. Insert catheters by use of aseptic technique and sterile equipment (A-III). 5. Use gloves, a drape, and sponges; a sterile or antiseptic
strategies for prevention of cauti S45
solution for cleaning the urethral meatus; and a single-use packet of sterile lubricant jelly for insertion (A-III). 6. Use as small a catheter as possible that is consistent with proper drainage, to minimize urethral trauma (B-III). E. Appropriate management of indwelling catheters 1. Properly secure indwelling catheters after insertion to prevent movement and urethral traction (A-III). 2. Maintain a sterile, continuously closed drainage system (A-I).
3. Senior management is accountable for ensuring that healthcare personnel, including licensed and nonlicensed personnel, are competent to perform their job responsibilities. 4. Direct healthcare providers (such as physicians, nurses, aides, and therapists) and ancillary personnel (such as housekeeping and equipment-processing personnel) are responsible for ensuring that appropriate infection prevention and control practices are used at all times (including hand hygiene, standard and isolation precautions, cleaning and disinfection of equipment and the environment, aseptic technique when inserting and caring for urinary catheters, and daily assessment of whether an indwelling urinary catheter is medically indicated).
3. Do not disconnect the catheter and drainage tube unless 5. Hospital and unit leaders are responsible for holding
the catheter must be irrigated (A-I).
their personnel accountable for their actions.
4. Replace the collecting system by use of aseptic technique and after disinfecting the catheter-tubing junction when breaks in aseptic technique, disconnection, or leakage occur (B-III). 5. For examination of fresh urine, collect a small sample by aspirating urine from the sampling port with a sterile needle and syringe after cleansing the port with disinfectant (A-III). a. Promptly transport urine specimens to the laboratory for culture. 6. Obtain larger volumes of urine for special analyses aseptically from the drainage bag (A-III). 7. Maintain unobstructed urine flow (A-II). 8. Empty the collecting bag regularly, using a separate collecting container for each patient, and avoid allowing the draining spigot to touch the collecting container (A-II). 9. Keep the collecting bag below the level of the bladder at all times (A-III). 10. Cleaning the meatal area with antiseptic solutions is unnecessary; routine hygiene is appropriate (A-I). F. Accountability 1. The hospital's chief executive officer and senior management are responsible for ensuring that the healthcare system supports an infection prevention and control program that effectively prevents CAUTIs and the transmission of epidemiologically significant pathogens. 2. Senior management is accountable for ensuring that an adequate number of trained personnel are assigned to the infection prevention and control program.
6. The person who manages the infection prevention and control program is responsible for ensuring that an active program to identify CAUTIs is implemented, that data on CAUTIs are analyzed and regularly provided to those who can use the information to improve the quality of care (eg, unit staff, clinicians, and hospital administrators), and that evidence-based practices are incorporated into the program. 7. Personnel responsible for healthcare personnel and patient education are accountable for ensuring that appropriate training and educational programs to prevent CAUTI are developed and provided to personnel, patients, and families. 8. Personnel from the infection prevention and control program, the laboratory, and information technology departments are responsible for ensuring that systems are in place to support the surveillance program. II. Special approaches for the prevention of CAUTI Perform a CAUTI risk assessment. These special approaches are recommended for use in locations and/or populations within the hospital with unacceptably high CAUTI rates despite implementation of the basic CAUTI prevention strategies listed above. 1. Implement an organization-wide program to identify and remove catheters that are no longer necessary, using 1 or more methods documented to be effective (A-II). a. Develop and implement institutional policy requiring continual, usually daily, review of the necessity of continued catheterization. b. Electronic or other types of reminders (see the Appendix) may be useful. Some examples include the following: i. Automatic stop orders requiring renewal of the order for continuation of the indwelling catheter ii. Standardized reminders placed into patient charts (Appendix) or the electronic patient record
S46 infection control and hospital epidemiology october 2008, vol. 29, supplement 1
c. Implement daily ward rounds by nursing and physician staff to review all patients with urinary catheters and to ascertain continuing necessity. 2. Develop a protocol for management of postoperative urinary retention, including nurse-directed use of intermittent catheterization and use of bladder scanners (B-I). a. If bladder scanners are used, indications must be clearly stated, and nursing staff must be trained in their use. 3. Establish a system for analyzing and reporting data on catheter use and adverse events from catheter use (B-III). a. Define and monitor adverse outcomes in addition to CAUTI, including catheter obstruction, unintended removal, catheter trauma, or reinsertion within 24 hours after removal. b. For analysis, stratify measurements of catheter use and adverse outcomes by relevant risk factors (eg, sex, age, ward, and duration). Review data in a timely fashion and report them to the appropriate stakeholders. III. Approaches that should not be considered a routine part of CAUTI prevention 1. Do not routinely use silver-coated or other antibacterial catheters (A-I). 2. Do not screen for asymptomatic bacteruria in catheterized patients (A-II). 3. Do not treat asymptomatic bacteruria in catheterized patients except before invasive urologic procedures (A-I). 4. Avoid catheter irrigation (A-I). a. Do not perform continuous irrigation of the bladder with antimicrobials as a routine infection prevention measure. b. If obstruction is anticipated, closed continuous irrigation may be used to prevent it. c. To relieve obstruction due to clots, mucus, or other causes, an intermittent method of irrigation may be used. 5. Do not use systemic antimicrobials routinely as prophylaxis (A-II). 6. Do not change catheters routinely (A-III). IV. Unresolved issues 1. Use of antiseptic solution versus sterile saline for meatal cleaning before catheter insertion 2. Use of antimicrobial-coated catheters for selected patients at high risk for infection
section 5: performance measures I. Internal reporting These performance measures are intended to support internal hospital quality improvement efforts and do not necessarily address external reporting needs. The process and outcome measures suggested here are derived from published guidelines, other relevant literature, and the opinions of the authors. Report both process and outcome measures to senior hospital leadership, nursing leadership, and clinicians who care for patients at risk for CAUTI. A. Process measures 1. Compliance with documentation of catheter insertion and removal dates a. Conduct random audits of selected units and calculate compliance rate. i. Numerator: number of patients with urinary catheters on the unit with proper documentation of insertion and removal dates. ii. Denominator: number of patients on the unit with a urinary catheter in place. iii. Multiply by 100 so that the measure is expressed as a percentage. 2. Compliance with documentation of indication for catheter placement a. Conduct random audits of selected units and calculate compliance rate. i. Numerator: number of patients with urinary catheters on the unit with proper documentation of indication. ii. Denominator: number of patients on the unit with a urinary catheter in place. iii. Multiply by 100 so that the measure is expressed as a percentage. B. Outcome measures 1. Rates of symptomatic CAUTI, stratified by risk factors (age, sex, ward, indication, and catheter-days) a. Although the validity of the current Centers for Disease Control and Prevention/National Healthcare Safety Network definition of symptomatic CAUTI for comparison of facility-to-facility outcomes is not established, measurement of rates allows an individual facility to gauge the longitudinal impact of implementation of prevention strategies. i. Numerator: number of symptomatic CAUTIs in each location monitored. ii. Denominator: total number of urinary catheter­ days for all patients in each location monitored who have an indwelling urinary catheter.
strategies for prevention of cauti S47
iii. Multiply by 1,000 so that the measure is expressed as cases per 1,000 catheter-days. 2. Rates of bacteremia attributable to CAUTI a. Use National Healthcare Safety Network definitions of laboratory-confirmed bloodstream infection.17 i. Numerator: number of episodes of bloodstream in- fections attributable to CAUTI. ii. Denominator: total number of urinary catheter­ days for all patients in each location monitored who have an indwelling urinary catheter. iii. Multiply by 1,000 so that the measure is expressed as cases per 1,000 catheter-days. II. External reporting There are many challenges in providing useful information to consumers and other stakeholders while preventing unintended adverse consequences of public reporting of healthcare-associated infections.48 Recommendations for public reporting of healthcare-associated infections have been provided by the Hospital Infection Control Practices Advisory Committee,49 the Healthcare-Associated Infection Working Group of the Joint Public Policy Committee,50 and the National Quality Forum.51
Because the validity of the current Centers for Disease Control and Prevention/National Healthcare Safety Network definition of CAUTI for comparison of facility-to-facility outcomes is not established, external reporting of CAUTI rates is not recommended. A. State and local requirements 1. Hospitals in states that have mandatory reporting requirements must collect and report the data required by the state. For information on state and federal requirements, check with your state or local health department. B. External quality initiatives 1. Hospitals that participate in external quality initiatives must collect and report the data required by the initiative. acknowledgments For Potential Conflicts of Interest statements and information on financial support, please see the Acknowledgments in the Executive Summary, on page S20 of this supplement.
appendix figure. Example of a urinary catheter reminder form (from Saint et al.41)
strategies for prevention of cauti S49
Address reprint requests to the Reprints Coordinator, University of Chicago Press, 1427 E. 60th St., Chicago, IL 60637 ([email protected]) or contact the journal office ([email protected]). references 1. Saint S, Chenowith CE. Biofilms and catheter-associated urinary tract infections. Infect Dis Clin North Am 2003; 17:411-432. 2. Weinstein JW, Mazon D, Pantelick E, Reagan-Cirincione P, Dembry LM, Hierholzer WJ. A decade of prevalence surveys in a tertiary-care center: trends in nosocomial infection rates, device utilization, and patient acuity. Infect Control Hosp Epidemiol 1999; 20:543-548. 3. Tambyah PA, Maki DG. Catheter-associated urinary tract infection is rarely symptomatic. Arch Intern Med 2000; 160:678-687. 4. Saint S, Kaufman SR, Rogers MAM, Baker PD, Boyko EJ, Lipsky B. Risk factors for nosocomial urinary tract related bacteremia: a case-control study. Am J Infect Control 2006; 34:401-407. 5. Saint S, Lipsky B, Goold SD. Indwelling urinary catheters: a one-point restraint? Ann Intern Med 2002; 137:125-127. 6. Tambyah PA, Knasinski V, Maki DG. The direct costs of nosocomial catheter-associated urinary tract infection in the era of managed care: the direct costs of nosocomial catheter-associated urinary tract infection in the era of managed care. Infect Control Hosp Epidemiol 2002; 23:2731. 7. Talja M, Korpela A, Jarvi K. Comparison of urethral reaction to full silicone, hydrogel-coated and siliconized latex catheters. Br J Urol 1990; 66:652-657. 8. Robertson GS, Everitt N, Burton PR, et al. Effect of catheter material on the incidence of urethral strictures. Br J Urol 1991; 68:612-617. 9. Johnson JR, Roberts PL, Olsen RJ, Moyer KA, Stamm WE. Prevention of catheter-associated urinary tract infection with a silver-oxide-coated urinary catheter: clinical and microbiologic correlation. J Infect Dis 1990; 162:1145-1150. 10. Huth TS, Burke JP, Larsen RA, Classen DC, Stevens LE. Randomized trial of meatal care with silver sulfa-diazine cream for the prevention of catheter-associated bacteriuria. J Infect Dis 1992; 165:14-18. 11. Riley DK, Classen DC, Stevens LE, Burke JP. A large, randomized clinical trial of a silver-impregnated urinary catheter: lack of efficacy and staphylococcal superinfection. Am J Med 1995; 98:349-356. 12. Bukhari SS, Sanderson PJ, Richardson DM, Kaufman ME, Aucken HM, Cookson BD. Endemic cross-infection in an acute medical ward. J Hosp Infect 1993; 24:261-271. 13. Schaberg DR, Weinstein RA, Stamm WE. Epidemics of nosocomial urinary tract infection caused by multiply resistant gram-negative bacilli: epidemiology and control. J Infect Dis 1976; 133:363-366. 14. Jarvis WR, Munn VP, Highsmith AK, Culver DH, Hughes JM. The epidemiology of nosocomial infections caused by Klebsiella pneumoniae. Infect Control 1985; 6:68-74. 15. Yoon HJ, Choi JY, Park YS, et al. Outbreaks of Serratia marcescens bacteriuria in a neurosurgical intensive care unit of a tertiary care teaching hospital: a clinical epidemiologic, and laboratory perspective. Am J Infect Control 2005; 33:595-601. 16. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008; 36:309-32. 17. National Healthcare Safety Network (NHSN). NHSN members' page. Available at: http://www.cdc.gov/ncidod/dhqp/nhsn_members.html. Accessed August 12, 2008. 18. Stark RP, Maki DG. Bacteriuria in the catheterized patient: what quantitative level of bacteriuria is relevant? N Engl J Med 1984; 311:560-564. 19. Wong ES, Hooton TM. Guideline for prevention of catheter-associated urinary tract infections. Am J Infect Control 1983; 11:28-36. 20. Pratt RJ, Pellowe C, Loveday HP, et al. The epic project: developing national evidence-based guidelines for preventing healthcare associated infections. Phase I: guidelines for preventing hospital-acquired infections. J Hosp Infect 2001; 47(Suppl):S3-S82.
21. Pratt RJ, Pellowe CM, Wilson JA, et al. Epic 2: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect 2007; 65(Suppl 1):S1-S64. 22. Niel-Weise BS, van den Broek PJ. Urinary catheter policies for shortterm bladder drainage in adults. Cochrane Database Syst Rev 2005; (3): CD004203. 23. Phipps S, Liim YN, McClinton S, Barry C, Rane A, N'Dow J. Short term urinary catheter policies following urogenital surgery in adults. Cochrane Database Syst Rev 2006; (2):CD004374. 24. Griffiths R, Fernandes R. Policies for the removal of short-term indwelling urethral catheters. Cochrane Database Syst Rev 2005; (1): CD004011. 25. Niel-Weise BS, van den Broek PJ. Antibiotic policies for short-term catheter bladder drainage in adults. Cochrane Database Syst Rev 2005; (3): CD005428. 26. Brosnahan J, Jull A, Tracy C. Types of urethral catheters for management of short-term voiding problems in hospitalized adults. Cochrane Database Syst Rev 2004; (1):CD004013. 27. Griffiths R, Fernandez R. Strategies for the removal of short-term indwelling urethral catheters in adults. Cochrane Database Syst Rev 2007; (2):CD004011. 28. Saint S, Kaufman SR, Rogers MAM, Baker PD, Ossenkop K, Lipsky BA. Condom versus indwelling urinary catheters: a randomized trial. J Am Geriatr Soc 2006; 54:1055-1061. 29. Lau H, Lam B. Management of postoperative urinary retention: a randomized trial of in-out versus overnight catheterization. ANZ J Surg 2004; 74:658-661. 30. Baan AH, Vermeulen H, van der Meulen J, Bossuyt P, Olszyna D, Gouma DJ. The effect of suprapubic catheterization after abdominal surgery on urinary tract infection: a randomized, controlled trial. Dig Surg 2003; 20:290-295. 31. Johnson JR, Kuskowski MA, Wilt TJ. Systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in hospitalized patients. Ann Intern Med 2006; 144:116-127. 32. Niel-Weise BS, Arend SM, van den Brock PJ. Is there evidence for recommending silver-coated urinary catheters in guidelines. J Hosp Infect 2002; 52:81-87. 33. Crnich CJ, Drenka PJ. Does the composition of urinary catheter influence clinical outcomes and the results of research studies. Infect Control Hosp Epidemiol 2007; 28:102-103. 34. Srinivasan A, Karchmer T, Richards A, Song X, Perl T. A prospective trial of a novel, silicone-based, silver-coated Foley catheter for the prevention of nosocomial urinary tract infection. Infect Control Hosp Epidemiol 2006; 27:38-43. 35. Gokula RRM, Hickner JA, Smith MA. Inappropriate use of urinary catheters in elderly patients at a midwestern community teaching hospital. Am J Infect Control 2004; 32:196-199. 36. Jain P, Parada JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med 1995; 155:1425-1429. 37. Saint S, Wiese J, Amory JK, et al. Are physicians aware of which of their patients have indwelling urinary catheters? Am J Med 2000; 109:476-480. 38. Stephan F, Sax H, Wachsmuth M, Hoffmeyer P, Clergue F, Pittet D. Reduction of urinary tract infection and antibiotic use after surgery: a controlled, prospective, before-after intervention study. Clin Infect Dis 2006; 42:1544-1551. 39. Doyle B, Mawji Z, Horgan M, et al. Decreasing nosocomial urinary tract infection in a large academic community hospital. Lippincotts Case Manag 2001; 6:127-136. 40. Cornia PB, Amory JK, Fraser S, Saint S, Lipsky BA. Computer-based order entry decreases duration of indwelling urinary catheterization in hospitalized patients. Am J Med 2003; 114:404-407. 41. Saint S, Kaufman SR, Thompson M, et al. A reminder reduces urinary catheterization in hospitalized patients. Jt Comm J Qual Patient Saf 2005; 31:455-462. 42. Huang WC, Wann SR, Lir SL, et al. Catheter-associated urinary tract
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infections in intensive care units can be reduced by prompting physicians to remove unnecessary catheters. Infect Control Hosp Epidemiol 2004; 25:974-978. 43. Topal J, Conklin S, Camp K, et al. Prevention of nosocomial catheterassociated urinary tract infections through computerized feedback to physicians and a nurse-directed protocol. Am J Med Qual 2005; 20:121126. 44. Dumigan DG, Kohan CA, Reed CR, Jekel JF, Fikrig MK. Utilizing national nosocomial infection surveillance system date to improve urinary tract infection rates in three intensive-care units. Clin Perform Qual Health Care 1998; 6:172-178. 45. Goetz AM, Kedzuf S, Wagener M, Muder RR. Feedback to nursing staff as an intervention to reduce catheter-associated urinary tract infections. Am J Infect Control 1999; 27:402-404. 46. Canadian Task Force on the Periodic Health Examination. The periodic health examination. Can Med Assoc J 1979; 121:1193-1254.
47. Marklew A. Urinary catheter care in the intensive care unit. Nurs Crit Care 2004; 9:21-27. 48. Wong ES, Rupp ME, Mermel L, et al. Public disclosure of healthcareassociated infections: the role of the Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol 2005; 26:210-212. 49. McKibben L, Horan TC, Tokars JI, et al. Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 2005; 26:580-587. 50. Healthcare-Associated Infection Working Group of the Joint Public Policy Committee. Essentials of public reporting of healthcare-associated infections: a tool kit. January 2007. Available at: http://www.cdc.gov/ ncidod/dhqp/pdf/ar/06_107498_Essentials_Tool_Kit.pdf. Accessed April 6, 2007. 51. National Quality Forum. National voluntary consensus standards, endorsed November 15, 2007. Available at: http://www.qualityforum.org/ pdf/news/lsCSACMeasures.pdf. Accessed December 20, 2007.
S51 infection control and hospital epidemiology october 2008, vol. 29, supplement 1 supplement article: shea/idsa practice recommendation Strategies to Prevent Surgical Site Infections in Acute Care Hospitals Deverick J. Anderson, MD, MPH; Keith S. Kaye, MD; David Classen, MD, MS; Kathleen M. Arias, MS, CIC; Kelly Podgorny, RN, MS, CPHQ; Helen Burstin, MD; David P. Calfee, MD, MS; Susan E. Coffin, MD, MPH; Erik R. Dubberke, MD; Victoria Fraser, MD; Dale N. Gerding, MD; Frances A. Griffin, RRT, MPA; Peter Gross, MD; Michael Klompas, MD; Evelyn Lo, MD; Jonas Marschall, MD; Leonard A. Mermel, DO, ScM; Lindsay Nicolle, MD; David A. Pegues, MD; Trish M. Perl, MD; Sanjay Saint, MD; Cassandra D. Salgado, MD, MS; Robert A. Weinstein, MD; Robert Wise, MD; Deborah S. Yokoe, MD, MPH
purpose Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals to implement and prioritize their surgical site infection (SSI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America "Compendium of Strategies to Prevent Healthcare-Associated Infections" Executive Summary and Introduction and accompanying editorial for additional discussion. section 1: rationale and statements of concern 1. Burden of SSIs as complications in acute care facilities. a. SSIs occur in 2%-5% of patients undergoing inpatient surgery in the United States.1 b. Approximately 500,000 SSIs occur each year.1 2. Outcomes associated with SSI a. Each SSI is associated with approximately 7-10 ad- ditional postoperative hospital days.1,2 b. Patients with an SSI have a 2-11 times higher risk of death, compared with operative patients without an SSI.3,4
i. Seventy-seven percent of deaths among patients with SSI are directly attributable to SSI.5 c. Attributable costs of SSI vary, depending on the type of operative procedure and the type of infecting pathogen; published estimates range from $3,000 to $29,000.4,6-12 i. SSIs are believed to account for up to $10 billion annually in healthcare expenditures.3,4,13 section 2: strategies to detect ssi 1. Definitions a. The Centers for Disease Control and Prevention Na- tional Nosocomial Infections Surveillance System14 and the National Healthcare Safety Network definitions for SSI are widely used.14,15 b. SSIs are classified as follows (Figure): i. Superficial incisional (involving only skin or sub- cutaneous tissue of the incision) ii. Deep incisional (involving fascia and/or muscular layers) iii. Organ/space 2. Methods for surveillance of SSI a. The direct method, with daily observation of the sur- gical site by the physician, physician extender, a trained nurse, or infection prevention and control professional
From the Duke University Medical Center, Durham, North Carolina (D.J.A., K.S.K.); the University of Utah, Salt Lake City (D.C.); the Association for Professionals in Infection Control and Epidemiology (K.M.A.) and the National Quality Forum (H.B.), Washington, D.C.; the Joint Commission, Oakbrook Terrace (K.P., R.W.), the Loyola University Chicago Stritch School of Medicine (D.N.G.) and the Stroger (Cook County) Hospital and Rush University Medical Center (R.A.W.), Chicago, and the Hines Veterans Affairs Medical Center, Hines (D.N.G.), Illinois; the Mount Sinai School of Medicine, New York, New York (D.P.C.); the Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania (S.E.C.); the Washington University School of Medicine, St. Louis, Missouri (E.R.D., V.F., J.M.); the Institute for Healthcare Improvement, Cambridge (F.A.G.), and Brigham and Women's Hospital and Harvard Medical School, Boston (D.S.Y., M.K.), Massachusetts; the Hackensack University Medical Center, Hackensack (P.G.), and the University of Medicine and Dentistry­New Jersey Medical School, Newark (P.G.), New Jersey; the Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island (L.A.M.); the David Geffen School of Medicine at the University of California, Los Angeles (D.A.P.); the Johns Hopkins Medical Institutions and University, Baltimore, Maryland (T.M.P.); the Ann Arbor Veterans Affairs Medical Center and the University of Michigan Medical School, Ann Arbor, Michigan (S.S.); the Medical University of South Carolina, Charleston (C.D.S.); and the University of Manitoba, Winnipeg, Canada (E.L., L.N.). Accepted June 2, 2008; electronically published September 16, 2008. Infect Control Hosp Epidemiol 2008; 29:S51­S61 2008 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2008/2910S1-0006$15.00. DOI: 10.1086/591064
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figure. The Centers for Disease Control and Prevention National Healthcare Safety Network classification for surgical site infection (SSI). Reproduced from Horan et al.14
starting 24-48 hours after surgery, is the most accurate method of surveillance.2,16-18 i. Although the direct method is used as the "gold standard" for studies, it is rarely used in practice because of its resource utilization requirements and impracticality. b. The indirect method of SSI surveillance consists of a combination of the following: i. Review of microbiology reports and patient medical records ii. Surgeon and/or patient surveys iii. Screening for readmission of surgical patients iv. Other information, such as coded diagnoses or operative reports c. The indirect method of SSI surveillance is less time consuming and can be readily performed by infection prevention and control personnel during surveillance rounds. d. The indirect method of SSI surveillance is both reliable (sensitivity, 84%-89%) and specific (specificity, 99.8%), compared with the "gold standard" of direct surveillance.19,20 e. Automated data systems can be used to broaden SSI surveillance. i. SSI surveillance can be expanded by using hospital databases that include data on administrative claims, days of antimicrobial use, readmission to the hospital, and return to the operating room, and/or by implementing a system that imports automated microbiologic culture data, surgical procedure data, and general demographic information into a single surveillance database.21-23
ii. These methods improve the sensitivity of indirect surveillance for detection of SSI and reduce the need for efforts by infection prevention and control professionals.21 3. Postdischarge surveillance a. Surgical procedures have been shifting to the out- patient setting during the past 3 decades.24 i. Patients now have shorter postoperative stays.25 b. No standardized or reliable method for postdischarge surveillance has been established. Different methods of postdischarge/outpatient SSI surveillance have been employed. Postdischarge surveillance based on surgeon and patient questionnaire results have been shown to have poor sensitivity and specificity. Regardless of which method is used, the overall rate of SSI for an institution typically increases after postdischarge surveillance methods are implemented.26 c. SSIs occurring and managed in the outpatient setting are usually superficial incisional infections. In contrast, deep incisional and organ/space infections typically require readmission to the hospital for management. section 3: strategies to prevent ssi 1. Existing guidelines, recommendations, and requirements a. Hospital Infection Control Practices Advisory Com- mittee guidelines i. The most recently published guidelines for preven- tion of SSI were released in 1999 by Mangram et al.5 ii. The pathogenesis of and likelihood of developing
an SSI involve a complex relationship among the following factors: (a) Microbial characteristics (eg, degree of contamination and virulence of pathogen) (b) Patient characteristics (eg, immune status and comorbid conditions) (c) Surgical characteristics (eg, type of procedure, introduction of foreign material, and amount of damage to tissues)27 iii. Risk factors for SSI can be separated into intrinsic, patient-related characteristics and extrinsic, procedurerelated characteristics. Table 1 summarizes the risk factors for each of these categories and provides recommendations (when available) to decrease the risk of SSI. b. Surgical Infection Prevention Collaborative i. The Centers for Medicare and Medicaid Services created the Surgical Infection Prevention Collaborative in 2002. ii. After review of published guidelines, an expert panel identified 3 performance measures for quality improvement related to antimicrobial prophylaxis:33,35 (a) Delivery of intravenous antimicrobial prophylaxis within 1 hour before incision (2 hours are allowed for the administration of vancomycin and fluoroquinolones) (b) Use of an antimicrobial prophylactic agent consistent with published guidelines (c) Discontinuation of use of the prophylactic antimicrobial agent within 24 hours after surgery (discontinuation within 48 hours is allowable for cardiothoracic procedures for adult patients) iii. The Surgical Infection Prevention Collaborative focuses on 7 procedures: abdominal hysterectomy, vaginal hysterectomy, hip arthroplasty, knee arthroplasty, cardiac surgery, vascular surgery, and colorectal surgery. iv. Many hospitals that implemented and improved compliance with Surgical Infection Prevention Collaborative performance measures decreased their rates of SSI.36 c. Surgical Care Improvement Project i. The Surgical Care Improvement Project, a multiagency collaboration created in 2003, is an extension of the Surgical Infection Prevention Collaborative. ii. The Surgical Care Improvement Project, in addition to assessing the 3 performance measures of the Surgical Infection Prevention Collaborative, also focuses on 3 additional evidence-supported process measures to prevent SSI:35 (a) Proper hair removal: no hair removal or hair removal with clippers or depilatory method is considered appropriate; use of razors is considered inappropriate (b) Controlling blood glucose level during the immediate postoperative period for patients undergoing cardiac surgery: controlled 6:00 am blood glucose level
strategies for prevention of ssi S53 (lower than 200 mg/dL) on postoperative day 1 and postoperative day 2, with procedure day being postoperative day 0 (c) Maintenance of perioperative normothermia for patients undergoing colorectal surgery d. Institute for Healthcare Improvement i. The Institute for Healthcare Improvement created a nationwide quality improvement project to improve outcomes for hospitalized patients.37 ii. The Institute for Healthcare Improvement recommends the same 6 preventive measures recommended by the Surgical Care Improvement Project and has included these in the 100,000 and 5 Million Lives campaigns.37 e. Federal requirements i. Centers for Medicare and Medicaid Services (a) In accordance with the Deficit Reduction Act of 2005, hospitals that are paid by Medicare under the acute care inpatient prospective payment system receive their full Medicare Annual Payment Update only if they submit required quality measure information to the Centers for Medicare and Medicaid Services. (b) The Centers for Medicare and Medicaid Services now requires inclusion of 2 Surgical Care Improvement Project measures (antimicrobial prophylaxis provided within 1 hour before incision and discontinuation of antimicrobial prophylaxis within 24 hours after surgery) in the quality measure set of the inpatient prospective payment system.38 (c) Furthermore, the Centers for Medicare and Medicaid Services has proposed that additional Surgical Care Improvement Project measures described above (appropriate antimicrobial prophylactic agent, proper hair removal, perioperative glucose level control, and maintenance of normothermia) be included in the quality measure set in the near future.38 2. Infrastructure requirements a. Trained personnel i. Infection prevention and control personnel must be specifically trained in methods of SSI surveillance, have knowledge of and the ability to prospectively apply the Centers for Disease Control and Prevention definitions of SSI, possess basic computer and mathematical skills, and be adept at providing feedback and education to healthcare personnel when appropriate.5 b. Education i. Regularly provide education to surgeons and perioperative personnel through continuing education activities directed at minimizing perioperative SSI risk through implementation of recommended process measures. (a) Several educational components can be com-
table 1. Selected Risk Factors for and Recommendations to Prevent Surgical Site Infections (SSIs)
Risk factor
Recommendation
Intrinsic, patient related (preoperative) Unmodifiable Age Modifiable Glucose control, diabetes Obesity Smoking cessation Immunosuppressive medications Extrinsic, procedure related (perioperative) Preparation of patient Hair removal Preoperative infections Operative characteristics Surgical scrub (surgical team members' hands and forearms) Skin preparation Antimicrobial prophylaxis Timing Choice Duration of therapy Surgeon skill/technique Asepsis Operative time Operating room characteristics Ventilation Traffic Environmental surfaces Sterilization of surgical equipment
No formal recommendation: relationship to increased risk of SSI may be secondary to comorbidities or immune senescence [28-30] Control serum blood glucose levels [5]; reduce glycosylated hemoglobin A1c levels to !7% before surgery, if possible [31] Increase dosing of prophylactic antimicrobial agent for morbidly obese patients [32] Encourage smoking cessation within 30 days before procedure [5] No formal recommendation; in general, avoid immunosuppressive medications in perioperative period, if possible Do not remove unless hair will interfere with the operation [5]; if hair removal is necessary, remove by clipping and do not use razors Identify and treat infections (eg, urinary tract infection) remote to the surgical site before elective surgery [5] Use appropriate antiseptic agent to perform 2-5­minute preoperative surgical scrub [5] or use an alcohol-based surgical hand antisepsis product Wash and clean skin around incision site; use an appropriate antiseptic agent [5] Administer only when indicated [5] Administer within 1 hour before incision to maximize tissue concentrationb [5, 33] Select appropriate agents on the basis of surgical proce- dure, most common pathogens causing SSI for a specific procedure, and published recommendations [5, 33] Stop prophylaxis within 24 hours after the procedure for all procedures except cardiac surgery; for cardiac surgery, antimicrobial prophylaxis should be stopped within 48 hours [5, 33] Handle tissue carefully and eradicate dead space [5] Adhere to standard principles of operating room asepsis [5] No formal recommendation in most recent guidelines; minimize as much as possible [34] Follow American Institute of Architects' recommendations [5] Minimize operating room traffic [5] Use a US Environmental Protection Agency­approved hospital disinfectant to clean surfaces and equipment [5] Sterilize all surgical equipment according to published guidelines; minimize the use of flash sterilization [5]
a See Table 2 for definitions. b Vancomycin and fluoroquinolones can be given 2 hours before incision.
Gradea ... A-II A-II A-II C-II A-I A-II A-II A-II A-I A-I A-I A-I A-III A-III A-III C-I B-II B-III B-I
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bined into concise, efficient, and effective recommendations that are easily understood and remembered.39 ii. Provide education regarding the outcomes associated with SSI, risks for SSI, and methods to reduce risk to all patients, patients' families, surgeons, and perioperative personnel. iii. Education for patients and patients' families is an effective method to reduce risk associated with intrinsic patient-related SSI risk factors.40,41 c. Computer-assisted decision support and automated reminders i. Several institutions have successfully employed computer-assisted decision-support methodology to improve the rate of appropriate administration of antimicrobial prophylaxis (including redosing during prolonged cases).42-44 ii. Computer-assisted decision support, however, is potentially expensive, can be time consuming to implement, and, in a single study, was reported to initially increase the rate of adverse drug reactions.45 iii. Institutions must appropriately validate computer-assisted decision-support systems after implementation. d. Utilization of automated data i. Install information technology infrastructure to facilitate data transfer, receipt, and organization to aid with the tracking of process and outcome measures. section 4: recommendations for implementing prevention and monitoring strategies Recommendations for preventing and monitoring SSIs are summarized in the following section. They are designed to assist acute care hospitals in prioritizing and implementing their SSI prevention efforts. Criteria for grading of the strength of recommendation and quality of evidence are described in Table 2. I. Basic practices for prevention and monitoring of SSI: recommended for all acute care hospitals A. Surveillance of SSI 1. Perform surveillance for SSI (A-II). a. Identify high-risk, high-volume operative procedures to be targeted for SSI surveillance on the basis of a risk assessment of patient populations, operative procedures performed, and available SSI surveillance data. b. Identify, collect, store, and analyze data needed for the surveillance program.5 i. Implement a system for collecting data needed to identify SSIs. ii. Develop a database for storing, managing, and accessing collected data on SSIs. iii. Prepare periodic SSI reports (the time frame will
depend on hospital needs and volume of targeted procedures). iv. Collect denominator data on all patients undergoing targeted procedures, to calculate SSI rates for each type of procedure.39 v. Identify trends (eg, in rates of SSI and pathogens causing SSIs). c. Use Centers for Disease Control and Prevention National Healthcare Safety Network definitions of SSI.14 d. Perform indirect surveillance for targeted procedures.19,20,47,48 e. Perform postoperative surveillance for 30 days; extend the postoperative surveillance period to 12 months if prosthetic material is implanted during surgery.14 f. Surveillance should be performed for patients readmitted to the hospital. i. If an SSI is diagnosed at your institution but the surgical procedure was performed elsewhere, notify the hospital where the original procedure was performed. g. Develop a system for routine review and interpretation of SSI rates to detect significant increases or outbreaks and to identify areas where additional resources might be needed to improve SSI rates.47 2. Provide ongoing feedback on SSI surveillance and process measures to surgical and perioperative personnel and leadership (A-II). a. Routinely provide feedback on SSI rates and process measures to individual surgeons and hospital leadership.5 i. For each type of procedure performed, provide riskadjusted rates of SSI. ii. Anonymously benchmark procedure-specific riskadjusted rates of SSI among peer surgeons.5 b. Confidentially provide data to individual surgeons, the surgical division, and/or department chiefs. 3. Increase the efficiency of surveillance through the use of automated data (A-II). a. Implement a method to electronically transfer operative data, including process measures when available, to infection prevention and control personnel to facilitate acquisition of denominator data and calculation of SSI rates for various procedures. b. If information technology and infrastructure resources are available, develop automated methods for detection of SSI by use of automated data on readmissions, microbiological test results, and antimicrobial dispensing.23 i. Implementation of automated surveillance may improve the sensitivity of surveillance. B. Practice 1. Administer antimicrobial prophylaxis in accordance with evidence-based standards and guidelines (A-I).5,49,50
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table 2. Strength of Recommendation and Quality of Evidence
Category/grade
Definition
Strength of recommendation A B C Quality of evidence I II III
Good evidence to support a recommendation for use Moderate evidence to support a recommendation for use Poor evidence to support a recommendation Evidence from x1 properly randomized, controlled trial Evidence from x1 well-designed clinical trial, without randomization; from cohort or case-control analytic studies (preferably from 11 center); from multiple time series; or from dramatic results from uncontrolled experiments Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
note. Adapted from the Canadian Task Force on the Periodic Health Examination.46
a. Administer prophylaxis within 1 hour before incision to maximize tissue concentration.33,35 i. Two hours are allowed for the administration of vancomycin and fluoroquinolones. b. Select appropriate agents on the basis of the surgical procedure, the most common pathogens causing SSI for a specific procedure, and published recommendations.33,35 c. Discontinue prophylaxis within 24 hours after surgery for most procedures; discontinue within 48 hours for cardiac procedures.33,35 2. Do not remove hair at the operative site unless the presence of hair will interfere with the operation; do not use razors (A-II).5 a. If hair removal is necessary, remove it by clipping or by use of a depilatory agent. 3. Control blood glucose level during the immediate postoperative period for patients undergoing cardiac surgery (AI).35 a. Maintain the postoperative blood glucose level at less than 200 mg/dL. i. Measure blood glucose level at 6:00 am on postoperative day 1 and postoperative day 2, with the procedure day being postoperative day 0. b. Initiating close blood glucose control in the intraoperative period has not been shown to reduce the risk of SSI, compared with starting blood glucose control in the postoperative period. In fact, a recently performed randomized controlled trial showed that initiating close glucose control during cardiac surgery may actually lead to higher rates of adverse outcomes, including stroke and death.51 4. Measure and provide feedback to providers on the rates of compliance with process measures, including antimicrobial
prophylaxis, proper hair removal, and glucose control (for cardiac surgery) (A-III).35 a. Routinely provide feedback to surgical staff and leadership, regarding compliance with targeted process measures. 5. Implement policies and practices aimed at reducing the risk of SSI that meet regulatory and accreditation requirements and that are aligned with evidence-based standards (eg, Centers for Disease Control and Prevention and professional organization guidelines) (A-II).5,35,36 a. Policies and practices should include but are not limited to the following: i. Reducing modifiable patient risk factors ii. Optimal cleaning and disinfection of equipment and the environment iii. Optimal preparation and disinfection of the operative site and the hands of the surgical team members iv. Adherence to hand hygiene v. Traffic control in operating rooms vi. See Table 1 for a more detailed list. C. Education 1. Educate surgeons and perioperative personnel about SSI prevention (A-III). a. Include risk factors, outcomes associated with SSI, local epidemiology (eg, SSI rates by procedure and the rate of methicillin-resistant Staphylococcus aureus [MRSA] infection in a facility), and basic prevention measures. 2. Educate patients and their families about SSI prevention, as appropriate (A-III). a. Provide instructions and information to patients before surgery, describing strategies for reducing SSI risk. Specifically provide preprinted materials to patients.
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b. Examples of printed materials for patients are available from the following Web pages: i. JAMA patient page: wound infections (from the Journal of the American Medical Association; available at: http://jama.ama-assn.org/cgi/reprint/294/16/2122) ii. Surgical Care Improvement Project consumer info sheet (available at: http://www.ofmq.com/Websites/ ofmq/Images/FINALconsumer_tips2.pdf) iii. What you need to know about infections after surgery: a fact sheet for patients and their family members (available at: http://www.ihi.org/NR/rdonlyres/ 0EE409F4-2F6A-4B55-AB01-16B6D6935EC5/0/ SurgicalSiteInfectionsPtsandFam.pdf) D. Accountability 1. The hospital's chief executive officer and senior management are responsible for ensuring that the healthcare system supports an infection prevention and control program that effectively prevents the occurrence of SSIs and the transmission of epidemiologically significant pathogens. 2. Senior management is accountable for ensuring that an adequate number of trained personnel are assigned to the infection prevention and control program. 3. Senior management is accountable for ensuring that healthcare personnel, including licensed and nonlicensed personnel, are competent to perform their job responsibilities. 4. Direct healthcare providers (such as physicians, nurses, aides, and therapists) and ancillary personnel (such as housekeeping and equipment-processing personnel) are responsible for ensuring that appropriate infection prevention and control practices are used at all times (including hand hygiene; strict adherence to aseptic technique; cleaning and disinfection of equipment and the environment; cleaning, disinfection, and sterilization of medical supplies and instruments; and appropriate surgical prophylaxis protocols). 5. Hospital and unit leaders are responsible for holding personnel accountable for their actions. 6. The person that manages the infection prevention and control program is responsible for ensuring that an active program to identify SSIs is implemented, that data on SSIs are analyzed and regularly provided to those who can use the information to improve the quality of care (eg, unit staff, clinicians, and hospital administrators), and that evidencebased practices are incorporated into the program. 7. Personnel responsible for healthcare personnel and patient education are accountable for ensuring that appropriate training and educational programs to prevent SSIs are developed and provided to personnel, patients, and families.
8. Personnel from the infection prevention and control program, the laboratory, and information technology departments are responsible for ensuring that systems are in place to support the surveillance program. II. Special approaches for the prevention of SSI Perform an SSI risk assessment. These special approaches are recommended for use in locations and/or populations within the hospital that have unacceptably high SSI rates despite implementation of the basic SSI prevention strategies listed above. 1. Perform expanded SSI surveillance to determine the source and extent of the problem and to identify possible targets for intervention (B-II). a. Expand surveillance to include additional procedures and possibly to all National Healthcare Safety Network procedures.5 Align expanded surveillance with the hospital's strategic plan. III. Approaches that should not be considered a routine part of SSI prevention 1. Do not routinely use vancomycin for antimicrobial prophylaxis (B-II). a. Vancomycin should not routinely be used for antimicrobial prophylaxis, but it can be an appropriate agent for specific scenarios. Reserve vancomycin for specific clinical circumstances, such as a proven outbreak of SSI due to MRSA, high endemic rates of SSI due to MRSA, targeted high-risk patients who are at increased risk for SSI due to MRSA (including cardiothoracic surgical patients and elderly patients with diabetes), and high-risk surgical procedures during which an implant is placed.52 i. No definitions for "high endemic rates of SSI due to MRSA" have been established. ii. Studies of the efficacy of vancomycin prophylaxis were published before the emergence of communityacquired MRSA. b. A recent meta-analysis of 7 studies comparing glycopeptide prophylaxis with b-lactam prophylaxis before cardiothoracic surgery showed that there was no difference in rates of SSI between the 2 antimicrobial prophylaxis regimens.53 c. No study has prospectively analyzed the effect of providing both glycopeptide and b-lactam antimicrobials for preoperative antimicrobial prophylaxis. Thus, it is unclear whether treatment with vancomycin, when indicated, should be added to or used in place of standard recommended antimicrobial prophylaxis. Because vancomycin does not have activity against gram-negative pathogens, some experts recommend adding vancomycin treatment to standard antimicrobial prophylaxis for the specific clinical circumstances described above.
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2. Do not routinely delay surgery to provide parenteral nutrition (A-I). a. Preoperative administration of total parenteral nutrition has not been shown to reduce the risk of SSI in prospective, randomized controlled trials and may increase the risk of SSI.54,55 IV. Unresolved issues 1. Preoperative bathing with chlorhexidine-containing products a. Preoperative showering with agents such as chlorhexidine has been shown to reduce bacterial colonization of the skin.56 Several studies have examined the utility of preoperative showers, but none has definitively proven that they decrease SSI risk. A recent Cochrane review57 evaluated the evidence for preoperative bathing or showering with antiseptics for SSI prevention. Six randomized, controlled trials evaluating the use of 4% chlorhexidine gluconate were included in the analysis, with no clear evidence of benefit noted. To gain the maximum antiseptic effect of chlorhexidine, it must be allowed to dry completely and not be washed off. 2. Routine screening for MRSA or routine attempts to decolonize surgical patients with an antistaphylococcal agent in the preoperative setting a. A recent double-blinded, randomized, controlled trial involving more than 4,000 patients showed that intranasal application of mupirocin did not significantly reduce the S. aureus SSI rate.58 In a secondary analysis of these data, however, the use of intranasal mupirocin was associated with an overall decreased rate of nosocomial S. aureus infection among the S. aureus carriers.58 Mupirocin resistance has been documented.59 b. In contrast, other studies have suggested that mupirocin may be effective for particular patient groups, including patients undergoing orthopedic60,61 or cardiothoracic62,63 surgery. However, these were not randomized controlled trials.
of SSI decreases from 15.2% among patients who received 30%-35% supplemental FiO2 to 11.5% among patients who received 80% FiO2 during surgery (3.7% absolute Risk Reduction; P p .10).67 4. Maintaining normothermia (temperature higher than 36.0C) immediately after colorectal surgery a. One randomized trial with 200 patients undergoing colorectal surgery found that infection rates were significantly reduced among patients randomized to have normothermia maintained during surgery.68 b. Controversy still exists regarding this recommendation, because of the following: i. The trial examined the effect of intraoperative normothermia, not postoperative normothermia, and did not include risk adjustment for type of procedure. ii. An observational study showed no impact of normothermia on infection rates.69 5. Preoperative intranasal and pharyngeal chlorhexidine treatment for patients undergoing cardiothoracic procedures70 a. Although data exist from a randomized, controlled trial to support its usage, chlorhexidine nasal cream is neither approved by the US Food and Drug Administration nor commercially available in the United States. section 5: performance measures I. Internal reporting These performance measures are intended to support internal hospital quality improvement efforts and do not necessarily address external reporting needs. The process and outcome measures suggested here are derived from published guidelines, other relevant literature, and the opinion of the authors. Report process and outcome measures to senior hospital leadership, nursing leadership, and clinicians who care for patients at risk for SSI. A. Process measures
3. Maintaining oxygenation with supplemental oxygen during and after colorectal procedures a. Three randomized clinical trials have been published comparing 80% fraction of inspired oxygen (FiO2) with 30%-35% FiO2 during the intra- and postoperative periods. i. Two trials showed a significant decrease in the rate of SSI associated with the higher FiO2 value,64,65 and one actually showed a significant increase in the rate of SSI.66 ii. Both studies with results showing a beneficial effect of supplemental oxygen included patients who underwent colorectal surgery, whereas the study with results showing a negative effect of supplemental oxygen included all types of patients. iii. When results of the 3 studies are pooled, the rate
1. Compliance with antimicrobial prophylaxis guidelines a. Measure the percentage of procedures in which an- timicrobial prophylaxis was appropriately provided. Appropriateness includes (1) correct type of agent, (2) start of administration of the agent within 1 hour before incision (2 hours allowed for vancomycin and fluoroquinolones) and (3) discontinuation of the agent within 24 hours after surgery (48 hours for cardiac procedures). i. Numerator: number of patients who appropriately received antimicrobial prophylaxis. ii. Denominator: total number of selected operations performed. iii. Multiply by 100 so that the measure is expressed as a percentage.
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2. Compliance with hair-removal guidelines a. Measure the percentage of procedures for which hair removal is appropriately performed (ie, clipping, use of a depilatory, or no hair removal, rather than use of a razor). i. Numerator: number of patients with appropriate perioperative hair removal. ii. Denominator: total number of selected operations performed. iii. Multiply by 100 so that the measure is expressed as a percentage. 3. Compliance with perioperative glucose control guidelines a. Measure the percentage of procedures for which se- rum glucose levels are maintained below 200 mg/dL at 6:00 am on postoperative day 1 and postoperative day 2 after cardiac surgery. i. Numerator: number of patients with appropriately maintained serum glucose at 6:00 am on both postoperative day 1 and postoperative day 2 after cardiac surgery. ii. Denominator: total number of cardiac procedures performed. iii. Multiply by 100 so that measure is expressed as a percentage.
expected number of SSIs can be obtained by multiplying the number of operations done by the surgeon in each procedure risk category by the National Nosocomial Infections Surveillance rate for the same procedure risk category and dividing by 100. Values that exceed 1.0 indicate that more SSIs than expected occurred. II. External reporting There are many challenges in providing useful information to consumers and other stakeholders while preventing unintended adverse consequences of public reporting of healthcare-associated infections.74 Recommendations for public reporting of healthcare-associated infections have been provided by the Hospital Infection Control Practices Advisory Committee,75 the Healthcare-Associated Infection Working Group of the Joint Public Policy Committee,76 and the National Quality Forum.77 The following is an example of an external performance measure that is currently required by some healthcare stakeholders and regulators. A. Process measure
B. Outcome measures 1. Surgical site infection rate a. Use National Healthcare Safety Network definitions and risk adjustment methods.15 i. Numerator: number of patients with surgical site infections after selected operations. ii. Denominator: total number of selected operations performed. iii. Multiply by 100 so that measure is expressed as a percentage. iv. Risk adjustment: rates of SSI can be risk adjusted by use of one of 2 methods: stratification using the National Nosocomial Infections Surveillance risk index27 or calculation of the standardized infection ratio.71 (a) The National Nosocomial Infections Surveillance risk index is a widely used, operation- and patient-specific, prospectively applied risk score that predicts SSI.72 This risk index includes 3 predictors of increased risk of SSI: estimators of wound microbial contamination, duration of operation, and markers for host susceptibility.73 Because rates of SSI published by National Healthcare Safety Network include superficial incisional infections, it is appropriate to collect data on superficial incisional infections for internal benchmarking. (b) The standardized infection ratio (SIR) is the ratio of the observed number of SSIs (O) that occurred to the expected number for surgeons performing a specific type of procedure (E) (ie, SIR p O/E).71 The
1. Compliance with Centers for Medicare and Medicaid Services antimicrobial prophylaxis guidelines (see section 5.I.A.1 above: Performance Measures; Internal Reporting; Process Measures) a. Measure the percentage of procedures in which antimicrobial prophylaxis was appropriately provided. Appropriateness includes correct type of agent, administration of the agent within 1 hour before incision (2 hours allowed for vancomycin and fluoroquinolones), and discontinuation of the agent within 24 hours after surgery (48 hours for cardiothoracic procedures).38 B. State and federal requirements 1. Federal requirements a. Hospitals that receive Medicare reimbursement must collect and report quality measures required by Centers for Medicare and Medicaid Services (see above). 2. State requirements a. Hospitals in states that have mandatory reporting re- quirements must collect and report the data required by the state. For information on state and federal requirements, check with your state or local health department. 3. External quality initiatives a. Hospitals that participate in external quality initia- tives must collect and report the data if required by the initiative.
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acknowledgments For Potential Conflicts of Interest statements and information on financial support, please see the Acknowledgments in the Executive Summary, on page S20 of this supplement. Address reprint requests to the Reprints Coordinator, University of Chicago Press, 1427 E. 60th St., Chicago, IL 60637 ([email protected]) or contact the journal office ([email protected]). references 1. Cruse P. Wound infection surveillance. Rev Infect Dis 1981; 3:734-737. 2. Cruse PJ, Foord R. The epidemiology of wound infection: a 10-year prospective study of 62,939 wounds. Surg Clin North Am 1980; 60:2740. 3. Engemann JJ, Carmeli Y, Cosgrove SE, et al. Adverse clinical and economic outcomes attributable to methicillin resistance among patients with Staphylococcus aureus surgical site infection. Clin Infect Dis 2003; 36:592-598. 4. Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 1999; 20:725-730. 5. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999; 20: 250-278; quiz 279-280. 6. Coello R, Glenister H, Fereres J, et al. The cost of infection in surgical patients: a case-control study. J Hosp Infect 1993; 25:239-250. 7. Boyce JM, Potter-Bynoe G, Dziobek L. Hospital reimbursement patterns among patients with surgical wound infections following open heart surgery. Infect Control Hosp Epidemiol 1990; 11:89-93. 8. Vegas AA, Jodra VM, Garcia ML. Nosocomial infection in surgery wards: a controlled study of increased duration of hospital stays and direct cost of hospitalization. Eur J Epidemiol 1993; 9:504-510. 9. VandenBergh MF, Kluytmans JA, van Hout BA, et al. Cost-effectiveness of perioperative mupirocin nasal ointment in cardiothoracic surgery. Infect Control Hosp Epidemiol 1996; 17:786-792. 10. Hollenbeak CS, Murphy DM, Koenig S, Woodward RS, Dunagan WC, Fraser VJ. The clinical and economic impact of deep chest surgical site infections following coronary artery bypass graft surgery. Chest 2000; 118:397-402. 11. Whitehouse JD, Friedman ND, Kirkland KB, Richardson WJ, Sexton DJ. The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost. Infect Control Hosp Epidemiol 2002; 23:183-189. 12. Apisarnthanarak A, Jones M, Waterman BM, Carroll CM, Bernardi R, Fraser VJ. Risk factors for spinal surgical-site infections in a community hospital: a case-control study. Infect Control Hosp Epidemiol 2003; 24:3136. 13. Wong ES. Surgical site infections. In: Mayhall CG, ed. Hospital Epidemiology and Infection Control. 3rd ed. Baltimore: Lippincott, Williams, and Wilkins; 2004:287­310. 14. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 1992; 13:606-608. 15. National Healthcare Safety Network (NHSN) members page. Available at: http://www.cdc.gov/ncidod/dhqp/nhsn_members.html. Accessed August 5, 2008. 16. Condon RE, Schulte WJ, Malangoni MA, Anderson-Teschendorf MJ. Effectiveness of a surgical wound surveillance program. Arch Surg 1983; 118:303-307.
17. Kerstein M, Flower M, Harkavy LM, Gross PA. Surveillance for postoperative wound infections: practical aspects. Am Surg 1978; 44:210-214. 18. Mead PB, Pories SE, Hall P, Vacek PM, Davis JH Jr, Gamelli RL. Decreasing the incidence of surgical wound infections: validation of a surveillance-notification program. Arch Surg 1986; 121:458-461. 19. Baker C, Luce J, Chenoweth C, Friedman C. Comparison of case-finding methodologies for endometritis after cesarean section. Am J Infect Control 1995; 23:27-33. 20. Cardo DM, Falk PS, Mayhall CG. Validation of surgical wound surveillance. Infect Control Hosp Epidemiol 1993; 14:211-215. 21. Chalfine A, Cauet D, Lin WC, et al. Highly sensitive and efficient computer-assisted system for routine surveillance for surgical site infection. Infect Control Hosp Epidemiol 2006; 27:794-801. 22. Miner AL, Sands KE, Yokoe DS, et al. Enhanced identification of postoperative infections among outpatients. Emerg Infect Dis 2004; 10:19311937. 23. Yokoe DS, Noskin GA, Cunnigham SM, et al. Enhanced identification of postoperative infections among inpatients. Emerg Infect Dis 2004; 10: 1924-1930. 24. Burke JP. Infection control--a problem for patient safety. N Engl J Med 2003; 348:651-656. 25. Sands K, Vineyard G, Platt R. Surgical site infections occurring after hospital discharge. J Infect Dis 1996; 173:963-970. 26. Mannien J, Wille JC, Snoeren RL, van den Hof S. Impact of postdischarge surveillance on surgical site infection rates for several surgical procedures: results from the nosocomial surveillance network in The Netherlands. Infect Control Hosp Epidemiol 2006; 27:809-816. 27. Culver DH, Horan TC, Gaynes RP, et al. Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System. Am J Med 1991; 91:152S157S. 28. Pessaux P, Msika S, Atalla D, Hay JM, Flamant Y. Risk factors for postoperative infectious complications in noncolorectal abdominal surgery: a multivariate analysis based on a prospective multicenter study of 4718 patients. Arch Surg 2003; 138:314-324. 29. Raymond DP, Pelletier SJ, Crabtree TD, Schulman AM, Pruett TL, Sawyer RG. Surgical infection and the aging population. Am Surg 2001; 67:827832; discussion 832-833. 30. Kaye KS, Schmit K, Pieper C, et al. The effect of increasing age on the risk of surgical site infection. J Infect Dis 2005; 191:1056-1062. 31. Dronge AS, Perkal MF, Kancir S, Concato J, Aslan M, Rosenthal RA. Long-term glycemic control and postoperative infectious complications. Arch Surg 2006; 141:375-380; discussion 380. 32. Forse RA, Karam B, MacLean LD, Christou NV. Antibiotic prophylaxis for surgery in morbidly obese patients. Surgery 1989; 106:750-756; discussion 756-757. 33. Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004; 38:1706-1715. 34. Haley RW, Culver DH, Morgan WM, White JW, Emori TG, Hooton TM. Identifying patients at high risk of surgical wound infection: a simple multivariate index of patient susceptibility and wound contamination. Am J Epidemiol 1985; 121:206-215. 35. Bratzler DW, Hunt DR. The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis 2006; 43:322-330. 36. Dellinger EP, Hausmann SM, Bratzler DW, et al. Hospitals collaborate to decrease surgical site infections. Am J Surg 2005; 190:9-15. 37. Institute for Healthcare Improvement. Available at: http://www.ihi.org/. Accessed May 1, 2007. 38. Medicare program; hospital outpatient prospective payment system and CY 2007 payment rates; CY 2007 update to the ambulatory surgical center covered procedures list; Medicare administrative contractors; and reporting hospital quality data for FY 2008 inpatient prospective payment system annual payment update program--HCAHPS survey, SCIP, and
strategies for prevention of ssi S61
mortality. Final rule with comment period and final rule. Fed Regist 2006; 71:67959-68401. 39. van Kasteren ME, Mannien J, Kullberg BJ, et al. Quality improvement of surgical prophylaxis in Dutch hospitals: evaluation of a multi-site intervention by time series analysis. J Antimicrob Chemother 2005; 56: 1094-1102. 40. Schweon S. Stamping out surgical site infections. RN 2006; 69:36-40; quiz 41. 41. Torpy JM, Burke A, Glass RM. JAMA patient page: wound infections. JAMA 2005; 294:2122. 42. Pestotnik SL, Classen DC, Evans RS, Burke JP. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes. Ann Intern Med 1996; 124:884-890. 43. Kanter G, Connelly NR, Fitzgerald J. A system and process redesign to improve perioperative antibiotic administration. Anesth Analg 2006; 103: 1517-1521. 44. Webb AL, Flagg RL, Fink AS. Reducing surgical site infections through a multidisciplinary computerized process for preoperative prophylactic antibiotic administration. Am J Surg 2006; 192:663-668. 45. Berger RG, Kichak JP. Computerized physician order entry: helpful or harmful? J Am Med Inform Assoc 2004; 11:100-103. 46. Canadian Task Force on the Periodic Health Examination. The periodic health examination. Can Med Assoc J 1979; 121:1193-1254. 47. Lee JT. Wound infection surveillance. Infect Dis Clin North Am 1992; 6: 643-656. 48. Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 1985; 121:182-205. 49. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. American Society of Health-System Pharmacists. Am J Health Syst Pharm 1999; 56:1839-1888. 50. Antimicrobial prophylaxis in surgery. Med Lett Drugs Ther 2001; 43:9297. 51. Gandhi GY, Nuttall GA, Abel MD, et al. Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery: a randomized trial. Ann Intern Med 2007; 146:233-243. 52. Dodds Ashley ES, Carroll DN, Engemann JJ, et al. Risk factors for postoperative mediastinitis due to methicillin-resistant Staphylococcus aureus. Clin Infect Dis 2004; 38:1555-1560. 53. Bolon MK, Morlote M, Weber SG, Koplan B, Carmeli Y, Wright SB. Glycopeptides are no more effective than b-lactam agents for prevention of surgical site infection after cardiac surgery: a meta-analysis. Clin Infect Dis 2004; 38:1357-1363. 54. Brennan MF, Pisters PW, Posner M, Quesada O, Shike M. A prospective randomized trial of total parenteral nutrition after major pancreatic resection for malignancy. Ann Surg 1994; 220:436-441; discussion 441-444. 55. Perioperative total parenteral nutrition in surgical patients. The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group. N Engl J Med 1991; 325:525-532. 56. Kaul AF, Jewett JF. Agents and techniques for disinfection of the skin. Surg Gynecol Obstet 1981; 152:677-685. 57. Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev 2007; (2):CD004985. 58. Perl TM, Cullen JJ, Wenzel RP, et al. Intranasal mupirocin to prevent postoperative Staphylococcus aureus infections. N Engl J Med 2002; 346: 1871-1877. 59. Miller MA, Dascal A, Portnoy J, Mendelson J. Development of mupirocin resistance among methicillin-resistant Staphylococcus aureus after widespread use of nasal mupirocin ointment. Infect Control Hosp Epidemiol 1996; 17:811-813. 60. Kallen AJ, Wilson CT, Larson RJ. Perioperative intranasal mupirocin for
the prevention of surgical-site infections: systematic review of the literature and meta-analysis. Infect Control Hosp Epidemiol 2005; 26:916922. 61. Wilcox MH, Hall J, Pike H, et al. Use of perioperative mupirocin to prevent methicillin-resistant Staphylococcus aureus (MRSA) orthopaedic surgical site infections. J Hosp Infect 2003; 54:196-201. 62. Nicholson MR, Huesman LA. Controlling the usage of intranasal mupirocin does impact the rate of Staphylococcus aureus deep sternal wound infections in cardiac surgery patients. Am J Infect Control 2006; 34:4448. 63. McKibben L, Horan T, Tokars JI, et al. Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee. Am J Infect Control 2005; 33:217-226. 64. Belda FJ, Aguilera L, Garcia de la Asuncion J, et al. Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial. JAMA 2005; 294:2035-2042. 65. Greif R, Akca O, Horn EP, Kurz A, Sessler DI. Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection. Outcomes Research Group. N Engl J Med 2000; 342:161-167. 66. Pryor KO, Fahey TJ 3rd, Lien CA, Goldstein PA. Surgical site infection and the routine use of perioperative hyperoxia in a general surgical population: a randomized controlled trial. JAMA 2004; 291:79-87. 67. Dellinger EP. Increasing inspired oxygen to decrease surgical site infection: time to shift the quality improvement research paradigm. JAMA 2005; 294:2091-2092. 68. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med 1996; 334:1209-1215. 69. Barone JE, Tucker JB, Cecere J, et al. Hypothermia does not result in more complications after colon surgery. Am Surg 1999; 65:356-359. 70. Segers P, Speekenbrink RG, Ubbink DT, van Ogtrop ML, de Mol BA. Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate: a randomized controlled trial. JAMA 2006; 296:2460-2466. 71. Gaynes RP, Culver DH, Horan TC, Edwards JR, Richards C, Tolson JS. Surgical site infection (SSI) rates in the United States, 1992-1998: the National Nosocomial Infections Surveillance System basic SSI risk index. Clin Infect Dis 2001;33(Suppl 2):S69-S77. 72. Gaynes RP, Solomon S. Improving hospital-acquired infection rates: the CDC experience. Jt Comm J Qual Improv 1996; 22:457-467. 73. The Society for Hospital Epidemiology of America; The Association for Practitioners in Infection Control; The Centers for Disease Control; The Surgical Infection Society. Consensus paper on the surveillance of surgical wound infections. Infect Control Hosp Epidemiol 1992; 13:599-605. 74. Wong ES, Rupp ME, Mermel L, et al. Public disclosure of healthcareassociated infections: the role of the Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol 2005; 26:210-212. 75. McKibben L, Horan TC, Tokars JI, et al. Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 2005; 26:580-587. 76. The Healthcare-Associated Infection Working Group of the Joint Public Policy Committee. Essentials of public reporting of healthcare-associated infections: a tool kit. January 2007. Available at: http://www.cdc.gov/ ncidod/dhqp/pdf/ar/06_107498_Essentials_Tool_Kit.pdf. Accessed April 6, 2007. 77. The National Quality Forum. National voluntary consensus standards, endorsed November 15, 2007. Available at: http://www.qualityforum.org/ pdf/news/lsCSACMeasures.pdf. Accessed December 20, 2007.
S3 infection control and hospital epidemiology october 2008, vol. 29, supplement 1 supplement article: introduction Improving Patient Safety Through Infection Control: A New Healthcare Imperative
Deborah S. Yokoe, MD, MPH; David Classen, MD, MS
Many healthcare organizations, professional associations, government and accrediting agencies, legislators, regulators, payers, and consumer advocacy groups have advanced the prevention of healthcare-associated infections as a national imperative, stimulating the creation of "A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals" in this supplement. In this introduction, we provide background and context and discuss the major issues that shaped the recommendations included in the compendium. Infect Control Hosp Epidemiol 2008; 29:S3-S11
introduction and background The Centers for Disease Control and Prevention estimates that 5%-10% of hospitalized patients develop a healthcare-associated infection (HAI),1 corresponding to approximately 2 million HAIs associated with nearly 100,000 deaths each year in US hospitals.2 The risk of serious complications due to HAIs is particularly high for patients requiring intensive care.3 A number of factors likely contribute to this problem, including increasing rates of antimicrobial resistance, the development of progressively more-complex medical procedures and invasive medical technology that place patients at risk for procedure- or device-related infections, and an increasingly elderly and immunocompromised patient population. Hospital-based infection surveillance, prevention, and control programs have been in place for many decades to monitor the occurrence of HAIs and to control the spread of hospitalacquired infections through internal quality improvement efforts (Table 1). The publication of the Institute of Medicine report "To Err is Human: Building a Safer Health System" in 1999, however, focused the attention of the larger healthcare community, policy makers, and the public on opportunities for improving patient safety in healthcare facilities.11 Although the report highlighted the need to prevent medication errors, many HAIs were acknowledged to fall within the category of preventable medical errors, galvanizing hospital-based, as well as more-widespread, HAI prevention efforts. The Institute of Medicine's 2003 report "Transforming Health Care Quality" included prevention of HAIs as one of the 20 "Priority Areas for National Action."12 Recent incorporation of performance measures focused on HAI prevention into regulatory and financial reimbursement systems reflects the growing consensus that many HAIs are preventable
and that payers should pay less, not more, when these infections occur (Table 2).10,13-19 strategies for the prevention of hais Recent reports have suggested that many HAIs can be prevented through implementation of evidence-based "best practices." A number of recent improvement efforts have involved simultaneous implementation of several practice improvements ("bundles"). Because studies that have evaluated the impact of these practices have typically focused on single interventions or bundling of multiple concurrent interventions, the effectiveness of and potential synergy between specific combinations of interventions are unknown. One example of an intervention bundle is the simultaneous implementation of several practices focused on central line­associated bloodstream infection (CLABSI) prevention, which has been associated with improvements in CLABSI rates in single- and multicenter studies.20-22 Pronovost et al.21 demonstrated, in a large-scale study involving 103 intensive care units in Michigan, that an intervention bundle focused on hand hygiene, use of full barrier precautions, cleaning of skin with chlorhexidine, avoiding insertion of lines into the femoral vein, and prompt removal of unnecessary intravascular catheters resulted in a large and sustained reduction in CLABSI rates. Other best practices have been identified for prevention of surgical site infection (SSI). Many studies have demonstrated that optimizing administration of perioperative antimicrobial prophylaxis reduces the risk for SSI after a variety of surgical procedures. SSI prevention practices aimed at optimizing the choice of antimicrobial agent, timing of administration, and duration of prophylaxis, as well as other perioperative prac-
From Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (D.S.Y.); and University of Utah, Salt Lake City (D.C.). Accepted June 2, 2008; electronically published September 16, 2008. 2008 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2008/2910S1-0002$15.00. DOI: 10.1086/591063
S4 infection control and hospital epidemiology october 2008, vol. 29, supplement 1
table 1. National Healthcare-Associated Infection (HAI) Surveillance Initiatives
Year
Event
Comment
1970 The CDC establishes the NNIS [4]
Hospitals voluntarily contribute surveillance data
for internal monitoring and benchmarking
1975 Hospital-based infection control
By 1974, more than half of US hospitals had or-
programs established
ganized surveillance programs with infection
control nurses [5]
1976 JCAHO established [6]
Detailed surveillance system requirements are
incorporated into JCAHO standards for
accreditation
1985 The CDC publishes the results of the
Results suggest that the combination of ongoing
SENIC Project [7]
surveillance, active control efforts, and quali-
fied staff could prevent up to one-third of
HAIs
2003 Illinois is the first state to enact manda- Hospitals are required to report process and
tory reporting of HAIs [8]
outcome measures for central line­associated
bloodstream infections, surgical site infections,
and ventilator-associated pneumonia
2005 NNIS restructured into the NHSN [9]
National open enrollment for hospitals and out-
patient dialysis centers in 2007
2005 Deficit Reduction Act of 2005 passed [10] The CMS requires hospitals to submit data on
10 quality measures, including antimicrobial
prophylaxis process measures
note. CDC, Centers for Disease Control and Prevention; CMS, Centers for Medicare and Medicaid Services; JCAHO, Joint Commission for Accreditation of Healthcare Organizations; NHSN, National Healthcare Safety Network; NNIS, National Nosocomial Infections Surveillance; SENIC, Study on the Efficacy of Nosocomial Infection Control.
tices, such as maintaining glucose control and avoidance of shaving of the operative site, have been advocated by the Centers for Medicare and Medicaid Services, the Joint Commission, and the Institute for Healthcare Improvement.15,18 The Centers for Medicare and Medicaid Services has linked reporting of adherence to recommended perioperative antimicrobial prophylaxis process measures by individual hospitals to reimbursement.10 In 2006, the Institute for Healthcare Improvement attracted widespread participation in their "100,000 Lives" campaign to encourage hospitals throughout the United States to implement best-practices bundles aimed at preventing complications of hospitalization, including prevention of CLABSI, SSI, and ventilator-associated pneumonia (VAP). The Institute for Healthcare Improvement has recently expanded this effort in their "5 Million Lives" campaign and has incorporated promotion of practices aimed at preventing healthcare-associated transmission of methicillin-resistant Staphylococcus aureus.18 It is important to acknowledge that some practices that are included in widely used prevention bundles, such as maintenance of semirecumbent position for patients undergoing mechanical ventilation, as a component of the Institute for Healthcare Improvement VAP prevention bundle, are inconsistently linked to improvement of outcomes in the medical literature.23,24 A systematic review of the evidence to support practices relevant to improving patient safety, published by the Stanford-UCSF Evidence-based Practice Center in 2001, included evaluation of a number of infection control prac-
tices, including those aimed at prevention of catheter-associated urinary tract infection (CAUTI), intravascular catheterassociated infection, VAP, and SSI.25 In the opinion of that review, practices such as the use of maximum sterile barriers while placing central lines, appropriate antimicrobial prophylaxis for surgical patients, continuous aspiration of subglottic secretions, and use of antimicrobial-impregnated central venous catheters were assessed to have the strongest evidence base. The authors noted that further research is needed to fill substantial gaps in the scientific basis for many infection control practice recommendations. A number of guidelines are available that provide recommendations for prevention of specific types of HAIs.26-33 Most of these include an assessment of the strength of evidence for each recommendation. These guidelines were created by multidisciplinary groups with expertise in healthcare epidemiology, including but not limited to the Healthcare Infection Control Practices Advisory Committee and the Centers for Disease Control and Prevention; professional societies, such as the Society for Healthcare Epidemiology of America, the Association for Professionals in Infection Control and Epidemiology, the American Thoracic Society, and the Infectious Diseases Society of America; as well as other not-for-profit groups focused on quality improvement, such as the Institute for Healthcare Improvement. Although these guidelines provide valuable evidence-based guidance regarding HAI detection and prevention, 2 major limitations are the frequent absence of recommendations regarding performance measures that can be used to
a new healthcare imperative S5
table 2. National Healthcare-Associated Infection Prevention Initiatives
Organization or initiative
Area of focus
Institute of Medicine Centers for Medicare and Medicaid Services The Joint Commission National Hospital Quality Measures (Joint Commission and Centers for Medicare and Medicaid Services) CDC National Quality Forum Institute for Healthcare Improvement Deficit Reduction Act of 2005
One of 20 "priority areas for transforming health care" [12] · Prevention of healthcare-associated infections One of 4 conditions targeted by the Hospital Quality Initiative [13] · Surgical infection prevention One of 8 National Patient Safety Goals for hospitals in 2007 [14] · Goal 7: Reduce the risk of healthcare-associated infections 7A: Comply with current CDC hand-hygiene guidelines One of 5 National Hospital Quality Measure sets [15] · Surgical Care Improvement Project Guidelines for protecting patients [16] · Hand hygiene in healthcare settings · Prevention of intravascular device­related infections · Prevention of surgical site infections · Management of multidrug-resistant organisms in healthcare settings Five of the 30 safe practices endorsed by the National Quality Forum [17] · 1. Create and sustain a healthcare culture of safety · 19. Action should be taken to prevent ventilator-associated pneumonia by implementing ventilator bundle intervention practices · 20. Adhere to effective methods of preventing central venous catheter­associated bloodstream infections, and specify the requirements in explicit policies and procedures · 21. Prevent surgical site infections by implementing 4 components of care: a. Appropriate use of antibiotics b. Appropriate hair removal c. Maintenance of postoperative glucose control for patients undergoing major cardiac surgery d. Establishment of postoperative normothermia for patients undergoing colorectal surgery · 22. Comply with current CDC hand-hygiene guidelines. Four of 12 interventions in the 5 Million Lives Campaign [18] · Prevent central line infections · Prevent surgical site infections · Prevent ventilator-associated pneumonia · Reduce methicillin-resistant Staphylococcus aureus infection Centers for Medicare and Medicaid Services [10] · Requires hospitals to report specific data, including some healthcareassociated infection prevention performance measures, to receive their full Medicare reimbursement · Will withhold higher payments for selected conditions, including some healthcare-associated infections, if not present at admission
note. Table adapted from the Institute for Healthcare Improvement's Alignment with National Health Care Improvement Initiatives (available at: http://www.ihi.org/IHI/Programs/Campaign/Campaign.htm?TabIdp2). CDC, Centers for Disease Control and Prevention.
assess the effectiveness of implemented interventions and the lack of integration of resource requirements and feasibility into these recommendations. Few resources are available that provide clear guidance regarding effective ways to implement best practices for HAI prevention. The Stanford-UCSF Evidence-based Practice Center recently assessed the published literature evaluating the effectiveness of quality improvement strategies in promoting adherence to interventions for prevention of SSI,
CLABSI, VAP, and CAUTI.34 Because the evidence for the strategies evaluated was generally of suboptimal quality, they were unable to make any firm recommendations regarding quality-improvement interventions, but they did note that preliminary data indicated that several strategies were worthy of future study. These included reminders for improving adherence to perioperative antimicrobial prophylaxis timing and duration and use of automatic stop orders to reduce unnecessary urethral catheterization.
S6 infection control and hospital epidemiology october 2008, vol. 29, supplement 1
performance measures for internal quality improvement and external reporting Monitoring of performance is critical for assessing the effectiveness of quality improvement interventions. Performance can be evaluated through outcome measures (eg, SSI rates) or process measures that are closely associated with patient outcomes (eg, optimal timing of perioperative antimicrobial prophylaxis administration).35 The relevance of process measures depends on choosing processes that, when adhered to, improve healthcare outcomes. A Society for Healthcare Epidemiology of America position paper published in 1995 described the criteria for selection of quality indicators. These include identifying indicator events that are clearly defined, with numerators and denominators; using indicator variables that are easy to identify and collect; selecting data collection methods that are sensitive enough to capture the data and that can be standardized across all institutions; selecting indicator events that occur frequently enough to provide an adequate sample size; and comparing populations with similar intrinsic risks or providing appropriate risk adjustments.35 Advantages of process measures include the clear goal of a 100% rate of adherence to the recommended practice and the fact that process measures do not require adjustment for patients' underlying risk of infection or severity of disease.36 A number of organizations, such as the Hospital Quality Alliance, the Joint Commission, and the LeapFrog Group, have collected data through voluntary reporting of HAI process measures (eg, rates of adherence to the recommended choice of perioperative antimicrobial prophylaxis agent, timing of administration, and duration of prophylaxis) as a means for hospitals to monitor their internal quality improvement efforts by benchmarking their adherence to recommended best practices against other hospitals. Data collected by the Hospital Quality Alliance on the performance of more than 4,000 acute care hospitals assessed by means of these voluntarily submitted process measures are also accessible to the public.37 Surveillance of HAI outcomes has typically focused on device- and procedure-associated infections because these infections occur relatively frequently among hospitalized patients and because these infections are associated with potentially modifiable risk factors (eg, prompt removal of central lines that are no longer required for care of the patient). The most widely used definitions are those of the National Healthcare Safety Network at the Centers for Disease Control and Prevention. Some outcome measures that are appropriate for internal monitoring within a healthcare institution may be inappropriate for comparisons among multiple institutions.38 HAI definitions, for example, can be variably interpreted and applied even when standardized National Healthcare Safety Network definitions are used.39-41 Variability in methods and available data sources used for surveillance can greatly impact the completeness of HAI ascertainment. There is growing evidence that HAI surveillance
methods that use readily accessible automated data (eg, claims, microbiology, or pharmacy data) for screening can provide a more resource-efficient approach; however, these information technology applications cannot replace the need for frontline surveillance by trained personnel.40,42,43 In addition, risk adjustment to account for underlying differences between healthcare facilities' patient populations is essential for meaningful comparisons, but little is known at present about how to optimally adjust for the risk of developing HAIs.35,36 Several methods, such as the All Patient Refined Diagnosis Related Groups (APR-DRG) and Acute Physiology and Chronic Health Evaluation (APACHE) score, have been used to adjust for mortality risk, but there are currently no well-validated aggregate severity-of-illness scoring systems for infectious disease outcomes. recent recommendations for public reporting of outcome measures Public reporting of outcome measures has been advocated as an incentive for healthcare facilities to improve care and as a means to enable consumers to choose safer care. Consumer groups, such as the Consumers Union and the Committee to Reduce Infection Deaths, have strongly advocated for public reporting of HAI rates. Partly in response to increasing demand from consumer groups, many states have legislated or are in the process of legislating mandatory public reporting of some HAI outcome measures. The reporting requirements proposed by each state have varied.44 In some countries, mandatory public reporting of HAIs is already in place. For example, in the United Kingdom, mandatory healthcare organization­based surveillance and public reporting of methicillin-resistant Staphylococcus aureus bloodstream infections have been in place since 2001.45 Despite this movement toward universal mandatory reporting of HAI rates, little is known about the effectiveness of public reporting for improving healthcare performance. A recent systematic review of the literature performed by the Healthcare Infection Control Practices Advisory Committee46 found the evidence for effectiveness of public reporting systems in improving healthcare performance to be inconclusive. Many challenges exist in providing useful information to consumers and other stakeholders and in preventing unintended consequences of public reporting.47 The Healthcare Infection Control Practices Advisory Committee published consensus recommendations for public reporting of HAIs in 2005, highlighting the importance of the thoughtful selection of the appropriate measures of healthcare performance and patient populations to monitor; the use of standardized casefinding methods and data validity checks; adequate support for infrastructure, resources, and infection control staff; the use of appropriate adjustments to control for differences in underlying infection risks; and production of useful and accessible reports for stakeholders, with feedback given to healthcare providers.36 They also recommended choosing pro-
a new healthcare imperative S7
table 3. Performance Measures Recommended by the National Quality Forum (NQF) for Public Reporting
Infection type, NQF endorsement
Recommended performance measure
Intravascular catheter­associated bloodstream infection Previously endorseda,b HAI-01 SSI HAI-02 Previously endorseda,d HAI-03 HAI-04 VAP and respiratory illness Previously endorsedb HAI-05 HAI-06 CAUTI Previously endorsedb HAI in pediatric populations HAI-7A HAI-7B
CLABSI rate CLABSI process measures · Hand hygiene · Maximal barrier precautions upon insertion · Chlorhexidine skin antisepsis · Optimal catheter site selection, with subclavian vein as the preferred site for nontunneled catheters in patients aged 18 years and older · Daily review of line necessity with prompt removal of unnecessary lines SSI ratec SSI process measures · Prophylactic antibiotic received within 1 hour before surgical incision · Prophylactic antibiotic selection for surgical patients · Prophylactic antibiotic discontinued within 24 hours after surgery end time (48 hours for coronary artery bypass graft or other cardiac surgery) SSI process measure: patients undergoing cardiac surgery who have controlled 6:00 am postoperative serum glucose level SSI process measure: surgical patients who undergo appropriate hair removal VAP rate for patients in intensive care unitse VAP process measures · Head of the bed elevation x30 (unless medically contraindicated) · Daily "sedation interruption" and daily assessment of readiness to extubate · Peptic ulcer disease prophylaxis · Deep venous thrombosis prophylaxis Number of healthcare personnel who receive influenza vaccination CAUTI rate among patients in intensive care unitse Rates of late sepsis or meningitis in neonates Rates of late sepsis or meningitis in neonates with very low birth weight
note. CAUTI, catheter-associated urinary tract infection; CLABSI, central line­associated bloodstream infection; HAI, healthcare-associated infection; SSI, surgical site infection; VAP, ventilator-associated pneumonia. a National Quality Forum Hospital Care (2003) project.50 b Nursing-Sensitive Care (2004) project.51 c Public reporting of this measure is recommended to be limited to deep incisional and organ/space infections occurring as a result of elective procedures in the following categories: coronary artery bypass graft surgery and other cardiac surgery, hip or knee arthroplasty, colon surgery, hysterectomy (abdominal or vaginal), and vascular surgery. d Cardiac Surgery (2004) project.52 e The National Quality Forum has requested an update of the measure to comport with current science and to improve the likelihood of comparable implementation across hospitals and other healthcare entities.
cess and outcome measures appropriate to the facility type and gradually phasing in these measures to allow time for facilities to adapt and to permit ongoing evaluation of data validity. Several process measures were recommended, including adherence to recommended central line insertion practices, surgical antimicrobial prophylaxis, and influenza vaccination coverage for healthcare personnel and patients. The two outcome measures noted to be appropriate for some
hospitals were rates of CLABSI and rates of SSI after selected operations. The Healthcare Infection Control Practices Advisory Committee document also discussed the possibility of using computerized information, when available, for data collection, limiting reporting to well-defined and readily identifiable events and using simpler and more-objective event definitions, with the goal of decreasing the burden of data collection and improving the consistency of reporting among
S8 infection control and hospital epidemiology october 2008, vol. 29, supplement 1
facilities. The Healthcare-Associated Infection Working Group of the Joint Public Policy Committee recently provided a tool kit to assist states and healthcare facilities facing mandates to publicly report HAIs. Their recommendations for public reporting of outcome measures mirrored the previous Healthcare Infection Control Practices Advisory Committee recommendations and included CLABSIs in intensive care units and SSIs for selected procedures performed with adequate frequency to permit meaningful comparisons between hospitals.48 In response to the increasing focus on public reporting of HAIs, the National Quality Forum recently made available recommendations for public reporting of HAIs49-52 and has identified 8 newly recommended HAI-related performance measures (Table 3). These recommendations target well-defined and objectively assessed outcome measures for public reporting by, for example, including only deep and organ/ space SSIs as SSI outcome measures. Importantly, the National Quality Forum noted the critical need for further research to evaluate optimal methods for monitoring of HAIs and HAI prevention strategies for VAP and CAUTI, as well as for HAIs associated with multidrug-resistant organisms. Pay for performance is another strategy that has been used by payers to strengthen the business case for quality improvement. More than 160 different private and public payfor-performance programs are currently in place in the United States.53 Most of these programs reward a mixture of quality, service, and/or efficiency measures of care. A series of recent reports from the Institute of Medicine outline the possible future roadmap of pay for performance and suggest that pay-for-performance programs may help to standardize both the measures used in these programs and the approach to rewarding improved performance.54 The potential impact of this approach, however, remains unclear, because several recent studies of pay-for-performance programs in combination with public reporting have resulted in only modest improvements in quality, and little is currently known about the impact of these strategies on HAI outcomes or overall patient safety.55 Given the risks to patient safety and the economic burden associated with HAIs, the Centers for Medicare and Medicaid Services has implemented a strategy to limit reimbursement for complications of specific HAIs, including CAUTIs, vascular catheter­associated infections, and mediastinitis after coronary artery bypass graft surgery, in an effort to motivate improvement. This alteration in reimbursement
will provide additional financial incentive for healthcare facilities to prevent infectious complications.19 the business case for hai prevention HAIs impose a major societal and financial burden. Although demonstrating value to hospital administrators to justify expansion of infection control programs is essential, HAIs are a significant risk to patient safety, and there is no inherent reason that infection control interventions must save society money.56 Nonetheless, the safest care is often the most costeffective care. Policy decisions on a local and national level to financially support investments in infection control or hospital reimbursements to support infection control, however, require supporting economic analyses. Current approaches to creating a compelling business case to justify resources required by infection control programs for prevention of HAIs are outlined in a recent Society for Healthcare Epidemiology of America report.56 Cost savings obtained by avoiding infections can be estimated using attributable costs of HAIs available from the medical literature57 (Table 4) or from hospital-specific data. A business case for infection control can also be based on fixed costs rather than cost savings,56 since the greatest opportunity for improving hospital profits through HAI prevention comes from reducing excess length of stay. Because patients who do not develop infections are discharged sooner, potential gains in revenue can be projected by estimating the additional bed days available through infection prevention efforts. An obstacle to building a compelling business case for HAI prevention programs is that current reimbursement approaches often reward organizations for treating HAIs, by increasing payment for these infections as they do for other complications. Prevention of HAIs currently accrues benefit to the payer and not to the hospital. For example, in one state in 2004, 76% of all reported hospital infections were billed to Medicare and Medicaid, leading to almost $1.4 billion in charges.58 Unfortunately, estimates of the economic impact of interventions to reduce HAIs required for optimal decision making by infection control experts and hospital administrators are limited in their availability.59 High-quality cost-effectiveness analyses are clearly needed. Numerous regulatory requirements for infection control infrastructure at the healthcare
table 4. Attributable Costs of Healthcare-Associated Infections
Infection type
Attributable cost,
Excess LOS,
mean (range), 2005 US$ mean (range), days
Ventilator-associated pneumonia Catheter-associated bloodstream infection CABG-associated surgical site infection Catheter-associated urinary tract infection
22,875 (9,986-54,503) 18,432 (3,592-34,410) 17,944 (7,874-26,668) 1,257 (804-1,710)
9.6 (7.4-11.5) 12 (4.5-19.6) 25.7 (20-35) ...
note. Adapted from Perencevich et al.56 CABG, coronary artery bypass graft; LOS, length of hospital stay.
a new healthcare imperative S9
delivery and organizational level are currently in place and are likely to expand, given the current public focus, complicating research efforts to effectively evaluate the true costeffectiveness of infection control programs. infrastructure and resource needs for surveillance, prevention, control, and reporting of hais Responding to increased demands for adherence to best practices and collecting process and outcome measurements for internal and external reporting is resource intensive. The collection of HAI and risk factor data required for mandatory reporting can result in diversion of resources away from prevention efforts. In addition, resources required for these efforts can compete with other functions of infection control professionals that are critical for patient safety.60 Implementing and maintaining even the most basic HAI detection and prevention efforts requires a trained and adequately staffed hospital-based infection control program with appropriate expert supervision, capacity that may be unavailable in many smaller community hospitals. In addition, many interventions require access to additional resources, such as information technology support. Reporting systems require infrastructure, including manuals; training; processes for data collection, entry, and analysis; and appropriate quality checks. Because risk adjustment requires collection of some information about the entire population being monitored (eg, for SSI surveillance, American Society of Anesthesiologists score, wound class, and procedure duration for all patients undergoing the targeted surgical procedure), access to automated information is required to sustain surveillance and reporting efforts in most hospitals. The implementation of some interventions, such as computerized reminders for removal of urinary catheters or timely administration and discontinuation of surgical antimicrobial prophylaxis, requires access to fairly advanced information technology. Implementing and maintaining prevention programs also requires adequate personnel, supplies, and clinical laboratory support, all of which necessitate allocation of adequate financial resources. conclusions Despite the best of intentions of healthcare providers, HAIs occur in US hospitals every day and result in serious illness and deaths. The compendium of strategies to prevent HAIs included in this supplement to Infection Control and Hospital Epidemiology was created to provide a concise, evidence-based resource containing practical recommendations for acute care hospitals. We believe that uniform implementation of these basic infection surveillance, control, and prevention recommendations in all acute care hospitals in the United States will lead to improvements in hospitals' infection rates and patient safety programs. Atul Gawande writes in the introduction to his book, Better:
A Surgeon's Notes on Performance, "In medicine, as in any profession, we must grapple with systems, resources, circumstances, people--and our own shortcomings, as well. We face obstacles of seemingly endless variety. Yet somehow we must advance, we must refine, we must improve."61(p8) The implementation of best practices to prevent HAI presents a number of challenges that can be overcome only by collaboration between the healthcare community, payers, purchasers, and patients. Adequate resources must be dedicated to local infection control programs and more widespread public health integration, as well as much-needed research to guide future HAI prevention efforts. Daunting as these challenges may be, protecting our patients from preventable infections is undeniably the responsibility of all hospitals and healthcare providers. acknowledgments We are grateful to Dr. Robert A. Weinstein and Kelly Podgorny for their thoughtful review of this document and their insightful suggestions. Potential conflicts of interest. D.S.Y. has received a research grant from Sage Products. D.C. is co-chair of the National Quality Forum Patient Safety Taxonomy Committee; is an employee of CSC, a healthcare technology consulting company; and has ownership in Theradoc, a medical software company. Address reprint requests to the Reprints Coordinator, University of Chicago Press, 1427 E. 60th St., Chicago, IL 60637 ([email protected]) or contact the journal office ([email protected]). references 1. Weinstein RA. Nosocomial infection update. Emerg Infect Dis 1998; 4: 416-420. 2. Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health careassociated infections and deaths in U.S. hospitals, 2002. Public Health Rep 2007; 122:160-166. 3. Saint S, Savel RH, Matthay MA. Enhancing the safety of critically ill patients by reducing urinary and central venous catheter-related infections. Am J Respir Crit Care Med 2002; 165:1475-1479. 4. Emori TG, Culver DH, Horan TC, et al. National nosocomial infections surveillance system (NNIS): description of surveillance methods. Am J Infect Control 1991; 19:19-35. 5. Haley RW, Shachtman RH. The emergence of infection surveillance and control programs in US hospitals: an assessment, 1976. Am J Epidemiol 1980; 111:574-591. 6. Joint Commission on Accreditation of Hospitals. Accreditation Manual for Hospitals. Chicago: Joint Commission on Accreditation of Hospitals; 1976. 7. Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 1985; 121:182-205. 8. Public Act 093-0563. Hospital Report Card Act. Approved August 30, 2003. Available at: http://www.ilga.gov/legislation/publicacts/fulltext .asp?Namep093-0563&GAp093. Accessed July 30, 2008. 9. National Healthcare Safety Network (NHSN). Available at: http://www .cdc.gov/ncidod/dhqp/nhsn.html. Accessed December 20, 2007. 10. Centers for Medicare & Medicaid Services. Deficit Reduction Act of 2005. Available at: http://www.cms.hhs.gov/LegislativeUpdate/downloads/ DRA0307.pdf. Accessed December 20, 2007. 11. Korn L, Corrigan J, Donaldson M. To err is human: building a safer health
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system. Washington, DC: Institute of Medicine, National Academy Press; 1999. 12. Adams K, Corrigan J, Institute of Medicine Committee on Identifying Priority Areas for Quality Improvement. Priority areas for national action: transforming health care quality. Washington, DC: National Academies Press; 2003. 13. Centers for Medicare & Medicaid Services. Hospital Quality Initiative Overview. Available at: http://www.hospitalcompare.hhs.gov/Hospital/Static/ About-HospQuality.asp?destpNAVFHomeFAboutFQualityMeasures #Top. Accessed August 7, 2007. 14. The Joint Commission. 2007 Hospitals and Critical Access Hospital National Patient Safety Goals. Available at: http://www.jointcommission .org/PatientSafety/NationalPatientSafetyGoals/07_hap_cah_npsgs.htm. Accessed December 20, 2007. 15. MedQIC. Surgical Care Improvement Project. Available at: http://www .medqic.org/dcs/ContentServer?cidp1122904930422&pagenamep Medqic%2FContent%2FParentShellTemplate&parentNamepTopic&c pMQParents. Accessed July 25, 2007. 16. Centers for Disease Control and Prevention. Infection control guidelines. Available at: http://www.cdc.gov/ncidod/dhqp/guidelines.html. Accessed August 7, 2007. 17. The National Quality Forum. Safe practices for better healthcare 2006 update: The National Quality Forum. Available at: http://www.quality forum.org/publications/reports/safe_practices_2006.asp. Accessed August 7, 2007. 18. Institute for Healthcare Improvement. Protecting 5 million lives from harm. Available at: http://www.ihi.org/IHI/Programs/Campaign/Campaign.htm ?TabIdp2#PreventSurgicalSiteInfection. Accessed July 25, 2007. 19. Centers for Medicare and Medicaid Services. Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 2008 rates. Available at: http://www.cms.hhs.gov/AcuteInpatientPPS/ downloads/CMS-1533-FC.pdf. Accessed September 19, 2007. 20. Warren DK, Cosgrove SE, Diekema DJ, et al. A multicenter intervention to prevent catheter-associated bloodstream infections. Infect Control Hosp Epidemiol 2006; 27:662-669. 21. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355:2725-2732. 22. Lobo RD, Levin AS, Gomes LM, et al. Impact of an educational program and policy changes on decreasing catheter-associated bloodstream infections in a medical intensive care unit in Brazil. Am J Infect Control 2005; 33:83-87. 23. Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogue S, Ferrer M. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet 1999; 354: 1851-1858. 24. van Nieuwenhoven CA, Vandenbroucke-Grauls C, van Tiel FH, et al. Feasibility and effects of the semirecumbent position to prevent ventilator-associated pneumonia: a randomized study. Crit Care Med 2006; 34:396-402. 25. Shojania KG, Duncan BW, McDonald KM, Wachter RM, Markowitz AJ. Making health care safer: a critical analysis of patient safety practices. Evidence report/technology assessment, number 43 (prepared by the University of California at San Francisco-Stanford Evidence-based Practice Center under contract no. 290-97-0013), AHRQ publication no. 01E058. Rockville, MD: Agency for Healthcare Research and Quality; July 2001. 26. O'Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. Infect Control Hosp Epidemiol 2002; 23:759-769. 27. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999; 20: 250-278; quiz 279-280. 28. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health-care­associated pneumonia, 2003: recommendations
of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004;53(RR-3):1-36. 29. Muto CA, Jernigan JA, Ostrowsky BE, et al. SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and enterococcus. Infect Control Hosp Epidemiol 2003; 24:362-386. 30. Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep 2002;51(RR-16):1-45, quiz CE41-CE44. 31. Mermel LA, Farr BM, Sherertz RJ, et al. Guidelines for the management of intravascular catheter-related infections. Clin Infect Dis 2001; 32:12491272. 32. Wong ES, Hooton T. Guideline for prevention of catheter-associated urinary tract infections. Available at: http://www.cdc.gov/ncidod/dhqp/ gl_catheter_assoc.html. Accessed July 25, 2007. 33. Siegel JD, Rhinehart E, Jackson M, Chiarello L, the Healthcare Infection Control Practices Advisory Committee. Management of multidrug-resistant organisms in healthcare settings, 2006. Available at: http://www .cdc.gov/ncidod/dhqp/pdf/ar/MDROGuideline2006.pdf. Accessed July 30, 2008. 34. 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. Vol. 6. Technical review 9 (prepared by the Stanford UniversityUCSF Evidence-based Practice Center under contract no. 290-02-0017). AHRQ publication no. 04(07)-0051-6. Rockville, MD: Agency for Healthcare Research and Quality; January 2007. 35. An approach to the evaluation of quality indicators of the outcome of care in hospitalized patients, with a focus on nosocomial infection indicators. The Quality Indicator Study Group. Infect Control Hosp Epidemiol 1995; 16:308-316. 36. McKibben L, Horan TC, Tokars JI, et al. Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 2005; 26:580-587. 37. Hospital Compare. Available at: http://www.hospitalcompare.hhs.gov/ Hospital/Search/SearchCriteria.asp?destpNAV_Home_Search_Search Criteria#TabTop. Accessed August 3, 2007. 38. Gaynes R. Nosocomial infection rates for inter-hospital comparison: limitations and possible solutions. Infect Control Hosp Epidemiol 1991; 12: 609-621. 39. Klompas M. Does this patient have ventilator-associated pneumonia? JAMA 2007; 297:1583-1593. 40. Trick WE, Zagorski BM, Tokars JI, et al. Computer algorithms to detect bloodstream infections. Emerg Infect Dis 2004; 10:1612-1620. 41. Emori TG, Edwards JR, Culver DH, et al. Accuracy of reporting nosocomial infections in intensive-care-unit patients to the National Nosocomial Infections Surveillance System: a pilot study. Infect Control Hosp Epidemiol 1998; 19:308-316. 42. Yokoe DS, Noskin GA, Cunnigham SM, et al. Enhanced identification of postoperative infections among inpatients. Emerg Infect Dis 2004; 10: 1924-1930. 43. Miner AL, Sands KE, Yokoe DS, et al. Enhanced identification of postoperative infections among outpatients. Emerg Infect Dis 2004; 10:19311937. 44. Association for Professionals in Infection Control and Epidemiology. Legislation in progress. Available at: http://www.apic.org/scriptcontent/ custom/dyncontent/legislation/index.cfm?sectionpgovernment _advocacy. Accessed December 20, 2007. 45. Mandatory surveillance of methicillin resistant Staphylococcus aureus (MRSA) bacteraemias. Available at: http://www.dh.gov.uk/assetRoot/04/ 11/25/90/04112590.pdf. Accessed July 25, 2007. 46. McKibben L, Fowler G, Horan T, Brennan PJ. Ensuring rational public
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reporting systems for health care-associated infections: systematic literature review and evaluation recommendations. Am J Infect Control 2006; 34:142-149. 47. Wong ES, Rupp ME, Mermel L, et al. Public disclosure of healthcareassociated infections: the role of the Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol 2005; 26:210-212. 48. The Healthcare-Associated Infection Working Group of the Joint Public Policy Committee. Essentials of public reporting of healthcare-associated infections: a tool kit. January 2007. Available at: http: //www.cdc.gov/ncidod/dhqp/pdf/ar/06_107498_Essentials_Tool _Kit.pdf. Accessed April 6, 2007. 49. The National Quality Forum. National voluntary consensus standards, endorsed November 15, 2007. Available at: http://www.qualityforum .org/pdf/news/lsCSACMeasures.pdf. Accessed December 20, 2007. 50. The National Quality Forum. National Voluntary Consensus for Hospital Care: An Initial Performance Measure Set. Washington, DC: NQF; 2003. 51. The National Quality Forum. National Voluntary Consensus Standards for Nursing-Sensitive Care: An Initial Performance Measure Set. Washington, DC: NQF; 2004. 52. The National Quality Forum. National Voluntary Consensus Standards for Cardiac Surgery. Washington, DC: NQF; 2004. 53. Rosenthal MB, Landon BE, Normand SL, Frank RG, Epstein AM. Pay for performance in commercial HMOs. N Engl J Med 2006; 355:18951902. 54. Institute of Medicine Committee on Redesigning Health Insurance Per-
formance Measures, Payment, and Performance Improvement Programs. Performance Measurement: Accelerating Improvement. Washington, DC: National Academies Press; 2006. 55. Lindenauer PK, Remus D, Roman S, et al. Public reporting and pay for performance in hospital quality improvement. N Engl J Med 2007; 356: 486-496. 56. Perencevich EN, Stone PW, Wright SB, Carmeli Y, Fisman DN, Cosgrove SE. Raising standards while watching the bottom line: making a business case for infection control interventions. Infect Control Hosp Epidemiol 2007; 28:1121-1133. 57. Stone PW, Braccia D, Larson E. Systematic review of economic analyses of health care-associated infections. Am J Infect Control 2005; 33:501509. 58. Council PHCCC. Reducing Hospital Acquired Infections: The Business Case. Harrisburg, PA: Pennsylvania Health Care Cost Containment Council; 2005. 59. Haas JP. Measurement of infection control department performance: state of the science. Am J Infect Control 2006; 34:543-549. 60. Scheckler WE, Brimhall D, Buck AS, et al. Requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: a consensus panel report. Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol 1998; 19:114-124. 61. Gawande A. Better: A Surgeon's Notes on Performance. New York: Metropolitan Books; 2007.
S62 infection control and hospital epidemiology october 2008, vol. 29, supplement 1 supplement article: shea/idsa practice recommendation Strategies to Prevent Transmission of Methicillin-Resistant Staphylococcus aureus in Acute Care Hospitals David P. Calfee, MD, MS; Cassandra D. Salgado, MD, MS; David Classen, MD, MS; Kathleen M. Arias, MS, CIC; Kelly Podgorny, RN, MS, CPHQ; Deverick J. Anderson, MD, MPH; Helen Burstin, MD; Susan E. Coffin, MD, MPH; Erik R. Dubberke, MD; Victoria Fraser, MD; Dale N. Gerding, MD; Frances A. Griffin, RRT, MPA; Peter Gross, MD; Keith S. Kaye, MD; Michael Klompas, MD; Evelyn Lo, MD; Jonas Marschall, MD; Leonard A. Mermel, DO, ScM; Lindsay Nicolle, MD; David A. Pegues, MD; Trish M. Perl, MD; Sanjay Saint, MD; Robert A. Weinstein, MD; Robert Wise, MD; Deborah S. Yokoe, MD, MPH
purpose Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). Our intent in this document is to highlight practical recommendations in a concise format to assist acute care hospitals in their efforts to prevent transmission of methicillin-resistant Staphylococcus aureus (MRSA). Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America "Compendium of Strategies to Prevent Healthcare-Associated Infections" Executive Summary, Introduction, and accompanying editorial for additional discussion. section 1: rationale and statements of concern 1. Burden of HAIs caused by MRSA in acute care facilities a. In the United States, the proportion of hospital-as- sociated S. aureus infections that are caused by strains resistant to methicillin has steadily increased. In 2004, MRSA accounted for 63% of S. aureus infections in hospitals.1 b. Although the proportion of S. aureus­associated
HAIs among intensive care unit (ICU) patients that are due to methicillin-resistant strains has increased (a relative measure of the MRSA problem), recent data suggest that the incidence of central line­associated bloodstream infection caused by MRSA (an absolute measure of the problem) has decreased in several types of ICUs since 2001.2 Although these findings suggest that there has been some success in preventing nosocomial MRSA transmission and infection, many patient groups continue to be at risk for such transmission. c. MRSA has also been documented in other areas of the hospital and in other types of healthcare facilities, including those that provide long-term care. 2. Outcomes associated with MRSA HAIs MRSA HAIs are associated with significant morbidity and mortality.3-5 a. Compared with patients with bacteremia caused by methicillin-susceptible S. aureus, those with MRSA bacteremia have nearly twice the mortality rate,3 significantly longer hospital stays,5 and significantly higher median hospital costs.6 b. Compared with patients with a surgical site infection
From the Mount Sinai School of Medicine, New York, New York (D.P.C.); the Medical University of South Carolina, Charleston (C.D.S.); the University of Utah, Salt Lake City (D.C.); the Association for Professionals in Infection Control and Epidemiology (K.M.A.) and the National Quality Forum (H.B.), Washington, D.C.; the Joint Commission, Oakbrook Terrace (K.P., R.W.), the Loyola University Chicago Stritch School of Medicine (D.N.G.) and the Stroger (Cook County) Hospital and Rush University Medical Center (R.A.W.), Chicago, and the Hines Veterans Affairs Medical Center, Hines (D.N.G.), Illinois; the Duke University Medical Center, Durham, North Carolina (D.J.A., K.S.K.); the Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania (S.E.C.); the Washington University School of Medicine, St. Louis, Missouri (E.R.D., V.F., J.M.); the Institute for Healthcare Improvement, Cambridge (F.A.G.), and Brigham and Women's Hospital and Harvard Medical School, Boston (D.S.Y., M.K.), Massachusetts; the Hackensack University Medical Center, Hackensack (P.G.), and the University of Medicine and Dentistry­New Jersey Medical School, Newark (P.G.), New Jersey; the Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island (L.A.M.); the David Geffen School of Medicine at the University of California, Los Angeles (D.A.P.); the Johns Hopkins Medical Institutions and University, Baltimore, Maryland (T.M.P.); the Ann Arbor Veterans Affairs Medical Center and the University of Michigan Medical School, Ann Arbor, Michigan (S.S.); and the University of Manitoba, Winnipeg, Canada (E.L., L.N.). Accepted June 4, 2008; electronically published September 16, 2008. Infect Control Hosp Epidemiol 2008; 29:S62­S80 2008 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2008/2910S1-0008$15.00. DOI: 10.1086/591061
strategies for prevention of mrsa transmission S63
caused by methicillin-susceptible S. aureus, those with a surgical site infection caused by MRSA have a 3.4 times higher risk of death and almost 2 times greater median hospital costs.4 c. The higher morbidity and mortality rates associated with MRSA are not necessarily due to increased virulence of resistant strains but rather may be due to other factors, such as delays in the initiation of effective antimicrobial therapy, less-effective antimicrobial therapy for infection due to resistant strains, and higher severity of underlying illness among persons with infection due to resistant strains. 3. Risk of MRSA HAI among MRSA-colonized patients A substantial proportion of MRSA-colonized patients will subsequently develop an MRSA infection.7,8 a. One study of persons in whom MRSA colonization had been identified during a previous hospital stay reported that the risk of developing an MRSA infection, such as bacteremia, pneumonia, or soft tissue infection, within 18 months after detection of MRSA colonization was 29%.7 4. Risk factors for MRSA colonization and HAI Traditional risk factors for MRSA colonization include severe underlying illness or comorbid conditions; prolonged hospital stay; exposure to broad-spectrum antimicrobials; the presence of foreign bodies, such as central venous catheters; and frequent contact with the healthcare system or healthcare personnel. a. Colonization pressure (the ratio of MRSA-carrierdays to total patient-days) has been identified as an independent risk factor for nosocomial acquisition of the organism.9 b. Community-associated MRSA, which is genetically and often clinically distinct from typical healthcare-associated strains, is now a significant and growing problem among persons without traditional healthcare-related risk factors.10-12 c. Transmission of community-associated MRSA can and does occur in hospitals. One recent study found that 15.7% of hospital-onset invasive MRSA infections were caused by USA300,13 the strain type most frequently associated with community-associated MRSA.
section 2: strategies to detect mrsa 1. Surveillance definitions a. Standardized definitions should be used to classify each patient's first MRSA isolate as either hospital or community onset. Although no classification system provides complete accuracy, for purposes of MRSA surveillance, recommendations for classifying each patient's first MRSA isolate (regardless of whether the isolate represents clinical infection or asymptomatic colonization) have been made by the Society for Healthcare Epidemiology of America, using the following time-based definitions:20 i. Hospital-onset MRSA: A patient's first MRSA isolate is classified as a new case of "hospital-onset MRSA" if it is identified from a specimen obtained after the third calendar day of hospitalization, with the day of admission being counted as calendar day number 1. (The admission date is defined as the date that the patient occupies a room for overnight stay, not the date of outpatient or emergency department visit.) For example, if a patient who was not previously known to be colonized or infected with MRSA is admitted on Monday, an MRSA isolate would be considered to be hospital onset if the specimen was obtained from the patient on or after Thursday. ii. Community-onset MRSA: A patient's first MRSA isolate is classified as "community-onset MRSA" if it is identified from a specimen obtained on or before the third calendar day of a patient's hospitalization, with the day of admission being counted as calendar day number 1. (For MRSA surveillance purposes, the term "community onset" is used to indicate that the MRSA isolate does not meet the surveillance definition for indicating hospital-onset MRSA. The MRSA isolate may be attributable to the community or to another healthcare facility.) b. Clinical definitions can also be used to classify MRSA isolates and/or episodes of MRSA infection as healthcare associated or community associated.20 Unlike the timebased definitions described above, which take into account only the time of specimen collection in relation to the time of hospital admission, these clinical definitions require evaluation of the patient's clinical history and prior healthcare exposures.
5. Reservoir for MRSA transmission in acute care facilities In healthcare facilities, antimicrobial use provides a selective advantage for MRSA to survive, and transmission occurs largely through patient-to-patient spread. a. MRSA-colonized and -infected patients readily contaminate their environment, and healthcare personnel coming into contact with patients or their environment readily contaminate their hands,14 clothing, and equipment.15-19
2. Methods for detection of patients with MRSA colonization or infection The reservoir for transmission of MRSA is largely composed of 2 groups of patients--those with clinical MRSA infection and a much larger group of patients who are merely colonized. Various detection methods can be used to identify one or both of these groups. a. Routine review of data from clinical specimens: Clinically infected patients and some asymptomatically colo-
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nized patients can be detected when MRSA is isolated from a clinical specimen sent to the microbiology laboratory. b. Review of active surveillance testing data: Active surveillance testing for MRSA is defined as performing diagnostic testing for the purpose of detecting asymptomatic MRSA colonization. section 3: strategies to prevent mrsa transmission 1. Existing guidelines and recommendations a. Several governmental, public health, and professional organizations have published evidence-based guidelines and/or policies for prevention and control of MRSA transmission.21-24 These guidelines include similar recommendations, differing primarily with regard to the routine use of active surveillance testing to identify patients asymptomatically colonized with MRSA. b. The major recommendations of each of these guidelines are summarized in Table 1. Although these guidelines specifically recommend a number of prevention measures,
guidance as to the implementation of these measures within hospitals is not provided. c. The Institute for Healthcare Improvement and the Association for Professionals in Infection Control and Epidemiology have developed practical suggestions for implementation and monitoring of several of the prevention measures specified in evidence-based guidelines.25,26 2. Infrastructure requirements a. Infrastructure requirements of an MRSA transmis- sion prevention program include the following: i. An active infection prevention and control program staffed by a sufficient number of trained personnel to allow implementation and continuation of MRSA surveillance and infection prevention efforts without compromising other infection prevention and control activities. ii. Information technology systems to allow rapid notification of clinical personnel and infection prevention and control personnel of new MRSA isolates, collection of data needed for MRSA surveillance and rate calcu-
table 1. Summary of Recommendations From Published Guidelines for Prevention and Control of Methicillin-Resistant Staphylococcus aureus (MRSA) and/or Other Multidrug-Resistant Organisms
Recommendation
Joint Working Party (2006)
SHEA (2003) [21] WIP (2005) [24]
[23]
CDC (2006) [22]
System to identify patients
Y (IB)
ND
with MRSA colonization or
infection
Feedback of information to
ND
ND
clinicians
Education
Y (IB)
ND
Hand hygiene
Y (IA)
Y
Environmental
Y (IB)
Y
decontamination
Dedicated equipment
Y (IB)
Y
Contact precautions
Y (IA)
Y
Masks
Y (II)
Y
Cohorting
Y (II)
ND
Antimicrobial stewardship
Y (IB)
Y
Active surveillance testing
Y (IA-IB)
Y
Decolonization therapy
S (IB)
S
Compliance with hand hygiene
Y (IB)
ND
Compliance with cleaning
ND
ND
protocols
Compliance with contact
ND
ND
precautions
MRSA prevalence or incidence
ND
Y
Y (IB) ND ND Y (IB) Y (IB) Y (IB) ND Y (IA-IB) Y (II) S (IB-II) ND ND ND ND
Y (IB) Y (IB) Y (IB) Y (IB) Y (IB) Y (IB) Y (IB) N S (IB) Y (IB) S (IB) S (II) Y (IB) S (IB) Y (IB) Y (IA)
note. The Society for Healthcare Epidemiology of America (SHEA) guideline and the US Centers for Disease Control and Prevention (CDC) recommendations use the CDC/Healthcare Infection Control Practices Advisory Committee system for categorizing recommendations as follows: IA, strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies; IB, strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale; and II, suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale. N, no (approach not recommended); ND, not discussed; S, approach recommended for use in certain subpopulations or specific circumstances; WIP, Dutch Workingparty on Infection Prevention; Y, yes (approach recommended).
strategies for prevention of mrsa transmission S65
lations, and identification of MRSA-colonized patients on readmission. iii. Sufficient supplies for hand hygiene and contact precautions (eg, gowns and gloves) iv. Resources to provide appropriate education and training to healthcare personnel, patients, and visitors v. Adequate laboratory support section 4: recommendations for implementing prevention and monitoring strategies Recommendations for preventing and monitoring MRSA transmission are summarized in the following section (also see Figure). They are designed to assist acute care hospitals in prioritizing and implementing their MRSA transmission prevention efforts. Criteria for grading of the strength of recommendations and quality of evidence are described in Table 2. These recommendations are primarily intended for the control of MRSA transmission in the setting of endemicity; however, they may also be appropriate for epidemic MRSA, with the exception of an accelerated time frame for implementation and the frequency at which outcomes are assessed. These recommendations are meant to be complementary to other general infection prevention measures, such as central line­associated bloodstream infection and ventilator-associated pneumonia "bundles." I. Basic practices for prevention of MRSA transmission: recommended for all acute care hospitals A. Components of an MRSA transmission prevention program 1. Conduct an MRSA risk assessment (B-III). a. Conduct an MRSA risk assessment. This risk assess- ment provides a baseline for subsequent assessments and other data comparisons. b. Types of data that can be useful in performing an MRSA risk assessment include the following: i. The proportion of S. aureus isolates resistant to methicillin ii. The number of new cases of MRSA colonization or infection over a given period of time (incidence) iii. The number of new cases of 1 or more specific types of MRSA infection (such as bacteremia) over a given period of time (incidence) iv. Point prevalence survey(s) of MRSA colonization or infection Note: These and other MRSA metrics are discussed in greater detail below in the "Performance Measures" section of this document. c. Use findings from the risk assessment to develop the hospital's surveillance, prevention, and control plan and
to develop goals to reduce MRSA acquisition and transmission. 2. Implement an MRSA monitoring program (A-III). a. A program should be in place to identify and track patients from whom MRSA has been isolated from any clinical or active surveillance testing specimen. b. A common detection strategy used by infection control programs includes a daily review of laboratory results to identify patients from whom MRSA has been isolated. c. A common method of tracking MRSA is a line list or case count. The line list includes the first MRSA isolate, regardless of body site, per patient and includes isolates identified by clinical culture and active surveillance testing, when available. These isolates should be classified as either hospital- or community-onset MRSA by use of prespecified definitions, as described above. In addition, patients known to be MRSA colonized or infected on the basis of testing performed at another healthcare facility may be included in the line list. Additional information contained in the line list may include patient identification, date of collection of specimen from which MRSA was isolated, site from which specimen was obtained, and hospital location at time of collection. Subsequent MRSA isolates from an individual patient may also be included in the line list but should be labeled to avoid being counted as additional new cases. The line list will allow MRSA isolates to be monitored and evaluated at the unit/ward and organizational levels. d. Outcome measures related to MRSA in hospitals are discussed in more detail below in this document. 3. Promote compliance with Centers for Disease Control and Prevention or World Health Organization hand-hygiene recommendations (A-II). a. Implement a hand-hygiene compliance program. b. Patient-to-patient transmission of MRSA commonly occurs through transient colonization of the hands of healthcare personnel, and some investigators have attributed reduced rates of MRSA among hospital inpatients to efforts made to improve hand-hygiene practices.28,29 c. Hand-hygiene practices compliant with Centers for Disease Control and Prevention or World Health Organization guidelines are critical to MRSA transmission control and prevention. Evidence-based recommendations for implementation and assessment of hand-hygiene programs in healthcare settings have been published.30 The 2005 World Health Organization Guidelines on Hand Hygiene in Health Care are available online.31 d. Information on promoting compliance with hand hygiene can be found in many published materials, such as the Institute for Healthcare Improvement's "How-To Guide: Improving Hand Hygiene."32
figure. Approach to control and prevention of methicillin-resistant Staphylococcus aureus (MRSA) transmission. IC, infection control.
strategies for prevention of mrsa transmission S67
table 2. Strength of Recommendation and Quality of Evidence
Category/grade
Definition
Strength of recommendation A B C Quality of evidence I II III
Good evidence to support a recommendation for use Moderate evidence to support a recommendation for use Poor evidence to support a recommendation Evidence from x1 properly randomized, controlled trial Evidence from x1 well-designed clinical trial, without randomization; from cohort or case-control analytic studies (preferably from 11 center); from multiple time series; or from dramatic results from uncontrolled experiments Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
note. Adapted from the Canadian Task Force on the Periodic Health Examination.27
4. Use contact precautions for MRSA-colonized or -infected patients (A-II). a. Place patients with MRSA colonization or infection under contact precautions to help reduce patient-to-patient spread of the organism within the hospital.22,33 i. Place patients in a single or private room when available. Cohorting of patients with MRSA colonization or infection is acceptable when a single or private room is not available. Cohorting does not eliminate the need for compliance with hand-hygiene guidelines and other infection prevention measures. ii. Wear a gown and gloves on entry into the patient's room. iii. Remove the gown and gloves before exiting the room. iv. Use appropriate hand hygiene on entering and exiting the patient's room. Wearing gloves does not eliminate the need for hand hygiene. b. Address potential adverse events associated with contact precautions. i. Educate healthcare personnel about isolation precautions, including the benefits and potential adverse effects associated with contact precautions. ii. Several uncontrolled studies have reported that patients in isolation are examined less frequently and for shorter periods, compared with those not in isolation.34-36 Some studies have reported significantly increased rates of depression and anxiety among these patients.37 iii. Patients isolated specifically for MRSA colonization or infection were more likely to experience preventable adverse events, such as pressure ulcers, falls, or electrolyte imbalances, compared with nonisolated patients without MRSA colonization or infection.38 iv. Authors of these studies emphasized that additional studies are needed to confirm their findings. Some
have also suggested that hospitals monitor adverse events potentially attributable to contact precautions.39 v. These potential adverse events should not be considered justification to avoid the use of contact precautions but rather should serve as a reminder to ensure that patients under contact precautions receive adequate care. vi. Ensure that hospital culture and leadership support the proper use of and enforce adherence to contact precautions for MRSA. vii. Educate patients, families, and visitors about isolation precautions. c. Criteria for discontinuation of contact precautions i. The duration of contact precautions necessary for patients colonized or infected with MRSA remains an unresolved issue. ii. Studies have suggested that patients may have persistent carriage of MRSA for prolonged periods (median duration, 8.5 months in one study40) and that MRSA shedding can be intermittent and thus may be missed if only a single surveillance culture is performed. iii. With regard to the duration of contact precautions, Healthcare Infection Control Practices Advisory Committee guidelines recommend the following: (a) When active surveillance testing is used to identify MRSA-colonized patients, contact precautions are to be continued throughout the duration of hospital stay; a reasonable approach to subsequent discontinuation would be to document clearance of the organism with 3 or more surveillance tests in the absence of antimicrobial exposure.22 When to consider retesting patients to document clearance is debatable, but 3-4 months after the last positive test result is commonly used as the time frame. Some hospitals may choose to consider MRSA-colonized patients to be colonized indefinitely.
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5. Ensure cleaning and disinfection of equipment and the environment (B-III). a. MRSA contaminates the patient's environment (eg, over-bed tables, bed rails, furniture, sinks, and floors)41-46 and patient care equipment (eg, stethoscopes and blood pressure cuffs).15,16,47-49 Exposure to this contaminated environment has been associated with acquisition of MRSA.50 b. Develop and implement protocols for cleaning and disinfecting environmental surfaces. i. Select appropriate cleaning and disinfecting agents for environmental surfaces. Recent guidelines have outlined environmental disinfection protocols.51 Routine cleaning and disinfection of the patient environment with US Environmental Protection Agency­registered hospital disinfectants (eg, quaternary ammonium compounds, sodium hypochlorite, iodophors, and phenolics) used in accordance with the manufacturers' directions is adequate to reduce MRSA contamination. ii. Develop written protocols for daily and terminal cleaning and disinfection of patient rooms. c. Pay close attention to cleaning and disinfection of frequently touched ("high-touch") surfaces in patient-care areas (eg, bed rails, carts, bedside commodes, doorknobs, and faucet handles). i. For terminal cleaning of rooms of patients colonized or infected with MRSA, pay special attention to ensuring adequate coverage of environmental surfaces with approved disinfectants at appropriate dilutions for the appropriate amount of contact time. ii. A system for monitoring adherence to environmental cleaning and disinfection protocols is desirable. iii. Develop and implement protocols for cleaning and disinfecting patient care equipment. iv. To reduce MRSA contamination, disinfect portable healthcare equipment, such as stethoscopes and otoscopes, with a 70% isopropyl alcohol swab or other disinfectant after each use. d. Dedicate noncritical patient care items, such as blood pressure cuffs and stethoscopes, to a single patient when they are known to be colonized or infected with MRSA. When this is not possible, ensure adequate cleaning and disinfection of items between patient encounters. e. Provide appropriate training for personnel responsible for cleaning and disinfecting the environment and patient care equipment. 6. Educate healthcare personnel about MRSA, including risk factors, routes of transmission, outcomes associated with infection, prevention measures, and local epidemiology (BIII). a. Modify healthcare personnel behavior: Several key components of an effective MRSA transmission prevention program involve modification of healthcare personnel behavior (eg, compliance with hand hygiene, contact pre-
cautions, environmental disinfection, and active surveillance testing protocols). b. Provide an educational program to foster desired behavior changes52 and include a discussion of MRSA risk factors, routes of transmission, outcomes associated with infection, prevention measures, local MRSA epidemiology (MRSA infection rates, etc.) and current data regarding healthcare personnel compliance with infection prevention and control measures. c. Target educational programs on the basis of healthcare personnel needs (eg, professional or nonprofessional). Given the wide range of educational backgrounds among hospital personnel, several educational programs will be needed to provide the information necessary at the appropriate level for all relevant personnel. Subsequent educational sessions and written communications may be of more limited scope and may include data related to MRSA process and outcome measures. d. Including opinion leaders and role models in the educational and behavioral modification program may be useful. 7. Implement a laboratory-based alert system that immediately notifies infection prevention and control personnel and clinical personnel of new MRSA-colonized or -infected patients (B-III). a. To place patients with MRSA colonization or infection under contact precautions in a timely manner, an alert system should be developed among the laboratory staff, infection prevention and control staff, and clinical personnel caring for the patient. b. This alert system should notify infection prevention and control staff when a patient is identified as positive for MRSA. This can be accomplished via fax, phone, pager, or automated secure electronic alerts. 8. Implement an alert system that identifies readmitted or transferred MRSA-colonized or -infected patients (B-III). a. An alert system allows information regarding the MRSA status of the patient to be available at the time of admission, before bed assignment. b. Information may come from prior testing by the hospital system or from information supplied by a referring facility. This information may be integrated into the computerized database used during admission and registration or may exist as a separate electronic or paper-based database. c. The alert should remain in effect until clearance of MRSA has been documented by subsequent culture or other forms of testing. (See the discussion regarding the duration of contact precautions.) d. Implement a system for communicating the MRSA status of a patient when transferring him/her to another hospital, so that appropriate precautions can be implemented at the accepting facility.
strategies for prevention of mrsa transmission S69
9. Provide MRSA data and outcome measures to key stakeholders, including senior leadership, physicians, and nursing staff (B-III). a. The process and outcome measures outlined in the "Performance Measures" section of this document should be provided to appropriate hospital staff and administrators on a regular basis. The frequency with which these data are provided will depend on the hospital's existing reporting structure and the type of data collected. These data can be added to routine quality assessment and performance improvement reports. 10. Educate patients and their families about MRSA, as appropriate (B-III). a. Education of the patient and the patient's family may help to alleviate patient fears regarding being placed into isolation.53 i. Include information about anticipated questions: General information about MRSA, colonization versus infection, the hospital's MRSA transmission prevention program, the components of and rationale for contact precautions, and the risk of transmission to family and visitors while in the hospital and after discharge. Helpful methods might include patient education sheets in appropriate languages, patient education channels, Web sites, or video presentations. B. Accountability 1. The hospital's chief executive officer and senior management are responsible for providing a healthcare system that supports an infection prevention and control program that effectively prevents healthcare-associated infections and the transmission of epidemiologically significant pathogens.
control program is responsible for ensuring that an active program for identifying MRSA is implemented, that data on MRSA are analyzed and regularly provided to those who can use the information to improve the quality of care (eg, unit staff, clinicians, and hospital administrators), and that evidence-based practices are incorporated into the program. 7. Personnel responsible for healthcare personnel and patient education are accountable for ensuring that appropriate training and educational programs on preventing MRSA transmission are developed and provided to healthcare personnel, patients, and families. 8. Personnel from the infection prevention and control program, the laboratory, and information technology are responsible for ensuring that a system is in place to support the surveillance program. II. Special approaches for the prevention of MRSA transmission Special approaches are recommended for use in locations and/or populations within the hospital that have unacceptably high MRSA rates despite implementation of the basic MRSA transmission prevention strategies listed above. There are several controversial issues regarding prevention of MRSA transmission. As a result, implementation of the recommendations beyond the basic practices to prevent MRSA transmission should be individualized at each healthcare facility. Facilities may consider a "tiered" approach in which recommendations are instituted individually or in groups; additional "tiers" are added if MRSA rates do not improve, with implementation of basic practices as the first tier.
2. Senior management is accountable for ensuring that trained personnel are assigned to the infection prevention and control program. 3. Senior management is accountable for ensuring that healthcare personnel, including licensed and nonlicensed personnel, are competent to perform their job responsibilities. 4. Direct healthcare providers (such as physicians, nurses, aides, and therapists) and ancillary personnel (such as housekeeping and equipment-processing personnel) are responsible for ensuring that appropriate infection prevention and control practices are used at all times (including hand hygiene, standard and isolation precautions, and cleaning and disinfection of equipment and the environment). 5. Hospital and unit leaders are responsible for holding personnel accountable for their actions. 6. The person who manages the infection prevention and
A. Active surveillance testing: MRSA screening program for patients Active surveillance testing is based on the premise that clinical cultures identify only a small proportion of hospital patients who are colonized with MRSA and that asymptomatically colonized MRSA carriers serve as a substantial reservoir for person-to-person transmission of MRSA in the acute care hospital setting. Studies have shown that routine use of clinical cultures alone does not identify the full reservoir of asymptomatically colonized patients, underestimating the overall hospital-wide prevalence of MRSA by as much as 85%54 and underestimating the monthly average prevalence of MRSA in ICUs by 18.6%-63.5%.55 In addition, active surveillance testing can reduce misclassification of MRSA isolates by identifying patients who are already colonized at the time of admission, so that subsequent MRSA isolates are not falsely attributed to intrafacility acquisition.55 The effectiveness of active surveillance testing in the prevention of MRSA transmission is currently an area of controversy, and optimal implementation strategies (including
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timing and target populations) are unresolved. Several published studies of high-risk or high-prevalence populations (including those in outbreak situations) have shown an association between the use of active surveillance testing to identify and isolate MRSA-colonized patients and the effective control of MRSA transmission and/or infection.56-59 Two recent studies evaluated the impact of universal active surveillance testing performed at the time of hospital admission combined with administration of decolonization therapy to MRSA carriers and came to conflicting conclusions. One study used an observational cohort design and reported a significant reduction in hospital-associated MRSA disease after the introduction of active surveillance testing of all patients and decolonization of MRSA carriers.60 The other study used a crossover cohort design and found no significant changes in the incidence of nosocomial MRSA infection among surgical patients.61 There are several possible explanations for the differences in outcome observed in these 2 studies, including differences in study design, patient population, adherence to routine infection control measures, and adherence to decolonization therapy protocols. Of note, a multicenter, cluster-randomized trial investigating the impact of active surveillance testing on MRSA in ICUs has been performed, but the results have not yet been published (ClinicalTrials.gov identifier NCT00100386). This was a very complex study. Preliminary analysis did not demonstrate a benefit from active surveillance testing during the 6-month study period under the specific study protocol. The authors have stated that those preliminary results should not be used to conclude that active surveillance testing is useless or that efforts to control MRSA are futile.62 The final analysis and peer review of study methods, results, and conclusions are pending. Because of conflicting results from these studies and the differences among acute care hospitals and their associated patient populations, a specific recommendation regarding universal screening for MRSA cannot be made. However, active surveillance testing as a single intervention in the absence of a multifaceted approach to MRSA transmission prevention (eg, the basic measures described above) is unlikely to be uniformly effective across healthcare institutions. Active surveillance testing may, however, be useful in facilities that have implemented and optimized adherence to basic MRSA transmission prevention practices but continue to experience unacceptably high MRSA rates. 1. Implement an MRSA active surveillance testing program as part of a multifaceted strategy to control and prevent MRSA transmission when evidence suggests that there is ongoing transmission of MRSA despite effective implementation of basic practices (B-II). Assess MRSA transmission as the basis for determining if, when, and where active surveillance testing is to be used at an individual hospital. In general, active surveillance testing is considered appropriate in a facility where there is direct or
indirect evidence of ongoing MRSA transmission despite adequate implementation of and adherence to basic practices. Although the use of serial active surveillance testing of hospital patients provides the most accurate measurement of MRSA transmission, other metrics may be used as surrogate markers for transmission when comprehensive active surveillance testing data are not available. Examples include the following: · A high or increasing prevalence or incidence of hospital-onset MRSA infection or colonization · An incidence of hospital-onset MRSA infection or colonization that is not decreasing despite the use of basic practices · An increasing proportion of hospital-onset S. aureus isolates that are resistant to methicillin · Identification of specific hospital units in which the colonization pressure (ie, the prevalence rate of MRSA) is above the level associated with an increased risk of transmission9 (Such units may be identified with the use of point prevalence surveys.) · Identification of specific patient populations at high risk for MRSA colonization or infection a. Convene a multidisciplinary team to review the MRSA risk assessment and to plan and oversee the active surveillance testing program. i. Because of the multidisciplinary nature of an active surveillance program, representatives from the microbiology laboratory, infection prevention and control personnel, nursing staff, medical staff, materials management, Environmental Services, and hospital administration should be involved in program development, implementation, and resource allocation. Careful consideration of the resources necessary for an active surveillance testing program is essential to ensure that the active surveillance testing program is implemented properly and that other important components of the hospital's infection control program are not disrupted. ii. Consultation with a trained individual who has expertise in MRSA transmission control and prevention may be useful for program development and assessment if such a person is not available within the hospital. iii. Pilot the program in one location before expanding to other locations. Select the pilot unit on the basis of the risk or prevalence of MRSA on the unit or the presence of motivated leadership and front-line personnel. iv. Expand the program to additional units once the pilot program has been evaluated and adjusted and initial goals have been met (eg, more than 90% compliance with specimen acquisition). b. Select and identify the patient population(s) to be screened. i. Determine which patients to screen (eg, all patients versus high-risk patients or patients on high-risk units). (a) Use the MRSA risk assessment to determine
whether all patients, patients admitted to specific high-risk units (eg, the ICU), or high-risk patient populations (regardless of location) will be included in the screening program. (b) Patient-level risk factors for MRSA colonization (eg, recent admission to a hospital or skilled nursing facility, long-term hemodialysis, and recent antimicrobial therapy) may also be used to determine inclusion in the screening program.63 (c) Consider available infrastructure and hospitalspecific characteristics (size; staffing for infection prevention and control, laboratory, and nursing; patient population; and information technology support) when selecting the patient population(s) to be screened. ii. Develop and implement a system to identify and screen patients who meet the screening program criteria. (a) A reliable system for identification of all patients meeting the criteria for inclusion in the screening program is necessary for the success of the program. (b) Identification of patients who meet criteria for MRSA screening may be more difficult when patientlevel risk factors, rather than patient care unit, are used to determine inclusion in the surveillance program. Take this into consideration during the planning stages of the screening program. Hospitals with well-developed electronic medical records and other computer databases may be able to identify such patients by use of a computer algorithm. (c) Consider developing and implementing a checklist to be completed at admission to assist in identifying patients to be screened for MRSA. (d) Determine how screening specimens will be ordered (eg, protocol admission order set or individual patient order), who will initiate the order (eg, physician or nurse) and who will obtain the specimens (eg, unit-based nursing personnel or designated MRSA monitoring program personnel). These decisions will need to take into account relevant hospital policies, staffing, and infrastructure. c. Determine when to perform screening tests. i. At a minimum, MRSA surveillance should be performed at admission to the hospital or to the specific unit in which surveillance is being performed. ii. To detect transmission while in the hospital, additional testing of patients with initial negative surveillance test results can be done either at regular intervals (eg, weekly) or at discharge from the hospital or unit. iii. Testing at regular intervals has the potential to detect patients who have acquired MRSA during their hospitalization earlier than testing only at discharge and thus allows implementation of contact precautions to prevent further transmission. iv. When testing is to be performed at regular inter-
strategies for prevention of mrsa transmission S71 vals, determine a specific day of the week when specimens will be collected. This will simplify the process and allow the microbiology laboratory to anticipate the increased volume of specimens and plan staffing and supplies accordingly. d. Determine the anatomic sites to include in screening program. i. Identify the anatomic site(s) to be tested. (a) Anterior nares: The sensitivity of surveillance specimens obtained from a variety of sites has been evaluated in several settings and patient populations. Although testing of no single site will detect all MRSAcolonized persons, the anterior nares appear to be the most frequently positive site, with sensitivity ranging from 73% to 93%.64-70 Because of this and the accessibility of the site, the anterior nares are generally considered to be the primary site for sampling in MRSA screening programs. (b) Collection of samples from other sites, such as wounds, foreign body (eg, gastrostomy or tracheostomy tube) exit sites, the throat, the perianal area, and/or the umbilicus (in neonates)71 will allow identification of additional colonized patients who would not be identified by testing of nasal specimens alone. e. Determine laboratory methods and assess resource requirements. i. Identify the screening test method to be used. ii. MRSA can be detected using culture-based methods or molecular diagnostic testing methods, such as polymerase chain reaction (PCR). Many factors must be considered when determining which laboratory method(s) will be used in an MRSA screening program. These factors include but are not limited to the following: (a) Performance characteristics of the test (eg, sensitivity and specificity) (b) Turnaround time (c) Capabilities of the laboratory (whether an inhouse or reference laboratory) that will be providing the service (d) Number of specimens that will be processed (e) Facility-specific cost-benefit calculations iii. A detailed discussion of the various laboratory methods for MRSA detection is beyond the scope of this document, but some of the key features of the most common methods are discussed below. (a) Culture-based methods: Culture-based techniques have been used in the majority of MRSA screening programs. Numerous microbiological media and techniques have been described for use in the detection of MRSA colonization. One of the more commonly used selective media is mannitol salt agar with or without antimicrobial (eg, oxacillin or cefoxitin) supplementation to increase specificity for methicillin-resistant organisms. Additional enrichment
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steps, such as overnight incubation in trypticase soy broth, can further increase the yield of standard culture-based methods.72 The time required for detection of MRSA by use of most culture-based techniques is approximately 48 hours. More recently, several chromogenic agar media have been developed that allow more-rapid detection of MRSA, usually within 24 hours. Studies using established collections of isolates and clinical specimens have shown that these chromogenic media rival or outperform more conventional microbiological techniques.73-81 (b) Molecular testing methods: In recent years, there have been advances in molecular diagnostic testing methods, such as real-time PCR, for detection of MRSA colonization. At least 2 PCR assays for direct detection of MRSA in nasal specimens have been approved for use. These PCR assays have been shown to be highly sensitive (90%-100%) and specific (91.7%-98.4%), compared with standard culturebased methods.82-85 Although it is more costly than culture-based techniques, one potential advantage of this technology is its ability to provide a result less than 2 hours from the time of specimen collection, although in actual practice the turnaround time may be longer because of batching of samples. Although at least 1 uncontrolled study86 and a mathematical model87 have suggested that rapid testing may allow for more effective use of isolation precautions and enhanced prevention of MRSA transmission, a recently published cluster-randomized crossover trial of universal screening in general wards failed to identify a difference in MRSA acquisition rates with the use of rapid testing, compared with the use of a culturebased method.88 These data suggest that the clinical and economic benefits of rapid testing may vary among individual hospitals and settings. f. Clarify how to manage patients while awaiting the results of screening tests. i. Before implementing a screening program, a decision should be made as to how a patient will be managed while waiting for the result of the admission MRSA screening test. There are 2 common approaches: (a) Await the screening test result and implement contact precautions only if the test result is positive. (b) Place the patient under empirical contact precautions until a negative admission screening test result is documented. ii. Implementing contact precautions at the time of receipt of a positive screening test result is a reasonable initial approach. Although empirical contact precautions minimize the risk of MRSA transmission from unrecognized sources and have been shown to contribute to effective control of MRSA,58 logistical difficulties are associated with this approach. Empirical use of contact precautions substantially increases the need for single
rooms and the amount of supplies needed to practice contact precautions. When only a small proportion of screened patients are colonized with MRSA and single rooms are of limited quantity, a large number of patients whose screening test results are negative will need to be moved so that their single room can be used for another patient. These room reassignments and the necessary cleaning before the vacated room can be reoccupied can slow down patient flow within the hospital. The empirical use of contact precautions for all tested patients while awaiting test results may be most feasible in hospitals in which a relatively large proportion of patient rooms are single rooms and in individual hospital units, such as many ICUs, in which each patient is in an individual room or bay. Despite its potential logistical difficulties, this approach should be considered if transmission continues despite introduction of a screening program in which contact precautions are implemented only after a positive MRSA screening test result is obtained. g. Assess the availability of single rooms and, if needed, plan for cohorting colonized or infected patients. i. When developing a screening program, address the availability of single rooms for MRSA-positive patients, including cohorting persons colonized or infected with the same organism, when single rooms are not available. Consider the following: (a) Prioritize MRSA-positive patients who are at greater risk for transmission (eg, those with draining wounds) for a single room. (b) Ensure that patients who are known or suspected to have other indications for isolation precautions (eg, colonization or infection with other multidrug-resistant organisms, influenza, or tuberculosis) are not cohorted with MRSA-positive patients. (c) Cohorting does not eliminate the need for full compliance with hand hygiene and other basic prevention recommendations. h. Assess the availability of personal protective equipment and other supplies. i. Ensure that gowns, gloves, and hand-hygiene products (eg, alcohol-based hand rubs, soap, and paper towels) are consistently available to healthcare personnel. The screening program will not be effective if healthcare personnel are not able to comply with contact precautions because of a lack of supplies. (a) Cooperation among the purchasing department, laundry/linen service (if reusable gowns are selected), and unit-based personnel is imperative. (b) Infection prevention and control experts, particularly those familiar with the use of active surveillance, can serve as a resource to help hospitals estimate the number of patients likely to be found to be colonized with MRSA and, thus, the amount of supplies needed.
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i. Assess compliance with the screening protocol. i. Monitor compliance with the screening and contact precautions protocols, because suboptimal compliance will prevent the surveillance program from providing its maximal benefit. The monitoring program should ensure that the following measures are taken: (a) Screening tests are collected and processed according to protocol. (b) Infection prevention and control personnel are notified of positive results within the proper time frame. (c) The clinical personnel caring for the patient are notified of positive results within the proper time frame. B. Active surveillance testing for MRSA among healthcare personnel Screening of healthcare personnel for MRSA is not routinely recommended in settings of endemicity unless they have been epidemiologically linked to new MRSA cases. Screening of healthcare personnel for MRSA should be considered in an outbreak setting. 1. Screen healthcare personnel for MRSA infection or colonization only if they are epidemiologically linked to a cluster of MRSA infections (B-III). a. Healthcare personnel can become transiently or persistently colonized with MRSA, and this has been determined to be the source of several outbreaks in hospitals. Molecular testing (eg, pulse-field gel electrophoresis) to establish clonality of MRSA isolates has been useful in such situations.89-93 C. Routine bathing with chlorhexidine Recent studies have demonstrated that the use of chlor- hexidine for routine cleansing of adult ICU patients may decrease the incidence of patient acquisition of MRSA94 and vancomycin-resistant Enterococcus95 and may reduce the incidence of catheter-associated bloodstream infections.96 The effect of chlorhexidine on transmission of bacterial pathogens is likely due to a reduction in the burden of organisms on the skin of colonized or infected patients, with a subsequent reduction in contamination of environmental surfaces and the hands of healthcare workers.95 The use of chlorhexidine for routine patient cleansing outside of the adult ICU setting has not been studied. 1. Routinely bathe adult ICU patients with chlorhexidine (B-III). a. Use chlorhexidine rather than regular soap and water or other nonmedicated cleansing regimens for routine patient cleansing. b. A variety of chlorhexidine products that could be used for patient bathing are available. These include singleuse bottles of aqueous chlorhexidine that can be added to
a basin of water and 2% chlorhexidine-impregnated cloths. It should be noted that the use of undiluted 4% aqueous chlorhexidine solution for skin cleansing has been associated with a relatively high rate of reversible adverse skin effects (eg, skin fissures, itching, and burning of the skin).97 c. When using chlorhexidine, the manufacturer's recommendations should be followed. Care must be taken to avoid contact with the eyes and middle ear (eg, in patients with perforated tympanic membranes). Chlorhexidine is in US Food and Drug Administration Pregnancy Category C. D. MRSA decolonization therapy for MRSA-colonized persons MRSA decolonization therapy can be defined as the administration of topical antimicrobial or antiseptic agents, with or without systemic antimicrobial therapy, to MRSA-colonized persons for the purpose of eradicating or suppressing the carrier state. The use of MRSA decolonization therapy in conjunction with active surveillance testing may be a useful adjunctive measure for prevention of MRSA transmission within a hospital. For example, one group of investigators observed a 52% reduction in incident cases of MRSA colonization or infection among adult ICU patients after the introduction of a decolonization regimen for all MRSA-colonized patients.98 Decolonization therapy has also been a component of several successful MRSA outbreak control programs.99-101 Decolonization therapy has also been used in certain patient populations in an attempt to reduce the risk of subsequent S. aureus infection among colonized persons. These populations have included patients undergoing dialysis,102 patients with recurrent S. aureus infections, and patients undergoing certain surgical procedures.103 Further discussion of this topic is beyond the scope of this document. 1. Provide decolonization therapy to MRSA-colonized patients in conjunction with an active surveillance testing program (B-III). a. The optimal decolonization therapy regimen has not been determined. Most experience has been with the use of 2% mupirocin administered intranasally with or without chlorhexidine bathing. In the previously mentioned study that observed a reduction in incident cases of MRSA colonization or infection after the introduction of decolonization therapy, the decolonization regimen consisted of intranasal administration of 2% mupirocin twice daily for 5 days and chlorhexidine baths for 7 days.98 In that study, bed baths were performed after adding a 4-oz bottle of 4% chlorhexidine gluconate to a 6-qt basin of warm water. b. Complications of decolonization therapy are relatively uncommon; however, hospital personnel involved in the decolonization therapy program should be familiar with potential adverse effects, such as development of re-
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sistance to the agents used (eg, mupirocin) and drug-related toxicities. III. Unresolved Issues There are a number of unresolved issues related to MRSA and its transmission. A full discussion of these issues is beyond the scope of this document, but a brief mention of some of these important topics is worthwhile. For example, the impact of antimicrobial stewardship efforts on the risk of MRSA infection and transmission has not been clearly defined. Also, further study of the epidemiology and prevention of MRSA transmission among family members and other close contacts of persons colonized or infected with MRSA is needed. Additionally, the emergence of community-associated MRSA has further complicated the epidemiology of MRSA in healthcare facilities and has generated new questions related to MRSA transmission prevention in hospitals. One such topic that requires further study is the approach to detection of carriers of community-associated MRSA. Current approaches that are largely based on the epidemiology of hospital-associated MRSA may be suboptimal, given differences in risk factors for colonization and the presence of some evidence that suggests that there are differences in the predominant sites of colonization, compared with hospital-associated MRSA. Differences in antimicrobial susceptibility and virulence between typical hospital-associated MRSA and community-associated MRSA suggest that the phenotypic characteristics (eg, antimicrobial susceptibility) of MRSA isolates from individual patients may need to be considered when it becomes necessary to cohort patients with MRSA colonization or infection. These and other aspects of MRSA transmission and control require further investigation. section 5: performance measures I. Internal reporting These performance measures are intended to support internal hospital quality improvement efforts and do not necessarily address external reporting needs. The process and outcome measures suggested here are derived from published guidelines20-22,30 and other relevant literature.25 Additional information regarding the rationale for and significance of some of these measures is provided in the Appendix. A more detailed description of these and other outcome measures that may be useful for MRSA transmission prevention programs is provided in the Society for Healthcare Epidemiology of America/Healthcare Infection Control Practices Advisory Committee position paper on measurement of multidrugresistant organisms in healthcare settings.20 Process and outcome measures should be reported to senior hospital leadership, nursing leadership, and clinicians who care for patients at risk for MRSA infection or colonization.
A. Process measures important for all acute care hospitals 1. Compliance with hand-hygiene guidelines a. Monitor healthcare personnel compliance with hand- hygiene guidelines both before and after contact with the patient or environment. b. Preferred measure of hand-hygiene compliance i. Numerator: number of observed adequate hand- hygiene episodes performed by healthcare personnel. ii. Denominator: number of observed opportunities for hand hygiene. iii. Multiply by 100 so that the measure is expressed as a percentage. 2. Compliance with contact precautions a. This assessment should be performed only as an in- ternal measure in institutions that use contact precautions as part of a MRSA transmission prevention program. This metric has not been validated for, and should not be used for, interhospital comparisons. b. Preferred measure of contact precautions compliance i. Numerator: number of observed patient care epi- sodes in which contact precautions are appropriately implemented. ii. Denominator: number of observed patient care episodes in which contact precautions are indicated. iii. Multiply by 100 so that the measure is expressed as a percentage. B. Process measures for settings where active surveillance testing for MRSA has been implemented 1. Compliance with the MRSA active surveillance testing program a. This assessment should be performed only as an internal measure in institutions that use active surveillance testing as part of a MRSA transmission prevention program. This metric has not been validated for, and should not be used for, interhospital comparisons. b. Preferred measure of compliance with the active surveillance testing program: Determine the percentage of persons from whom screening test specimens were appropriately collected. i. Numerator: number of persons from whom surveillance specimens were appropriately collected. ii. Denominator: number of persons meeting the selected criteria for surveillance testing. iii. Multiply by 100 so that the measure is expressed as a percentage. C. Outcome measures important for all acute care hospitals 1. Methicillin resistance among S. aureus isolates a. The Clinical and Laboratory Standards Institute has
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issued a consensus document to assist clinical laboratories in the preparation of this type of information.104 b. The proportion of inpatient S. aureus isolates resistant to methicillin is calculated as 1 minus the proportion of isolates susceptible to methicillin. The proportion of inpatient isolates susceptible to methicillin is calculated as follows: i. Numerator: number of nonduplicate S. aureus isolates susceptible to methicillin recovered from inpatients. ii. Denominator: total number of S. aureus isolates recovered from inpatients. iii. Multiply by 100 so that the measure is expressed as a percentage. 2. Incidence or incidence density of hospital-onset MRSA bacteremia a. How to calculate the incidence of hospital-onset MRSA bacteremia i. Numerator: number of first bloodstream MRSA isolates per infection for each unit or facility that occur more than 3 calendar days after admission to the unit or facility during the surveillance period (eg, 1 month). ii. Denominator: number of patient admissions for that unit or facility during the surveillance period (eg, 1 month). iii. Multiply by 100 so that the measure is expressed as cases per 100 patient admissions. b. How to calculate the incidence density of hospitalonset MRSA bacteremia i. Numerator: number of first bloodstream MRSA isolates per infection for each unit or facility that occur more than 3 calendar days after admission to the unit or facility during the surveillance period (eg, 1 month). ii. Denominator: number of patient-days for that unit or facility during the surveillance period (eg, 1 month). iii. Multiply by 1,000 so that the measure is expressed as cases per 1,000 patient-days. c. With regard to the numerator used in the calculation of hospital-onset MRSA bacteremia incidence and incidence density, a single patient could be counted more than once in a surveillance period (eg, 1 month) if the positive blood culture results are from samples collected at least 14 days apart. Similarly, multiple bloodstream MRSA isolates from the same patient should not be counted as unique infections if the samples are collected within 14 days after a previous positive culture sample, even if it spans 2 surveillance periods. Note that this metric includes both primary and secondary bloodstream infections as defined by the National Healthcare Safety Network, Centers for Disease Control and Prevention.
a. How to calculate the incidence of hospital-onset MRSA i. Numerator: number of first MRSA isolates (from colonization or infection), regardless of source, per patient for each unit or facility from specimens obtained more than 3 calendar days after admission to the unit or facility detected during the surveillance period (eg, 1 month). This includes MRSA identified from clinical culture and active surveillance testing, if performed. This excludes historically MRSA-positive patients (ie, patients with a known history of MRSA positivity). ii. Denominator: number of patient admissions for that unit or facility during the surveillance period (eg, 1 month). iii. Multiply by 100 so that the measure is expressed as cases per 100 patients. b. How to calculate the incidence density of hospitalonset MRSA i. Numerator: number of first MRSA isolates (from colonization or infection), regardless of source, per patient for each unit or facility from specimens obtained more than 3 calendar days after admission to the unit or facility detected during the surveillance period (eg, 1 month). This includes MRSA identified from clinical culture and active surveillance testing, if performed). This excludes historically MRSA-positive patients (ie, patients with a known history of MRSA positivity). ii. Denominator: number of patient-days for that unit or facility during the surveillance period (eg, 1 month). iii. Multiply by 1,000 so that the measure is expressed as cases per 1,000 patient-days. D. Special/advanced outcome measures The basic outcome measures included in the previous sec- tion are designed to provide estimates of those outcomes (eg, patients with new acquisition of MRSA) that may be most rapidly influenced by an effective MRSA transmission prevention program. The prevalence measures listed here provide estimates of the overall burden of MRSA colonization and infection in a hospital, including those patients already known to be colonized with MRSA. This may allow a hospital to estimate the amount of exposure that patients in that hospital have to other patients who are either colonized or infected with MRSA and who could therefore potentially transmit MRSA. Such information may be useful in determining the need for and designing certain components of an MRSA transmission prevention program, such as an active surveillance testing program.
3. Incidence or incidence density of hospital-onset MRSA (See section 2.1, "Surveillance Definitions," for the definition of "hospital-onset MRSA.")
1. Overall prevalence or prevalence density of MRSA colonization and/or infection
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a. How to calculate the overall prevalence of MRSA colonization and/or infection i. Numerator: total number of patients during a given surveillance period (eg, month) who were known to be colonized or infected with MRSA (includes all patients with MRSA as determined by medical history, previous clinical cultures, and, if available, active surveillance testing). ii. Denominator: number of patient admissions during surveillance period (eg, 1 month). iii. Multiply by 100 so that the measure is expressed as a percentage.
a. Surveillance for hospital-associated MRSA infections (eg, device-associated or procedure-associated infections) may be useful to assess the burden of specific MRSA infections and to monitor the impact of prevention activities within a facility or population. Further discussion of this type of surveillance is beyond the scope of this document. Additional information and guidance related to performing this type of surveillance is available from the National Healthcare Safety Network.105 E. Outcome measures for settings where active surveillance testing for MRSA has been implemented
2. Admission prevalence of MRSA colonization and/or infection a. How to calculate admission prevalence of MRSA colonization and/or infection i. Numerator: number of first MRSA isolates (from colonization or infection), regardless of source, per patient for each unit or facility from specimens obtained less than 3 calendar days after admission to the unit or facility, detected during the surveillance period (eg, 1 month). This includes MRSA identified from clinical culture and, if available, active surveillance testing plus the number of historically MRSA-positive patients (ie, patients with a known history of MRSA positivity). ii. Denominator: number of patient admissions for that unit or facility during the surveillance period (eg, 1 month). iii. Multiply by 100 so that the measure is expressed as a percentage. 3. Point prevalence of MRSA colonization and/or infection a. Point prevalence surveys typically involve performing active surveillance testing on all patients in the population of interest (eg, all patients with a specific risk factor, all patients in a specific hospital unit or units, or all patients in the hospital) at a specific point in time. In the absence of an ongoing MRSA active surveillance testing program, point prevalence surveys may be useful in identifying populations or locations in which there is a high level of endemic MRSA or, when performed serially, in monitoring the impact of MRSA transmission prevention activities. b. How to calculate the point prevalence of MRSA colonization and/or infection i. Numerator: total number of MRSA isolates (from colonization or infection), regardless of specimen source (eg, clinical culture or active surveillance testing), per patient for each unit or facility at the time of the survey. ii. Denominator: total number of patients on the unit or in the facility at the time of the survey. iii. Multiply by 100 so that the measure is expressed as a percentage. 4. Incidence or incidence density of MRSA infection(s)
1. MRSA transmission incidence a. This assessment should be performed only as an in- ternal measure in institutions that use active surveillance testing as part of a MRSA transmission prevention program. This metric has not been validated for, and should not be used for, interhospital comparisons. b. How to calculate MRSA transmission incidence i. Numerator: number of patients without a history of MRSA colonization or infection and with a previously negative MRSA surveillance test result who subsequently have a positive MRSA surveillance test result or clinical culture result during the surveillance period (eg, 1 month). ii. Denominator: total number of patients or number of patients without a history of MRSA with a negative MRSA surveillance test result during the surveillance period (eg, 1 month). iii. Multiply by 1,000 so that the measure is expressed as transmissions per 1,000 patients. II. External reporting Many challenges exist in providing useful information to consumers and other stakeholders and in preventing unintended consequences of public reporting of HAIs.106 Recommendations for public reporting of HAIs have been provided by the Hospital Infection Control Practices Advisory Committee,107 the Healthcare-Associated Infection Working Group of the Joint Public Policy Committee,108 and the National Quality Forum.109 Given the current absence of standardized definitions and standardized surveillance methodology and the difficulties in ascertaining the specific time and location when MRSA was acquired (in the absence of hospital-wide screening at admission and periodically throughout hospitalization and/or at discharge), specific recommendations for external reporting of process and outcome measures cannot be made. A. State and federal requirements 1. Hospitals in states that have mandatory reporting requirements for MRSA must collect and report the data required by the state.
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2. Hospitals in states that require active surveillance cultures for MRSA must implement a program that complies with state requirements. 3. For information on state and federal requirements, check with your state or local health department. acknowledgments For Potential Conflicts of Interest statements and information on financial support, please see the Acknowledgments in the Executive Summary, on page S20 of this supplement. appendix performance measures rationale Process Measures Compliance With Hand Hygiene Although several measurements of compliance with hand hygiene have been described, there is currently no standardized method of measurement, and each method is associated with certain advantages and disadvantages.110 Guidelines for hand hygiene in healthcare settings describe 2 indicators for use in measuring improvements in hand hygiene among healthcare personnel.30 The first is a direct measurement of adherence, calculated as the number of hand-hygiene episodes performed by healthcare personnel divided by the number of observed opportunities for hand hygiene. The result is then multiplied by 100 to determine the percentage of opportunities in which hand hygiene is performed. Ideally, the goal for compliance should be 100%. These data should be collected on a regular basis by use of a standardized data collection form. Collection and analysis of observation data at the unit-specific and job category­specific (eg, physician, nurse, or respiratory therapist) level should be considered, especially in larger hospitals, so that education and enforcement resources can be allocated appropriately. The other suggested performance indicator for hand hygiene calculates the volume of alcohol-based hand rub (or soap for hand washing) used per patient day. Further dividing this by the average volume of hand-hygiene product used per hand-hygiene episode provides an estimate of the number of hand-hygiene episodes performed per patient day. Although this second indicator can be a useful and, in many instances, much less resource-intensive method for monitoring trends over time, the data may not be as meaningful to healthcare personnel and do not provide the detail and opportunity for immediate feedback that direct observation provides. Compliance With Contact Precautions Hospitals should periodically monitor healthcare personnel adherence to contact precautions (ie, proper use and removal of gown and gloves) when providing care to patients colonized or infected with MRSA (or to other patients for whom
contact precautions have been implemented). Adherence to contact precautions is a direct measurement, calculated as the number of observed patient care episodes in which contact precautions are appropriately implemented divided by the number of observed patient care episodes in which contact precautions are indicated. The result is then multiplied by 100 to give the percentage of opportunities in which contact precautions are appropriately implemented. The frequency of observation and the number of opportunities that should be observed will vary among hospitals but must be sufficient to allow meaningful interpretation of the data. These data should be collected on a regular basis by use of a standardized data collection form. As with hand hygiene, collection and analysis of data at the unit/ward- and job category­specific level is recommended, especially in larger hospitals, so that education and enforcement can be targeted appropriately. Ideally, the goal for compliance should be 100%. Compliance With Active Surveillance Testing When active surveillance testing is included in MRSA transmission prevention activities, compliance with the screening protocol should be monitored. This is calculated as the number of persons from whom surveillance specimens were obtained divided by the number of persons meeting the selected criteria for surveillance. Ideally, this statistic should be calculated at the level of the individual unit, so that identification of barriers to specimen collection can be determined and appropriate interventions can be made. This is especially important if different individuals are responsible for ordering and/or collecting specimens on different units. It is unlikely that 100% compliance would be routinely achievable, because of uncontrollable events such as the transfer of a patient to another location (eg, an operating room or ICU), the death of a patient without sufficient time for sampling, or a patient's refusal to undergo testing. A goal of 90% or greater may be more reasonable. Outcome Measures When comparing trends in outcome measures over time, one must be aware of changes in detection techniques (eg, change to a more sensitive detection method or addition or expansion of a screening program) so that data can be interpreted appropriately. For instance, the addition of a screening program for MRSA will most likely result in a notable increase in the number of new MRSA cases identified. If this change in surveillance techniques is not considered during data analysis, an increase in identified cases could be incorrectly interpreted as evidence of increased transmission. A more detailed description of outcome measures that may be useful for MRSA transmission prevention programs is provided in the Society for Healthcare Epidemiology of America/Healthcare Infection Control Practices Advisory Committee position paper on metrics for multidrug-resistant organisms in healthcare settings.20
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39. Diekema D, Edmond M. Look before you leap: active surveillance for multidrug-resistant organisms. Clin Infect Dis 2007; 44:1101-1107. 40. Scanvic A, Denic L, Gaillon S, Giry P, Andremont A, Lucet J. Duration of colonization by methicillin-resistant Staphylococcus aureus after hospital discharge and risk factors for prolonged carriage. Clin Infect Dis 2001; 32:1393-1398. 41. Hardy K, Oppenheim B, Gossain S, Gao F, Hawkey P. A study of the relationship between environmental contamination with methicillinresistant Staphylococcus aureus (MRSA) and patients' acquisition of MRSA. Infect Control Hosp Epidemiol 2006; 27:127-132. 42. Sexton T, Clarke P, O'Neill E, Dillane T, Humphreys H. Environmental reservoirs of methicillin-resistant Staphylococcus aureus in isolation rooms: correlation with patient isolates and implications for hospital hygiene. J Hosp Infect 2006; 62:187-194. 43. French G, Otter J, Shannon K, Adams N, Watling D, Parks M. Tackling contamination of the hospital environment by methicillin-resistant Staphylococcus aureus (MRSA): a comparison between conventional terminal cleaning and hydrogen peroxide vapour decontamination. J Hosp Infect 2004; 57:31-37. 44. Lemmen S, HaЁfner H, Zolldann D, Stanzel S, Lutticken R. Distribution of multi-resistant Gram-negative versus Gram-positive bacteria in the hospital inanimate environment. J Hosp Infect 2004; 56:191-197. 45. Oie S, Hosokawa I, Kamiya A. Contamination of room door handles by methicillin-sensitive/methicillin-resistant Staphylococcus aureus. J Hosp Infect 2002; 51:140-143. 46. Rampling A, Wiseman S, Davis L, et al. Evidence that hospital hygiene is important in the control of methicillin-resistant Staphylococcus aureus. J Hosp Infect 2001; 49:109-116. 47. de Gialluly D, Morange V, de Gialluly E, Loulergue J, van der Mee N, Quentin R. Blood pressure cuffs as a potential vector of pathogenic microorganisms: a prospective study in a teaching hospital. Infect Control Hosp Epidemiol 2006; 27:940-943. 48. Madar R, Novakova E, Baska T. The role of non-critical health-care tools in the transmission of nosocomial infections. Bratisl Lek Listy 2005; 106:348-350. 49. Sengupta S, Sirkar A, Shivananda P. Stethoscopes and nosocomial infection. Indian J Pediatr 2000; 67:197-199. 50. Huang S, Datta R, Platt R. Risk of acquiring antibiotic-resistant bacteria from prior room occupants. Arch Intern Med 2006; 166:1945-1951. 51. Centers for Disease Control and Prevention. Guidelines for environmental infection control in health-care facilities: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep 2003; 52(RR-10):22-26. 52. Seto W. Training the work force--models for effective education in infection control. J Hosp Infect 1995; 30(Suppl):241-247. 53. Lewis A, Gammon J, Hosein I. The pros and cons of isolation and containment. J Hosp Infect 1999; 43:19-23. 54. Salgado C, Farr B. What proportion of hospital patients colonized with methicillin-resistant Staphylococcus aureus are identified by clinical microbiological cultures? Infect Control Hosp Epidemiol 2006; 27:116-121. 55. Huang S, Rifas-Shiman S, Warren D, et al. Improving methicillin-resistant Staphylococcus aureus surveillance and reporting in intensive care units. J Infect Dis 2007; 195:330-338. 56. West T, Guerry C, Hiott M, Morrow N, Ward K, Salgado C. Effect of targeted surveillance for control of methicillin-resistant Staphylococcus aureus in a community hospital system. Infect Control Hosp Epidemiol 2006; 27:233-238. 57. Huang S, Yokoe D, Hinrichsen V, et al. Impact of routine intensive care unit surveillance cultures and resultant barrier precautions on hospital-wide methicillin-resistant Staphylococcus aureus bacteremia. Clin Infect Dis 2006; 43:971-978. 58. Safdar N, Marx J, Meyer N, Maki D. Effectiveness of preemptive barrier precautions in controlling nosocomial colonization and infection by methicillin-resistant Staphylococcus aureus in a burn unit. Am J Infect Control 2006; 34:476-483. 59. Lucet J, Paoletti X, Lolom I, et al. Successful long-term program for
controlling methicillin-resistant Staphylococcus aureus in intensive care units. Intensive Care Med 2005; 31:1051-1057. 60. Robicsek A, Beaumont J, Paule S, et al. Universal surveillance for methicillin-resistant Staphylococcus aureus in 3 affiliated hospitals. Ann Intern Med 2008; 148:409-418. 61. Harbarth S, Fankhauser C, Schrenzel J, et al. Universal screening for methicillin-resistant Staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. JAMA 2008; 299:1149-1157. 62. Huskins C. Results of the Strategies to Reduce Transmission of Antimicrobial Resistant Bacteria in Adult Intensive Care Units (STARICU) Trial. In: Program and abstracts of the 17th Annual Scientific Meeting of the Society of Healthcare Epidemiology of America; April 14-17, 2007; Baltimore, MD. 63. Haley C, Mittal D, LaViolette A, Jannapureddy S, Parvez N, Hall D. Methicillin-resistant Staphylococcus aureus infection or colonization present at hospital admission: multivariable risk factor screening to increase efficiency of surveillance culturing. J Clin Microbiol 2007; 45: 3031-3038. 64. Manian F, Senkel D, Zack J, Meyer L. Routine screening for methicillinresistant Staphylococcus aureus among patients newly admitted to an acute rehabilitation unit. Infect Control Hosp Epidemiol 2002; 23:516519. 65. Sanford M, Widmer A, Bale M, Jones R, Wenzel R. Efficient detection and long-term persistence of the carriage of methicillin-resistant Staphylococcus aureus. Clin Infect Dis 1994; 19:1123-1128. 66. Cox R, Conquest C, Mallaghan C, Marples R. A major outbreak of methicillin-resistant Staphylococcus aureus caused by a new phage-type (EMRSA-16). J Hosp Infect 1995; 29:87-106. 67. Lucet J, Chevret S, Durand-Zaleski I, Chastang C, Reґgnier B. Prevalence and risk factors for carriage of methicillin-resistant Staphylococcus aureus at admission to the intensive care unit. Arch Intern Med 2003; 163: 181-188. 68. Eveillard M, de Lassence A, Lancien E, Barnaud G, Ricard J, Joly-Guillou M. Evaluation of a strategy of screening multiple anatomical sites for methicillin-resistant Staphylococcus aureus at admission to a teaching hospital. Infect Control Hosp Epidemiol 2006; 27:181-184. 69. Rohr U, Wilhelm M, Muhr G, Gatermann S. Qualitative and (semi)quantitative characterization of nasal and skin methicillin-resistant Staphylococcus aureus carriage of hospitalized patients. Int J Hyg Environ Health 2004; 207:51-55. 70. Girou E, Pujade G, Legrand P, Cizeau F, Brun-Buisson C. Selective screening of carriers for control of methicillin-resistant Staphylococcus aureus (MRSA) in high-risk hospital areas with a high level of endemic MRSA. Clin Infect Dis 1998; 27:543-550. 71. Rosenthal A, White D, Churilla S, Brodie S, Katz K. Optimal surveillance culture sites for detection of methicillin-resistant Staphylococcus aureus in newborns. J Clin Microbiol 2006; 44:4234-4236. 72. Safdar N, Narans L, Gordon B, Maki D. Comparison of culture screening methods for detection of nasal carriage of methicillin-resistant Staphylococcus aureus: a prospective study comparing 32 methods. J Clin Microbiol 2003; 41:3163-3166. 73. Diederen B, van Duijn I, van Belkum A, Willemse P, van Keulen P, Kluytmans J. Performance of CHROMagar MRSA medium for detection of methicillin-resistant Staphylococcus aureus. J Clin Microbiol 2005; 43:1925-1927. 74. Diederen B, van Leest M, van Duijn I, Willemse P, van Keulen P, Kluytmans J. Performance of MRSA ID, a new chromogenic medium for detection of methicillin-resistant Staphylococcus aureus. J Clin Microbiol 2006; 44:586-588. 75. Flayhart D, Hindler J, Bruckner D, et al. Multicenter evaluation of BBL CHROMagar MRSA medium for direct detection of methicillin-resistant Staphylococcus aureus from surveillance cultures of the anterior nares. J Clin Microbiol 2005; 43:5536-5540. 76. Stoakes L, Reyes R, Daniel J, et al. Prospective comparison of a new chromogenic medium, MRSASelect, to CHROMagar MRSA and mannitol-salt medium supplemented with oxacillin or cefoxitin for detec-
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tion of methicillin-resistant Staphylococcus aureus. J Clin Microbiol 2006; 44:637-639. 77. Perry J, Davies A, Butterworth L, Hopley A, Nicholson A, Gould F. Development and evaluation of a chromogenic agar medium for methicillin-resistant Staphylococcus aureus. J Clin Microbiol 2004; 42:45194523. 78. Han Z, Lautenbach E, Fishman N, Nachamkin I. Evaluation of mannitol salt agar, CHROMagar Staph aureus, and CHROMagar MRSA for detection of methicillin-resistant Staphylococcus aureus from nasal swab specimens. J Med Microbiol 2007; 56:43-46. 79. Louie L, Soares D, Meaney H, Vearncombe M, Simor A. Evaluation of a new chromogenic medium, MRSA Select, for detection of methicillinresistant Staphylococcus aureus. J Clin Microbiol 2006; 44:4561-4563. 80. Nsira S, Dupuis M, Leclercq R. Evaluation of MRSA Select, a new chromogenic medium for the detection of nasal carriage of methicillinresistant Staphylococcus aureus. Int J Antimicrob Agents 2006; 27:561564. 81. Smyth R, Kahlmeter G. Mannitol salt agar-cefoxitin combination as a screening medium for methicillin-resistant Staphylococcus aureus. J Clin Microbiol 2005; 43:3797-3799. 82. Huletsky A, Lebel P, Picard F, et al. Identification of methicillin-resistant Staphylococcus aureus carriage in less than 1 hour during a hospital surveillance program. Clin Infect Dis 2005; 40:976-981. 83. Warren D, Liao R, Merz L, Eveland M, Dunne W. Detection of methicillin-resistant Staphylococcus aureus directly from nasal swab specimens by a real-time PCR assay. J Clin Microbiol 2004; 42:5578-5581. 84. Bishop E, Grabsch E, Ballard S, et al. Concurrent analysis of nose and groin swab specimens by the IDI-MRSA PCR assay is comparable to analysis by individual specimen PCR and routine culture assays for detection of colonization by methicillin-resistant Staphylococcus aureus. J Clin Microbiol 2006; 44:2904-2908. 85. Drews S, Willey B, Kreiswirth N, et al. Verification of the IDI-MRSA assay for detecting methicillin-resistant Staphylococcus aureus in diverse specimen types in a core clinical laboratory setting. J Clin Microbiol 2006; 44:3794-3796. 86. Cunningham R, Jenks P, Northwood J, Wallis M, Ferguson S, Hunt S. Effect on MRSA transmission of rapid PCR testing of patients admitted to critical care. J Hosp Infect 2007; 65:24-28. 87. Bootsma M, Diekmann O, Bonten M. Controlling methicillin-resistant Staphylococcus aureus: quantifying the effects of interventions and rapid diagnostic testing. Proc Natl Acad Sci U S A 2006; 103:5620-5625. 88. Jeyaratnam D, Whitty C, Phillips K, et al. Impact of rapid screening tests on acquisition of methicillin resistant Staphylococcus aureus: cluster randomized crossover trial. BMJ 2008; 336:927-930. 89. Bertin M, Vinski J, Schmitt S, et al. Outbreak of methicillin-resistant Staphylococcus aureus colonization and infection in a neonatal intensive care unit epidemiologically linked to a healthcare worker with chronic otitis. Infect Control Hosp Epidemiol 2006; 27:581-585. 90. Stein M, Navon-Venezia S, Chmelnitsky I, et al. An outbreak of new, nonmultidrug-resistant, methicillin-resistant Staphylococcus aureus strain (SCCmec type iiia variant-1) in the neonatal intensive care unit transmitted by a staff member. Pediatr Infect Dis J 2006; 25:557-559. 91. Meier P, Carter C, Wallace S, Hollis R, Pfaller M, Herwaldt L. A prolonged outbreak of methicillin-resistant Staphylococcus aureus in the burn unit of a tertiary medical center. Infect Control Hosp Epidemiol 1996; 17:798-802. 92. Wang J, Chang S, Ko W, et al. A hospital-acquired outbreak of methicillin-resistant Staphylococcus aureus infection initiated by a surgeon carrier. J Hosp Infect 2001; 47:104-109. 93. Blok H, Troelstra A, Kamp-Hopmans T, et al. Role of healthcare workers in outbreaks of methicillin-resistant Staphylococcus aureus: a 10-year evaluation from a Dutch university hospital. Infect Control Hosp Epidemiol 2003; 24:679-685. 94. Climo M, Bush A, Fraser V, et al. Daily bathing with chlorhexidine reduces the incidence of methicillin resistant Staphylococcus aureus
(MRSA), vancomycin resistant enterococci (VRE) and healthcare-associated bloodstream infections (HABSI): results of a multicenter trial. In: Program and abstracts of the 17th Annual Scientific Meeting of the Society for Healthcare Epidemiology of America; April 14-17, 2007; Baltimore, MD. Absract 297. 95. Vernon M, Hayden M, Trick W, Hayes R, Blom D, Weinstein R. Chlorhexidine gluconate to cleanse patients in a medical intensive care unit: the effectiveness of source control to reduce bioburden of vancomycinresistant enterococci. Arch Intern Med 2006; 166:306-312. 96. Bleasdale S, Trick W, Gonzalez I, Lyles R, Hayden M, Weinstein R. Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med 2007; 167:2073-2079. 97. Wendt C, Schinke S, WuЁrttemberger M, Oberdorfer K, Bock-Hensley O, von Baum H. Value of whole-body washing with chlorhexidine for the eradication of methicillin-resistant Staphylococcus aureus: a randomized, placebo-controlled, double-blind clinical trial. Infect Control Hosp Epidemiol 2007; 28:1036-1043. 98. Ridenour G, Lampen R, Federspiel J, Kritchevsky S, Wong E, Climo M. Selective use of intranasal mupirocin and chlorhexidine bathing and the incidence of methicillin-resistant Staphylococcus aureus colonization and infection among intensive care unit patients. Infect Control Hosp Epidemiol 2007; 28:1155-1161. 99. Saiman L, Cronquist A, Wu F, et al. An outbreak of methicillin-resistant Staphylococcus aureus in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2003; 24:317-321. 100. Nambiar S, Herwaldt LA, Singh N. Outbreak of invasive disease caused by methicillin-resistant Staphylococcus aureus in neonates and prevalence in the neonatal intensive care unit. Pediatr Crit Care Med 2003; 4:220-226. 101. Hitomi S, Kubota M, Mori N, et al. Control of a methicillin-resistant Staphylococcus aureus outbreak in a neonatal intensive care unit by unselective use of nasal mupirocin ointment. J Hosp Infect 2000; 46: 123-129. 102. Herwaldt L. Reduction of Staphylococcus aureus nasal carriage and infection in dialysis patients. J Hosp Infect 1998;40(Suppl B):S13-S23. 103. Kluytmans JA, Mouton JW, VandenBergh MF, et al. Reduction of surgical-site infections in cardiothoracic surgery by elimination of nasal carriage of Staphylococcus aureus. Infect Control Hosp Epidemiol 1996; 17:780-785. 104. Clinical and Laboratory Standards Institute (CLSI). Analysis and presentation of cumulative antimicrobial susceptibility data. Approved guideline M39-A2. Wayne, PA: CLSI, 2006. 105. National Healthcare Safety Network (NHSN). Available at: http:// www.cdc.gov/ncidod/dhqp/nhsn.html. Accessed August 7, 2008. 106. Wong E, Rupp M, Mermel L, et al. Public disclosure of healthcareassociated infections: the role of the Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol 2005; 26:210-212. 107. McKibben L, Horan T, Tokars J, et al. Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 2005; 26:580-587. 108. The Healthcare-Associated Infection Working Group of the Joint Public Policy Committee. Essentials of public reporting of healthcare-associated infections: a tool kit. Available at: http://www.cdc.gov/ncidod/ dhqp/pdf/ar/06_107498_Essentials_Tool_Kit.pdf. Accessed July 8, 2008. 109. National Quality Forum. National voluntary consensus standards for the reporting of healthcare-associated infection data: a consensus report. Washington, DC: National Quality Forum; 2008. Available at: http:// www.qualityforum.org/pdf/reports/HAI%20Report.pdf. Accessed August 7, 2008. 110. Haas J, Larson E. Measurement of compliance with hand hygiene. J Hosp Infect 2007; 66:6-14.
S31 infection control and hospital epidemiology october 2008, vol. 29, supplement 1 supplement article: shea/idsa practice recommendation Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals Susan E. Coffin, MD, MPH; Michael Klompas, MD; David Classen, MD, MS; Kathleen M. Arias, MS, CIC; Kelly Podgorny, RN, MS, CPHQ; Deverick J. Anderson, MD, MPH; Helen Burstin, MD; David P. Calfee, MD, MS; Erik R. Dubberke, MD; Victoria Fraser, MD; Dale N. Gerding, MD; Frances A. Griffin, RRT, MPA; Peter Gross, MD; Keith S. Kaye, MD; Evelyn Lo, MD; Jonas Marschall, MD; Leonard A. Mermel, DO, ScM; Lindsay Nicolle, MD; David A. Pegues, MD; Trish M. Perl, MD; Sanjay Saint, MD; Cassandra D. Salgado, MD, MS; Robert A. Weinstein, MD; Robert Wise, MD; Deborah S. Yokoe, MD, MPH
purpose Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their ventilator-associated pneumonia (VAP) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America "Compendium of Strategies to Prevent Healthcare-Associated Infections" Executive Summary and Introduction and accompanying editorial for additional discussion. section 1: rationale and statements of concern 1. Occurrence of VAP in acute care facilities. a. VAP is one of the most common infections acquired by adults and children in intensive care units (ICUs).1,2 i. In early studies, it was reported that 10%-20% of patients undergoing ventilation developed VAP.3,4 Morerecent publications report rates of VAP that range from 1 to 4 cases per 1,000 ventilator-days, but rates may exceed 10 cases per 1,000 ventilator-days in some neo-
natal and surgical patient populations.5-9 The results of recent quality improvement initiatives, however, suggest that many cases of VAP might be prevented by careful attention to the process of care. 2. Outcomes associated with VAP a. VAP is a cause of significant patient morbidity and mortality, increased utilization of healthcare resources, and excess cost.10-13 i. The mortality attributable to VAP may exceed 10%.14-22 ii. Patients with VAP require prolonged periods of mechanical ventilation,23 extended hospitalizations,4,11,16 excess use of antimicrobial medications, and increased direct medical costs.11,13,14 3. Pathogenesis of and risk factors for VAP a. VAP arises when there is bacterial invasion of the pulmonary parenchyma in a patient receiving mechanical ventilation. i. Inoculation of the formerly sterile lower respiratory tract typically arises from aspiration of secretions, colonization of the aerodigestive tract, or use of contaminated equipment or medications.24
From the Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania (S.E.C.); the Brigham and Women's Hospital and Harvard Medical School, Boston (M.K., D.S.Y.), and the Institute for Healthcare Improvement, Cambridge (F.A.G.), Massachusetts; the University of Utah, Salt Lake City (D.C.); the Association for Professionals in Infection Control and Epidemiology (K.M.A.) and the National Quality Forum (H.B.), Washington, D.C.; the Loyola University Chicago Stritch School of Medicine (D.N.G.), the Stroger (Cook County) Hospital and the Rush University Medical Center (R.A.W.), Chicago, the Joint Commission, Oakbrook Terrace (K.P., R.W.), and the Hines Veterans Affairs Medical Center, Hines (D.N.G.), Illinois; the Duke University Medical Center, Durham, North Carolina (D.J.A., K.S.K.); the Mount Sinai School of Medicine, New York, New York (D.P.C.); the Washington University School of Medicine, St. Louis, Missouri (E.R.D., V.F., J.M.); the Hackensack University Medical Center, Hackensack (P.G.) and the University of Medicine and Dentistry­New Jersey Medical School, Newark (P.G.), New Jersey; the Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island (L.A.M.); the David Geffen School of Medicine at the University of California, Los Angeles (D.A.P.); the Johns Hopkins Medical Institutions and University, Baltimore, Maryland (T.M.P.); the Ann Arbor Veterans Affairs Medical Center and the University of Michigan Medical School, Ann Arbor, Michigan (S.S.); the Medical University of South Carolina, Charleston (C.D.S.); and the University of Manitoba, Winnipeg, Canada (E.L., L.N.). Accepted June 4, 2008; electronically published September 16, 2008. Infect Control Hosp Epidemiol 2008; 29:S31­S40 2008 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2008/2910S1-0005$15.00. DOI: 10.1086/591062
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ii. Risk factors for VAP include prolonged intubation,25 enteral feeding,26 witnessed aspiration,27 paralytic agents,27 underlying illness,7,11,27,28 and extremes of age.28 section 2: strategies to detect vap 1. Surveillance definition a. The definition of VAP is perhaps the most subjective of the common device-related healthcare-associated infections.29-32 Most hospital epidemiologists and infection prevention and control professionals use the VAP definition put forth by the National Healthcare Safety Network, which uses 3 groups of criteria: clinical, radiographic, and microbiological.33 i. Despite the use of a common definition, significant interobserver variability has been noted.34-36 ii. Factors such as the surveillance strategy, diagnostic techniques, and microbiology and laboratory procedures likely account for some of the differences in VAP rates between different institutions.29 2. Methods for surveillance of VAP a. Active surveillance is required to accurately identify patients with VAP.22,37 Case finding by review of administrative data alone, such as discharge diagnosis codes, is inaccurate and lacks both sensitivity and specificity.38,39 i. Case finding of VAP is complex as a result of clinical criteria that vary with age and other host factors. ii. The need for review of 2 or more chest radiographs for patients with underlying pulmonary or cardiac disease also contributes to the difficulties in identifying patients with VAP. iii. Gram staining and semiquantitative culture of endotracheal secretions or quantitative culture of specimens obtained through bronchoalveolar lavage should be performed for a patient suspected to have VAP. The question of which method is optimal for specimen collection of lower respiratory tract secretions for diagnosis of VAP is controversial.22,37,40-42 iv. Information technology, such as electronic surveillance tools, can assist in the identification of patients with possible VAP but cannot provide definitive identification and are not yet widely available.43,44 section 3: strategies to prevent vap 1. Existing guidelines and recommendations a. Guidelines to prevent VAP have been published by several expert groups and, when fully implemented, improve patient outcomes and are cost-effective.45-51 b. Because few studies have evaluated the prevention of VAP in children, the majority of these recommendations stem from studies that were performed in adults. The core recommendations are designed to interrupt the 3 most common mechanisms by which VAP develops: i. Aspiration of secretions
ii. Colonization of the aerodigestive tract iii. Use of contaminated equipment 2. General strategies that have been found to influence the risk of VAP a. General strategies i. Conduct active surveillance for VAP.52,53 ii. Adhere to hand-hygiene guidelines published by the Centers for Disease Control and Prevention or the World Health Organization.52,53 iii. Use noninvasive ventilation whenever possible.54-61 iv. Minimize the duration of ventilation.53,62,63 v. Perform daily assessments of readiness to wean5,50 and use weaning protocols.57,62,64-69 vi. Educate healthcare personnel who care for patients undergoing ventilation about VAP.52,53,70,71 b. Strategies to prevent aspiration i. Maintain patients in a semirecumbent position (30-45 elevation of the head of the bed) unless there are contraindications.28,50,52,53,57,65,72-76 (a) Experimental trials have demonstrated that backrest elevation is associated with a reduced risk of pulmonary aspiration.72,75 (b) Multivariable analysis of risk factors associated with VAP found up to a 67% reduction in VAP among patients maintained in semirecumbency during the first 24 hours of mechanical ventilation.28 (c) The impact of semirecumbency was confirmed in an observational study50 and a randomized trial.73 (d) However, recent studies indicate that semirecumbent positioning is rarely maintained77 and may not be associated with a reduced rate of tracheal colonization77 or VAP.78 ii. Avoid gastric overdistention.26,57,79,80 iii. Avoid unplanned extubation and reintubation.7,25,52,53 iv. Use a cuffed endotracheal tube with in-line or subglottic suctioning.52,57,81-86 (a) Meta-analysis demonstrated that subglottic secretion drainage was effective in preventing early-onset VAP.85 v. Maintain an endotracheal cuff pressure of at least 20 cm H2O.87 c. Strategies to reduce colonization of the aerodigestive tract i. Orotracheal intubation is preferable to nasotracheal intubation. (a) Nasotracheal intubation increases the risk of sinusitis,88,89 which may increase the risk for VAP.90,91 ii. Avoid histamine receptor 2 (H2)­blocking agents and proton pump inhibitors for patients who are not at high risk for developing a stress ulcer or stress gastritis.53,57,76,92 (a) Acid-suppressive therapy may increase the col-
strategies for prevention of vap S33
onization density of the aerodigestive tract with potentially pathogenic organisms. (b) Seven meta-analyses have yielded inconsistent results regarding the magnitude of risk associated with the colonization of the aerodigestive tract.93-98 Healthcare Infection Control Practices Advisory Committee Guidelines identified the preferential use of sucralfate or H2-blocking agents as an unresolved issue.52 (c) A single retrospective study of children undergoing ventilation found that the rate of VAP did not vary according to the strategy used to prevent gastrointestinal bleeding.99 iii. Perform regular oral care57,100-103 with an antiseptic solution.101,104-108 The optimal frequency for oral care is unresolved. d. Strategies to minimize contamination of equipment used to care for patients receiving mechanical ventilation i. Use sterile water to rinse reusable respiratory equipment.52 ii. Remove condensate from ventilatory circuits. Keep the ventilatory circuit closed during condensate removal.52,53,57,109 iii. Change the ventilatory circuit only when visibly soiled or malfunctioning.21,52,110-114 iv. Store and disinfect respiratory therapy equipment properly.52 (See the Appendix.) section 4: recommendations for implementing prevention and monitoring strategies Recommendations for preventing and monitoring VAP are summarized in the following section. They are designed to assist acute care hospitals in prioritizing and implementing their VAP prevention efforts. Criteria for grading the strength of recommendation and quality of evidence are described in the Table.
I. Basic practices for prevention and monitoring of VAP: recommended for all acute care hospitals A. Education 1. Educate healthcare personnel who care for patients undergoing ventilation about VAP, including information about the following (A-II): a. Local epidemiology b. Risk factors c. Patient outcomes 2. Educate clinicians who care for patients undergoing ventilation about noninvasive ventilatory strategies (B-III). B. Surveillance of VAP 1. Perform direct observation of compliance with VAPspecific process measures (B-III). a. VAP-specific process measures include hand hygiene, bed position, daily sedation interruption and assessment of readiness to wean, and regular oral care. b. Use structured observation tools at regularly scheduled intervals. 2. Conduct active surveillance for VAP and associated process measures in units that care for patients undergoing ventilation who are known or suspected to be at high risk for VAP on the basis of risk assessment (A-II). a. Collect data that will support the identification of patients with VAP and calculation of VAP rates (ie, the number of VAP cases and number of ventilator-days for all patients who are undergoing ventilation and in the population being monitored). C. Practice 1. Implement policies and practices for disinfection, ster-
table. Strength of Recommendation and Quality of Evidence
Category/grade
Definition
Strength of recommendation A B C Quality of evidence I II III
Good evidence to support a recommendation for use Moderate evidence to support a recommendation for use Poor evidence to support a recommendation Evidence from x1 properly randomized, controlled trial Evidence from x1 well-designed clinical trial, without randomization; from cohort or case-control analytic studies (preferably from 11 center); from multiple time series; or from dramatic results from uncontrolled experiments Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
note. Adapted from the Canadian Task Force on the Periodic Health Examination.115
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ilization, and maintenance of respiratory equipment that are aligned with evidence-based standards (eg, guidelines from the Centers for Disease Control and Prevention and professional organizations) (A-II).52 a. See the Appendix for a list of recommended practices. 2. Ensure that all patients (except those with medical contraindications) are maintained in a semirecumbent position (B-II). 3. Perform regular antiseptic oral care in accordance with product guidelines (A-I). 4. Provide easy access to noninvasive ventilation equipment and institute protocols to promote the use of noninvasive ventilation (B-III). D. Accountability
tient education are accountable for ensuring that appropriate training and educational programs to prevent VAP are developed and provided to personnel, patients, and families. 8. Personnel from the infection prevention and control program, the laboratory, and information technology departments are responsible for ensuring that systems are in place to support the surveillance program. II. Special approaches for the prevention of VAP Perform a VAP risk assessment. These special approaches are recommended for use in locations and/or populations within the hospital that have unacceptably high VAP rates despite implementation of the basic VAP prevention procedures listed above. 1. Use an endotracheal tube with in-line and subglottic suctioning for all eligible patients (B-II).
1. The hospital's chief executive officer and senior management are responsible for ensuring that the healthcare system supports an infection prevention and control program to effectively prevent VAP. 2. Senior management is accountable for ensuring that an adequate number of trained personnel are assigned to the infection prevention and control program. 3. Senior management is accountable for ensuring that healthcare personnel, including licensed and nonlicensed personnel, are competent to perform their job responsibilities. 4. Direct healthcare providers (such as physicians, nurses, aides, and therapists) and ancillary personnel (such as housekeeping and equipment-processing personnel) are responsible for ensuring that appropriate infection prevention and control practices are used at all times (including hand hygiene, standard and isolation precautions, cleaning and disinfection of equipment and the environment, aseptic techniques when suctioning secretions and handling respiratory therapy equipment, patient positioning, sedation and weaning protocols, and oral care). 5. Hospital and unit leaders are responsible for holding their personnel accountable for their actions. 6. The person who manages the infection prevention and control program is responsible for ensuring that an active program to identify VAP is implemented, that data on VAP are analyzed and regularly provided to those who can use the information to improve the quality of care (eg, unit staff, clinicians, and hospital administrators), and that evidencebased practices are incorporated into the program. 7. Personnel responsible for healthcare personnel and pa-
2. Ensure that all ICU beds used for patients undergoing ventilation have a built-in tool to provide continuous monitoring of the angle of incline (B-III). III. Approaches that should not be considered a routine part of VAP prevention 1. Do not routinely administer intravenous immunoglobulin,52 white-cell­stimulating factors (filgrastim or sargramostim),52 enteral glutamine,52 or chest physiotherapy52,116 (AIII). 2. Do not routinely use rotational therapy with kinetic or continuous lateral rotational therapy beds (B-II).52,117 3. Do not routinely administer prophylactic aerosolized or systemic antimicrobials (B-III).2,52,118 IV. Unresolved issues 1. Avoidance of H2 antagonist or proton pump inhibitors for patients who are not at high risk for developing gastrointestinal bleeding76,93,94,98,119-122 2. Selective digestive tract decontamination for all patients undergoing ventilation123-128 3. Use of antiseptic-impregnated endotracheal tubes129,130 4. Intensive glycemic control131-134 section 5: performance measures I. Internal reporting These performance measures are intended to support internal hospital quality improvement efforts and do not necessarily address external reporting needs.
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The process and outcome measures suggested here are derived from published guidelines, other relevant literature, and the opinions of the authors. Report both process and outcome measures to senior hospital leadership, nursing leadership, and clinicians who care for patients at risk for VAP. A. Process measures 1. Compliance with hand-hygiene guidelines for all clinicians who deliver care to patients undergoing ventilation a. Collect data on a sample of healthcare personnel from all disciplines who provide hands-on care to patients undergoing ventilation, including physicians, nurses, respiratory therapists, and radiology technicians. Perform observations at regular intervals (eg, 1 set of measurements per week). The frequency of observations can be adjusted on the basis of compliance rates (eg, as compliance improves, less frequent observations may be needed). b. Preferred measure for hand-hygiene compliance i. Numerator: number of observed appropriate hand- hygiene episodes performed by healthcare personnel. ii. Denominator: number of observed opportunities for hand hygiene. iii. Multiply by 100 so that the measure is expressed as a percentage. 2. Compliance with daily sedation interruption and assessment of readiness to wean a. Assessment should be performed by chart review of a sample of all patients currently undergoing ventilation. Evidence of daily documentation on the patient's chart, bedside paperwork, or electronic medical record of a sedation interruption and assessment of readiness to wean should be present unless clinically contraindicated. Perform assessments at regular intervals (eg, 1 set of measurements per week). The frequency of observations can be adjusted on the basis of compliance rates (eg, as compliance improves, less frequent observations may be needed). b. Preferred measure of compliance with sedation interruption and assessment of readiness to wean i. Numerator: number of patients undergoing ventilation with daily documentation of consideration of sedation interruption and assessment of readiness to wean or contraindication. ii. Denominator: number of patients undergoing ventilation. iii. Multiply by 100 so that the measure is expressed as a percentage. 3. Compliance with regular antiseptic oral care a. Assessment should be performed by chart review of a sample of all patients currently undergoing ventilation. Perform assessments at regular intervals (eg, 1 set of measurements per week). The frequency of observations can
be adjusted on the basis of compliance rates (eg, as compliance improves, less frequent observations may be needed). b. Preferred measure of assessment of compliance with antiseptic oral care i. Numerator: number of patients undergoing ventilation with daily documentation of regular oral care according to product instructions. ii. Denominator: number of patients undergoing ventilation. iii. Multiply by 100 so that the measure is expressed as a percentage. 4. Compliance with semirecumbent positioning for all eligible patients a. Assessment should be performed for all patients currently undergoing ventilation, by direct observation of the position of the head of bed. Perform assessments at regular intervals (eg, 1 set of measurements per week). The frequency of observations can be adjusted on the basis of compliance rates (eg, as compliance improves, less frequent observations may be needed). b. Preferred measure of assessment of semirecumbent positioning compliance i. Numerator: number of patients undergoing ventilation who are in a semirecumbent position (30-45 elevation of the head of the bed) at the time of observation. ii. Denominator: number of patients undergoing ventilation who are eligible to be in a semirecumbent position. iii. Multiply by 100 so that the measure is expressed as a percentage. B. Outcome measures Perform ongoing surveillance of the incidence density of VAP on units that care for patients undergoing ventilation who are known or suspected to be at high risk for VAP, to permit longitudinal assessment of process of care. 1. Incidence density of VAP, reported as the number of episodes of VAP per 1,000 ventilator-days. a. Preferred measure of VAP incidence density i. Numerator: number of patients undergoing me- chanical ventilation who have VAP, defined using National Healthcare Safety Network definitions. ii. Denominator: number of ventilator-days. iii. Multiply by 1,000 so that the measure is expressed as cases per 1,000 ventilator-days. II. External reporting There are many challenges in providing useful information to consumers and other stakeholders while preventing unintended adverse consequences of public reporting of healthcare-associated infections.135 Recommendations for public re-
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porting of healthcare-associated infections have been provided by the Hospital Infection Control Practices Advisory Committee,136 the Healthcare-Associated Infection Working Group of the Joint Public Policy Committee,137 and the National Quality Forum.138 Because of the difficulties in diagnosing VAP,30 the validity of comparing VAP rates between facilities is poor, and external reporting of rates of VAP is not recommended.29 A. State and federal requirements 1. Hospitals in states that have mandatory reporting requirements for VAP must collect and report the data required by the state. 2. For information on local requirements, check with your state or local health department. B. External quality initiatives 1. Hospitals that participate in external quality initiatives or state programs must collect and report the data required by the initiative or the program. acknowledgments For Potential Conflicts of Interest statements and information on financial support, please see the Acknowledgments in the Executive Summary, on page S20 of this supplement.
b. Whenever possible, use steam sterilization or highlevel disinfection by wet heat pasteurization at temperatures higher than 70C (158F) for 30 minutes for reprocessing semicritical equipment or devices (ie, items that come into direct or indirect contact with mucous membranes of the lower respiratory tract). Use low-temperature sterilization methods (as approved by the Office of Device Evaluation, Center for Devices and Radiologic Health, US Food and Drug Administration) for equipment or devices that are heat or moisture sensitive. After disinfection, proceed with appropriate rinsing, drying, and packaging, taking care not to contaminate the disinfected items (category IA). c. Preferentially use sterile water to rinse reusable semicritical respiratory equipment and devices when rinsing is needed after chemical disinfection. If this is not feasible, rinse the device with filtered water (ie, water that has been through a 0.2-mm filter) or tap water, and then rinse with isopropyl alcohol and dry with forced air or in a drying cabinet (category IB). d. Adhere to provisions in the US Food and Drug Administration's enforcement document for single-use devices that are reprocessed by third parties (category IC). 2. Mechanical ventilators a. Do not routinely sterilize or disinfect the internal machinery of mechanical ventilators (category II).
appendix sterilization, disinfection, and maintenance of respiratory equipment, based on healthcare infection control practices advisory committee recommendations The Healthcare Infection Control Practices Advisory Committee52 system for categorization of recommendations is as follows: Category IA: Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies. Category IB: Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale. Category IC: Required for implementation, as mandated by federal or state regulation or standard. Category II: Suggested for implementation and supported by suggestive clinical or epidemiological studies or a theoretical rationale. 1. General measures a. Thoroughly clean all respiratory equipment to be sterilized or disinfected (category IA).
3. Breathing circuits, humidifiers, and heat-moisture exchangers a. Do not, on the basis of duration of use, routinely change the breathing circuit (ie, ventilator tubing and exhalation valve and the attached humidifier) that is in use by an individual patient. Change the circuit when it is visibly soiled or mechanically malfunctioning (category IA). b. Periodically drain and discard any condensate that collects in the tubing of a mechanical ventilator, taking precautions not to allow condensate to drain toward the patient (category IB). c. Wear gloves to perform the above procedure or handle the fluid (category IB). d. Decontaminate hands with soap and water (if hands are visibly soiled) or with an alcohol-based hand rub, after performing the procedure or handling the fluid (category IA). e. Use sterile (not distilled nonsterile) water to fill bubbling humidifiers (category II). f. Change a heat-moisture exchanger that is in use by a patient when it malfunctions mechanically or becomes visibly soiled (category II). g. Do not routinely change more frequently than every 48 hours a heat-moisture exchanger that is in use by a patient (category II).
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care reduces incidence of ventilator-associated pneumonia in ICU populations. Intensive Care Med 2006; 32:230-236. 104. Bergmans DC, Bonten MJ, Gaillard CA, et al. Prevention of ventilatorassociated pneumonia by oral decontamination: a prospective, randomized, double-blind, placebo-controlled study. Am J Respir Crit Care Med 2001; 164:382-388. 105. Houston S, Hougland P, Anderson JJ, LaRocco M, Kennedy V, Gentry LO. Effectiveness of 0.12% chlorhexidine gluconate oral rinse in reducing prevalence of nosocomial pneumonia in patients undergoing heart surgery. Am J Crit Care 2002; 11:567-570. 106. Segers P, Speekenbrink RG, Ubbink DT, van Ogtrop ML, de Mol BA. Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate: a randomized controlled trial. JAMA 2006; 296:2460-2466. 107. Silvestri L, van Saene JJ, van Saene HK, Weir I. Topical chlorhexidine and ventilator-associated pneumonia. Crit Care Med 2007; 35:2468. 108. Chan EY, Ruest A, Meade MO, Cook DJ. Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis. BMJ 2007; 334:889. 109. Craven DE, Goularte TA, Make BJ. Contaminated condensate in mechanical ventilator circuits: a risk factor for nosocomial pneumonia? Am Rev Respir Dis 1984; 129:625-628. 110. Stamm AM. Ventilator-associated pneumonia and frequency of circuit changes. Am J Infect Control 1998; 26:71-73. 111. Kollef MH, Shapiro SD, Fraser VJ, et al. Mechanical ventilation with or without 7-day circuit changes: a randomized controlled trial. Ann Intern Med 1995; 123:168-174. 112. Hess DR, Kallstrom TJ, Mottram CD, Myers TR, Sorenson HM, Vines DL. Care of the ventilator circuit and its relation to ventilator-associated pneumonia. Respir Care 2003; 48:869-879. 113. Dreyfuss D, Djedaini K, Weber P, et al. Prospective study of nosocomial pneumonia and of patient and circuit colonization during mechanical ventilation with circuit changes every 48 hours versus no change. Am Rev Respir Dis 1991; 143:738-743. 114. Markowicz P, Ricard JD, Dreyfuss D, et al. Safety, efficacy, and costeffectiveness of mechanical ventilation with humidifying filters changed every 48 hours: a prospective, randomized study. Crit Care Med 2000; 28:665-671. 115. Canadian Task Force on the Periodic Health Examination. The periodic health examination. Can Med Assoc J 1979; 121:1193-1254. 116. Ntoumenopoulos G, Presneill JJ, McElholum M, Cade JF. Chest physiotherapy for the prevention of ventilator-associated pneumonia. Intensive Care Med 2002; 28:850-856. 117. Goldhill DR, Imhoff M, McLean B, Waldmann C. Rotational bed therapy to prevent and treat respiratory complications: a review and metaanalysis. Am J Crit Care 2007; 16:50-61; quiz 62. 118. Hoth JJ, Franklin GA, Stassen NA, Girard SM, Rodriguez RJ, Rodriguez JL. Prophylactic antibiotics adversely affect nosocomial pneumonia in trauma patients. J Trauma 2003; 55:249-254. 119. Kahn JM, Doctor JN, Rubenfeld GD. Stress ulcer prophylaxis in mechanically ventilated patients: integrating evidence and judgment using a decision analysis. Intensive Care Med 2006; 32:1151-1158. 120. Kantorova I, Svoboda P, Scheer P, et al. Stress ulcer prophylaxis in critically ill patients: a randomized controlled trial. Hepatogastroenterology 2004; 51:757-761. 121. Yildizdas D, Yapicioglu H, Yilmaz HL. Occurrence of ventilator-associated pneumonia in mechanically ventilated pediatric intensive care patients during stress ulcer prophylaxis with sucralfate, ranitidine, and omeprazole. J Crit Care 2002; 17:240-245. 122. Levy MJ, Seelig CB, Robinson NJ, Ranney JE. Comparison of omeprazole and ranitidine for stress ulcer prophylaxis. Dig Dis Sci 1997; 42:1255-1259. 123. Liberati A, D'Amico R, Pifferi, Torri V, Brazzi L. Antibiotic prophylaxis to reduce respiratory tract infections and mortality in adults receiving intensive care. Cochrane Database Syst Rev 2004; (1):CD000022. 124. van Nieuwenhoven CA, Buskens E, van Tiel FH, Bonten MJ. Relation-
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ship between methodological trial quality and the effects of selective digestive decontamination on pneumonia and mortality in critically ill patients. JAMA 2001; 286:335-340. 125. Bonten MJ. Selective digestive tract decontamination--will it prevent infection with multidrug-resistant gram-negative pathogens but still be applicable in institutions where methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci are endemic? Clin Infect Dis 2006; 43(Suppl 2):S70­S74. 126. de Jonge E, Schultz MJ, Spanjaard L, et al. Effects of selective decontamination of digestive tract on mortality and acquisition of resistant bacteria in intensive care: a randomised controlled trial. Lancet 2003; 362:1011-1016. 127. Krueger WA, Lenhart FP, Neeser G, et al. Influence of combined intravenous and topical antibiotic prophylaxis on the incidence of infections, organ dysfunctions, and mortality in critically ill surgical patients: a prospective, stratified, randomized, double-blind, placebo-controlled clinical trial. Am J Respir Crit Care Med 2002; 166:1029-1037. 128. Silvestri L, van Saene HK, Milanese M, Gregori D, Gullo A. Selective decontamination of the digestive tract reduces bacterial bloodstream infection and mortality in critically ill patients: systematic review of randomized, controlled trials. J Hosp Infect 2007; 65:187-203. 129. Pacheco-Fowler V, Gaonkar T, Wyer PC, Modak S. Antiseptic impregnated endotracheal tubes for the prevention of bacterial colonization. J Hosp Infect 2004; 57:170-174. 130. Berra L, De Marchi L, Yu ZX, Laquerriere P, Baccarelli A, Kolobow T. Endotracheal tubes coated with antiseptics decrease bacterial colonization of the ventilator circuits, lungs, and endotracheal tube. Anesthesiology 2004; 100:1446-1456.
131. Collier B, Diaz J Jr, Forbes R, et al. The impact of a normoglycemic management protocol on clinical outcomes in the trauma intensive care unit. JPEN J Parenter Enteral Nutr 2005; 29:353-358; discussion 359. 132. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001; 345:1359-1367. 133. Toschlog EA, Newton C, Allen N, et al. Morbidity reduction in critically ill trauma patients through use of a computerized insulin infusion protocol: a preliminary study. J Trauma 2007; 62:1370-1375; discussion 1375-1376. 134. Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358:125139. 135. Wong ES, Rupp ME, Mermel L, et al. Public disclosure of healthcareassociated infections: the role of the Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol 2005; 26:210-212. 136. McKibben L, Horan TC, Tokars JI, et al. Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 2005; 26:580-587. 137. The Healthcare-Associated Infection Working Group of the Joint Public Policy Committee. Essentials of public reporting of healthcare-associated infections: a tool kit. Available at: http://www.cdc.gov/ncidod/ dhqp/pdf/ar/06_107498_Essentials_Tool_Kit.pdf. Accessed April 6, 2007. 138. The National Quality Forum. National voluntary consensus standards, endorsed November 15, 2007. Available at: http://www.qualityforum .org/pdf/news/lsCSACMeasures.pdf. Accessed December 20, 2007.
S22 infection control and hospital epidemiology october 2008, vol. 29, supplement 1 supplement article: shea/idsa practice recommendation Strategies to Prevent Central Line­Associated Bloodstream Infections in Acute Care Hospitals Jonas Marschall, MD; Leonard A. Mermel, DO, ScM; David Classen, MD, MS; Kathleen M. Arias, MS, CIC; Kelly Podgorny, RN, MS, CPHQ; Deverick J. Anderson, MD, MPH; Helen Burstin, MD; David P. Calfee, MD, MS; Susan E. Coffin, MD, MPH; Erik R. Dubberke, MD; Victoria Fraser, MD; Dale N. Gerding, MD; Frances A. Griffin, RRT, MPA; Peter Gross, MD; Keith S. Kaye, MD; Michael Klompas, MD; Evelyn Lo, MD; Lindsay Nicolle, MD; David A. Pegues, MD; Trish M. Perl, MD; Sanjay Saint, MD; Cassandra D. Salgado, MD, MS; Robert A. Weinstein, MD; Robert Wise, MD; Deborah S. Yokoe, MD, MPH
purpose Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their central line­associated bloodstream infection (CLABSI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America "Compendium of Strategies to Prevent Healthcare-Associated Infections" Executive Summary and Introduction and accompanying editorial for additional discussion. section 1: rationale and statements of concern 1. Patients at risk for CLABSIs in acute care facilities a. Intensive care unit (ICU) population: The risk of CLABSI in ICU patients is high. Reasons for this include the frequent insertion of multiple catheters, the use of specific types of catheters that are almost exclusively inserted in ICU patients and associated with substantial risk (eg, arterial catheters), and the fact that catheters are frequently
placed in emergency circumstances, repeatedly accessed each day, and often needed for extended periods.1,2 b. Non-ICU population: Although the primary focus of attention over the past 2 decades has been the ICU setting, recent data suggest that the greatest numbers of patients with central lines are in hospital units outside the ICU, where there is a substantial risk of CLABSI.3-5 2. Outcomes associated with hospital-acquired CLABSI a. Increased length of hospital stay6-10 b. Increased cost; the non­inflation-adjusted attribut- able cost of CLABSIs has been found to vary from $3,700 to $29,000 per episode7,10,11 3. Independent risk factors for CLABSI (in 2 or more published studies)12-14 Note: femoral catheterization was found to be an independent risk factor in 1 study.15 a. Factors associated with increased risk i. Prolonged hospitalization before catheterization ii. Prolonged duration of catheterization iii. Heavy microbial colonization at the insertion site iv. Heavy microbial colonization of the catheter hub v. Internal jugular catheterization
From the Washington University School of Medicine, St. Louis, Missouri (J.M., E.R.D., V.F.); the Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island (L.A.M.); the University of Utah, Salt Lake City (D.C.); the Association for Professionals in Infection Control and Epidemiology (K.M.A.) and the National Quality Forum (H.B.), Washington, D.C.; the Joint Commission, Oakbrook Terrace (K.P., R.W.), the Loyola University Chicago Stritch School of Medicine (D.N.G.) and the Stroger (Cook County) Hospital and Rush University Medical Center (R.A.W.), Chicago, and the Hines Veterans Affairs Medical Center, Hines (D.N.G.), Illinois; the Duke University Medical Center, Durham, North Carolina (D.J.A., K.S.K.); the Mount Sinai School of Medicine, New York, New York (D.P.C.); the Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania (S.E.C.); the Institute for Healthcare Improvement, Cambridge (F.A.G.), and Brigham and Women's Hospital and Harvard Medical School, Boston (D.S.Y., M.K.), Massachusetts; the Hackensack University Medical Center, Hackensack (P.G.), and the University of Medicine and Dentistry­New Jersey Medical School, Newark (P.G.), New Jersey; the David Geffen School of Medicine at the University of California, Los Angeles (D.A.P.); the Johns Hopkins Medical Institutions and University, Baltimore, Maryland (T.M.P.); the Ann Arbor Veterans Affairs Medical Center and the University of Michigan Medical School, Ann Arbor, Michigan (S.S.); the Medical University of South Carolina, Charleston (C.D.S.); and the University of Manitoba, Winnipeg, Canada (E.L., L.N.). Accepted June 9, 2008; electronically published September 16, 2008. Infect Control Hosp Epidemiol 2008; 29:S22­S30 2008 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2008/2910S1-0004$15.00. DOI: 10.1086/591059
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vi. Neutropenia vii. Prematurity (ie, birth at an early gestational age) viii. Total parenteral nutrition ix. Substandard care of the catheter (eg, excessive manipulation of the catheter or reduced nurse-to-patient ratio) b. Factors associated with reduced risk i. Female sex section 2: strategies to detect clabsi 1. Surveillance protocol and definitions a. Use consistent surveillance methods and definitions to allow comparison with benchmark data b. Refer to the NHSN Manual: Patient Safety Component Protocol16 for information on the appropriate surveillance methodology, including information about blood specimen collection, and for surveillance definitions of CLABSI. The relevant sections of the manual are "Identifying Healthcareassociated Infections (HAI) in NHSN," "Device-Associated Module: Methodology," and "Device-Associated Module: Central Line-Associated Bloodstream Infection (CLABSI) Event." section 3: strategies to prevent clabsi 1. Existing guidelines and recommendations a. Several governmental, public health, and professional organizations have published evidence-based guidelines and/or implementation aids regarding the prevention of CLABSI, including the following: i. The Healthcare Infection Control Practices Advisory Committee17 ii. The Institute for Healthcare Improvement18 and iii. Making Health Care Safer, Agency for Healthcare Research and Quality19 b. The recommendations in this document focus on central venous catheters (CVCs) unless noted otherwise. i. These recommendations are not stratified on the basis of the type of catheter (eg, tunneled, implanted, cuffed, noncuffed catheter, or dialysis catheter). ii. These recommendations may not be applicable for prevention of bloodstream infections with other intravascular devices. 2. Infrastructure requirements a. An adequately staffed infection prevention and con- trol program responsible for identifying patients with CLABSI b. Information technology to collect and calculate catheter-days as a denominator for computing rates of CLABSI and patient-days to allow calculation of CVC utilization; catheter-days from information systems should be validated against a manual method.
c. Resources to provide appropriate education and training d. Adequate laboratory support for timely processing of specimens and reporting of results 3. Practical implementation a. Educate physicians, nurses, and other healthcare per- sonnel about guidelines to prevent CLABSI (eg, with online and paper versions). These guidelines should be easily accessible. b. Develop and implement a catheter insertion checklist. Educate nurses, physicians, and other healthcare personnel involved in catheter insertion, regarding the use of the catheter insertion checklist. c. Educate healthcare personnel about the insertion and maintenance of catheters.20 One method is to require healthcare personnel to complete an educational program including a posteducation test to ensure their knowledge and competency before being allowed to insert CVCs. d. Establish catheter insertion kits/carts containing all necessary items for insertion. section 4: recommendations for implementing prevention and monitoring strategies Recommendations for preventing and monitoring CLABSI are summarized in the following section. They are designed to assist acute care hospitals in prioritizing and implementing their CLABSI prevention efforts. Criteria for grading the strength of the recommendation and quality of evidence are described in the Table. Note: Some of the following measures have been combined into a "prevention bundle" that focuses on catheter insertion (eg, measures B.2, B.3, B.5, B.6, and C.2).22-24 I. Basic practices for prevention and monitoring of CLABSI: recommended for all acute care hospitals A. Before insertion 1. Educate healthcare personnel involved in the insertion, care, and maintenance of CVCs about CLABSI prevention (A-II).20,25-28 a. Include the indications for catheter use, appropriate insertion and maintenance, the risk of CLABSI, and general infection prevention strategies. b. Ensure that all healthcare personnel involved in catheter insertion and maintenance complete an educational program regarding basic practices to prevent CLABSI before performing these duties. c. Periodically assess healthcare personnel knowledge of and adherence to preventive measures. d. Ensure that any healthcare professional who inserts a CVC undergoes a credentialing process (as established
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table. Strength of Recommendation and Quality of Evidence
Category/grade
Definition
Strength of recommendation A B C Quality of evidence I II III
Good evidence to support a recommendation for use Moderate evidence to support a recommendation for use Poor evidence to support a recommendation Evidence from x1 properly randomized, controlled trial Evidence from x1 well-designed clinical trial, without randomization; from cohort or case-control analytic studies (preferably from 11 center); from multiple time series; or from dramatic results of uncontrolled experiments Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports from expert committees
note. Adapted from the Canadian Task Force on the Periodic Health Examination.21
by the individual healthcare institution) to ensure their competency before they independently insert a CVC. B. At insertion 1. Use a catheter checklist to ensure adherence to infection prevention practices at the time of CVC insertion (B-II).23,29 a. Use a checklist to ensure and document compliance with aseptic technique. i. CVC insertion should be observed by a nurse, physician, or other healthcare personnel who has received appropriate education (see above), to ensure that aseptic technique is maintained. b. These healthcare personnel should be empowered to stop the procedure if breaches in aseptic technique are observed. 2. Perform hand hygiene before catheter insertion or manipulation (B-II).30-33 a. Use an alcohol-based waterless product or antiseptic soap and water. i. Use of gloves does not obviate hand hygiene. 3. Avoid using the femoral vein for central venous access in adult patients (A-I).15,34,35 a. Use of the femoral access site is associated with greater risk of infection and deep venous thrombosis in adults. i. Increased risk of infection with femoral catheters may be limited to overweight adult patients with a body mass index higher than 28.4.36 ii. Femoral vein catheterization can be done without general anesthesia in children and has not been associated with an increased risk of infection in children.37 b. Several nonrandomized studies show that the subclavian vein site is associated with a lower risk of CLABSI than is the internal jugular vein, but the risks and benefits
in light of potential infectious and noninfectious complications must be considered on an individual basis when determining which insertion site to use. c. The use of peripherally inserted CVCs is not an evidence-based strategy to reduce the risk of CLABSI. i. The risk of infection with peripherally inserted CVCs in ICU patients approaches that with CVCs placed in the subclavian or internal jugular veins.38 4. Use an all-inclusive catheter cart or kit (B-II).23 a. A catheter cart or kit that contains all necessary com- ponents for aseptic catheter insertion is to be available and easily accessible in all units where CVCs are inserted. 5. Use maximal sterile barrier precautions during CVC insertion (A-I).39-42 a. Use maximal sterile barrier precautions. i. A mask, cap, sterile gown, and sterile gloves are to be worn by all healthcare personnel involved in the catheter insertion procedure. ii. The patient is to be covered with a large sterile drape during catheter insertion. b. These measures must also be followed when exchanging a catheter over a guidewire. 6. Use a chlorhexidine-based antiseptic for skin preparation in patients older than 2 months of age (A-I).43-46 a. Before catheter insertion, apply an alcoholic chlorhexidine solution containing a concentration of chlorhexidine gluconate greater than 0.5% to the insertion site. i. The antiseptic solution must be allowed to dry before making the skin puncture. ii. Chlorhexidine products are not approved by the US Food and Drug Administration for children younger
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than 2 months of age; povidone-iodine can be used for children in this age group. C. After insertion 1. Disinfect catheter hubs, needleless connectors, and injection ports before accessing the catheter (B-II).47-49 a. Before accessing catheter hubs or injection ports, clean them with an alcoholic chlorhexidine preparation or 70% alcohol to reduce contamination. 2. Remove nonessential catheters (A-II).50,51 a. Assess the need for continued intravascular access on a daily basis during multidisciplinary rounds. Remove catheters not required for patient care. 3. For nontunneled CVCs in adults and adolescents, change transparent dressings and perform site care with a chlorhexidine-based antiseptic every 5-7 days or more frequently if the dressing is soiled, loose, or damp; change gauze dressings every 2 days or more frequently if the dressing is soiled, loose, or damp (A-I).52,53 4. Replace administration sets not used for blood, blood products, or lipids at intervals not longer than 96 hours (AII).54 5. Perform surveillance for CLABSI (B-II).55 a. Measure unit-specific incidence of CLABSI (CLABSIs per 1,000 catheter-days) and report the data on a regular basis to the units, physician and nursing leadership, and hospital administrators overseeing the units. b. Compare CLABSI incidence with historical data for individual units and with national rates (ie, data from the National Healthcare Safety Network56). c. CLABSI has been documented in large numbers of non-ICU patients with CVCs. Surveillance for CLABSI in these settings requires additional resources.4,5,57 6. Use antimicrobial ointments for hemodialysis catheter insertion sites (A-I).58-62 a. Povidone-iodine or polysporin ointment should be applied to hemodialysis catheter insertion sites in patients with a history of recurrent Staphylococcus aureus CLABSI. b. Mupirocin ointment should not be applied to the catheter insertion site due to the risks of mupirocin resistance and damage to polyurethane catheters. D. Accountability 1. The hospital's chief executive officer and senior management are responsible for ensuring that the healthcare system supports an infection prevention and control program that effectively prevents the occurrence of CLABSI.
2. Senior management is accountable for ensuring that an adequate number of trained personnel are assigned to the infection prevention and control program. 3. Senior management is accountable for ensuring that healthcare personnel, including licensed and nonlicensed personnel, are competent to perform their job responsibilities. 4. Direct healthcare providers (such as physicians, nurses, aides, and therapists) and ancillary personnel (such as housekeeping and equipment-processing personnel) are responsible for ensuring that appropriate infection prevention and control practices are used at all times (including hand hygiene, standard and isolation precautions, cleaning and disinfection of equipment and the environment, aseptic technique when inserting and caring for CVCs, maximal barrier precautions, appropriate site selection, and daily assessment of the need for a CVC). 5. Hospital and unit leaders are responsible for holding personnel accountable for their actions. 6. The person who manages the infection prevention and control program is responsible for ensuring that an active program to identify CLABSIs is implemented, that data on CLABSIs are analyzed and regularly provided to those who can use the information to improve the quality of care (eg, unit staff, clinicians, and hospital administrators), and that evidence-based practices are incorporated into the program. 7. Individuals responsible for healthcare personnel and patient education are accountable for ensuring that appropriate training and educational programs to prevent CLABSIs are developed and provided to personnel, patients, and families. 8. Personnel from the infection prevention and control program, laboratory, and information technology departments are responsible for ensuring that systems are in place to support the surveillance program. II. Special approaches for the prevention of CLABSI Perform a CLABSI risk assessment. These special approaches are recommended for use in locations and/or populations within the hospital that have unacceptably high CLABSI rates despite implementation of the basic CLABSI prevention strategies listed above. 1. Bathe ICU patients older than 2 months of age with a chlorhexidine preparation on a daily basis (B-II).63 a. Chlorhexidine products are not approved by the US Food and Drug Administration for children younger than 2 months of age but are used at some institutions for cleaning CVC insertion sites or as a sponge dressing for children in this age group.
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b. A povidone-iodine preparation should be used to clean CVC insertion sites for children younger than 2 months of age, especially low-birth-weight neonates. 2. Use antiseptic- or antimicrobial-impregnated CVCs for adult patients (A-I).64-70 a. The risk of CLABSI is reduced with some currently marketed catheters impregnated with antiseptics (eg, chlorhexidine-silver sulfadiazine) or antimicrobials (eg, minocycline-rifampin). Consider the use of such catheters in the following circumstances: i. Hospital units or patient populations have a CLABSI rate higher than the institutional goal, despite compliance with basic CLABSI prevention practices. ii. Patients have limited venous access and a history of recurrent CLABSI. iii. Patients are at heightened risk for severe sequelae from a CLABSI (eg, patients with recently implanted intravascular devices, such as a prosthetic heart valve or aortic graft). b. These catheters are not approved by the US Food and Drug Administration for use in children. i. Preliminary data suggest that antimicrobial-impregnated catheters appear to be safe and may hold promise for pediatric ICU patients.71,72 3. Use chlorhexidine-containing sponge dressings for CVCs in patients older than 2 months of age (B-I).73-75 a. Consider the addition of such a dressing in the following circumstances: i. Hospital units or patient populations have a CLABSI rate higher than the institutional goal, despite compliance with an evidence-based prevention bundle. ii. Patients have limited venous access and a history of recurrent CLABSI. iii. Patients are at heightened risk for severe sequelae from a CLABSI (eg, patients with recently implanted intravascular devices, such as a prosthetic heart valve or aortic graft). b. Do not use chlorhexidine-containing sponge dressings for low-birth-weight neonates. 4. Use antimicrobial locks for CVCs (A-I).76-80 a. Antibiotic locks are created by filling the lumen of the catheter with a supraphysiologic concentration of an antimicrobial solution and leaving the solution in place until the catheter hub is reaccessed. Such an approach can reduce the risk of CLABSI. Because of concerns regarding the potential for the emergence of resistance in exposed organisms and the potential for systemic toxicity from leakage of the lock solution into the bloodstream, use antimicrobial locks as a preventative strategy only for the following:
i. Prophylaxis for patients with limited venous access and a history of recurrent CLABSI. ii. Patients who are at heightened risk for severe sequelae from a CLABSI (eg, patients with recently implanted intravascular devices such as a prosthetic heart valve or aortic graft). III. Approaches that should not be considered a routine part of CLABSI prevention 1. Do not use antimicrobial prophylaxis for short-term or tunneled catheter insertion or while catheters are in situ (AI).81-84 a. Systemic antimicrobial prophylaxis is not recommended. 2. Do not routinely replace CVCs or arterial catheters (AI).85-87 a. Routine catheter replacement is not recommended. 3. Do not routinely use positive-pressure needleless connectors with mechanical valves before a thorough assessment of risks, benefits, and education regarding proper use (BII).88-91 a. Routine use of the currently marketed devices that are associated with an increased risk of CLABSI is not recommended. IV. Unresolved issues 1. Nurse-to-patient ratio and use of float nurses in ICUs92-94 a. Observational studies suggest that there should be a nurse-to-patient ratio of at least 2 : 1 in ICUs where nurses are managing patients with CVCs and that the number of float nurses working in the ICU environment should be minimized. Formal recommendations await the results of interventional trials. 2. Intravenous therapy teams for reducing CLABSI rates95 a. Studies have shown that an intravenous therapy team responsible for insertion and maintenance of peripheral intravenous catheters reduces the risk of bloodstream infections.96 However, few studies have been performed regarding the impact of intravenous therapy teams on CLABSI rates. 3. Surveillance of other types of catheters (eg, peripheral arterial catheters)1,2 a. Peripheral arterial catheters have not been included in most surveillance systems, although they are associated with a risk of bloodstream infection. Future surveillance systems may need to include bloodstream infections associated with these types of catheters.
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4. Estimating catheter-days for determining incidence density of CLABSI a. Surveillance can be facilitated in settings with a limited workforce by estimating the number of catheterdays.97,98 section 5: performance measures I. Internal reporting These performance measures are intended to support internal hospital quality improvement efforts and do not necessarily address external reporting needs. The process and outcome measures suggested here are derived from published guidelines, other relevant literature, and the opinion of the authors. Report process and outcome measures to senior hospital leadership, nursing leadership, and clinicians who care for patients at risk for CLABSI. A. Process measures (in rank order from highest to lowest priority) 1. Compliance with CVC insertion guidelines as documented on an insertion checklist a. Assess compliance with the checklist in all hospital settings where CVCs are inserted (eg, ICUs, emergency department, operating room, radiology, and general wards) and assign healthcare personnel familiar with catheter care to this task. i. For an example of a central catheter checklist, see the Institute for Healthcare Improvement Web site.99 b. Measure the percentage of CVC insertion procedures in which compliance with appropriate hand hygiene, use of maximal sterile barrier precautions, and use of chlorhexidine-based cutaneous antisepsis of the insertion site is documented. i. Numerator: number of CVC insertions that have documented the use of all 3 interventions (hand hygiene, maximal barrier precautions, and chlorhexidine-based cutaneous antiseptic use) performed at the time of CVC insertion. ii. Denominator: number of all CVC insertions. iii. Multiply by 100 so that the measure is expressed as a percentage. 2. Compliance with documentation of daily assessment regarding the need for continuing CVC access a. Measure the percentage of patients with a CVC for whom there is documentation of daily assessment. i. Numerator: number of patients with a CVC for whom there is documentation of daily assessment. ii. Denominator: number of patients with a CVC. iii. Multiply by 100 so that the measure is expressed as a percentage.
3. Compliance with cleaning of catheter hubs and injection ports before they are accessed a. Assess compliance through observations of practice. i. Numerator: number of times that a catheter hub or port is observed to be cleaned before being accessed. ii. Denominator: number of times a catheter hub or port is observed to be accessed. iii. Multiply by 100 so that the measure is expressed as a percentage. 4. Compliance with avoiding the femoral vein site for CVC insertion in adult patients a. Perform point prevalence surveys or use information collected as part of the central line insertion checklist to determine the percentage of patients whose CVCs are in the femoral vein versus the subclavian or internal jugular veins. b. Calculate the percentage of patients with a femoral vein catheter. i. Numerator: number of patients with a CVC in the femoral vein. ii. Denominator: total number of patients with a CVC in unit population being assessed. iii. Multiply by 100 so that the measure is expressed as a percentage. B. Outcome measures 1. CLABSI rate a. Use National Healthcare Safety Network definitions. i. Numerator: number of CLABSIs in each unit assessed (using National Healthcare Safety Network definitions). ii. Denominator: total number of catheter-days in each unit assessed (using National Healthcare Safety Network definitions). iii. Multiply by 1,000 so that the measure is expressed as number of CLABSIs per 1,000 catheter-days. iv. Risk adjustment: stratify CLABSI rates by type of patient-care unit.100-102 (a) Report comparisons based on historical data and National Healthcare Safety Network data, if available.56 II. External reporting There are many challenges in providing useful information to consumers and other stakeholders while preventing unintended adverse consequences of public reporting of healthcare-associated infections.103 Recommendations for public reporting of healthcare-associated infections have been provided by the Healthcare Infection Control Practices Advisory Committee,104 the Healthcare-Associated Infection Working Group of the Joint Public Policy Committee,105 and the National Quality Forum.106
S28 infection control and hospital epidemiology october 2008, vol. 29, supplement 1
A. State and federal requirements 1. Hospitals in states that have mandatory reporting requirements for CLABSI must collect and report the data required by the state. 2. For information on state and federal requirements, contact your state or local health department. B. External quality initiatives 1. Hospitals that participate in external quality initiatives or state programs must collect and report the data required by the initiative or the program. acknowledgments For Potential Conflicts of Interest statements and information on financial support, please see the Acknowledgments in the Executive Summary, on page S20 of this supplement. Address reprint requests to the Reprints Coordinator, University of Chicago Press, 1427 E. 60th St., Chicago, IL 60637 ([email protected]) or contact the journal office ([email protected]). references 1. Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc 2006; 81:1159-1171. 2. Esteve F, Pujol M, Limon E, et al. Bloodstream infection related to catheter connections: a prospective trial of two connection systems. J Hosp Infect 2007; 67:30-34. 3. Climo M, Diekema D, Warren DK, et al. Prevalence of the use of central venous access devices within and outside of the intensive care unit: results of a survey among hospitals in the prevention epicenter program of the Centers for Disease Control and Prevention. Infect Control Hosp Epidemiol 2003; 24:942-945. 4. Vonberg RP, Behnke M, Geffers C, et al. Device-associated infection rates for non­intensive care unit patients. Infect Control Hosp Epidemiol 2006; 27:357-361. 5. Marschall J, Leone C, Jones M, Nihill D, Fraser VJ, Warren DK. Catheter-associated bloodstream infections in general medical patients outside the intensive care unit: a surveillance study. Infect Control Hosp Epidemiol 2007; 28:905-909. 6. Pittet D, Tarara D, Wenzel RP. Nosocomial bloodstream infection in critically ill patients: excess length of stay, extra costs, and attributable mortality. JAMA 1994; 271:1598-1601. 7. DiGiovine B, Chenoweth C, Watts C, Higgins M. The attributable mortality and costs of primary nosocomial bloodstream infections in the intensive care unit. Am J Respir Crit Care Med 1999; 160:976-981. 8. Renaud B, Brun-Buisson C, ICU-Bacteremia Study Group. Outcomes of primary and catheter-related bacteremia: a cohort and case-control study in critically ill patients. Am J Respir Crit Care Med 2001; 163: 1584-1590. 9. Dimick JB, Pelz RK, Consunji R, Swoboda SM, Hendrix CW, Lipsett PA. Increased resource use associated with catheter-related bloodstream infection in the surgical intensive care unit. Arch Surg 2001; 136:229234. 10. Warren DK, Quadir WW, Hollenbeak CS, et al. Attributable cost of catheter-associated bloodstream infection among intensive care patients in a nonteaching hospital. Crit Care Med 2006; 34:2084-2089. 11. Mermel LA. Prevention of intravascular catheter-related infections
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51. Parenti CM, Lederle FA, Impola CL, Peterson LR. Reduction of unnecessary intravenous catheter use: internal medicine house staff participate in a successful quality improvement project. Arch Intern Med 1994; 154:1829-1832. 52. Maki DG, Stolz SS, Wheeler S, Mermel LA. A prospective, randomized trial of gauze and two polyurethane dressings for site care of pulmonary artery catheters: implications for catheter management. Crit Care Med 1994; 22:1729-1737. 53. Rasero L, Degl'Innocenti M, Mocali M, et al. Comparison of two different time interval protocols for central venous catheter dressing in bone marrow transplant patients: results of a randomized, multicenter study. Haematologica 2000; 85:275-279. 54. Gillies D, O'Riordan L, Wallen M, Morrison A, Rankin K, Nagy S. Optimal timing for intravenous administration set replacement. Cochrane Database Syst Rev 2005; (4):1-42. 55. Gastmeier P, Geffers C, Brandt C, et al. Effectiveness of a nationwide nosocomial infection surveillance system for reducing nosocomial infections. J Hosp Infect 2006; 64:16-22. 56. National Healthcare Safety Network (NHSN), Department of Health and Human Services, Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/ncidod/dhqp/nhsn.html. Accessed July 15, 2008. 57. Edwards JR, Peterson KD, Andrus ML, et al. National Healthcare Safety Network (NHSN) report, data summary for 2006, issued June 2007. Am J Infect Control 2007; 35:290-301. 58. Levin A, Mason AJ, Jindal KK, Fong IW, Goldstein MB. Prevention of hemodialysis subclavian vein catheter infections by topical povidoneiodine. Kidney Int 1991; 40:934-938. 59. Zakrzewska-Bode A, Muytjens HL, Liem KD, Hoogkamp-Korstanje JA. Mupirocin resistance in coagulase-negative staphylococci, after topical prophylaxis for the reduction of colonization of central venous catheters. J Hosp Infect 1995; 31:189-193. 60. Riu S, Ruiz CG, Martinez-Vea A, Peralta C, Oliver JA. Spontaneous rupture of polyurethane peritoneal catheter: a possible deleterious effect of mupirocin ointment. Nephrol Dial Transplant 1998; 13:1870-1871. 61. Lok CE, Stanley KE, Hux JE, Richardson R, Tobe SW, Conly J. Hemodialysis infection prevention with polysporin ointment. J Am Soc Nephrol 2003; 14:169-179. 62. Fong IW. Prevention of haemodialysis and peritoneal dialysis catheter related infection by topical povidone-iodine. Postgrad Med J 1993; 69(Suppl 3):S15-S17. 63. Bleasdale SC, Trick WE, Gonzales IM, Lyles RD, Hayden MK, Weinstein RA. Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med 2007; 167:2073-2079. 64. Maki DG, Stolz SM, Wheeler S, Mermel LA. Prevention of central venous catheter-related bloodstream infection by use of an antisepticimpregnated catheter: a randomized, controlled trial. Ann Intern Med 1997; 127:257-266. 65. Raad I, Darouiche R, Dupuis J. Central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infections: a randomized, double-blind trial. The Texas Medical Center Catheter Study Group. Ann Intern Med 1997; 127:267-274. 66. Veenstra DL, Saint S, Saha S, Lumley T, Sullivan SD. Efficacy of antiseptic-impregnated central venous catheters in preventing catheter-related bloodstream infections: a meta-analysis. JAMA 1999; 281:261-267. 67. Darouiche RO, Raad II, Heard SO, et al. A comparison of two antimicrobial-impregnated central venous catheters: Catheter Study Group. N Engl J Med 1999; 340:1-8. 68. Hanna HA, Raad II, Hackett B, et al., M.D. Anderson Catheter Study Group. Antibiotic-impregnated catheters associated with significant decrease in nosocomial and multidrug-resistant bacteremias in critically ill patients. Chest 2003; 124:1030-1038. 69. Hanna H, Benjamin R, Chatzinikolaou I, et al. Long-term silicone central venous catheters impregnated with minocycline and rifampin decrease rates of catheter-related bloodstream infection in cancer patients: a prospective randomized clinical trial. J Clin Oncol 2004; 22:3163-3171.
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70. Rupp ME, Lisco SJ, Lipsett PA, et al. Effect of a second-generation venous catheter impregnated with chlorhexidine and silver sulfadiazine on central catheter-related infections: a randomized, controlled trial. Ann Intern Med 2005; 143:570-580. 71. Chelliah A, Heydon KH, Zaoutis TE, et al. Observational trial of antibiotic-coated central venous catheters in critically ill pediatric patients. Pediatr Infect Dis J 2007; 26:816-820. 72. Bhutta A, Gilliam C, Honeycutt M, et al. Reduction of bloodstream infections associated with catheters in paediatric intensive care unit: stepwise approach. BMJ 2007; 334:362-365. 73. Garland JS, Alex CP, Mueller CD, et al. A randomized trial comparing povidone-iodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates. Pediatrics 2001; 107:1431-1436. 74. Levy I, Katz J, Solter E, et al. Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: a randomized controlled study. Pediatr Infect Dis J 2005; 24: 676-679. 75. Ho KM, Litton E. Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis. J Antimicrob Chemother 2006; 58:281-287. 76. Carratala J, Niubo J, Fernandez-Sevilla A, et al. Randomized, doubleblind trial of an antibiotic-lock technique for prevention of gram-positive central venous catheter-related infection in neutropenic patients with cancer. Antimicrob Agents Chemother 1999; 43:2200-2204. 77. Henrickson KJ, Axtell RA, Hoover SM, et al. Prevention of central venous catheter-related infections and thrombotic events in immunocompromised children by the use of vancomycin/ciprofloxacin/heparin flush solution: a randomized, multicenter, double-blind trial. J Clin Oncol 2000; 18:1269-1278. 78. Safdar N, Maki DG. Use of vancomycin-containing lock or flush solutions for prevention of bloodstream infection associated with central venous access devices: a meta-analysis of prospective, randomized trials. Clin Infect Dis 2006; 43:474-484. 79. Labriola L, Crott R, Jadoul M. Preventing haemodialysis catheter-related bacteraemia with an antimicrobial lock solution: a meta-analysis of prospective randomized trials. Nephrol Dial Transplant 2008; 23:16661672. 80. Saxena AK, Panhotra BR, Naguib M. Sudden irreversible sensory-neural hearing loss in a patient with diabetes receiving amikacin as an antibiotic heparin lock. Pharmacotherapy 2002; 22:105-8. 81. McKee R, Dunsmuir R, Whitby M, Garden OJ. Does antibiotic prophylaxis at the time of catheter insertion reduce the incidence of catheter-related sepsis in intravenous nutrition? J Hosp Infect 1985; 6:419425. 82. Ranson MR, Oppenheim BA, Jackson A, Kamthan AG, Scarffe JH. Double-blind placebo controlled study of vancomycin prophylaxis for central venous catheter insertion in cancer patients. J Hosp Infect 1990; 15:95-102. 83. Sandoe JA, Kumar B, Stoddart B, et al. Effect of extended perioperative antibiotic prophylaxis on intravascular catheter colonization and infection in cardiothoracic surgery patients. J Antimicrob Chemother 2003; 52:877-879. 84. Van de Wetering MD, van Woensel JBM, Kremer LCM, Caron HN. Prophylactic antibiotics for preventing early Gram-positive central venous catheter infections in oncology patients, a Cochrane systematic review. Cancer Treat Rev 2005; 31:186-196. 85. Eyer S, Brummitt C, Crossley K, Siegel R, Cerra F. Catheter-related sepsis: prospective, randomized study of three methods of long-term catheter maintenance. Crit Care Med 1990; 18:1073-1079. 86. Cobb DK, High KP, Sawyer RG, et al. A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters. N Engl J Med 1992; 327:1062-1068. 87. Cook D, Randolph A, Kernerman P, et al. Central venous catheter replacement strategies: a systematic review of the literature. Crit Care Med 1997; 25:1417-1424.
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S12 infection control and hospital epidemiology october 2008, vol. 29, supplement 1 supplement article: executive summary A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals
Deborah S. Yokoe, MD, MPH; Leonard A. Mermel, DO, ScM; Deverick J. Anderson, MD, MPH; Kathleen M. Arias, MS, CIC; Helen Burstin, MD; David P. Calfee, MD, MS; Susan E. Coffin, MD; Erik R. Dubberke, MD; Victoria Fraser, MD; Dale N. Gerding, MD; Frances A. Griffin, RRT, MPA; Peter Gross, MD; Keith S. Kaye, MD; Michael Klompas, MD; Evelyn Lo, MD; Jonas Marschall, MD; Lindsay Nicolle, MD; David A. Pegues, MD; Trish M. Perl, MD; Kelly Podgorny, RN, MS, CPHQ; Sanjay Saint, MD; Cassandra D. Salgado, MD, MS; Robert A. Weinstein, MD; Robert Wise, MD; David Classen, MD, MS
Preventable healthcare-associated infections (HAIs) occur in US hospitals. Preventing these infections is a national priority, with initiatives led by healthcare organizations, professional associations, government and accrediting agencies, legislators, regulators, payers, and consumer advocacy groups. To assist acute care hospitals in focusing and prioritizing efforts to implement evidence-based practices for prevention of HAIs, the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America Standards and Practice Guidelines Committee appointed a task force to create a concise compendium of recommendations for the prevention of common HAIs. This compendium is implementation focused and differs from most previously published guidelines in that it highlights a set of basic HAI prevention strategies plus special approaches for use in locations and/or populations within the hospital when infections are not controlled by use of basic practices, recommends that accountability for implementing infection prevention practices be assigned to specific groups and individuals, and includes proposed performance measures for internal quality improvement efforts. Infect Control Hosp Epidemiol 2008; 29:S12-S21
executive summary The Centers for Disease Control and Prevention estimates that 1 of every 10-20 patients hospitalized in the United States develops a healthcare-associated infection (HAI). Infection prevention and control efforts have long been focused on monitoring and preventing HAIs, but HAI prevention has recently emerged as a national priority, with initiatives led by healthcare organizations, professional associations, government and accrediting agencies, legislators, regulators, payers, and consumer advocacy groups. Previous guidelines have provided detailed, evidence-based recommendations for detecting and preventing HAIs. In contrast, the accompanying documents go one important step further by presenting prac-
tical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their HAI prevention efforts. Four device- and procedure-associated HAI categories are targeted (central line­associated bloodstream infections [CLABSIs], ventilator-associated pneumonia [VAP], catheter-associated urinary tract infections [CAUTIs], and surgical site infections [SSIs]). In addition, 2 organism-specific HAI categories (methicillin-resistant Staphylococcus aureus [MRSA] infection and Clostridium difficile infection [CDI]) are included because of the increasing incidence and morbidity associated with acquisition of these organisms in the acute care setting.1,2 The following is a summary of the strategies to prevent
From the Brigham and Women's Hospital and Harvard Medical School, Boston (D.S.Y., M.K.), and the Institute for Healthcare Improvement, Cambridge (F.A.G.), Massachusetts; the Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island (L.A.M.); the Duke University Medical Center, Durham, North Carolina (D.J.A., K.S.K.); the Association for Professionals in Infection Control and Epidemiology (K.M.A.) and the National Quality Forum (H.B.), Washington, D.C.; the Mount Sinai School of Medicine, New York, New York (D.P.C.); the Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania (S.E.C.); the Washington University School of Medicine, St. Louis, Missouri (E.R.D., V.F., J.M.); the Loyola University Chicago Stritch School of Medicine (D.N.G.), the Stroger (Cook County) Hospital and the Rush University Medical Center (R.A.W.), Chicago, the Joint Commission, Oakbrook Terrace (K.P., R.W.), and the Hines Veterans Affairs Medical Center, Hines (D.N.G.), Illinois; the Hackensack University Medical Center, Hackensack (P.G.), and the University of Medicine and Dentistry­New Jersey Medical School, Newark (P.G.), New Jersey; the David Geffen School of Medicine at the University of California, Los Angeles (D.A.P.); the Johns Hopkins Medical Institutions and University, Baltimore, Maryland (T.M.P.); the Ann Arbor Veterans Affairs Medical Center and the University of Michigan Medical School, Ann Arbor, Michigan (S.S.); the Medical University of South Carolina, Charleston (C.D.S.); the University of Utah, Salt Lake City (D.C.); and the University of Manitoba, Winnipeg, Canada (E.L., L.N.). Accepted June 9, 2008; electronically published September 16, 2008. 2008 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2008/2910S1-0003$15.00. DOI: 10.1086/591060
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HAIs in acute care hospitals presented in this compendium. Criteria for grading the strength of recommendation and quality of evidence are described in Table 1. Prevention of CLABSI I. Basic practices for prevention and monitoring of CLABSI: recommended for all acute care hospitals A. Before insertion 1. Educate healthcare personnel involved in the insertion, care, and maintenance of central venous catheters about CLABSI prevention (A-II). B. At insertion 1. Use a catheter checklist to ensure adherence to infection prevention practices at the time of central venous catheter insertion (B-II). 2. Perform hand hygiene before catheter insertion or manipulation (B-II). 3. Avoid using the femoral vein for central venous access in adult patients (A-I). 4. Use an all-inclusive catheter cart or kit (B-II). 5. Use maximal sterile barrier precautions during central venous catheter insertion (A-I). 6. Use a chlorhexidine-based antiseptic for skin preparation in patients older than 2 months of age (A-I). C. After insertion 1. Disinfect catheter hubs, needleless connectors, and injection ports before accessing the catheter (B-II). 2. Remove nonessential catheters (A-II). 3. For nontunneled central venous catheters in adults and adolescents, change transparent dressings and perform site care with a chlorhexidine-based antiseptic every 5-7 days or more frequently if the dressing is soiled, loose, or damp; change gauze dressings every 2 days or
more frequently if the dressing is soiled, loose, or damp (A-I). 4. Replace administration sets not used for blood, blood products, or lipids at intervals not longer than 96 hours (A-II). 5. Perform surveillance for CLABSI (B-II). 6. Use antimicrobial ointments for hemodialysis catheter insertion sites (A-I). II. Special approaches for the prevention of CLABSI: Perform a CLABSI risk assessment. These special approaches are recommended for use in locations and/or populations within the hospital for which outcome data and/or risk assessment suggest lack of effective control despite implementation of basic practices. 1. Bathe intensive care unit (ICU) patients older than 2 months of age with a chlorhexidine preparation on a daily basis (B-II). 2. Use antiseptic- or antimicrobial-impregnated central venous catheters for adult patients (A-I). 3. Use chlorhexidine-containing sponge dressings for central venous catheters in patients older than 2 months of age (B-I). 4. Use antimicrobial locks for central venous catheters (A-I). III. Approaches that should not be considered a routine part of CLABSI prevention 1. Do not use antimicrobial prophylaxis for short-term or tunneled catheter insertion or while catheters are in situ (A-I). 2. Do not routinely replace central venous catheters or arterial catheters (A-I). 3. Do not routinely use positive-pressure needleless connectors with mechanical valves before a thorough assess-
table 1. Strength of Recommendation and Quality of Evidence
Category/grade
Definition
Strength of recommendation A B C Quality of evidence I II III
Good evidence to support a recommendation for use Moderate evidence to support a recommendation for use Poor evidence to support a recommendation Evidence from x1 properly randomized, controlled trial Evidence from x1 well-designed clinical trial, without randomization; from cohort or case-control analytic studies (preferably from 11 center); from multiple time series; or from dramatic results from uncontrolled experiments Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
note. Adapted from the Canadian Task Force on the Periodic Health Examination.3
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ment of risks, benefits, and education regarding proper use (B-II). Prevention of VAP I. Basic practices for prevention and monitoring of VAP: recommended for all acute care hospitals A. Education 1. Educate healthcare personnel who care for patients undergoing ventilation about VAP, including information about local epidemiology, risk factors, and patient outcomes (A-II). 2. Educate clinicians who care for patients undergoing ventilation about noninvasive ventilatory strategies (B-III). B. Surveillance of VAP 1. Perform direct observation of compliance with VAP-specific process measures (B-III). 2. Conduct active surveillance for VAP and associated process measures in units that care for patients undergoing ventilation who are known or suspected to be at high risk for VAP on the basis of risk assessment (A-II). C. Practice 1. Implement policies and practices for disinfection, sterilization, and maintenance of respiratory equipment that are aligned with evidence-based standards (eg, guidelines from the Centers for Disease Control and Prevention and professional organizations) (A-II). 2. Ensure that all patients (except those with medical contraindications) are maintained in a semirecumbent position (B-II). 3. Perform regular antiseptic oral care in accordance with product guidelines (A-I). 4. Provide easy access to noninvasive ventilation equipment and institute protocols to promote the use of noninvasive ventilation (B-III). II. Special approaches for the prevention of VAP: Perform a VAP risk assessment. These special approaches are recommended for use in locations and/or populations within the hospital for which outcome data and/or risk assessment suggest a lack of effective control despite implementation of basic practices. 1. Use an endotracheal tube with in-line and subglottic suctioning for all eligible patients (B-II). 2. Ensure that all ICU beds used for patients undergoing ventilation have a built-in tool to provide continuous monitoring of the angle of incline (B-III). III. Approaches that should not be considered a routine part of VAP prevention
1. Do not routinely administer intravenous immunoglobulin, white-cell­stimulating factors (filgrastim or sargramostim), enteral glutamine, or chest physiotherapy (AIII). 2. Do not routinely use rotational therapy with kinetic or continuous lateral rotational therapy beds (B-II). 3. Do not routinely administer prophylactic aerosolized or systemic antimicrobials (B-III). Prevention of CAUTI I. Basic practices for prevention and monitoring of CAUTI: recommended for all acute care hospitals A. Appropriate infrastructure for preventing CAUTI 1. Provide and implement written guidelines for catheter use, insertion, and maintenance (A-II). 2. Ensure that only trained, dedicated personnel insert urinary catheters (B-III). 3. Ensure that supplies necessary for aseptic-technique catheter insertion are available (A-III). 4. Implement a system for documenting the following information in the patient record: indications for catheter insertion, date and time of catheter insertion, individual who inserted catheter, and date and time of catheter removal (A-III). 5. Ensure that there are sufficient trained personnel and technology resources to support surveillance of catheter use and outcomes (A-III). B. Surveillance of CAUTI 1. Identify the patient groups or units in which to conduct surveillance, on the basis of risk assessment, considering the frequency of catheter use and the potential risk factors (eg, types of surgery, obstetrics, and critical care) (B-III). 2. Use standardized criteria to identify patients who have a CAUTI (numerator data) (A-II). 3. Collect information on catheter-days (denominator data) for all patients in the patient groups or units being monitored (A-II). 4. Calculate CAUTI rates for target populations (AII). 5. Measure the use of indwelling urinary catheters, including the percentage of patients with an indwelling urinary catheter inserted during hospitalization, the percentage of catheter use with accepted indications, and duration of indwelling catheter use (B-II). 6. Use surveillance methods for case finding that are appropriate for the institution and are documented to be valid (A-III). C. Education and training 1. Educate healthcare personnel involved in the insertion, care, and maintenance of urinary catheters about
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CAUTI prevention, including alternatives to indwelling catheters and procedures for catheter insertion, management, and removal (A-III). D. Appropriate technique for catheter insertion 1. Insert urinary catheters only when necessary for patient care and leave them in place only as long as indications persist (A-II). 2. Consider other methods for management, including condom catheters or in-and-out catheterization, when appropriate (A-I). 3. Practice hand hygiene (in accordance with Centers for Disease Control and Prevention or World Health Organization guidelines) immediately before insertion of the catheter and before and after any manipulation of the catheter site or apparatus (A-III). 4. Insert catheters by use of aseptic technique and sterile equipment (A-III). 5. Use gloves, a drape, and sponges; a sterile or antiseptic solution for cleaning the urethral meatus; and a single-use packet of sterile lubricant jelly for insertion (A-III). 6. Use as small a catheter as possible that is consistent with proper drainage, to minimize urethral trauma (BIII). E. Appropriate management of indwelling catheters 1. Properly secure indwelling catheters after insertion to prevent movement and urethral traction (A-III). 2. Maintain a sterile, continuously closed drainage system (A-I). 3. Do not disconnect the catheter and drainage tube unless the catheter must be irrigated (A-I). 4. Replace the collecting system by use of aseptic technique and after disinfecting the catheter-tubing junction when breaks in aseptic technique, disconnection, or leakage occur (B-III). 5. For examination of fresh urine, collect a small sample by aspirating urine from the sampling port with a sterile needle and syringe after cleansing the port with disinfectant (A-III). 6. Obtain larger volumes of urine for special analyses aseptically from the drainage bag (A-III). 7. Maintain unobstructed urine flow (A-II). 8. Empty the collecting bag regularly, using a separate collecting container for each patient, and avoid allowing the draining spigot to touch the collecting container (AII). 9. Keep the collecting bag below the level of the bladder at all times (A-III). 10. Cleaning the meatal area with antiseptic solutions is unnecessary; routine hygiene is appropriate (A-I). II. Special approaches for the prevention of CAUTI: Perform a CAUTI risk assessment. These special approaches are
recommended for use in locations and/or populations within the hospital for which outcome data and/or risk assessment suggest lack of effective control despite implementation of basic practices. 1. Implement an organization-wide program to identify and remove catheters that are no longer necessary, using 1 or more methods documented to be effective (A-II). 2. Develop a protocol for management of postoperative urinary retention, including nurse-directed use of intermittent catheterization and use of bladder scanners (B-I). 3. Establish a system for analyzing and reporting data on catheter use and adverse events from catheter use (BIII). III. Approaches that should not be considered a routine part of CAUTI prevention 1. Do not routinely use silver-coated or other antibacterial catheters (A-I). 2. Do not screen for asymptomatic bacteruria in catheterized patients (A-II). 3. Do not treat asymptomatic bacteruria in catheterized patients except before invasive urologic procedures (A-I). 4. Avoid catheter irrigation (A-I). 5. Do not use systemic antimicrobials routinely as prophylaxis (A-II). 6. Do not change catheters routinely (A-III). Prevention of SSI I. Basic practices for prevention and monitoring of SSI: recommended for all acute care hospitals A. Surveillance of SSI 1. Perform surveillance for SSI (A-II). 2. Provide ongoing feedback on SSI surveillance and process measures to surgical and perioperative personnel and leadership (A-II). 3. Increase the efficiency of surveillance through the use of automated data (A-II). B. Practice 1. Administer antimicrobial prophylaxis in accordance with evidence-based standards and guidelines (AI). 2. Do not remove hair at the operative site unless the presence of hair will interfere with the operation; do not use razors (A-II). 3. Control blood glucose level during the immediate postoperative period for patients undergoing cardiac surgery (A-I). 4. Measure and provide feedback to providers on the rates of compliance with process measures, including antimicrobial prophylaxis, proper hair removal, and glucose control (for cardiac surgery) (A-III).
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5. Implement policies and practices aimed at reducing the risk of SSI that meet regulatory and accreditation requirements and that are aligned with evidence-based standards (eg, Centers for Disease Control and Prevention and professional organization guidelines) (A-II). C. Education 1. Educate surgeons and perioperative personnel about SSI prevention (A-III). 2. Educate patients and their families about SSI prevention, as appropriate (A-III). II. Special approaches for the prevention of SSI: Perform an SSI risk assessment. These special approaches are recommended for use in locations and/or populations within the hospital for which outcome data and/or risk assessment suggest a lack of effective control despite implementation of basic practices. 1. Perform expanded SSI surveillance to determine the source and extent of the problem and to identify possible targets for intervention (B-II). III. Approaches that should not be considered a routine part of SSI prevention 1. Do not routinely use vancomycin for antimicrobial prophylaxis; vancomycin can, however, be an appropriate agent for specific clinical circumstances (B-II). 2. Do not routinely delay surgery to provide parenteral nutrition (A-I).
8. Implement an alert system that identifies readmitted or transferred MRSA-colonized or -infected patients (B-III). 9. Provide MRSA data and other outcome measures to key stakeholders, including senior leadership, physicians, and nursing staff (B-III). 10. Educate patients and their families about MRSA, as appropriate (B-III). II. Special approaches for the prevention of MRSA transmission: These special approaches are recommended for use in locations and/or populations within the hospital for which outcome data and/or risk assessment suggest lack of effective control despite implementation of basic practices. A. Active surveillance testing: MRSA screening program for patients 1. Implement an MRSA active surveillance testing program as part of a multifaceted strategy to control and prevent MRSA transmission when evidence suggests that there is ongoing transmission of MRSA despite effective implementation of basic practices (B-II). B. Active surveillance testing for MRSA among healthcare personnel 1. Screen healthcare personnel for MRSA infection or colonization only if they are epidemiologically linked to a cluster of MRSA infections (B-III).
Prevention of MRSA Transmission I. Basic practices for prevention and monitoring of MRSA transmission: recommended for all acute care hospitals
C. Routine bathing with chlorhexidine 1. Routinely bathe adult ICU patients with chlorhexidine (B-III).
A. Components of an MRSA transmission prevention program 1. Conduct an MRSA risk assessment (B-III). 2. Implement an MRSA monitoring program (A-III). 3. Promote compliance with Centers for Disease Control and Prevention or World Health Organization handhygiene recommendations (A-II). 4. Use contact precautions for MRSA-colonized or -infected patients (A-II). 5. Ensure cleaning and disinfection of equipment and the environment (B-III). 6. Educate healthcare personnel about MRSA, including risk factors, routes of transmission, outcomes associated with infection, prevention measures, and local epidemiology (B-III). 7. Implement a laboratory-based alert system that immediately notifies infection prevention and control personnel and clinical personnel of new MRSA-colonized or -infected patients (B-III).
D. MRSA decolonization therapy for MRSA-colonized persons 1. Provide decolonization therapy to MRSA-colonized patients in conjunction with an active surveillance testing program (B-III). Prevention of CDI I. Basic practices for prevention and monitoring of CDI: recommended for all acute care hospitals A. Components of a CDI prevention program 1. Use contact precautions for infected patients, with a single-patient room preferred (A-II for hand hygiene, A-I for gloves, B-III for gowns, and B-III for singlepatient room). 2. Ensure cleaning and disinfection of equipment and the environment (B-III for equipment and B-II for the environment).
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3. Implement a laboratory-based alert system to provide immediate notification to infection prevention and control personnel and clinical personnel about patients with newly diagnosed CDI (B-III). 4. Conduct CDI surveillance and analyze and report CDI data (B-III). 5. Educate healthcare personnel, housekeeping personnel, and hospital administration about CDI (B-III). 6. Educate patients and their families about CDI, as appropriate (B-III). 7. Measure compliance with Centers for Disease Control and Prevention or World Health Organization handhygiene and contact precaution recommendations (BIII). II. Special approaches for the prevention of CDI: Perform a CDI risk assessment. These special approaches are recommended for use in locations and/or populations within the hospital for which outcome data and/or risk assessment suggest lack of effective control despite implementation of basic practices. A. Approaches to minimize C. difficile transmission by healthcare personnel 1. Intensify the assessment of compliance with process measures (B-III). 2. Perform hand hygiene with soap and water as the preferred method before exiting the room of a patient with CDI (B-III). 3. Place patients with diarrhea under contact precautions while C. difficile test results are pending (B-III). 4. Prolong the duration of contact precautions after the patient becomes asymptomatic until hospital discharge (B-III). B. Approaches to minimize CDI transmission from the environment 1. Assess the adequacy of room cleaning (B-III). 2. Use sodium hypochlorite (bleach)­containing cleaning agents for environmental cleaning. Implement a system to coordinate with the housekeeping department if it is determined that sodium hypochlorite is needed for environmental disinfection (B-II). C. Approaches to reduce the risk of CDI acquisition 1. Initiate an antimicrobial stewardship program (AII). III. Approaches that should not be considered a routine part of CDI prevention 1. Do not test patients without signs or symptoms of CDI for C. difficile (B-II). 2. Do not repeat C. difficile testing at the end of suc-
cessful therapy for a patient recently treated for CDI (BIII). introduction The US Centers for Disease Control and Prevention estimates that nearly 2 million patients (5%-10% of hospitalized patients) experience an HAI each year; these infections lead to almost 100,000 deaths and $4.5-$6.5 billion in extra costs.4-6 The accompanying compendium of HAI prevention strategies is the result of collaboration among professional societies, including the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology, and other organizations committed to improving the safety and quality of patient care, including the Joint Commission and the American Hospital Association. Recognizing the importance of HAI prevention, these organizations worked in partnership to provide acute care hospitals with concise, practical, and evidence-based strategies to enhance their HAI prevention programs. Healthcare facilities are currently straining to accommodate an increasing number of infection prevention initiatives, regulatory obligations, and requirements for collection and reporting of performance measures. In addition, some recommended practices aimed at HAI prevention require infrastructure that is not currently available at all hospitals, such as surveillance methods that require information technology support. To assist healthcare facilities in focusing and prioritizing their HAI prevention efforts, the recommendations contained within this compendium are prioritized on the basis of the strength of the supporting evidence, the consensus of the authors, and the intensity of resources required for implementation. The recommendations within this compendium are largely based on previously published HAI prevention guidelines available from a number of organizations, including the Healthcare Infection Control Practices Advisory Committee and the Centers for Disease Control and Prevention, SHEA, the IDSA, and the Association for Professionals in Infection Control and Epidemiology,7-15 and relevant literature published after these guidelines. They are not meant to supplant these more detailed documents. Rather, the aim of this compendium is to provide acute care hospitals with practical guidance by use of an implementation-focused format. Despite the existence of guidelines for the prevention of specific types of HAIs, there is often a gap between what is recommended and what is practiced.16,17 To reduce this gap and to promote a culture of safety and individual accountability, this compendium aims to promote the establishment of infrastructure required to support these detection and prevention approaches, including adequate staffing of hospitals with trained infection prevention and control professionals, and to assign accountability for implementing effective in-
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table 2. Literature Search Subject Headings and Date Ranges
Topic
Subject headings
Catheter-associated bloodstream infection Ventilator-associated pneumonia Catheter-associated urinary tract infection Surgical site infection Methicillin-resistant Staphylococcus aureus Clostridium difficile­associated disease
Catheter; central line; central venous; intravascular; bacteremia; bloodstream infection; prevention Pneumonia, ventilator associated; infection AND pneumonia, bacterial; infection control AND pneumonia, bacterial Catheter AND urinary; urinary tract infection AND catheter; urinary tract infection AND nosocomial AND catheter; urinary tract infection AND nosocomial Wound infection; surgical site infection; postoperative infection; surgical wound; surgical wound infection Staphylococcus aureus; methicillin resistance; prevention; surveillance Clostridium difficile
Date range 2002-2007 1950-2007 1990-2007 1980-2007 1996-Apr 2008 2002-2007
fection prevention practices to hospital leaders, healthcare providers, and support staff. Six documents are included, each focused on a category of HAI selected by the task force members (hereafter referred to as the HAI Allied Task Force) on the basis of the frequency of occurrence, impact on the morbidity and mortality of patients hospitalized in acute care facilities, and potential preventability through adherence to evidence-based practices. These categories include · central line­associated bloodstream infection (CLABSI), · surgical site infection (SSI), · ventilator-associated pneumonia (VAP), · catheter-associated urinary tract infection (CAUTI), · methicillin-resistant S. aureus (MRSA) transmission, and · C. difficile infection (CDI). References to more detailed information available in previously published guidelines are provided in each article. Each article contains a statement of concern and a brief summary of previously described detection and prevention methods, recommendations for implementing evidencebased prevention approaches, and proposed performance measures (both process and outcome measures) for internal monitoring. Each recommendation is ranked on the basis of the strength of recommendation and quality of evidence as required by the IDSA Standards and Practice Guidelines Committee (Table 1). Recommendations are prioritized into (1) evidence-based basic practices that should be adopted by all acute care hospitals and (2) special approaches for use in locations and/or populations within the hospitals when infections are not controlled by use of basic practices. Recommendations that might ordinarily be included in a guideline with a C-level strength of recommendation were excluded from these sections of the compendium and are discussed in the "unresolved issues" sections; this was done to help hospitals to focus their implementation efforts on the most strongly recommended prevention practices. Hospitals can prioritize their efforts by initially focusing on implementation of the prevention approaches listed as basic practices rec-
ommended for all acute care hospitals. If HAI surveillance or other risk assessments suggest that there is ongoing transmission despite implementation of basic practices, hospitals should then consider adopting some or all of the prevention approaches listed under the "special approaches" section of each document. These can be implemented within specific locations or patient populations or can be implemented hospitalwide, depending on outcome data, risk assessment, and/ or local requirements. Most of the special approaches listed in these documents are supported by studies based on the control of HAI outbreaks and require additional personnel and financial resources for implementation. methods Panel Composition SHEA and the IDSA Standards and Practice Guidelines Committee convened experts in the prevention and monitoring of HAIs. The HAI Allied Task Force members are listed at the end of the text of this summary. Literature Review and Analysis For this compendium, the HAI Allied Task Force reviewed previously published guidelines and recommendations relevant to each section and performed computerized literature searches using PubMed. Searches of the English-language literature focused on human studies published after existing guidelines through 2007, using the subject headings listed in Table 2. Process Overview In evaluating the evidence regarding the prevention and monitoring of HAIs, the HAI Allied Task Force followed a process used in the development of other IDSA guidelines, including a systematic weighting of the quality of the evidence and the grade of recommendation (Table 1). Consensus Development The HAI Allied Task Force met on 17 occasions via teleconference to complete the compendium. The purpose of the
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teleconferences was to discuss the questions to be addressed, make writing assignments, and discuss recommendations. All members of the HAI Allied Task Force participated in the preparation and review of the draft documents. The compendium was then submitted to a subgroup of the HAI Allied Task Force with implementation expertise that, through a series of additional teleconferences and communications, performed extensive editing and reformatting to create implementation-focused text. Review and Approval Process A critical stage in the development process is peer review. peer reviewers are relied on for expert, critical, and unbiased scientific appraisals of the documents. The SHEA/IDSA employed a process used for all SHEA/IDSA guidelines that includes a multilevel review and approval. Comments were obtained from several outside reviewers who complied with the SHEA/IDSA policy on conflict of interest disclosure. In addition, 8 stakeholder organizations provided comments on the document. Finally, the guideline was reviewed and approved by the IDSA Standards and Practice Guidelines Committee and the Board of Directors of the SHEA and the IDSA prior to dissemination. Disclosure of Conflicts of Interest All members of the HAI Allied Task Force and the external peer reviewers complied with the IDSA policy on conflicts of interest, which requires disclosure of any financial or other interest within the past 2 years that might be construed as constituting an actual, potential, or apparent conflict. Members of the HAI Allied Task Force and the external reviewers were provided with the IDSA conflicts of interest disclosure statement and were asked to identify ties to companies developing products that might be affected by promulgation of the compendium. Information was requested regarding employment, consultancies, stock ownership, honoraria, research funding, expert testimony, and membership on company advisory committees. The task force made decisions on a case-by-case basis as to whether an individual's role should be limited as a result of a conflict. Potential conflicts are listed in the Acknowledgments. Mechanism for Updating the Compendium At annual intervals, SHEA, the Association for Professionals in Infection Control and Epidemiology, the IDSA Standards and Practice Guidelines Committee liaison advisor, and the chair of the Standards and Practice Guidelines Committee will determine the need for revisions to the compendium on the basis of an examination of current literature. If necessary, the entire task force will be reconvened to discuss potential changes. When appropriate, the panel will recommend revision of the compendium to SHEA, Association for Professionals in Infection Control and Epidemiology, the IDSA
Standards and Practice Guidelines Committee, and the boards of directors of these organizations for review and approval. members of the healthcareassociated infections task force David Classen, MD, MS; Infectious Diseases Society of America Co-Chair (University of Utah, Salt Lake City, UT) Deborah S. Yokoe, MD, MPH; Society for Healthcare Epidemiology of America Co-Chair (Brigham & Women's Hospital and Harvard Medical School, Boston, MA) Deverick J. Anderson, MD, MPH; Section Leader, Surgical Site Infection (Duke University Medical Center, Durham, NC) Kathleen M. Arias, MS, CIC; Association for Professionals in Infection Control and Epidemiology liaison, Implementation Subgroup (Association for Professionals in Infection Control and Epidemiology, Washington, DC) Helen Burstin, MD; National Quality Forum liaison (National Quality Forum, Washington, DC) David P. Calfee, MD, MS; Section Leader, Methicillin-Resistant S. aureus (Mount Sinai School of Medicine, New York, NY) Susan E. Coffin, MD, MPH; Section Leader, VentilatorAssociated Pneumonia (Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, PA) Erik R. Dubberke, MD; Section Leader, C. difficile­Associated Disease (Washington University School of Medicine, St. Louis, MO) Victoria Fraser, MD; Society for Healthcare Epidemiology of America President (Washington University School of Medicine, St. Louis, MO) Dale N. Gerding, MD; Section Leader, C. difficile­Associated Disease (Hines Veterans Affairs Medical Center, Hines, IL, and Loyola University Chicago Stritch School of Medicine, Chicago, IL) Frances A. Griffin, RRT, MPA; Institute for Healthcare Improvement liaison (The Institute for Healthcare Improvement, Cambridge, MA) Peter Gross, MD (Hackensack University Medical Center, Hackensack, NJ and the University of Medicine and Dentistry of New Jersey­New Jersey Medical School, Newark, NJ) Keith S. Kaye, MD; Section Leader, Surgical Site Infection (Duke University Medical Center, Durham, NC) Michael Klompas, MD; Section Leader, Ventilator-Associated Pneumonia (Brigham & Women's Hospital and Harvard Medical School, Boston, MA) Evelyn Lo, MD; Section Leader, Catheter-Associated Urinary Tract Infection (University of Manitoba and St. Boniface General Hospital, Winnipeg, Manitoba, Canada) Jonas Marschall, MD; Section Leader, Catheter-Associated Bloodstream Infection (Washington University School of Medicine, St. Louis, MO) Leonard A. Mermel, DO, ScM; Section Leader, Catheter-
S20 infection control and hospital epidemiology october 2008, vol. 29, supplement 1
Associated Bloodstream Infection (Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, RI) Lindsay Nicolle, MD; Section Leader, Catheter-Associated Urinary Tract Infection (University of Manitoba and Health Sciences Center, Winnipeg, Manitoba, Canada) David A. Pegues, MD; Healthcare Infection Control Practices Advisory Committee liaison (David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA) Trish M. Perl, MD (Johns Hopkins Medical Institutions and University, Baltimore, MD) Kelly Podgorny, RN, MS, CPHQ; The Joint Commission liaison, Implementation Subgroup (The Joint Commission, Oakbrook Terrace, IL) Sanjay Saint, MD (Ann Arbor Veterans Affairs Medical Center and University of Michigan Medical School, Ann Arbor, MI) Cassandra D. Salgado, MD, MS; Section Leader, Methicillin-Resistant S. aureus (Medical University of South Carolina, Charleston, SC) Robert A. Weinstein, MD (Stroger [Cook County] Hospital and Rush University Medical Center, Chicago, IL) Robert Wise, MD; The Joint Commission liaison (The Joint Commission, Oakbrook Terrace, IL) acknowledgments We thank Edward Septimus, MD, Donald Goldmann, MD, Richard Platt, MD, the SHEA Pediatric Special Interest Committee, members of and liaisons to the Healthcare Infection Control Practices Advisory Committee, the Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, and Association for Professionals in Infection Control and Epidemiology boards of directors, and the many stakeholder organizations with infection prevention and control expertise who reviewed these documents for their very insightful comments and suggestions. We are also grateful to Jennifer Bright, Jennifer Padberg, Nancy Olins, and Annette Mucha for their organizational assistance and expertise. Financial support. Support for this compendium was provided by the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America. Potential conflicts of interest. D.S.Y. has received a research grant from Sage Products. L.A.M. has received research grants from and served as a consultant to 3M, Angiotech, and Cadence and is a consultant to Ash Access Technology. D.J.A. has received a research grant from Pfizer and has served on advisory councils for Schering-Plough and Pfizer. K.M.A. is the immediate past president of the Association for Professionals in Infection Control and Epidemiology and serves on its board of directors. H.B.'s participation does not represent official endorsement of the compendium by the National Quality Forum. D.P.C. is a member of the speakers' bureau for Enturia. S.E.C. has received a research grant from Merck. E.R.D. is a member of the speakers' bureaus for Elan, Enzon, Schering-Plough, Viropharma, Pfizer, and Astellas and serves on the advisory boards of Schering-Plough, Genzyme, and Salix. V.F. is the past president of the Society for Healthcare Epidemiology of America, has been a consultant to Steris, Verimetrix, and Merck, and is a member of the speakers' bureaus for Cubist and Merck. P.G. has received a research grant from Becton, Dickinson and Company (BD); has been on the
speakers' bureau for Ortho-McNeil; and served on the Zostervax advisory board of Merck. K.S.K has received research grants from Pfizer, Merck, and Cubist; is a member of the speakers' bureaus for Pfizer, Merck, Cubist, Schering-Plough, and Wyeth; and serves on the advisory board for ScheringPlough. J.M. has received a research grant from the Swiss National Science Foundation. T.M.P. is a past president of the Society for Healthcare Epidemiology of America; is on the advisory board or the speakers' bureau for Theradoc, 3M, Replydine, and Ortho-McNeil; and has received honoraria from VHA and the Institute for Healthcare Improvement. S.S. has received an honorarium from VHA. C.D.S. is a member of the speakers' bureau for Pfizer. R.A.W. has received research grants from Sage Products and the Centers for Disease Control and Prevention and has been a consultant on Tolevamer for Genzyme and a consultant to the Centers for Disease Control and Prevention. D.C. is co-chair of the National Quality Forum Patient Safety Taxonomy Committee and an employee of CSC, a healthcare technology consulting company, and has ownership in Theradoc, a medical software company. All other authors report no relevant conflicts of interest. Address reprint requests to the Reprints Coordinator, University of Chicago Press, 1427 E. 60th St., Chicago, IL 60637 ([email protected]) or contact the journal office ([email protected]). references 1. Klevens RM, Morrison MA, Nadle J, et al. Invasive methicillin-resistant Staphylococcus aureus infections in the United States. JAMA 2007; 298: 1763-1771. 2. McDonald LC, Killgore GE, Thompson A, et al. An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med 2005; 353:24332441. 3. Canadian Task Force on the Periodic Health Examination. The periodic health examination. Can Med Assoc J 1979; 121:1193-1254. 4. Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health careassociated infections and deaths in U.S. hospitals, 2002. Public Health Rep 2007; 122:160-166. 5. Public health focus: surveillance, prevention, and control of nosocomial infections. MMWR Morb Mortal Wkly Rep 1992; 41:783-787. 6. Stone PW, Braccia D, Larson E. Systematic review of economic analyses of health care-associated infections. Am J Infect Control 2005; 33:501509. 7. Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health-care­associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004; 53(RR-3):1-36. 8. O'Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002; 51(RR-10):1-29. 9. Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med 2000; 132:391-402. 10. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1999; 20: 250-278; quiz 279-280. 11. Gerding DN, Johnson S, Peterson LR, Mulligan ME, Silva J Jr. Clostridium difficile-associated diarrhea and colitis. Infect Control Hosp Epidemiol 1995; 16:459-477. 12. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Committee THICPA. Management of multidrug-resistant organisms in healthcare settings 2006. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/ar/ MDROGuideline2006.pdf. Accessed July 10, 2008. 13. Wong ES, Hooton T. Guideline for prevention of catheter-associated
compendium of strategies to prevent hais S21
urinary tract infections. Available at: http://www.cdc.gov/ncidod/dhqp/ gl_catheter_assoc.html. Accessed July 25, 2007. 14. Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep 2002; 51(RR-16):1-45, quiz CE41-CE44.
15. Mermel L. Correction: catheter-related bloodstream infections. Ann Intern Med 2000; 133:395. 16. Goldmann D. System failure versus personal accountability--the case for clean hands. N Engl J Med 2006; 355:121-123. 17. Jarvis WR. The Lowbury Lecture. The United States approach to strategies in the battle against healthcare-associated infections, 2006: transitioning from benchmarking to zero tolerance and clinician accountability. J Hosp Infect 2007; 65(Suppl 2):3-9.
S1 infection control and hospital epidemiology october 2008, vol. 29, supplement 1 supplement article: editorial Primum Non Nocere Nalini Singh, MD, MPH; Patrick J. Brennan, MD; Michael Bell, MD
"First, do no harm." The edict reminds physicians that they must consider the possible harm that might be caused by any intervention. Since as early as 1860, this phrase among physicians has been an expression of hope, intention, humility, and recognition that acts with good intentions may have unwanted consequences. The vast majority of patients who have access to medical services today are healed. There are some, however, who suffer unintended consequences of care, such as healthcare-associated infections (HAIs). Since the 1860s, when Joseph Lister, a pioneer of infection control, developed antisepsis to prevent wound infections, health care has become increasingly complex and sophisticated, presenting opportunities to save the lives of patients who would not have survived 3 decades ago--for example, very-low-birth-weight infants and critically ill adults in highly specialized intensive care units. To ensure that such life-saving care does not result in HAI, modern health care has developed an extensive system for infection prevention. Indeed, as we rely increasingly on cost-efficient ambulatory delivery of surgical procedures, endoscopy, infusion care, and other invasive procedures, we must now address the need for appropriate oversight and maintenance of infection prevention practices in these new settings, as well. Likewise, attention to infection prevention for populations that have not been the focus of traditional infection control research--for example, pediatric and behavioral medicine patients--is increasingly needed. Prevention of HAI is at the heart of patient safety. This issue is receiving welcome attention at regional and national levels and from consumers, payers, legislators, and the media, in addition to experts in the field. The Society for Healthcare Epidemiology of America/Infectious Diseases Society of America "Compendium of Strategies to Prevent HealthcareAssociated Infections in Acute Care Hospitals," published in this supplement to Infection Control and Hospital Epidemiology, is a means of giving healthcare professionals access to prevention recommendations in a succinct format, promoting the application of current recommendations to clinical practice. Success stories, including the prevention of central line­ associated bloodstream infections and the use of antimicro-
bial prophylaxis to prevent selected surgical site infections, have demonstrated that prevention of HAI is possible and can be sustained by use of "best practices" and bundled approaches to intervention, which are quality improvement efforts that benefit from the inclusion of both outcome measures, such as rates of bloodstream infection or surgical site infection, and process measures, such as rates of adherence to recommended practices. Some facilities have implemented a top-down strategy that assigns accountability for implementation to the facilities' chief executives and senior managers. Others have applied "positive deviance" programs in a bottom-up approach that engages frontline staff, including environmental services and transport personnel, in addition to clinical staff, to shift cultural norms. Regardless of the approaches taken, healthcare facilities must strive for 100% adherence to recommended infection control practices. Challenges to prevention include measurement of outcomes that may be complicated by diagnostic limitations-- for example, diagnosis of ventilator-associated pneumonia. In contrast to the diagnosis of central line­associated bloodstream infection, diagnosis of ventilator-associated pneumonia is less objective and frequently relies on clinical judgment. In addition to the complexity of combining clinical criteria, laboratory evidence, and radiographic evidence, underlying lung and cardiac disease in premature infants and in adults receiving intensive care further complicates the diagnosis of ventilator-associated pneumonia. Nevertheless, processes are implemented to reduce the incidence of ventilator-associated pneumonia in critical care settings, and adherence to those processes can and should be measured, despite the diagnostic challenges. The microbial ecology of colonization might not be entirely within our control; however, interventions for the prevention of transmission can be implemented. Administrative strategies, such as standing orders or nurse-driven protocols for patient testing, admittancebased alert systems to notify infection control and clinical personnel about readmitted or transferred patients with a history of infection or colonization, and routine assessment of education and training among healthcare personnel, can improve infection prevention at the facility level. New chal-
From the Children's National Medical Center, Division of Infectious Diseases, and Department of Pediatrics, George Washington University, Washington, DC (N.S.); the University of Pennsylvania, Philadelphia (P.J.B.); and the Centers for Disease Control and Prevention, Atlanta, Georgia (M.B.). Infect Control Hosp Epidemiol 2008; 29:S1-S2 2008 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2008/2910S1-0001$15.00. DOI: 10.1086/591865
S2 infection control and hospital epidemiology october 2008, vol. 29, supplement 1
lenges, such as community-associated methicillin-resistant Staphylococcus aureus soft tissue infections among adults and late-onset disease in neonates, continue to test the boundaries of infection prevention and healthcare epidemiology and will drive the need for ongoing tailoring of prevention recommendations to protect new locations and populations. Since the early 1990s, infection prevention guidelines have been prepared by the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee. The main challenge to prevention has been not a lack of guidelines but, rather, a dearth of methods for efficient and consistent implementation of recommended practices. Guidelines are produced to guide practices; however, guidelines also drive policies and mandates. It is, therefore, essential that the guideline development process be rigorous and transparent. Infection prevention recommendations are generally supported by high-quality evidence; however, some may rely on indirect evidence. The latter is particularly true for recommendations related to implementation strategies, which, nevertheless, are essential components of infection prevention. In either case, there must be careful evaluation of the relevance and quality of supporting evidence. Therefore, to ensure that recommendations are evaluated as consistently as possible, Centers for Disease Control and Prevention guidelines are produced by means of extensive systematic assessment of the quality and weight of evidence to support each recommendation while also allowing public scrutiny and comment. The Society for Healthcare Epidemiology of America/Infectious Diseases Society of America compendium has the advantage of being based on a more
nimble approach that relies on the judgment of individual reviewers, which allows rapid production and efficient consensus. Although there is potential for variability among reviewers in their assessment of recommendation strength or evidence quality, this compendium represents an important tool that facilitates implementation of practices and procedures to prevent HAI, complementing official Centers for Disease Control and Prevention guidelines. The Society for Healthcare Epidemiology of America/Infectious Diseases Society of America compendium includes metrics and indicators of success that can be applied to implementation and also includes assignment of accountability for facilities to ensure that implementation occurs. In addition, the compendium delivers updated guidance in areas where official guidelines have revisions pending (e.g., surgical site infection prevention and urinary tract infection prevention guidelines currently in preparation). The compendium published here is a concise, easily applied distillation of current guidelines for the prevention of HAI that brings together recommendations from respected sources in a format suited to implementation in the clinical setting. As the Centers for Disease Control and Prevention continues to produce official guidelines in collaboration with professional societies and academic partners, implementation tools such as this compendium will serve as a means to ensure that the best practices for infection prevention are successfully brought to the bedside. Its publication could not be better timed to make the most of current heightened interest in safe health care. Address reprint requests to the Reprints Coordinator, University of Chicago Press, 1427 E. 60th St., Chicago, IL 60637 ([email protected]) or contact the journal office ([email protected]).

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