Facing the Threat – The Journal of Healthcare Contracting

Infection prevention will take a committed effort from providers across the care continuum

At any given time, about one in 25 inpatients has an infection related to hospital care, according to federal government figures. In nursing homes, an estimated 1 to 3 million serious healthcare-associated infections (HAIs) occur every year resulting in hospitalizations and associated mortality and morbidity.

HAIs are, of course bad medicine. They are also bad business – for inpatient and post-acute-care providers. That’s because value-based purchasing, readmission penalties and bundled payment programs reward providers for delivering cost-effective, high-quality care – but penalize them for failing to prevent infection.

In response, infection prevention professionals are working with caregivers, patients and families across the care continuum to minimize the chances of infection prior to, during or after an inpatient stay or surgical procedure – or wherever care is provided, independent of a hospital stay.

‘Absolutely makes sense’
“It absolutely makes sense to manage infection prevention across the care continuum and at all points or transitions of care,” says Gina Pugliese, RN, MS, FSHEA, vice president emeritus, Premier Safety Institute®, Premier Inc. “However, this has made sense for a long time – ever since the movement from a fee-for-service to a value-based payment system began.”

A surge in the number of ambulatory surgery centers – which continue to provide more complex and invasive procedures – has expanded the populations most at risk for HAIs, she adds. (The Medicare Payment Advisory Commission reported this spring that nearly 5,500 ambulatory surgery centers treated 3.4 million Medicare beneficiaries in 2015.)

“We are seeing more attention given to HAIs through care coordination and prevention efforts among patients in different settings with the emergence and expansion of value-based care models, such as accountable care organizations, bundled payment models and patient-centered medical homes,” says Pugliese.

Even so, gaps persist in infection prevention, she says. “In particular is the need for interoperability between various data streams. This includes the ability to track a patient across all the care centers, including specific details like the development of surgical-site infection, or colonization or infection with serious threats such as Clostridium difficile, or drug-resistant organisms like Carbapenem-resistant Enterobacteriaceae (CRE).”

Amna Handley, MSN, FNP-C, APRN, CIC, director of clinical development at Georgia-Pacific Professional, says that “pay-for-performance, quality patient outcomes, and increasing public awareness, are key drivers for healthcare systems to focus on infection prevention across the continuum of care.” GP PRO is a manufacturer of hand hygiene and skin care systems.

“With shorter acute inpatient length-of-stays, patients are transitioned to alternate levels of care for extended stays to allow for healing, rehabilitation, and recovery,” she says. “If patients develop exacerbations of illness or complications, such as infections, they are transferred back to the acute care setting, which results in costly admissions. Healthcare-acquired infections cause increases in morbidity and mortality, and therefore impact the bottom line in healthcare systems.

“While the role of the infection control practitioner has always been focused on surveillance, prevention, and controlling the spread of infections, it hasn’t always been viewed as a top organizational priority by system level executives,” continues Handley. But that is changing.

“There is movement amongst healthcare system executives to better understand infection prevention and allocate the resources that are needed to have successful programs that are organizational priorities. This movement spans the continuum of care.”

Progress
Infection preventionists have always taken a population-health view of care delivery, says Pugliese. “This reflects training in public health, which really is somewhat synonymous with population health, as there’s an emphasis on preventing infection no matter what the setting.”

The good news is, healthcare professionals and health system leaders are more engaged than ever in the effort to prevent healthcare-acquired infections, she adds.

Pugliese points to a nationwide effort among professional organizations to address research, tracking and prevention efforts for HAIs across the continuum. Those organizations include the Association for Professionals in Infection Control and Epidemiology (APIC), Society for Healthcare Epidemiology of America (SHEA), Infectious Diseases Society of America (IDSA), as well as federal and state governmental agencies, including the Centers for Disease Control and Prevention and state departments of health, which work closely with state hospital associations, CMS-funded networks and hospital networks.

This collaboration has advanced the industry’s ability to track infections between healthcare facilities, and also to focus on HAI prevention using CDC’s National Healthcare Safety Network (NHSN) data and CDC tools and evidence-based guidelines, says Pugliese.

“One such effort is the CMS Partnership for Patients program, which unites hospitals through Hospital Improvement Innovation Networks (HIINs) to collaboratively prevent harm,” she says. “With more than 460 hospitals, Premier’s HIIN has been working to achieve a 20 percent decrease in overall patient harm by 2019. It’s a significant effort that requires training, transparency, education and awareness.”

Another collaborative effort to prevent HAIs and other harmful events is Premier’s QUEST 2020 collaborative, for which hospitals have created specialized networks to target specific areas to improve infection prevention, she adds. “Approximately 350 of these hospitals have been working together for nearly a decade to improve quality and safety, and have saved nearly 200,000 lives in the process.”

Many other prevention programs are up and running, says Pugliese. For example:

The CDC supports HAI and antimicrobial resistance programs in every state.
NHSN data is now used by more than 19,000 healthcare facilities to track healthcare-acquired infections and antimicrobial resistance, as well as by states for public reporting, by CMS for quality reporting, and by the U.S. Department of Health and Human Services to measure national progress and track national goals.
Among the new tools being used by infection prevention professionals in all settings and public health departments is the CDC’s Antibiotic Resistance Safety Atlas, a new web app with interactive data to assess drug-resistant threats in local areas and moving between healthcare facilities to help guide HAI prevention efforts.

Transitions of care
Every healthcare setting presents its own set of infection-prevention-related challenges. But the risk of spreading infection or neglecting to treat it increases as patients are transferred from one facility or setting to another, according to experts.

“There are numerous infection-prevention-related issues that must be addressed with the transition of patient care from one setting to the next,” says Handley. “For example, upon discharge from the hospital, it is imperative to communicate if the patient is colonized or infected with drug-resistant organisms. It is important to notify the receiving facility so they can implement necessary precautions – private room, contact precautions, cohort with similar patient – to prevent the transmission and spread of these organisms.

“Communicating the need for continuation of antimicrobial therapy is another important factor,” she continues. “If antibiotics are not taken for the full course, the patient may suffer a relapse of the infection and/or develop drug resistance.

“Making sure the receiving facility has the skill to use aseptic technique when managing central lines, foley catheters, ventilators, etc., is also very important, as breaches in infection control techniques can increase the patient’s risk of infection, ending up in costly, avoidable re-hospitalizations. Effective communication between the transferring facility and receiving facility is critical for safe transition of care.”

Antimicrobial stewardship
Pugliese points out that a key challenge of HAI prevention during transitions of care is the serious threat of Clostridium difficile, which causes close to a half a million illnesses a year, kills approximately 29,000 patients within 30 days of their initial diagnosis, and reoccurs in one of every five patients that were previously diagnosed.

“C. difficile has emerged as a significant threat because it is more aggressive and severe, with a high mortality rate due to the emergence of a new strain that produces more toxins and is resistant to a commonly used class of antibiotics known as fluororquinolones,” she says. “This makes C. difficile a priority for prevention and control across the continuum.”

The CDC says that two-thirds of C. difficile cases in the U.S. are related to a recent inpatient stay in a healthcare facility, and patients with C. difficile in the community report a recent visit to a doctor or dentist, says Pugliese. “Even dentists can contribute to antimicrobial resistance,” she says, adding that the CDC recently reported that 10 percent of all antibiotic prescriptions are from dentists.

“It has been proven that the overuse of antibiotics has contributed to this problem and that antimicrobial stewardship is critical in all settings where care is provided,” says Pugliese. “Providers must monitor antimicrobial use in each setting and report on antibiotic use during transitions of care.”

“C. difficile can be prevented through effective communication about patients who may still be colonized or infected at every transition of care, including transfers between units in acute care, or transfers to other facilities, including long-term care and home care,” says Pugliese. “This communication has included the development of protocols on the proper protective apparel (gloves, gown) to wear, importance of hand hygiene, and environmental cleaning with EPA-approved agents and bleach solution of proper dilution.”

Business as usual?
HAI prevention across the continuum is moving toward “business as usual,” says Pugliese. This is especially true for the leading hospitals in Premier’s QUEST 2020 collaborative and HIIN, which are taking steps to collaborate and share data in order to accelerate performance improvement in this area, she adds.

Says Handley, “Healthcare communities in today’s world encompass the entire continuum of care. Infection prevention is paramount in each setting for optimal patient outcomes.

“Consumers are becoming increasingly aware of the importance of hand hygiene, environmental cleanliness, and the cost of their healthcare,” she continues. “By the year 2030, it is predicted that one in five Americans will be over the age of 65. As the population of individuals over the age of 65 continues to grow daily, the demand for healthcare services continues to increase and serves as an opportunity for creating well-designed infrastructures, clinical workflow practices, and innovative solutions that support infection prevention.

“A collaborative effort between the infection prevention department and system level executives is paramount to determining adequate allocation of resources to accomplish improved processes and patient outcomes. Transformational leadership, innovation, and knowledge of evidence-based best practices are skills that will be required to drive changes that impact patient outcomes.

“It is important to recognize that there are innovative solutions that require both technical solutions and adoptive behavior strategies to sustain change over time.”

Editor’s note: For more information on healthcare-acquired infections, go to https://www.cdc.gov/hai/surveillance/. In addition, the CDC has provided the “Core Elements of Hospital Antimicrobial Stewardship Programs” (https://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html) to help providers reduce the risk of antimicrobial resistance and help improve the quality of care through better cure rates.

Hot spots in the care continuum

Every healthcare setting – inpatient and outpatient – presents its own set of infection-prevention-related challenges. Among the greatest are unsafe injection practices, says Gina Pugliese RN, MS, FSHEA, vice president emeritus, Premier Safety Institute®, Premier Inc. “Despite tremendous efforts by the Centers for Disease Control and Prevention and the Safe Injection Practices Coalition to educate providers and patients on the risks, outbreaks continue to cause harm to patients,” she says.

Some of the unsafe practices that have led to patient harm include:

Use of a single syringe to administer medication to more than one patient.
Reinsertion of a used needle into a medication vial and then reusing the vial for another patient.
Preparation of medications in close proximity to contaminated supplies or equipment.

“The lack of knowledge and oversight contributes to these risks in many small non-acute settings, like physician offices and even in non-traditional healthcare settings, like community health fairs,” she says.

Another oversight? Neglecting vaccinations. “Seasonal flu immunization is important for people of all ages,” says Pugliese. “It is important for patients and residents, and it is important for all hands-on healthcare workers. All settings that involve the very young or the elderly ought to make seasonal flu vaccination a priority for both patients and caregivers.”

Hand hygiene, environmental cleanliness, antimicrobial stewardship, and sharps safety are equally important in long-term care, home health care, and ambulatory care, says Amna Handley, MSN, FNP-C, APRN, CIC, director of clinical development at Georgia-Pacific Professional. “The Centers for Disease Control and Prevention and the Obama administration made antibiotic stewardship a national priority, as drug-resistant pathogens continue to emerge, making infections more difficult to treat. For example, the Centers for Medicare & Medicaid Services has passed new regulations requiring infection prevention officers in long-term-care settings with formalized training in infection prevention.

“There are approximately 5,500 hospitals in the U.S., compared to 15,000 long-term-care facilities, where approximately 4 million Medicare and Medicaid recipients are admitted annually, and approximately 1 to 3 million serious infections occur every year,” she says. “As a result, pay-for-performance, new infection control requirements, and antimicrobial stewardship programs are now also requirements in the long-term care industry.

“Challenges to implement such new requirements include high staff turnover, limited funding, and multiple competing priorities in healthcare.”

Adult day centers and the threat of infection

Infection prevention is – or should be – a major factor for families choosing an adult day center for a family member or friend, according to the Association for Professionals in Infection Control and Epidemiology.

Nearly 5,000 adult day service centers operate in the United States, reports the Centers for Disease Control and Prevention. Half of them provide skilled nursing, therapeutic, and social work services, and almost all of them provide transportation services to and from the center. Nearly 300,000 participants enroll in these centers daily.

Factors to consider when selecting an adult day center include:

Overall cleanliness and accessibility of the environment.
Observed appropriate handwashing compliance from caregivers, as well as accessibility to sinks and handwashing supplies for clientele. Do caregivers assist clientele with hand hygiene and encourage appropriate hand hygiene before and after meals and after toileting?
Bathroom and locker room cleanliness, including sanitizing surfaces after changing soiled clothing. Note the type of disinfectants used, the manner in which clients’ clothing is bagged, and whether clothing is kept separate from other clients’ personal belongings.
Observe personnel compliance with hand hygiene practice before food preparation.
General food preparation area and serving of meals. Consider compliance with food safety rules, including maintaining appropriate serving and storage for hot and cold food items.
In addition to standard childhood vaccines, what are the facility’s requirements for the flu, pneumonia, and shingles vaccine? The elderly are particularly susceptible to these diseases.
The facility’s requirement for tuberculosis screening.
Medication storage and accessibility.
Staff training requirements for first aid. How are clients protected from the blood and /or body fluids of others? Are gloves and other forms of personal protective equipment accessible and available?
Procedure for how clients are kept safe and protected from illness and injury. Facility policy for clientele and personnel illness.
How are shared medical devices, such as stethoscopes and thermometers, cleaned between each client use?

Source: Association for Professionals in Infection Control and Epidemiology, http://www.apic.org/For-Consumers/Monthly-alerts-for-consumers/Article?id=preventing-infection-in-adult-day-centers

Fighting hospital-acquired conditions

The federal government has been after inpatient facilities to reduce the amount of hospital-acquired conditions (HACs) – including infection – for some time.

In July 2008, the Centers for Medicare & Medicaid Services included 10 categories of conditions for which Medicare would no longer pay providers. Since then, CMS has added new categories.

Among the 14 categories of HACs are several related to infection:

Catheter-associated urinary tract infection (UTI).
Vascular catheter-associated infection.
Surgical site infection, mediastinitis, following coronary artery bypass graft (CABG).
Surgical site infection following bariatric surgery for obesity (laparoscopic gastric bypass, gastroenterostomy, laparoscopic gastric restrictive surgery).
Surgical site infection following certain orthopedic procedures (spine, neck, shoulder, elbow).
Surgical site infection following cardiac implantable electronic device.

Other (non-infection-prevention-related) “never events” include:

Foreign object retained after surgery.
Air embolism.
Blood incompatibility.
Stage III and IV pressure ulcers.
Falls and trauma.
Manifestations of poor glycemic control (e.g., diabetic ketoacidosis, hypoglycemic coma, etc.).
Deep vein thrombosis (DVT)/pulmonary embolism following total knee replacement or hip replacement.
Iatrogenic pneumothorax with venous catheterization.

Source: Centers for Medicare & Medicaid Services, https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitalacqcond/hospital-acquired_conditions.html

Infection prevention and long-term care

Over 4 million Americans are admitted to or reside in nursing homes and skilled nursing facilities each year, and nearly 1 million persons reside in assisted living facilities. Data about infections in long-term-care facilities is limited, but it has been estimated in the medical literature that:

1 to 3 million serious infections occur every year in these facilities.
Infections include urinary tract infection, diarrheal diseases, antibiotic-resistant staph infections and many others.
Infections are a major cause of hospitalization and death; as many as 380,000 people die of the infections in long-term-care facilities every year.

Source: Centers for Disease Control and Prevention, https://www.cdc.gov/longtermcare/