Hospital-acquired infections (HAIs) are associated with high morbidity and mortality, as well as high costs. The most common device-associated infections encountered by hospitalists are catheter-associated urinary tract infections (CAUTI) and central line associated blood stream infections (CLABSI).
Ventilator-associated pneumonia (VAP) and surgical site infections (SSI) are device-associated infections that are less often encountered by hospitalists. Of all device-associated infections encountered by hospitalists, CAUTI are the most common (approximately 450,000 infections annually with a 2.5% mortality rate) and CLABSI account for the most deaths (approximately 100,000 infections annually with 12.5% mortality rate).
Recent estimates suggest that the incremental cost to a hospital of a patient acquiring a CLABSI is up to $30,000 per infection, totalling up to $2.5 billion in costs annually. The incremental hospital cost of a CAUTI is up to a $1000 per infection, totalling up to $500 million annually. Given the high costs resulting from these infections, the Centers for Medicare and Medicaid Services (CMS) instituted a policy in October 2008 of no additional reimbursements for healthcare-associated conditions (HACs) that are "reasonably preventable." This includes CAUTI and CLABSIs.
In addition, many states have mandated the public reporting of these infections. The challenge for hospitalists is to identify device-associated infections on admission, and prevent device-associated infections from occurring in the hospital.
II. Identify the Goal Behavior
When it comes to HAIs, the old adage "prevention is the best medicine" is of the utmost importance. For hospitalists, the most preventable HAIs are CAUTIs and CLABSIs, so we will focus on these below. It is also critical to be able to identify these HAIs when they occur, so we will define these HAIs per the National Healthcare Safety Network (NHSN) of the Centers for Disease Control and Prevention (CDC).
III. Describe a Step-by-Step approach/method to this problem.
CAUTIs are defined as presence of a foley catheter within the last 48 hours and:
At least one sign or symptom of UTI (e.g. fever, suprapubic pain or tenderness to palpation, or costovertebral angle tenderness to palpation) AND a urine culture with greater than 100,000 colony forming units per milliliter (CFU/cc) of two or fewer pathogenic bacteria (e.g. ecoli, enterococcus, pseudomonas, klebsiella).
At least one sign or symptom of UTI AND a urine culture with between 100 and 100,000 CFU/cc of two or fewer pathogenic bacteria AND a "positive" urinalysis (e.g. "positive" leukocyte esterase or nitrite, OR pyuria, OR an organism on gram strain).
To prevent CAUTIs:
1) Ensure that foley catheters are being used only when indicated, and leave in place only as long as needed. Commonly accepted indications for use include:
Acute urinary retention or obstruction,
accurate measurement of urine output in the critically ill,
to assist in healing of open sacral or perineal wounds in those with incontinence,
patients requiring prolonged immobilization,
comfort at the end of life, and
peri-operative use, especially for surgeries of the genitourinary tract, those requiring decompression of the bladder, surgeries of prolonged duration or with anticipated large volume infusions or diuretic use, and for those surgeries requiring close monitoring of intake and output.
Catheters should NOT be used:
As part of nursing care for the incontinent,
to obtain samples for urinalysis or cultures in those who can provide clean-catch samples on their own, and
for prolonged duration without indication in the post-operative setting. For catheters inserted peri-operatively, they should be removed as soon as possible post-operatively, preferably within 24 hours unless there are other appropriate indications for use.
) Ensure that foley catheters are inserted by properly trained personnel using aseptic technique and sterile equipment. Properly trained personnel usually means nurses who have formal training and regular refreshers in catheter insertion. Medical students, residents, fellows and attendings should NOT be inserting catheters unless they have undergone formal training and have regular refreshers. Such training can frequently be accomplished in simulation centers.
Ensure that foley catheters are properly maintained. This includes keeping the catheter system "closed" (i.e. don't remove the bag from the catheter, and replace the entire system if a "break" in the closed system occurs), maintaining unobstructed urine flow (i.e. keep the catheter from kinking, keep the bag below the bladder and off of the floor, and empty the bag at regular intervals), performing routine daily hygiene in patients with catheters.
Other critical recommendations include:
Use alternatives to foley catheters when appropriate (e.g. condom catheters in cooperative men without urinary retention or obstruction),
do not routinely use antibiotics or silver alloy coated or antibiotic impregnated catheters to prevent CAUTI, and
do not perform routine screening of catheterized patients for asymptomatic bacteriuria.
CLABSIs are defined as presence of a central line and:
A recognized pathogen (e.g. Staphylococcus aureus, enterococcus, gram negative rods) isolated from greater than or equal to one blood culture AND no other known source of infection.
Clinical manifestations (e.g. fever, chills, hypotension) AND a recognized skin contaminant (e.g. coagulase negative staph) isolated from greater than or equal to two blood cultures drawn on separate occassions AND no other known source of infection.
To prevent CLABSIs, the bundle of five items below was examined and found to be effective in a large study of ICUs in Michigan:
Use maximum sterile barrier precautions when inserting central lines (e.g. sterile gown, gloves)
Even in the context of maximum sterile barrier precautions and glove use, perform hand hygiene before and after inserting or manipulating catheters
Prep the catheter site with chlorhexidine
Avoid the femoral site whenever possible
Remove unnecessary catheters as soon as possible
Additional measures used in the above study included:
Use of a central line cart containing all of the essential supplies
Use of a checklist
Stoppage of central line insertion by any of the team members if checklist was not followed
Prompt central line removal during rounds
Feedback about CLABSI rates
Buy-in from CEO that chlorhexidine be stocked in the hospital
Other interventions to decrease the risk of CLABSIs include:
Use of IV teams to insert central lines
Use of bedside ultrasound to insert central lines
Routinely changing transparent dressings at least every 7 days, gauze dressings at least every 2 days, or using chlorhexidine sponge dressings when CLABSI rates are high
As soon as possible, remove or replace central lines placed in urgent or emergent situations
Avoiding manipulation of central lines
Using lines with as few lumens as possible
Placing peripheral lines instead of central lines when possible
Using ports or tunnelled central lines as opposed to non-tunnelled central lines in those requiring central lines for long durations (e.g. chemotherapy or temporary hemodialysis access)
Avoiding the insertion of catheters close to wounds
Bathing catheterized patients with chlorhexidine washes
Using antibiotic or antimicrobial impregnated or coated lines when CLABSI rates are high (e.g. minocycline, rifampin, chlorhexidine, silver)
IV. Common Pitfalls.
In the area of CAUTI prevention, remove catheters ASAP, do not perform routine screening of catheterized patients for asymptomatic bacteriuria, and do not use routine antibiotic prophylaxis to prevent CAUTI.
In the area of CLABSI prevention, remove central lines ASAP (e.g. don't wait until the end of rounds to remove a line if the team decides during the beginning of rounds to remove a line), and avoid manipulation of lines.
V. National Standards, Core Indicators and Quality Measures.
The federal government's "Partnership for Patients" has identified nine core areas of focus. Four of those areas are HAIs: 1) CAUTI, 2) CLABSI, 3) SSI and 4) VAP. In addition, the Joint Commission includes prevention of HAIs in its 2011 National Patient Safety Goals (NPSG):
NPSG.07.04.01 recommends using "proven guidelines to prevent infection of the blood from central lines."
NPSG.07.05.01 recommends using "proven guidelines to prevent infections after surgery."
Moreover, the new NPSG.07.06.01 recommends implementing "evidence-based practices to prevent indwelling catheter-associated urinary tract infections."
What's the evidence?
Umscheid, CA, Mitchell, MD, Doshi, JA, Agarwal, R, Williams, K, Brennan, PJ. "Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs". Infect Control Hosp Epidemiol. vol. 32. 2011. pp. 101-14.
Klevens, RM, Edwards, JR, Richards, CL Jr. "Estimating healthcare-associated infections and deaths in US hospitals, 2002". Public Health Rep. vol. 122. 2007. pp. 160-6.
Ranji, SR, Shetty, K, Posley, KA. "Volume 6 - prevention of healthcare-associated infections.". Agency for Healthcare Research and Quality. 2007.
Scott, RD. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention.. 2011. http://www.cdc.gov/ncidod/dhqp/pdf/scott_costpaper.pdf.
Pronovost, PJ, Goeschel, CA, Wachter, RM. "The wisdom and justice of not paying for "preventable complications."". JAMA. vol. 299. 2008. pp. 2782-4.
Gould, CV, Umscheid, CA, Agarwal, RK, Kuntz, G, Pegues, DA. "the Healthcare Infection Control Practices Advisory Committee: Guideline for the Prevention of Catheter-Associated Urinary Tract Infections, 2009.". 2011. http://www.cdc.gov/hicpac/cauti/001_cauti.html.
O'Grady, NP, Alexander, M, Burns, LA. 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections.. 2011. http://www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html.
Pronovost, PJ. "An intervention to decrease catheter-related blood stream infections in the ICU". NEJM. vol. 355. 2006. pp. 2725-32.
Dixon-Woods, M, Bosk, CL, Aveling, EL, Goeschel, CA, Pronovost, PJ. "Explaining Michigan: Developing an ex post theory of a quality improvement program". Milbank Quaterly. vol. 89. 2011. pp. 167-205.
National Patient Safety Goals.. 2011. http://www.jointcommission.org/standards_information/npsgs.aspx.
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