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ICU Infection Prevention Practices Lax

 |  By cclark@healthleadersmedia.com  
   January 30, 2014

Better adherence and development of infection control protocols in intensive care units would significantly reduce hospital-acquired infections, which result in $33 billion in additional costs to the healthcare system each year, researchers say.

While most hospital intensive care units now have infection control policies to prevent central line-associated bloodstream (CLABSI) and ventilator- associated pneumonia (VAP) infections, many clinicians do not adhere to those policies at the bedside, says a report from Columbia University and the CDC.

What's more, for four measures linked to catheter-associated urinary tract infection (CAUTI) prevention, roughly one-third of hospitals had no policy for one of the measures and half or more of the hospitals had no policy for the other three. Observance of those policies for those hospitals that had one was even lower.

"It's a pitiful state of affairs when the most common hospital-acquired infection, CAUTI, only 184 hospitals, or only 27% of these ICUs, reported adherence to using a simple urinary reminder or stop order," says Patricia Stone, director of the Center for Health Policy at  Columbia University School of Nursing, New York, NY, and the lead author of the report.

Better adherence and development of infection control protocols would reduce hospital-acquired infections, which the report estimates result in $33 billion in additional costs to the healthcare system each year.

What's more, hospitals with higher-than-expected CAUTI and CLABSI rates will receive lower payments from Medicare under value-based purchasing provisions in the Patient Protection and Affordable Care Act now in effect.

The report, published in the February edition of the American Journal of Infection Control, is described as the largest study of its kind. It examined data spanning up to six years from 1,653 ICUs within 975 hospitals that participate in the Centers for Disease Control's National Healthcare Safety Network reporting program.

Bedside practices were observed by third-party hospital personnel, hospital infection preventionists, and so-called observers who witness procedures much like "secret shoppers," Stone says.

The key take-aways are found in two tables in the paper that show hospital personnel compliance with 16 evidence-based practices proven to prevent hospital-acquired infections, six for CLABSI, six for VAP and four for CAUTI.

For example, for CLABSI, 92% of ICUs had a policy for an insertion checklist, but only 52% of the healthcare professionals were seen to adhere to that policy. For hand hygiene, 94% had a policy, but only 62% were observed to adhere to it.

For VAP, the percentages of ICUs that had policies as well as adherence to those practices were lower. While 74% of ICUs had a ventilator bundle checklist, only 52% of those treating patients were seen to adhere to that checklist. 

For the policy of raising the head of a patient's bed 45 degrees, 91% had such a policy, but only 49% of caregivers adhered to it.

And for CAUTI prevention, 27% of ICUs had a policy for a nurse-assisted catheter insertion, but only 22% were seen to observe that practice.

The report also found that on average, the number of infection preventionists per 100 ICU beds was 1.2, which is higher than the current guideline of 1 per 250 beds, developed in 1985, and a survey a decade ago which recommended .8 per 100 beds.

Stone says, however, that the ratio is not optimal because the guidelines are out of date, because the cost of HAIs has risen, and because proven strategies can reduce infections when clinicians adhere to them.

Another finding from the study was that the number of infection preventionists and hospital epidemiologists who have appropriate certification "varied across institutions."

For example, only 49.6% of the hospitals had a physician hospital epidemiologist, and 38.4% had no personnel who were certified in infection prevention and control, a training program that Stone says is associated with lower rates of hospital-acquired infections.

Stone says that her team strongly believes that professional organizations or The Joint Commission should come up with stronger guidelines or accreditation requirements for hospital ICU physician epidemiologists and infection preventionists with appropriate certification.

"There never has been an exact staffing ratio," Stone says, "although we know that economies of scale do exist. A hospital with 1,000 ICU beds may not need as many.  It would be nice if APIC and SHEA (the Association for Professionals in Infection Control and Epidemiology and the Society for Healthcare Epidemiology of America) would come out and say that the guidelines should be above this."

Asked what hospitals and policymakers should do now, Stone replies, "we have to get better guidelines. And we need to get more professional certification. And we need to improve practice at the bedside, and the way we improve practice at the bedside is to have more certified infection preventionists and better guidelines that can help, because we have to get these hospital-acquired infection rates down.

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