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Top 10 Infection Control Challenges

 |  By cclark@healthleadersmedia.com  
   June 27, 2011

The spotlight is shining on infection control chiefs.  The burden is on them to identify weaknesses and danger zones within their hospitals, not only to  improve patient safety, but to thwart any financial penalties Medicare might impose on their organizations in the months and years ahead.

It's a big responsibility, especially with continued pressure from federal reports that remind inpatients that one in 20 of them will contract a hospital-acquired infection, with annual direct medical costs to U.S. hospitals ranging from $28.4 billion to $45.7 billion a year in 2007 dollars.

On Monday, 4,000 such professionals are expected to discuss the issues on their minds and perhaps share some solutions as the Association of Professionals in Infection Control and Epidemiology, (APIC) kicks off its annual conference in Baltimore.

What's uppermost on their minds?  What do they think are the most pressing problems, issues and concerns they hope to address?  Infection control experts shared their toughest challenges:

1. Clostridium difficile
 "C. diff and diarrhea have become a huge problem at our hospitals," Stephen Parodi, Chief of Infectious Disease for 21 hospitals in Kaiser Permanente's Northern California system said in a telephone interview. Parodi said that C. diff is more common than the combined rate of central line bloodstream infections, catheter associated bloodstream infections and ventilator associated pneumonia.

An important undertaking within Kaiser hospitals and many other facilities across the country is how to empower nurses to recognize patients with diarrhea as potentially harboring C. diff, isolating them and testing them immediately to minimize the chance of the spread of the bacteria, he said.

""The attributable mortality one-year out from having the original infection is 16.7% – and that's pretty high. It's almost one-sixth of the people are not alive in a year. And remember, it's not the thing the patient originally came in with."

2. Handwashing
Estimates vary among hospitals and various units, from as low as 30% compliance to well above 80%. But experts agree that improving and then sustaining good hand-washing practices is an ever-present challenge.

To make it easier, patient units can be revamped at minimal expense so that dispensers are placed as conveniently as possible to patient care practices, and become an automatic step for the care provider entering and leaving the room.

But next up is to create a system to monitor healthcare workers' handwashing practices without creating a system in which workers instinctively wash their hands only when the monitors – whose identities will quickly become known – are present.

And some workers will object to a big-brother intrusion on their practices. "But we really at a point where we need to draw a line in the sand," Parodi said. "This is just something that has to be done. We don't tolerate unsterile conditions in the operating room, and that's audited...I don't see this as any different just because a patient on a regular hospital floor, why shouldn't we expect the same standards?"

Parodi and others discussed technology that uses electronic means to conduct hand hygiene surveillance, perhaps with a radiofrequency tag.  "We need to look into these technologies to figure out if we have an objective quality measure," he said.  Some of these products have yet to be thoroughly tested.

3. Surveillance Practice for MRSA and Other Infections
Hospitals are debating whether to swab every patient upon admission for Methicillin-Resistant Staphylococcus aureus, or just every patient admitted to the intensive care unit, or just certain patient populations such as those undergoing dialysis or those in pediatric settings.

Or perhaps they should avoid such practice altogether, except for patients scheduled for higher risk invasive cardiac, neuro or joint replacement surgeries, the practice in place at Virginia Commonwealth University Medical Center's Infectious Disease Chairman Michael Edmond, MD, has in place at his hospital. 

"Even if your active surveillance was 100% effective, and you were able to reduce your infections from methicillin-resistant Staphylococcus aureus to zero, that program is not going to have much effect on other organisms. We'll never be able to culture our way out of this problem because there [are] always new bugs that are evolving."

Once certain patients are discovered to be carriers of infections such as MRSA, the decision must be made whether to decolonize those patients with antibiotics, an activity that could increase the emergence of resistant bacterial strains.

"I think we've all made our decisions on this, and chosen the populations we will target," said Sharon Jacobs, manager of infection prevention and control for St. Clair Hospital in Pittsburgh. "Of course, we need to re-assess periodically but that's part of the ever-changing infection prevention environment."

4. Collaboration with Community Organizations
Many infection control officials surveyed for this list indicated the need for hospitals to engage with their competing and neighboring hospitals and nursing homes in ways once thought impractical or impossible. 

In communities, towns, and cities where these facilities share patients, one institution's infection control lapse or outbreak can translate to a nightmare, and significant expense, for other facilities in the region that care for those same patients.

Deb Burdsall, RN, an infection preventionist at Lutheran Home in Palatine, IL said educating long-term care providers on correct practices and working with nursing homes in the community as well as hospitals to her are top priorities.

5. Emerging Infectious Organisms and Resistance
There are pervasive concerns about problems with newer resistant organisms and the emergence of new infectious bacteria, such as NDM-1 drug resistant Klebsiella pneumonia. Decisions to decolonize certain patients, discovered to be carriers, with antibiotics create the risk of emergence of resistant bacterial strains.

6. Persuading the C-Suite
Speaking in general from conversations with fellow infection control preventionists, Kaiser's Parodi acknowledged that for some hospitals, it's a challenge to convince the C-suite that hospital-acquired infections aren't just unavoidable risks of doing business, and unavoidable.

"It takes some convincing of the C-suite and making the business case to show them that we need to invest resources into preventing these, and it's not a slam dunk that every executive is going to buy into this. You have to keep at it, and make that business case, and push for interventions that you know need to be done."

Parodi added that he believes that in the C-suite "the tide is changing, and they're recognizing this, if for nothing else because more states are requiring public reporting of these HAIs. Beyond the issue of cost, there's the issue of the hospital's reputation. You don't want a bad reputation either in your local market or the broader market."

Chris Cahill, an infection control hospital consultant who formerly worked for the California Department of Public Health, says a key issue throughout hospitals and other healthcare settings is the lack of resources.

"What infection control chiefs now don't have is buy-in from the top down, or the bottom up.  Administration is telling them, 'This is not my problem. It's your problem. Make it go away.'"

We're entering a whole new era for infection control," Cahill said. "And a lot of hospitals just don't have the resources they need to prepare. Though they may have an infection control person assigned, that person doesn't have the training or the ability to swallow everything that's happening now. The biggest issue today is getting the C-suite educated."

7. Reducing Clinicians' Unnecessary Use of Antibiotics
Another important topic for discussion is the effort infection control chiefs must make strategically and tactfully to reduce the use of unnecessary antibiotics in their facilities. Parodi noted that in the U.S. each year, "we prescribe 25 million pounds of antibiotics to humans, and about half are inappropriate for one reason or another – either the patient doesn't need the antibiotics at all, or the antibiotics are too broad-spectrum, covering too many strains, or they're the wrong dose, or wrong interval."

Coming soon to many hospitals will be concerted teams of physicians and pharmacists – antibiotic stewardship committees – who will identify those doctors and other clinicians who are prescribing inappropriately.

Understanding the scope of the issue may require re-education for the physician or even broader hospital-wide policies on how to treat certain conditions.

8. Engaging Housekeeping and Environmental Services Staff
Often among the lowest paid housekeeping and environmental services teams are being called upon to embrace the importance of work ethic and thoroughness in infection control for their patients and each other. 

How this takes place is a mixed-bag effort. Some strategies include having housekeeping staff meet regularly with nursing and physician teams, and even allowing them to engage directly with the patient. One hospital encourages its cleaning staff to pick flowers from the hospital grounds to bring to the patients whose rooms they clean.

9. Raising Levels of Vaccination Among Healthcare Workers
No one fully understands why so many healthcare workers – more than half in some settings – refuse to receive influenza vaccinations, although many feel that they themselves are not at risk for getting seriously ill. But Parodi says this will be an increasingly important topic in hospitals in years to come.

"It's not just an employee safety issue, it's a patient safety issue. We can't tolerate influenza occurring because it was related to a patient being hospitalized. The only way to do that is to make sure healthcare staff get vaccinated. You have to have the political will within your organization to get this done."

10. Understanding Reporting and Transparency

Sharon Jacobs, manager of infection prevention and Control at St. Clair Hospital in Pittsburgh, echoed concerns expressed by many of her peers that how infections are reported today lacks standardization, an issue raised in a recent commentary in the New England Journal of Medicine.

"I am a firm believer in transparency but until the reported measurements are being collected in the same fashion using the same definitions, the comparison between providers should not be encouraged," she said.

Added Carol McLay, an infection prevention consultant from Louisville, KY, indicated that infection control teams will need to improve competency in reporting under the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) protocols.

See Also:
For Infection Prevention, Try Duct Tape
Risk of Surgical Infection Rises with OR Noise Levels
Infection Prevention Pilot Slashes CLABSI by 35%
CDC, NIH Revise Bloodstream Infection Prevention Guidelines
Private ICU Rooms Slash HAI Rates by Half

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