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Dear Colleague:
Hospital-acquired conditions (HACs) including infections, are in the limelight this month with CMS reducing reimbursement for ten HACs, and infection preventionists reaffirming goals during infection control week. A number of our stories this month address infection prevention strategies.
Sincerely,
Gina Pugliese, editor
Vice President, Premier Safety Institute
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Results of a recent laboratory study are being interpreted to suggest that biocides – common cleaning and disinfecting agents – could select for, or even create bacterial strains that are also resistant to certain classes of antibiotics. CDC experts explain that there is no evidence to suggest that microbes are becoming resistant to disinfectants or that there is any cross-resistance to antibiotics.
The study The study on disinfecting agents by
Huett and colleagues published in the Microbiology (October issue) describes creation of mutant strains of various bacteria that expressed efflux pumps following exposure to low concentration of biocides or dyes. (Efflux pumps actively pump unwanted toxic substances out of the cell). However, this study is only suggestive and requires further characterization of the genetic changes in the efflux pumps and reproduction in a natural setting to provide a clearer picture of the significance of this new finding. There have been numerous inaccurate interpretations of this study by the media
(see release), including one suggesting that the CDC supports the correlation between use of biocides and resistance mechanisms.
Arjun Srinivasan, MD, a medical epidemiologist in the CDC's Division of Healthcare Quality Promotion, in an interview with Premier
Safety Share editors stated, "CDC has not seen evidence that the use of disinfectants in healthcare has led to the development of antibiotic resistance. However, CDC has always encouraged healthcare facilities to use disinfectants properly, that is only when indicated and always in accordance with the manufacturer's recommendations."
Srinivasan added that the "CDC's current recommendations have not changed and are summarized in the
CDC Guidelines for Environmental Infection Control 2003." (link to SI Guidelines below)
Environmental biocide agents are different than antibiotics Environmental biocide agents (cleaners/disinfectants) are formulated and used at specific levels of concentration that far exceed those one can achieve with oral or intravenous antibiotics.
Premier’s Safety Share editors found to date, there is little evidence that use of biocides at manufacturer-recommended use-dilution and contact time will select for resistance or alter the susceptibility of pathogens causing healthcare-associated infections to antibiotics. This also is true for biocides marketed for commercial use in domestic settings. This current report is interpreting a laboratory study for a theoretical situation and suggests, at best, a theoretical clinical impact. It is worth noting that:
- Prior studies of potential biocide resistance are typically
laboratory-based studies – not real world use-dilutions that are applied in the healthcare or home environment. There were claims some years ago that one formulation (triclosan) posed potential risks for resistance but again, this was a laboratory-based study. It has since been shown even by the original researchers that the approach used in testing to demonstrate resistance was not correct.
- The premise of the Microbiology study is correct; on a purely statistical basis, biocide resistance is
theoretically possible, based on the mechanism described, and it is fully expected that exposure of some chemicals to organisms at sub-lethal concentrations of chemicals occurs in nature and may lead to resistance. Scientists have been looking for more than 50 years, but not yet found it occurring with the formulations used and sold for healthcare or domestic settings. See
Live and let die; and
Clin Micro Rev. Further, there are strict guidelines on proper use-dilutions that must be used for healthcare EPA-registered products and these have never shown evidence of resistance. These disinfectants kill sensitive and resistant organisms the same way as MRSA, MSSA or any other sensitive/resistant microorganisms.
Over-use of antimicrobials does promote resistance There has been an ongoing concern that antiseptic skin cleaners and/or environmental surface disinfectants may encourage antibiotic resistance. However, there is no evidence that resistance has occurred with hand cleaners/antiseptic solutions or environmental disinfectants of any type. Experts do agree that the primary driver of antibiotic resistance continues to be overuse or misuse of antibiotics that result in these antibiotics becoming resistant to the microbes. This antibiotic or antimicrobial resistance in humans does have the potential to lead to cross-resistance or co-resistance to other
antimicrobials used to treat patients, as we have seen happen with strains of
S. aureus resistant to methicillin (MRSA) developing resistance to vancomycin resulting in vancomycin resistant S. aureus or
VRSA.
Recommended practices Antimicrobial stewardship programs in healthcare settings involving collaboration among care providers and pharmacists are essential to assure appropriate antimicrobial use.
"Appropriate use of environmental cleaners 'using the right solution – at the right concentration – at the right place and time' is also needed," agrees Srinivasan.
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On October 1, 2008, the FY 2009 Inpatient Prospective Payment System (IPPS) rule took effect, proving the potential for lower reimbursement rates for 10 hospital-acquired conditions (HAC), including three healthcare-associated infections (HAIs).
IPPS policy and HAC The IPPS rule requires an adjustment in Medicare Diagnosis-Related Group (DRG) payment for certain HACs with a component that addresses "Present on Admission" (POA) coding. CMS had to select at least two conditions for which hospitals under the IPPS would not receive additional payment if the conditions were not POA. Further, the HAC had to be: (a) high cost or high volume or both; (b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis; and (c) could reasonably have been prevented through the application of evidence-based guidelines. (See Premier CMS.)
HACs CMS selected a final set of 10 HACs that have the potential for lower reimbursement rates since hospitals will receive only basic payment for cases in which any of the selected HACs was not POA. That is, the case would be paid as though the secondary diagnosis was not present; however, if the patient has another coded complication (but not a HAC), the case will still be paid at the higher DRG rate. Three of the 10 are HAIs, with seven being drawn from the National Quality Forum's list of 28 "Serious Reportable Events." Details are available from
Premier's September Safety Share
HAC-HAI resources Premier Safety Institutes'
Guidelines – Infection Prevention and Safety Web site provides detailed information on the CMS HAC and Present on Admission (POA) indicators. Included are resources and fact sheets as well as related links to tools for the control and prevention of falls, healthcare-associated infections (HAIs),
pressure ulcers, and venous thromboembolism (VTE). The
HAI site provides a comprehensive framework for incorporating the HACs into a HAI elimination program.
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The newly released "SHEA-IDSA Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals" provides practical guidance on how to prevent infections and measure progress and include patient guides developed by CDC.
The compendium has been published by The Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Other partnering organizations in this effort include the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA) and the Joint Commission.
Science-based and practical strategies addressed in the compendium include the four major device-related or procedure-related healthcare-associated infections (HAIs): catheter-associated bloodstream infections; catheter-associated urinary tract infections, ventilator-associated pneumonia; surgical site infections; and two major pathogens of current concern – Methicillin-resistant
S.aureus (MRSA) and Clostridium difficile. Each strategy is based on CDC/HICPAC guidelines for each of these topics.
Compendium The goal of these strategies is to improve the quality of patient care by focusing on implementation and performance measurement. The compendium of strategies uses concise,
evidence-based resources in an outline format to explain how to prevent each infection and also identifies the need for adequate resources dedicated to local infection control programs, more widespread public health integration, and more research to guide future HAI prevention efforts.
CDC patient guides. In addition to the strategies, the organizations also partnered with CDC to publish
patient guides for each of the six infections addressed by the compendium. The guides identify strategies that hospitals, patients and family members can all take to prevent infections.
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The increasing number of states with public reporting requirements for healthcare-associated infections (HAI) has driven hospitals to the CDC's
National Healthcare Safety Network (NHSN) as a ready-made solution for HAI reporting. NHSN, a free, secure, Internet-based surveillance system, eases data collection, analysis and reporting of a variety of HAIs across many states. In slightly over a year, the number of hospitals using NHSN grew from 491 to 1,722 as of August 2008.
Of the 30 states now requiring some type of public reporting of HAIs, states using NHSN for mandatory HAI reporting has grown from eight to 18. The NHSN Web-based software managed by the Division of Healthcare Quality Promotion (DHQP) at CDC ensures automatic use of standard definitions for device-related infections such as catheter-related bloodstream infections, procedure-related (surgical site infections), and antimicrobial resistance trends. Recently, the CDC has added new algorithm-based modules for multi-drug resistant organisms,
C. difficile, as well as process measures such as adherence to prevention recommendations.
In addition, the Government Accounting Office (GAO) recently examined the design and implementation of 23 states' HAI reporting systems and experiences that hospitals have had in overcoming the challenges of implementing such initiatives. The GAO also found a similarly dramatic increase in the use of NHSN. It found that frequently states use technical advisors or advisory committees and focus on a few measures developed or endorsed by the CDC and that the majority use the NHSN for data collection. The GAO noted that the NHSN system and generated data was not originally intended for public use, but rather for internal hospital use to help improve processes. In the past, the CDC has conducted validation studies on its surveillance definitions but GAO points out that specific procedures for validating HAI data need to be developed and tested, and resources allocated to implement them. Experts agree there is a need to validate the completeness and accuracy of submitted data, but also agree that
how hospitals actually achieve reductions in HAI rates will vary with each hospital's interventions.
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The rate of fatal medication error (FME) increased over the past 20 years by more than 360 percent, with drugs taken at home involving interactions with alcohol increasing the most. A recent study attributes the change in part to trends in medical care increasingly shifting from the inpatient to outpatient setting; patients have more responsibility for their own care and the increasing number of prescribed medications being readily available over the counter.
Phillips and colleagues examined the incidence of fatal medication errors (FMEs) occurring in the home to determine what percent of these FMEs might involve alcohol or street drugs and whether these percentages are changing over time. They examined almost 50 million United States death certificates from January 1, 1983, through December 31, 2004, with greater than 200,000 of these cases involving FME.
The large increase in FMEs from combining medications with alcohol and/or street drugs suggests the need for physicians to screen patients for the use of alcohol and/or street drugs, to use extra precautions when prescribing medicines with known dangerous interactions with alcohol and/or street drugs, and to emphasize to their patients the risks involved with mixing medications with alcohol and/or street drugs.
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The first new hospital accreditation organization in more than 40 years has been approved by the Centers for Medicare & Medicaid Services giving hospitals more choices when seeking to participate in Medicare or Medicaid. The approval of Det Norske Veritas Healthcare Inc.'s
(DNV) program
for conferring deemed status on hospitals adds to existing accreditation programs by The Joint Commission (TJC), the American Osteopathic Association (AOA) or certification by a state survey agency. Hospitals receiving accreditation from an organization with "deeming authority" are considered to be in compliance with CMS standards and may be reimbursed by CMS for Medicare and Medicaid services without a separate CMS survey.
The DNV accreditation program, called the National Integrated Accreditation for Healthcare Organizations (NIAHO), integrates the International Organization for Standards' ISO 9001 quality management system standards with the Medicare conditions of participation. NIAHO is the first accreditation program to integrate hospital accreditation with ISO 9001.
According to DNV, the integration of ISO 9001 enables hospitals to identify and document the clinical and administrative processes that contribute to desirable outcomes in order to institute them as standard practices. The DNV survey cycle is annual, in an effort to ensure continual quality improvement. Survey teams have a collaborative approach and are comprised of clinicians, generalists and life safety specialists; DNV/NIHAO surveyors have also been cross-trained as ISO 9001 lead auditors. DNV works with the National Health Service in England in the review and risk assessment all of hospitals in the UK and currently certifies 27 U.S. hospitals through its ISO 9001 program.
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The dangers associated with anticoagulants such as heparin and warfarin have been highlighted in the latest "sentinel event alert" from The Joint Commission. Administered incorrectly, anticoagulants can cause serious harm such as deep vein thrombosis (DVT). The Joint Commission release of
Preventing errors relating to commonly used anticoagulants emphasizes the need for increased attention to the dangers associated with anticoagulants. The alert describes the common factors associated with anticoagulant medication errors, including labeling and packaging issues, documentation errors, communication failures, and inappropriate use of medication, particularly inappropriate dosing of pediatric patients.
Anticoagulation medication errors are addressed in the 2008 National Patient Safety Goals, with full implementation of the requirements expected by January 1, 2009, for U.S. hospitals, outpatient clinics, home care and long-term care organizations. The Joint Commission's alert recommends that healthcare organizations take a series of 15 specific steps, including the importance of assessing risk and use of best practices regarding anticoagulants, establishing dose limits, clearly labeling syringes/container of anticoagulants, and special care in dosing of pediatric patients.
Additional strategies for reducing anticoagulant-related errors include staff communication and collaboration; patient education and participation; designating pharmacists to manage anticoagulant services; and use of computerized physician order entry (CPOE) and bar coding technology, if available.
A webcast on anticoagulation therapy from Premier is available, and includes speakers from hospitals with successful anticoagulation therapy programs, including slides and an audio file along with other resources.
AHRQ's guide and new consumer education materials are available from the Safety Institute's
Venous Thromboembolism (VTE) Web site.
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A recent study published online in the Annals of Emergency Medicine found more than three-quarters of patients do not understand the care and discharge instructions they receive in the emergency department (ED), and that most of them are unaware they do not understand what they have been told by their doctors. Family or friends' assistance in remembering instructions may be one solution.
Misunderstanding ED care or their discharge instructions is more common than not in patients, according to the
study. Additionally, most of them are unaware of their lack of understanding while reporting inappropriate confidence in their understanding and recall. Researchers conducted interviews of 140 patients or caregivers after discharge to determine their understanding in four areas: (1) diagnosis and cause; (2) ED care; (3) post-ED care; and (4) return instructions. Seventy-eight percent of patients did not understand instructions in at least one area and 51 percent did not understand instructions in two or more of the areas. The greatest confusion occurred with instructions on medications, rest, wound care and when to have a follow-up visit with a doctor. Among the patients with comprehension problems, only 20 percent realized that their understanding was incomplete or inaccurate.
An article on this study in the New York Times elaborates on the issue, reporting that similar results have been found for all discharge patients, not just those from the ED. Study author Dr. Kirsten Engel states that better strategies for identifying patients who are having difficulty understanding their care and instructions in the emergency department are needed. Patients need to be encouraged to ask ED staff to repeat themselves or clarify points that are unclear. When possible, patients may benefit from being accompanied to the emergency department by a family member or friend, who can ask questions and help remember the patient's post-ED care instructions.
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With vaccination rates continuing to be less than optimal, experts are trying the popular Internet video site YouTube to reach a wider audience. A YouTube video documentary features the personal stories of parents who have lost or nearly lost a child to the flu. "Why Flu Vaccination Matters" was developed by Centers for Disease Control and Prevention (CDC) together with Families Fight Flu (FFF), a non-profit organization dedicated to educating people about the importance of vaccinating children against the flu every year. More immunization resources are available.
Quick summary of resources
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A recent review of 38 studies focused on nurse staffing and healthcare-associated infection (HAIs) found the majority (82 percent) of the studies had a significant association between nurse staffing levels and HAIs. Four of the studies linked temporary staffing to HAIs.
A large body of research focuses on the relationships between healthcare providers, working conditions and patient safety outcomes, including healthcare associated infection (HAI). Authors of a recent
article conducted a comprehensive review of the evidence linking hospital staffing to the risk of HAI.
Most of the 42 studies examined involved nurse staffing (38 or 90 percent). Nurses have the most exposure to patients and most often perform procedures that have a risk of infection.
- Of the studies examining nurse staffing and single site-specific infections, two looked at temporary nurses and found an increased risk of bloodstream infections (BSI) with temporary nurse staffing.
- Reports of studies examining nurse staffing and multiple HAIs all indicated an increased risk of HAI.
- Seven studies involved organism-specific infections and nurse staffing, and all but one found a significant relationship between levels of staffing and infection risk.
- Two of the seven involved temporary nurses and found an association between their use and patient risk of acquiring methicillin-resistant Staphylococcus aureus.
- Higher infection control professional staffing levels were related to lower rates of HAI in two studies.
No association between patient risk of HAI and physician staffing was noted.
Authors conclude that temporary staff may not have enough familiarity with specific facility procedures and "best practices" for preventing HAIs. They may also not have developed the relationships needed to provide clear communication among team members.
The researchers' state that more research is needed, optimally using a multi-site, randomized, controlled trial with reliable and valid measures. Additional research on other types of staffing such as hospitalists and physician assistants would also contribute to this body of knowledge. As the role of infection control changes, additional studies characterizing the infection control department's role in reducing HAIs are also needed, according to the authors.
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Safety Tools
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A compendium of 115 original research papers by the Agency for Healthcare Research and Quality (AHRQ) grantees and other authors entitled, "Advances in Patient Safety: New Directions and Alternative Approaches," has been released by AHRQ. The compendium is a four-volume set, also available as a searchable CD-ROM, that highlights new knowledge and lessons learned in such critical areas as reporting systems, risk assessment, health IT, clinical process redesign, and medical simulation. The new compendium is a follow-up to an earlier version published in 2005. A single copy of the printed compendium or the CD-ROM is available by sending an e-mail to
ahrqpubs@ahrq.gov.
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The Facility Guidelines Institute (FGI) is calling for public comment on draft text for the "2010 Guidelines for Design and Construction of Hospital and Health Care Facilities." The Guidelines impact nearly every state planning new healthcare construction and/or renovation. The shaded text version for comment is available to the general public through December 15, 2008. Go to
http://www.fgiguidelines.org/ to comment after registering. The Guidelines address infection control, sustainability and patient safety for all types of healthcare facilities and is used by architects, engineers and healthcare professionals as a guideline and reference for codes and standards. The Guidelines are now published by the American Hospital Association's American Society for Healthcare Engineering (ASHE) and is anticipated to be available in January 2010. See Premier Safety Institute's
Single Room – Guidelines revision - Introduction.
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The American Society for Gastrointestinal Endoscopy (ASGE) has updated its infection control guidelines regarding gastrointestinal (GI) endoscopy, "Infection control during GI endoscopy"
The guidelines note that endoscopy-related infections are a very rare event since the adoption of endoscope reprocessing (cleaning) guidelines. The ASGE infection control guidelines appear in the May issue of
GIE: Gastrointestinal Endoscopy, the monthly peer-reviewed scientific journal of the ASGE.
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The World Health Organization's Alliance for Patient
Safety initiated work on the second Global Patient Safety
Challenge in January 2007. The initiative, "Safe
Surgery Saves Lives," aims to improve the safety of surgical care around the world. This initiative provides a surgical safety checklist and related educational and training materials to encourage international adoption of a core set of safety standards. The checklist is not a regulatory device, but is intended as a practical, easy-to-use tool. The manual provides suggestions for implementing the checklist, understanding that different practice settings will adapt it to their own circumstances. The implementation manual is designed to help ensure that surgical teams are able to implement the checklist consistently. By following a few critical steps, healthcare professionals can minimize the most common and avoidable risks endangering the lives and well being of surgical patients
http://www.who.int/patientsafety/safesurgery/ss_checklist/en/index.html.
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The latest monograph from the Center for Healthcare Governance, "Putting Quality First: How Boards Can Make Quality Improvement a Higher Priority," describes how hospitals boards can weave quality and patient safety into the fabric of their organizations. Author David Bjork discusses the formal and informal processes boards can use for moving quality higher up on an organization's agenda. Formal processes include performance management goal setting, feedback, performance appraisal, and pay-for-performance. Informal processes discussed include agendas for meetings, discussing priorities and performance in board and committee meetings, providing informal feedback, asking how performance can be improved, and questioning how proposed operational changes would affect performance. The monograph also provides practical tips for promoting quality improvement in an organization. The monograph is $15 and is available at
www.hospitalconnect.com/americangovernance/publications/monographs.html.
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The Institute for Safe Medication Practices (ISMP) has released automatic dispensing cabinet (ADC) guidelines designed to help health professionals safely use automated dispensing cabinets to store and dispense drugs near the
point of care. The guidelines address the number and location of ADCs and related resources; ADC security, screen information, storage configuration and inventory control; and procedures in the case of a power loss or malfunction. ISMP recommends using pharmacy-profiled ADCs, which ensure the pharmacist validates new medication orders in the pharmacy computer system before medication is dispensed.
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Editorial team
- Gina Pugliese, RN, MS editor
- Judene Bartley, MS, MPH, CIC, associate editor
- John Hall, BSJ, contributor
- Judith Luca, RN, BSN, contributor
- David Huntley, BA, Web master
Premier Inc., 2006 Malcolm Baldrige National Quality Award recipient Serving 2,000 U.S. hospitals and more than 51,000 other healthcare sites, the Premier healthcare alliance and its members are transforming healthcare together. Owned by not-for-profit hospitals, Premier operates one of the leading healthcare purchasing networks and the nation's most comprehensive repository of hospital clinical and financial information. A world leader in helping healthcare providers deliver dramatic improvements in care, Premier is working with the United Kingdom's National Health Service North West and the Centers for Medicare and Medicaid Services to improve hospital performance. Premier's Safety Institute provides publicly available safety resources and tools to promote a safe healthcare delivery environment for patients, workers, communities and the environment. Headquartered in San Diego, Premier has offices in Charlotte, N.C., Philadelphia, and Washington.
Safety Share © 2008 Premier, Inc.
You may forward this newsletter to your colleagues. If you would like to reprint any of these stories, please cite the "Safety Share newsletter, Premier, Inc." as your source and send an email to
safety_institute@premierinc.com and alert us. Thank you.
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