Related to infections
Terms and definitions The term healthcare-associated infection (HAI) refers to infections associated with healthcare delivery in any setting (e.g., hospitals, long-term care facilities, ambulatory settings, home care). This term reflects the uncertainty in always being able to determine where the pathogen is acquired. Patients may be colonized with, or exposed to, potential pathogens outside of the healthcare setting before receiving healthcare, or may develop infections caused by those pathogens when exposed to the conditions associated with delivery of healthcare. Additionally, patients frequently move among the various settings within a healthcare system.
Risk factors Many factors promote HAIs in healthcare settings, including decreased immunity among patients, as well as diagnostic and therapeutic procedures, invasive techniques, and medical devices that increase the risk of infections. For example, patients are at increased risk of infection from invasive devices such as intravenous needles or cannulae that are inserted through a person's skin, bypassing the body's first line of defense. Other invasive devices include artificial airways and tubes to assist breathing, and urinary devices – all providing a pathway for bacteria and other organisms to enter the blood stream, lungs and bladder, and increasing the risk of infection and other medical complications. The risk of infection related to invasive devices increases the longer the device is left in place.
Patients in the healthcare setting are also at increased risk of HAIs from exposure to organisms from other patients, generally from lack of staff compliance with basic infection prevention measures, like handwashing or use of alcohol-based hand cleaners.
Major types of infection The four major types of HAIs are related to invasive or surgical procedures and include:
- Surgical site infection (SSI)
- Central line-associated bloodstream infection (CLA-BSI)
- Catheter-associated urinary tract infection (CA-UTI)
- Ventilator-associated pneumonia (VAP)
CDC has developed definitions, tracking methods, and prevention guidelines to assist with the elimination of HAIs.
HAIs are infections that patients acquire during the course of receiving healthcare treatment for other conditions. The CDC estimated the burden of U.S. HAIs in 2002 as 1.7 million infections in hospitals (9.3 infections per 1000 patient days or 4.5 per 100 admissions) noting that more than 98,000 of these patients die (Klevens). Approximately 1 out of every 20 hospitalized patients will contract an HAI. One source estimates the direct hospital costs for HAIs are between $35.7 billion to $45 billion annually after adjusting to 2007 dollars using the CPI for inpatient hospital services (Scott).
The following documents provide information about the problem of HAIs in the United States.
- Umscheid CA, Mitchell MD, Doshi JA et al. "Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs." J. Infect Control Hosp Epidemiol. 2011 Feb;32(2):101-14.
- Van Den Bos J, et al. "The $17.1 billion problem: the annual cost of measurable medical errors. Health Aff. 2011;30(April):4596-603";
Shreve J, Van Den Bos J, et al. "The economic measurement of medical errors [Internet] (Denver CO): Society of Actuaries; 2010 Jun [cited 2011 Mar 2]"
- Scott II, DR. "The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention." CDC, DHQP. 2009;(March).
- Stone PW. "Economic burden of healthcare-associated infections: an American perspective. NIH Public Access Author Manuscript."
- Klevens, R.M. "Estimating health care-associated infections and deaths in U.S. hospitals, 2002." Public Health Reports March-April 2007:22; 160-66.
- Stone PW. "A systematic audit of economic evidence linking nosocomial infections and infection control interventions: 1990-2000." Am J Infect Control 2002; 30:145-52. (doc) (31kb)
These data highlight the enormous personal financial burden of HAIs and provide a baseline for tracking the success of improvement efforts to prevent HAIs as we move forward. See the CDC website "HAI the Burden" at: www.cdc.gov/HAI/burden.html
The reduction of HAIs is a top priority for the U.S. Department of Health and Human Services (HHS). The HHS Steering Committee for the Prevention of Healthcare-Associated Infections was established in July 2008. The Steering Committee was charged with developing a national strategy to reduce HAIs and issuing a plan which establishes national goals for HAI prevention and outlines key actions for achieving identified short- and long-term objectives. The plan is also intended to enhance collaboration with external stakeholders to strengthen coordination and impact of national efforts.
On January 6, 2009, HHS released an Action Plan to identify key actions in the prevention of HAIs. The document establishes national goals for enhancing and coordinating HHS-supported efforts.
A revision to the Action Plan has been developed which incorporates comments received during this initial comment period. The home page link listed below will take you to the revised Action Plan document: http://www.hhs.gov/ash/initiatives/hai/index.html
- Final HHS Action Plan to Prevent Healthcare-Associated Infections (complete document, printable (pdf 424 KB) (June 2009)
- Please note Appendix G regarding revisions to the Action Plan metrics and targets.
- 2010 updated progress toward reduction goals
The HHS Action Plan working group chairs' presentations from national and regional stakeholder meetings conducted in Summer and Fall 2009 summarizes changes to the Action Plan in response to written comments as well as each working group's scope of work.
This CDC site tracks states efforts to meet the goals of the plan and can be located at this CDC link: CDC Healthcare-Associated Infections: Recovery Act
Tool kits to assist HHS-HAI implementation
- CLABSI (Catheter-related bloodstream infection)
- CDI (Clostridium difficile infection)
- CAUTI (Catheter-related urinary tract infections)
- MRSA (Methicillin-resistant S. aureus)
- SSI (Surgical site infection)
For more information regarding registration for any of these meetings, contact Ms. Amber Brummer at firstname.lastname@example.org or (970) 513-5805 (phone).
The CMS Innovation Center initiated "The Partnership for Patients" in April 2011 as a public-private partnership that will offer support to physicians, nurses and other clinicians working in and out of hospitals to make patient care safer and to support effective transitions of patients from hospitals to other settings. The two goals of this new partnership are to:
- Keep patients from getting injured or sicker. By the end of 2013, preventable hospital-acquired conditions would decrease by 40 percent compared to 2010.
- Help patients heal without complication. By the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20 percent compared to 2010.
Achieving the Partnership's two goals has the potential to both save lives and costs for CMS programs. The combined efforts of this partnership have the potential to save 60,000 American lives and reduce millions of preventable injuries and complications in patient care over the next three years. It also has the potential to save as much as $35 billion, including up to $10 billion in Medicare savings.
See Partnership for patients for more on goals and resources for each area of focus, as well as other Premier resources.
Combine elimination goal with prevention practices The CDC encourages hospitals and healthcare organizations to set a goal to eliminate preventable HAIs. This means healthcare organizations should aim for 100 percent adherence to prevention recommendations – that is, evidence-based practices that have been shown to prevent some infections. The CDC and other healthcare partners continue to work together to further identify improvements in clinical practice, medical procedures, and evidence-based practices and guidelines with the goal of elimination of preventable HAIs.
Framework for HAI elimination program There are several key issues to consider for a successful "HAI Elimination Program." One is the healthcare organization's assessment of key elements using local data to determine priorities in targeting HAIs for elimination. The assessment is conducted by hospital leaders including at minimum, patient safety, infection prevention and control, and quality/risk management staff.
A framework of an overall HAI elimination program is available here and begins with assessing past and current experience (e.g., measurement of prior HAIs), development of a safety culture, interventions to reduce or eliminate preventable infections, and adherence to known proven evidence-based practices to prevent transmission (e.g., hand hygiene).
- Download new HAI Elimination Program Framework 10-21-08 (doc) (68KB)
Among new resources available to use during this assessment is the Compendium of Strategies to Prevent HAIS. See Guidelines and HAI Compendium
Safety culture The HAI Elimination Program is part of the overall safety and quality improvement program. A culture of safety that empowers and supports staff in their efforts to reduce risks and improve patient care is the key to success. A number of tools and resources are available to assess the safety culture of an organization.
- Safety Institute "Culture of Safety" (Survey tools, benchmarking data, resources)
Hand hygiene Hand hygiene by healthcare personnel is considered one of the most important strategies to prevent patient-to-patient transmission of organisms causing HAIs in the healthcare setting. Healthcare settings should set a goal of 100 percent compliance with CDC's hand-hygiene guideline.
- Safety Institute Hand Hygiene Website (CDC guidelines, slides, tools and resources)
Bundling – evidence-based practices There has been dramatic success in improving the quality of patient care by focusing on the implementation of an entire group or bundle of evidenced-based practices to achieve a better outcome than when implemented individually. This process is referred to as "bundling" of evidence-based practices. The science behind each element of the bundle is so well established that its implementation is considered a generally accepted practice. Separate elements of a bundle can be easily measured as completed or not completed. But the entire bundle – all of the elements taken together – can be similarly measured as a whole. The effect of all the right processes occurring together should have a positive impact on the disease process and improve patient outcomes; the outcome being measured may be reported using a variety of rates. Unprecedented reductions in rates of VAP and CLA-BSI, for example, have been reported by hospitals participating in local, regional, state and national bundling initiatives.
- Safety Institute Bundling - evidence based practices (Best practices, success stories, guidelines)
Surgical site infection (SSI) prevention Preventing SSIs is part of the national Surgical Care Improvement Project (SCIP) that promotes the adoption of a specific set of evidence-based practices aimed at reducing SSIs. The overall goal of the SCIP project is to reduce surgical complications by 25 percent by the year 2010. SCIP is sponsored by the Centers for Medicare and Medicaid Services (CMS) in collaboration with a number of other national partners serving on the steering committee, including the American Hospital Association (AHA), CDC, the Institute for Healthcare Improvement (IHI), and The Joint Commission and other supporting partners, including Premier. SCIP is an extension of a previous CMS initiative called the Surgical Infection Prevention Project (SIPP) that focused on appropriate antimicrobial prophylaxis to reduce the risk of SSIs.