Although considerable progress has been made in reducing targeted healthcare-associated infections (HAIs), the Department of Health and Human Services (HHS) has set a new baseline and established ambitious new goals for 2020.
Using 2015 targets as a baseline, the HHS “National Action Plan to Prevent Health Care-Associated Infections”1 sets the following goals for healthcare by 2020:
- Reduce central line-associated bloodstream infections (CLABSI) in intensive care units and ward-located patients by 50%.
- Reduce catheter-associated urinary tract infections (CAUTI) in intensive care units and ward-located patients by 25%.
- Reduce the incidence of invasive healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA) infections by 50%.
- Reduce facility-onset methicillin-resistant Staphylococcus aureus (MRSA) in facility-wide healthcare by 50%.
- Reduce facility-onset Clostridium difficile infections by 30%.
- Reduce the rate of Clostridium difficile hospitalizations by 30%.
- Reduce surgical site infection (SSI) admission and readmission by 30%.
The data are reported to the CDC’s National Healthcare Safety Network (NHSN). Reductions are tracked using a standardized infection ratio (SIR), which compares actual number of HAIs to the predicted number of infections. The results since the program began in 2009 have been decidedly mixed, with CLABSIs falling by an impressive 50% by 2014, but C. diff only dropping 8% and CAUTIs showing no decline. We asked Susan A. Dolan, RN, MS, CIC, hospital epidemiologist at Children’s Hospital Colorado and 2016 president of the Association for Professionals in Infection Control and Epidemiology, to comment on the new HHS goals.
HIC: Can you speak a little bit to how the broad goals in the HHS plan translate down to the individual infection preventionist?
Dolan: The HAI action plan we look at as sort of an overarching report card. It does reflect the work that IPs do each and every day to keep their patients safe. The IPs are actually the ones doing the measurement and interpretation of the definitions through NHSN. We do that and then we are also the ones submitting that data to NHSN. The good thing is these national targets -- these standardized infection ratios -- are the same SIRs we use when we are determining if our own facility is measuring up with what we expected. So not only are we using it as an overarching report card, but we use many of these measurements and metrics at the local level and even the state and regional level to see what progress we are making. If we see problems in one area, we can target that.
HIC: You also have mentioned the CDC’s Targeted Assessment for Prevention (TAP) programs to use the data to drive improvements.
Dolan: Yes, the other nice thing the NHSN has done with this work is that they have been able to look at high performers to see if they can help inform the science. On the other hand, they can also target the low performers – it’s not a punitive thing, but they use it as an opportunity to go out and evaluate and educate individuals at those locations so they can help to bring those numbers up. You want to look at where is your bang [for the buck] to try to move these needles. By using that methodology of targeting the low and high performers they can really focus on where those low performers are and make some real-time improvement efforts. They make sure first of all that they are doing all the things that they should be doing correctly. Are they doing surveillance correctly, implementation measures – standard of care type measures that we should be doing? Are those all being implemented reliably? Also, they say look at these high performers – is there something we can learn from them?
HIC: It’s really striking how formalized and structured this has become. I can remember when NNIS had 300 hospitals and everybody just basically benchmarked their data.
Dolan: That’s correct, and now this is a very large organization with a lot of organizations including APIC. And one of the other roles that APIC has – and it’s something I’ve seen make a difference over time – is to help to make sure that we are informing and working with CDC to make these NHSN definitions for HAIs accurate and relevant as much as possible. For example, when we are looking at BSIs related to central lines – the CLABSIs. Whn we looked at that really closely at the unit level, as our providers and our nursing staff were describing these patients, it became clear to us that some type of CLABSIs by the current definition included patients that were not getting infected because of bad care of their catheter or their line. It was really because of their underlying conditions and treatments -- something [else] resulted in getting infections in their blood.
For example, an oncology patient who is on a specific chemotherapy and/or has recently had a bone marrow transplant that has altered the integrity of their intestines. There is opportunity for [pathogens] to leak out into the blood stream. Those you can’t prevent even with 100% perfect care of the catheter. So, we helped work on the definition and we called those the mucosal barrier injuries or MBI. And we tracked those for several years with NHSN and now when they set the metric based on the 2015 baseline, that baseline will no longer have the CLABSIs we were classifying as NBIs. So hopefully what that new measures will be are the ones that we think probably are preventable. That’s a good example of getting these measurements more accurate and relevant to the patients we are measuring.
HIC: These goals are ambitious, do you think they are attainable – particularly a 30% reduction in C. diff?
Dolan: I think if they really wanted to be overly ambitious they might have gone with 50% or higher. I think 30% is probably a reasonable target. Will we get there? I don’t think anyone really knows, but I do think it’s reasonable. Ambitious but reasonable. And the reason I say that is as you look at the report card progress in 2014 -- they didn’t make a lot of progress -- there’s an 8% reduction [in C. diff]. So, when they started to see that the needle wasn’t moving on the C. diff target people began to really question this. [That became] a major impetus for the development and the strong and heavy movement toward antibiotic stewardship. It’s quite a robust effort that is taking place across the whole continuum of care. A lot of the emphasis on this is not just in hospitals, but also on the community impact.
HIC: The HHS has set an overall agency goal to speed the uptake of antibiotic stewardship programs which are currently only established in 40% of hospitals. Of course, reining in antibiotics should reduce C. diff, which is often triggered by antimicrobial therapy.
Dolan: I think that what they are trying to do is to align many of these federal programs. I wouldn’t call them silos, because they are trying to bridge the difference of federal organizations and the efforts that are happening. There is a concerted effort to try to make sure that they are interconnected. [Antibiotic stewardship] concerted effort across these various federal programs.
REFERENCE
- HHS. National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination. https://health.gov/hcq/prevent-hai-action-plan.asp
