Leapfrog Patient Safety Group Pushing for Lower HAI Rates
After pandemic increases infections, pressure on to lower rates
The Leapfrog Group, a patient safety watchdog organization, is redoubling efforts to prevent healthcare-associated infections (HAIs) and other adverse events that have increased during the pandemic as it examines data and results from its policy suggestions.
“We are not taking our foot off the gas on requiring hospitals to put an extremely high priority on preventing, addressing, and transforming their operations so that they don’t have this level of infections,” said Leah Binder, president and CEO of Leapfrog. “We need to get back on track by bringing them down.”
Many important HAIs increased in 2020 during the chaos of the pandemic. Data from the Centers for Disease Control and Prevention (CDC) revealed the rate of central line-associated bloodstream infections was 47% higher than 2019 in the last half of 2020. The CDC also found that catheter-associated urinary tract infections, ventilator-associated events, and methicillin-resistant Staphylococcus aureus (MRSA) infections rose sharply in 2020.1 (See Hospital Infection Control & Prevention, October 2021.)
In some cases, incremental gains over several years were wiped out, as infection preventionists (IPs) tried to deal with the pandemic and incoming COVID-19 cases. “There is ongoing concern about all the ground we lost in terms of HAI reduction,” says Ann Marie Pettis, RN, BSN, CIC, president of the Association for Professionals in Infection Control and Epidemiology (APIC).
“We are really trying very hard to put that genie back in the bottle, but with the Delta surges and everything else, it does make it difficult,” she adds. “We cannot lose sight of the multidrug-resistant organisms like MRSA and Candida auris.”
The Leapfrog Group, which represents employers and other healthcare payers, has pushed the healthcare industry on patient safety and data transparency for two decades. It issues an annual survey of quality measures to healthcare facilities. The group may assign grades based on the responses and give awards for high-achieving organizations.
The group is something of double-edged sword for IPs: It can use its clout to demand more resources for IPs, but also puts pressure on them to prevent infections in multiple settings.
Hand Hygiene Standard
For example, the group raised its hand hygiene standard just before the pandemic hit, putting many IPs in a difficult position to meet the requirements. In part, the standard requires that hospitals and ambulatory surgery centers collect compliance data on at least 200 hand hygiene opportunities monthly, providing feedback to those who touch patients or items used by patients. Direct observation or an electronic compliance monitoring system can be used.
Leapfrog is pushing for the latter, but wanted to include a low-tech alternative, said Binder, who spoke at a recent “fireside chat” webinar with Devin Jopp, EdD, MS, CEO of APIC.
“I recognize that this is a difficult standard,” Binder said. “We have always had a hand hygiene standard on our survey, but we elevated it. Now the elevation of that standard happened prior to COVID — we just put the finishing touches on it at the end of 2019. So, we did not know about the [coming] pandemic, but a panel of top experts in infection prevention and hand hygiene — from a variety of fields in the research — came to the table and really said, ‘It’s time.’ I have to agree.”
Still, realizing the high bar set by the standard, Leapfrog has not “dinged” any hospitals yet, but plans to take the gloves off in the new year, she said.
“We’re looking at the fall of 2022 when there will be consequences if they’re not reaching the highest levels of the standard,” Binder said.
The hand hygiene standard is based on the World Health Organization’s standard of monitoring at 200 handwashing encounters a month at the unit level, she said.
“That got a lot of attention, because that’s a lot to do,” Binder said. “The best way to be able to do that is to have an electronic monitoring system.” Binder acknowledged that such a system will require an investment, but added, “It is not sending a human being to the moon to have electronic monitoring. Other industries do this routinely for anything where there’s a great deal of risk involved. And in this case, there is a lot of risk involved, for everyone — for the worker and for the patient, as well as the family members who are visiting.”
The feedback, training, and educational aspects of the standard were pioneered by IPs, she noted. The standard has helped some IPs justify the purchase and implementation of electronic hand hygiene monitoring systems, Jopp added.
“That is part of the reason why this relationship [with Leapfrog] is such an important one, I know, to us at APIC,” Jopp said, adding that one of APIC’s key strategic goals is to elevate the influence of IPs.
Leapfrog May Help IP Presence
“There’s a lot of competing demands within these organizations for attention, and the infection prevention unit and leadership sometimes get lost in that,” Jopp said. “One of the things that we really want to see happen is building that linkage where IPs have the ability to reach out and elevate concerns, and really get to the level of the senior leadership in the organization.”
Leapfrog is open to using its influence to bolster IP programs and get needed resources, Binder said, asking, “What can we do from the outside, as purchasers who are driving some of the revenues — significant portions in some cases, of revenues in these hospitals? How can we highlight the importance of the IP?”
The message needs to reach the executive level, possibly chief financial officers and CEOs, Jopp said.
“There’s tremendous opportunity for employers to be drivers of some of this change, to your point,” he said. “I think, coming out of this, these are some of the conversations we need to have. How do you fix this for all organizations, so it’s not just, ‘Here are the islands that did it really well and those that did really poorly.’”
Beyond hand hygiene monitoring, Leapfrog will continue to push for healthcare innovation, Binder said.
“The whole healthcare system now has completely transformed telemedicine,” she said. “That’s now a norm in the healthcare system, and it seemed like it happened overnight once we had the pandemic. That has taught us that innovation is possible. We now know that. So, watch out, we’re going to look for some more innovation at Leapfrog. We’re also going to try to be more cutting-edge in how we think about the digital transformation.”
Providing another example, Jopp said the whole issue of masks and respirators must be addressed.
“Having masks that actually fit and they don’t have to be fit tested,” he said. “We started realizing early on that masking is really important. IPs knew that always — everybody needs an N95 mask. Well, you couldn’t get them, or if you could get them, who’s going to fit test them? So, I think looking ahead, it’s how do you get smarter about the kinds of PPE (personal protective equipment) or other [IP] tools we have in the workplace?”
Public Reporting Beyond the Hospital
With transparency a key tenet of its mission, Leapfrog sees public reporting of infections as a path to improved quality of care.
“We are recommitting to our advocacy efforts around public reporting of infections, but not just [in] hospitals,” Binder said. “We need reporting to the CDC [from] nursing homes, ambulatory surgery centers, and other settings. I think it’s very important that we start to have that in place. So that if — God forbid — we have another pandemic, we won’t have to wait for nursing homes, for instance, to get used to reporting to the CDC. That [happened] in this pandemic. It took them months to get it right because they weren’t used to it.”
It is a preparedness issue, but it is also really an issue for all who use healthcare, she said. It is something that cannot be ignored because “we know that these infections are taking place,” Binder said. “We’re recommitted around the policy objective of public reporting and CDC reporting. So far, the [Biden] administration has actually funded more reporting for all those settings, which is good.”
Given this push by Leapfrog and the continued movement of healthcare delivery beyond the hospital, surveillance for infections is going to be a challenge, Jopp said. APIC has called for undiluted infection program requirements in long-term care. Likewise, the longstanding problem of identifying surgical site infections after discharge will not get any easier as more complex procedures and joint replacements are performed on an outpatient basis.
“With that comes a whole new level of complexity around ‘distributive infection prevention control,’ which we have to figure out,” he said. “There’s no bones about it. But it is going to take investment, too. It’s not just as easy as saying, ‘Well, we’re going to get them out of the hospital and, phew, we don’t have to worry about infection prevention.’”
On the contrary, HAI surveillance systems will have to cast a wide net to capture infections beyond the hospital, he added.
“And again, that’s where we come in,” Binder said. “We need to say, ‘Here’s what employers care about, here’s the standards they would have,’ and in doing so, hopefully elevate the influence of infection control specialists and the leaders who are out there trying to make this happen.”
The Risk-Benefit of Visitors
Another issue that Leapfrog is exploring is the effect of restrictions on visitors during the pandemic. “We have heard from a number of nurses that [visitor bans] were problematic for them,” she said. “They realized through this the extent to which they have depended on patient families to help them — to be their eyes and ears at the bedside. So, it seems like it’s had a real impact.”
The role and responsibilities of visitors to observe infection measures might need to be rethought, given the effect on nurses who already are short-staffed in many areas. Jopp shared a personal example, saying his dad helped his mother remain mobile during a recent hospitalization.
“My dad was there every day, helping her get out of bed, walking her around,” he said. “Those are things that the healthcare workers didn’t have to do because he was there and doing that. So, her outcome was improved by his engagement process.”
Visitors also can help alleviate the loneliness and isolation that can lead to depression and worse patient outcomes, he said. On the other hand, it was found — particularly early in the pandemic — that visitors to nursing homes were spreading SARS-CoV-2, he said. Visitor bans or limitations became common policy across healthcare facilities.
“I think it was certainly the right move at the right time, but the question coming out of this is, ‘Well, how do you build a better mouse trap?’” Jopp said. “Are there ways we can [rethink] visitation policies? That might be a fruitful area for both of our organizations to study together.”
Increased vaccination and, perhaps, improvements in rapid testing could “allow us to get some level of assurance that a person walking in the door isn’t carrying COVID or whatever the next virus is,” he said.
Jopp asked Binder how APIC and IPs can best support Leapfrog’s work, describing employers as the ultimate consumer of healthcare.
“I think the first thing is to communicate with us, tell us what’s happening,” Binder said. “I really want to hear from infection prevention professionals who really understand what is actually happening within a healthcare system to address this critical problem of infections.”
This feedback helps Leapfrog stay attuned to the issues and informs their standards and hospital grades.
“We don’t want to lower our standards, but we want to be helpful in setting standards that can move everyone forward, that can create momentum for the direction that both of our organizations and our members all want to go in,” Binder said.
That said, Leapfrog has established clear boundaries with healthcare and avoids affiliations and entanglements to preserve its independence. “But we have many other opportunities for engagement with people on the ground, because that’s critical,” she said.
REFERENCE
- Weiner-Lastinger LM, Pattabiraman V, Konnor RY, et al. The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: A summary of data reported to the National Healthcare Safety Network. Infect Control Hosp Epidemiol 2021; Sep 3:1-14.
The Leapfrog Group, a patient safety watchdog organization, is redoubling efforts to prevent healthcare-associated infections and other adverse events that have increased during the pandemic as it examines data and results from its policy suggestions.
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