Battling HAIs: A Primer for Infection Preventionists - Infection Control Today

In order of occurrence, the most common types of HAIs are catheter-associated urinary tract infection (CAUTI) at 32%; surgical site infection (SSI) at 22%; pneumonia (ventilator-associated pneumonia) at 15%; and central-line associated bloodstream infection (CLABSI) at 14%.

No one should ever have to fight for their health over an infection they didn't have when they entered a health care facility. Health care procedures can leave a patient vulnerable to microorganisms, such as bacteria, fungus, or viruses, that can cause health care–acquired infections (HAIs). HAIs are infections people get while receiving health care for another condition. They are defined as "infections not present and without evidence of incubation at the time of admission to a health care setting."¹

Infection preventionists (IPs) don't provide any hands-on patient care, but they should be knowledgeable on current best practices for that care. Detailed knowledge of practices and processes for insertion/maintenance of medical devices, instrument reprocessing, and cleaning and disinfection—to name a few—are critical. This is how IPs know what they are doing when they observe practices so they can assess whether there are any gaps and provide education and training, if needed, to help drive down HAIs. IPs don't have to do this alone. Infection prevention and control is a team sport. When IPs share what they know with other health care personnel (HCP), they are helping to build their team of knowledgeable participants. HAI reduction needs to be on the minds of everyone who touches a patient. IPs can be the coaches to lead the way. IPs don't have to start from scratch with resources to share with HCP because the Centers for Disease Control and Prevention (CDC) has a done the work for IPs, providing a good starting point that IPs can use as is or tweak to fit their facility and its needs.

What We Know

HAIs can spread in health care settings from patient to patient via the unclean hands of HCP, unclean equipment, improper use or reuse of equipment, or they can be associated with the devices used in medical or surgical procedures. They can be localized or systemic and involve any system of the body. They can happen in any health care facility—hospitals, ambulatory surgical centers, end-stage renal disease facilities, and long-term care facilities—making them a huge concern in health care. They have serious emotional and medical consequences and are a significant cause of illness and death.

The CDC estimates that on any given day, 1 in 31 hospital patients and 1 in 43 nursing home residents have an HAI.² According to CDC data from 2020, there are about 1.7 million infections and 99,000 associated deaths each year.³ If the number of infections or death toll didn't raise an eyebrow, maybe this will: HAIs cost the US health care system about $96 billion to $147 billion annually.4 Nevertheless, these infections are considered preventable.

In order of occurrence, the most common types of HAIs are catheter-associated urinary tract infection (CAUTI) at 32%; surgical site infection (SSI) at 22%; ventilator-associated pneumonia at 15%; and central-line associated bloodstream infection (CLABSI) at 14%.³

HAIs are commonly caused by antibiotic-resistant bacteria, which can lead to sepsis or death. One in 7 catheter- and surgery-related HAIs in acute care hospitals and 1 in 4 catheter- and surgery-related HAIs in long-term acute care hospitals are caused by any of 6 antibiotic-resistant bacteria (not including Clostridioides difficile). These 6 bacteria are among the deadliest antibiotic-resistant bacteria, identified as urgent or serious threats by the CDC: carbapenem-resistant Enterobacteriaceae (CRE), methicillin-resistant Staphylococcus aureus (MRSA), extended spectrum ß-lactamases (ESBL-producing Enterobacterales), vancomycin-resistant enterococci, multidrug-resistant Pseudomonas, and multidrug-resistant Acinetobacter.⁵ Unfortunately, the number of multidrug-resistant organisms (MDROs) continue to increase, raising worldwide concern.

Prevention Efforts

Hospital-based programs of surveillance, prevention, and control of HAIs have been in place since the 1950s¹—yes, you read that correctly, over 70 years—and we keep developing new strategies with new names, slowly making progress. The Study on the Efficacy of Nosocomial Infection Control Project from the 1970s showed nosocomial rates could be reduced by 32% if infection surveillance was coupled with appropriate infection control programs. In 2005, the National Healthcare Safety Network was established with the purpose of integrating and succeeding the previous surveillance systems at the CDC: National Nosocomial Infections Surveillance System, Dialysis Surveillance Network, and National Surveillance System for Healthcare Workers. In 2008, the US Department of Health and Human Services (HHS) identified the reduction of HAIs as an "agency priority goal."⁶ HHS committed to reducing the national rate of HAIs, creating the 2009 National Action Plan to Prevent Health Care–Associated Infections: Road Map to Elimination, released in April 2013.⁷ This HAI Action Plan provided a road map for preventing HAIs in acute care hospitals, ambulatory surgical centers, end-stage renal disease facilities, and long-term care facilities, and for implementing antibiotic stewardship efforts as a method of HAI prevention. The HAI Action Plan also included a chapter on increasing influenza coverage of HCP, which was long overdue.

This HAI Action Plan was updated again in 2016, with new targets for the national acute care hospital metrics data from 2015 as a baseline, which were in effect 2015 to 2020. These new targets replaced the previous targets that expired in December 2013. The new target 2016 HAI Action Plan goals, which HHS states are "ambitious, but achievable" for reduction of HAIs include the following⁸:

• reduce CLABSI in intensive care units and ward-located patients
• reduce CAUTI in intensive care units and ward-located patients
• reduce the incidence of invasive MRSA HAIs

• reduce hospital-onset MRSA bloodstream infections
• reduce hospital-onset C. difficile infections
• reduce the rate of C. difficile hospitalizations
• reduce SSIs

Resources

The CDC website has a section called "Infection Control Assessment Tools⁸" under its HAI section that constitute the basic elements of an infection prevention program designed to prevent the spread of infection in different health care settings. These assessment tools are broken down by type of health care setting—acute care (including long-term acute care), long-term care, outpatient, hemodialysis, and oncology. Each assessment tool for the different health care settings is a bit different because different health care settings have different populations, practices, and procedures. When these basic elements are part of an infection prevention and control program and are practiced consistently—with consistency being key—the risk of infection among patients and HCP is reduced.

The assessment tools break down infection prevention practices into domains of practice, such as hand hygiene (HH), PPE, instrument reprocessing, and SSI prevention, where a templated set of questions can be used to perform a gap analysis to determine training, competencies, policies, and procedures. IPs should be familiar with these and use them, as they are readily available so they don't have to reinvent them. In addition to these assessment tools, there are others under the CDC's "Preventing Healthcare-Associated Infections" section9 that IPs should at least review or know if they cover any of these specific settings:

Urine culture stewardship is a method to ensure urine cultures are performed only when appropriate indications are present to determine whether treatment with antibiotics is indicated—think catheter-associated asymptomatic bacteriuria vs CAUTI. This section includes diagnosis and treatment guidelines from the Infectious Diseases Society of America.⁹ Institutions that have implemented urine culture stewardship programs have reported a decreased number of total urine cultures ordered, inappropriately treated ASB cases, costs related to overtreatment of ASB, and CAUTIs.10 Because CAUTIs are the No. 1 HAI (32%), IPs should provide education on the importance of this program because it works.

The targeted assessment for prevention strategy uses voluntarily submitted data from facilities or targeted units that may be struggling with HAIs. It includes an assessment of gaps in HAI prevention and can recommend opportunities for improvement from the experts at the CDC. Single-person IP departments struggling to get ahead of HAIs might wish to consider contacting the CDC for help.

Prevention tool kits have resources to assist clinicians, administrators, and health department personnel with preventing infections in nursing homes, assisted living facilities, and other long-term care facilities. There are tool kits for dialysis, acute care MDRO control, environmental infection prevention for surfaces and water, CRE, norovirus, vancomycin-resistant S aureus, and CLABSI. An example of 1 nice resource in this tool kit is a very detailed inter-facility transfer form with patient-specific details, such as MDRO history, devices present, transmission-based precautions status, antibiotic usage, vaccination status, and sending/receiving facility contact information. All valuable information for the IP and receiving unit.

Basic infection control and prevention plan for outpatient oncology settings is an amazing section that should be titled "Everything an IP Needs to Know for An Oncology Setting." It covers the basics from HH and PPE to access and maintenance of long-term central venous catheters, and safe injection practices, with recommendations adapted directly from the Access Device Standards of Practice for Oncology Nursing and the Infusion Therapy Standard of Practice.¹¹ These are must-reads for IPs in this area.

Guide to infection prevention for outpatient settings: Minimum expectations for safe care is a summary guide of infection prevention recommendations for outpatient (ambulatory care) settings based on existing evidence-based guidelines from the CDC and the Healthcare Infection Control Practices Advisory Committee. It emphasizes the importance of standard precautions as the foundation for preventing transmission of infectious agents during patient care in all health care settings. It also speaks to HH, PPE, environmental cleaning, disease surveillance, respiratory etiquette, and injection safety, and it has a nice checklist to help with auditing an outpatient facility. It also has links to full guidelines and source documents for more details—1-stop shopping for IPs who cover this setting.

Tools for protecting HCP promotes patient safety through improved use of PPE by HCP. It has PowerPoint slides and posters on how to select PPE to limit the spread of contamination. It is a ready-made training document that can be shared with all HCP.

Educate and Encourage

IPs should work to create a team of highly engaged HCPs. They should educate and encourage the use of guidelines and tools that increase widespread adoption of best practices to prevent infections, such as the CDC resources and tools outlined above. IP-led infection control and prevention education and training to HCP should focus on proven methods to prevent HAIs:

• HH
• appropriate and safe PPE use
• appropriate and timely transmission-based precautions
• surveillance
• cleaning and disinfection of environment/medical equipment and devices
• decolonization and antibiotic stewardship programs

Remember, teams are usually built 1 member at a time, and not all members have the same strengths or beliefs. If available, recognize staff members or units that have worked hard to prevent central line infections and try to recruit them first. They have experience with success and would probably like to be on an IP's team to share what they know. Or an IP can start with the basics so they can build a strong foundation for team member buy-in⁵:

• Make sure HCP understand the importance of HH, transmission-based precautions and environmental/device cleaning and disinfection practices.
• Educate on the CDC guidelines for preventing infections using those prevention bundles.
• Promote data use to target prevention and improvements.
• Follow recommendations for preventing C. difficile and infections that can occur after surgery or that are related to single-use catheters.
• Educate on why IPs isolate patients and when it's appropriate to discontinue.
• Educate on antibiotics, including the importance of antibiotic-resistance patterns in a facility/area to improve antibiotic use; why prescribing antibiotics correctly is important; the role culturing plays in starting antibiotics promptly, reassessing 24 to 48 hours later, and when to stop antibiotic treatment.

IPs should not forget to include patients and their families as part of the team. Empower them by educating them on questions to ask regarding their care: ⁵

• If they have a catheter, ask daily whether it's necessary.
• If they are having surgery, ask their doctor how they prevent infections.
• Insist that everyone clean their hands before touching them and to clean their own hands often.
• Insist that everyone who enters their room wear PPE if it's required.
• Ask what their antibiotic is for and whether it is necessary.

The knowledge, tools, and resources are now available for organizations to make major progress in reducing rates of HAIs in their facilities. IPs should start building their teams to win the battle against HAIs.

SHARON WARD-FORE, MS, MT(ASCP), CIC, is an infection prevention consultant located in Chicago, Illinois. She is also a member of the Infection Control Today® Editorial Advisory Board.

References:

1. Custodio HT. Hospital-acquired infections. Medscape. Updated October 21, 2021. Accessed October 6, 2021. https://emedicine.medscape.com/article/967022-overview#a5
2. HAI and antibiotic use prevalence survey. Centers for Disease Control and Prevention. Accessed October 6, 2021. https://www.cdc.gov/hai/eip/antibiotic-use.html
3. Healthcare-acquired infections (HAIs). Patient CareLink. Accessed October 6, 2021. https://www.patientcarelink.org/improving-patient-care/healthcare-acquired-infections-hais/
4. Marchetti A, Rossiter R. Economic burden of healthcare-associated infection in US acute care hospitals: societal perspective. J Med Econ. 2013;16(12):1399-1404. doi.org/10.3111/13696998.2013.842922
5. Making healthcare safer. CDC Vital Signs. Accessed October 6, 2021. https://www.cdc.gov/vitalsigns/pdf/2016-03-vitalsigns.pdf
6. Healthcare-associated infections. US Department of Health and Human Services. Accessed October 7, 2021. https://health.gov/our-work/national-health-initiatives/health-care-quality/health-care-associated-infections
7. National action plan to prevent health care-associated infections: road map to elimination. US Department of Health and Human Services. Updated August 24, 2021. Accessed October 8, 2021. https://health.gov/our-work/national-health-initiatives/health-care-quality/health-care-associated-infections/national-hai-action-plan
8. National HAI targets & metrics. US Department of Health and Human Services. Updated August 24, 2021. Accessed October 7, 2021. https://health.gov/our-work/national-health-initiatives/health-care-quality/health-care-associated-infections/targets-metrics
9. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010;50(5):625-663. doi:10.1086/650482
10. Urine culture stewardship in hospitalized patients. Centers for Disease Control and Prevention. Reviewed May 9, 2019. Accessed October 12, 2021. https://www.cdc.gov/hai/prevent/cauti/index.html
11. Camp-Sorrell D, Matey L, eds. Access Device Standards of Practice for Oncology Nursing. Oncology Nursing Society; 2011.