Nosocomial Infections - Research Paper Example

Running head: NOSOCOMIAL INFECTIONS Nosocomial Infections Cindy L. Robinson HCA375: Continuous Quality Monitoring and Accreditation Teresa Thomas October 3, 2011 Nosocomial infections or hospital acquired infections (HAI) have become a major concern in the United States, since it is associated with high morbidity, mortality and increased financial burden. According to the Agency of Healthcare Research and Quality (AHRQ), “hospital-acquired infections, are the most common complication of hospital care, resulting in 1.7 million infections and 99,000 deaths each year” (2009). These infections are acquired by patients in a healthcare facility, while they are undergoing treatment for another medical condition. It has been estimated that nosocomial infections cost the country between $28 billion to $33 billion each year (AHRQ, 2009). Although there are many types of bacteria responsible for HAIs, the most common is methicillin-resistant Staphylococcus Aureus (MRSA). Studies have revealed that the number of hospital stays associated with MRSA tripled from 128,500 in 2000 to 368,600 in 2005 (Elixhauser & Steiner, 2007). Patients who contract nosocomial infections during their hospital stay have extended hospital stays and have a higher rate of death when compared to patients who do not contract these infections. Typically, these infections are associated with invasive medical devices and surgical procedures and therefore they commonly occur in the intensive care units of hospitals. Description of the Issue Based on current trends, about 5% to 10% of patients develop nosocomial infections during their hospital stay (Pharmaceutical Market Research, 2011). The four most frequently occurring hospital acquired infections are (Pharmaceutical Market Research, 2011): 1. Urinary tract infection – 35% 2. Hospital acquired pneumonia – 15% 3. Surgical site infections and – 14% 4. Blood stream infections – 10% Among these infections, the infection of the lower respiratory tract and bloodstream are more fatal. In the United States, the current trend reveals that 2.4 cases out of every 100 hospital admissions would acquire urinary tract infection while 1 out of every 100 hospital admissions would acquire pneumonia during their hospital stay (Eriksen, 2005). Again, 2.8 cases out of every 100 operations would contract surgical site infections (Eriksen, 2005). One of the important facts about HAIs is that over the years, the infections caused by gram-positive bacteria like staphylococcus aureus and enteroccoci have increased significantly (Pharmaceutical Market Research, 2011). Several of these gram-positive bacteria have also developed resistance towards many of the antibiotics that are currently available in the market. Although majority of the HAIs are caused by gram-positive bacteria, there has been a significant rise in the prevalence of nosocomial multi-drug resistant, gram-negative bacteria like extended-spectrum beta-lactamase producing E-coli, K. pnemoniae and certain strains of P. aeruginosa and A. baumannii (Pharmaceutical Market Research, 2011). Major Stakeholders Involved in Addressing Nosocomial Infections There are numerous stakeholders who are involved in addressing the quality issue regarding nosocomial infections: Federal and State Governments At the federal level, the Department of Health and Human Services ensures patient safety through the Agency of Healthcare Research and Quality (AHRQ). The AHRQ implements preventive evidence-based practices and collects and distributes various healthcare quality measurements through the Center for Quality Improvement and Patient Safety. The Centers for Disease Control and Prevention (CDC) is a federal body that has been surveying nosocomial infections through its National Healthcare Safety Network. Currently it has more than 300 hospitals registered across the country for the purpose of conducting surveillance of nosocomial infections. Non Profit Organizations The National Quality Forum (NQF) is a non-profit organization which aims to improve the healthcare quality across the United States of America by providing education and outreach, endorsing of national quality standards and developing and implementing performance improvement programs. The NQF has developed a list of twenty eight events that can compromise health care quality and should therefore never occur in a health care organization. Healthcare Organizations Healthcare organizations in the country are required to report forty two measures of quality to the Centers of Medicare and Medicaid Services. They also have to report certain medical errors, including hospital acquired infections, so as to receive complete payment update for rates for the next year. Again, each organization has to ensure that all their personnel follow the protocols pertaining to the prevention of HAIs. For e.g. I work in a long term care facility. As part of the protocol, we are required to wear personal protective equipment and follow strict guidelines. In case a patient has MRSA, we are required to treat the patient within his/her room and use masks, gloves and gowns. We are also required to dispose these items properly before leaving the patient’s room. It is also mandatory to have a TB test annually. Insurance Companies The State Medicaid programs of four states in the country have attempted to improve patient safety and overall quality in healthcare by publicly announcing that they would not reimburse providers for events listed in the NQF list. The federal government has identified ten “reasonably preventable conditions” and has announced that it would not pay for them as a measure to promote patient safety and health care quality. These ten conditions include few hospital acquired infections as well. Patients Patients have a big role in reducing nosocomial infections. They can do this by strictly adhering to the prescribed medications and completing the course of medications without fail. This simple act would significantly reduce the occurrence of antibiotic resistant bacteria. Quality Improvement Strategies Adopted by Health Care Organizations Healthcare organizations across the world have adopted several types of quality improvement strategies to improve healthcare quality outcomes. They include: Clinician Education Clinician education programs with respect to quality improvement include conducting workshops and conferences, educational outreach visits like academic detailing and distribution of educational materials. Some of the important aspects regarding quality control that are covered in clinician education programs are hand washing, appropriate use of perioperative antibiotics, shaving of the operative site and improving perioperative glucose control. Data regarding the compliance to these preventive interventions are collected before and after conducting clinician education programs. The corresponding data for infection rates are also collected and compared. Such a study conducted in a tertiary care university hospital in Israel revealed that the infection rate drastically reduced from 4.2% of cases before clinician education to 0% of cases after clinician education (Borer et al., 2004). Patient Education Patient education programs include holding classes that focus on educating the patient and their family on the various methods of preventing HAIs. Information can also be given thorough pamphlets. These education programs also provide important strategies that encourage self-management of chronic conditions. Data regarding compliance to these preventive interventions are collected before and after conducting the patient education programs. The outcome would be lesser rates of HAIs especially as patients adhere to the prescribed treatment plan and medications as it would significantly reduce antibiotic resistant strains of bacteria. Audit and Feedback As part of this strategy, individual providers are audited and provided feedback on their performance with respect to appropriate use of perioperative antibiotics, decreased use of these drugs and improving perioperative glucose control. This project also helps to develop a benchmark, wherein the outcomes data of top performers is made available so that individual provider can compare their own data to it. The performance data may also be made public. Data regarding compliance to the set standard of prescription and use of perioperative antibiotics is collected periodically and a report on compliance rate is generated for each provider. The outcome for this project would include increased physician compliance to the prescription of perioperative antibiotics. Studies conducted at multiple hospitals in the United States have revealed that there was a 56% change in physician’s adherence to administering perioperative antibiotics for appropriate duration and 15% change in adherence to appropriate timing of perioperative antibiotics (Ritchie et al., 2004). Clinician Reminder Systems As part of this strategy, providers are assisted with computer based reminders and computer based decision support to make appropriate choices regarding the use of perioperative antibiotics. Data with respect to compliance to the set standard of prescription and use of perioperative antibiotics is collected periodically and a report is generated for each provider. The outcome includes increased physician compliance to the prescription of perioperative antibiotics and decrease in infection rate. Studies conducted at multiple hospitals in the United States have revealed that the adherence to appropriate timing of perioperative antibiotics changed from 20% before the reminder system was implemented to 57% after the reminder system was implemented (Jacques, et al., 2005). The infection rate also reduced from 1.1% of cases before implementation to 0.7% of cases after implementation of the reminder system (Larsen, et al., 1989). Organizational Change This strategy involves skill mixing, increased staffing, changing from paper-based to computer-based record keeping, multidisciplinary teams, implementing cycles of quality improvement, disease management and total quality management. Interventions would involve washing hands prior to any procedure, using full barrier precautions, cleaning around the insertion site with chlorhexadine and removing unnecessary catheters. In one study, nurses were empowered to stop a central line insertion (in non-emergency situations) if providers did not comply with evidence based infection control practices. Data with respect to infection rates prior to the implementation of intervention and post intervention are collected. Studies conducted at multiple hospitals in the United States have revealed that the median infection rate with respect to central line associated blood stream infections reduced from 2.8 per 1000 catheter days to 0 per 1000 catheter days (Pronovost, et al., 2006). Financial and Regulatory Incentives for Patients or Clinicians This strategy focuses on reducing HAIs and increase patient safety by providing incentives to providers, patients or the health system. Four states in the U.S. have adopted the “never events” listed by the NQF, and have developed incentive systems that aim to improve quality with respect to reduced HAIs. A study conducted in a tertiary care hospital in Taiwan provided financial incentives to nurses for maintaining high quality standards within the organization (Won, et al., 2004). The outcomes observed was a greater adherence to hand washing procedures, which increased from 43% to 81% and a corresponding decrease in infection rate. Another study focused on regulatory incentives by providing continuing education credits to nurses for attending educational meetings regarding ventilator care, neurologic assessment, oral care and hand washing. Implementation of these programs was found to reduce the rate of ventilator-associated pneumonia from 17 per 1000 ventilator days to 5 per 1000 ventilator days. Potential Barriers to Quality Improvement in Healthcare System Although the quality improvement strategies discussed above are very practical, there are several barriers in the current healthcare system that makes it difficult to implement: 1. While hand hygiene is a very important measure to avoid HAIs, it is a very dull and repetitive solution and many nurses and physicians tend to skip this important aspect. Some of the common barriers to provider’s compliance to hand hygiene guidelines include lack of access to hand washing sinks, insufficient time, skin irritation, ignorance about the issue and individual habits (Haas & Larson, 2008). 2. Proper disposal of infected materials is also an important requirement to avoid HAIs. However, it is interesting to note that several providers are still careless about this very important aspect of quality improvement. I have worked as an occupational therapist assistant at Reliant Rehabilitation for nearly twelve years and for the last seven years, I have worked in a long term healthcare facility. In both these organizations, I have seen providers not follow proper protocol for the disposal of gloves. Very frequently, I have observed gloves on the floor of patient’s rooms and even in the hallways of the facility. 3. Auditing individual providers for compliance to appropriate use of perioperative antibiotics, making individual performance data public and use of reminder systems may sometimes be interpreted as intrusion into the provider’s work and lack of trust in them by questioning their judgment. These factors can demotivate the providers. Recommendations to Overcome These Barriers In order to overcome these barriers, I would make the following recommendations: 1. Hospital Administrator and the management should value and emphasize the need for proper hand hygiene and waste disposal measures since it has been found that compliance rates significantly depend on whether the leaders and managers value these quality improvement measures or not. 2. Departments which have been able to ensure zero HAIs in their patients should be recognized and awarded for their performance. This will ensure that all the providers and caregivers in the department are united in their approach towards ensuring patient safety and share the responsibility as a team to achieve zero HAIs. Conclusion In conclusion, Nosocomial infections have become a major concern in the United States due to the high morbidity, mortality and increased financial burden associated with it. Although there are many quality improvement strategies that healthcare organizations can adopt, the success of implementation of these strategies largely depend the management, healthcare providers and patients. Hospital acquired infections can therefore be prevented when all stakeholders feel responsible and take proper measures to curtail it. References Agency of Healthcare Research and Quality. (2009). AHRQ’s efforts to prevent and reduce healthcare-associated infections, Publication No. 09-P013. Agency of Healthcare Research and Quality. Retrieved from http://www.ahrq.gov/qual/haiflyer.htm Borer, A., Gilad, J., Hyam, E., Schlaeffer, F., Schlaeffer, P., Eskira, S., …Katz, A. (2004). Prevention of infections associated with permanent cardiac antiarrhythmic devices by implementation of a comprehensive infection control program. Infection Control and Hospital Epidemiology, 25(6), 492-497. Elixhauser, A. & Steiner, C. (2007). Infections with methicillin-resistant Staphyloccocus aureus (MRSA) in U.S. Hospitals, 1993-2005. The Healthcare Cost and Utilization Project. Retrieved from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb35.jsp Eriksen, H. (2005). Surveillance of nosocomial infections. Folkehelseinstituttet. Retrieved from www.epinorth.org/dav/4C7EAAFACA.ppt Haas, J.P., & Larson, E.L. (2008). Compliance with hand hygiene guidelines: Where are we in 2008? American Journal of Nursing, 108(8), 40-44. Jacques, P., Sanders, N., Patel, N., Talbot, T.R., Deshpande, J.K., & Higgins, M. (2005). Improving timely surgical antibiotic prophylaxis redosing administration using computerized record prompts. Surgical Infections (Larchmt), 6(2), 215-221. Larsen, R. A., Evans, R. S., Burke, J. P., Pestotnik, S. L., Gardner, R. M., & Classen, D. C. (1989). Improved perioperative antibiotic use and reduced surgical wound infections through the use of computer decision analysis. Infection Control and Hospital Epidemiology, 10(7), 316-320. Pharmaceutical Market Research. (2011). Stakeholder opinions: nosocomial infections: The need for new gram-negative drugs. Pharmaceutical Market Research. Retrieved from http://www.pharmaceutical-market-research.com/publications/diseases_conditions/ stakeholder_opinions_nosocomial_infections.html Pronovost, P.J., Needham, D.M., Berenholtz, S.M., Sinopli, D.J., Chu, H., Cosgrov, S., Sexton, B., …Goeschel, C. (2006). A multifaceted intervention to reduce catheter-related blood stream infections in Michigan intensive care units. New England Journal of Medicine, 355, 2725-2732. Ritchie, S., Scanlon, N., Lewis, M., & Black, P. (2004). Use of a preprinted sticker to improve the prescribing of prophylactic antibiotics for hip fracture surgery. Quality and Safety in Health Care, 13(5), 384. Won, S.P., Chou, H.C., Hsieh, W.S., Chen, C.Y., Huang, S.M., Tsou, K.I., & Tsao, P.N. (2004). Hand washing program for the prevention of nosocomial infections in a neonatal intensive care unit. Infection Control and Hospital Epidemiology, 25(9), 742-746. Read More