It should come as no surprise to most hospitalists that healthcare-associated infections (HAIs) are among the leading causes of death in the U.S. The Centers for Disease Control and Prevention (CDC) estimates that from 5% to 10% of hospitalized patients develops an HAI, which leads to nearly 100,000 deaths every year.
The big four infection categories are catheter-associated urinary tract infections (CAUTIs), ventilator-associated pneumonia (as well as non-ventilator-associated hospital-acquired pneumonia), central-line-associated bloodstream infections, and surgical-site infections. In addition, Clostridium difficile (C-diff) and methicillin-resistant Staphylococcus aureus (MRSA) infections add to the burden.
While the toll on patients is substantial, the financial burden is equally staggering. It is estimated that HAIs lead to $28 billion to $33 billion in excess healthcare costs each year. So what does this have to do with hospitalists? Everything.
National Efforts to Curb HAIs
The morbidity, mortality, and financial consequences of HAIs have not been lost on patients, payors, and policymakers; each group is demanding action. The Department of Health and Human Services (HHS) is coordinating a national effort addressing HAIs; it aims to bring together many of HHS’ agencies (CDC, Agency for Healthcare Research and Quality, National Institutes of Health, Centers for Medicare and Medicaid Services, etc.) and engage patients, payors, and care providers. As a show of support for these efforts, Congress provided HHS with more than $200 million to target HAIs. After much work, HHS released its action plan to prevent HAIs in January.
SHM was one of the organizations asked to comment on the prevention plan. We did.
- We supported HHS’ focus on process measures (rather than outcomes), which recognizes the inevitability of some HAIs;
- We asked to be more involved in the process of developing and implementing the action plan; and
- We specifically asked for hospitalist representation on the Healthcare Infection Control Practices Advisory Committee (HICPAC), which develops the guidelines and prioritizes national efforts targeting HAI prevention.
Wish granted. In June, I was invited to HHS’ offices in Washington, D.C., along with key stakeholders to hear details of the final plan of action and discuss implementation. The plan (www.hhs.gov/ophs/initiatives/hai/infection.html) addresses key HAIs, establishes baseline rates, and proposes five-year national targets for reductions in infections.
The National Quality Foundation (NQF) has endorsed most of the metrics. The targeted reductions seem reasonable, and they are mostly in line with current evidence on best practices.
Of note, HHS dropped ventilator-associated pneumonia as a target area because of feedback from stakeholders (e.g., SHM) who argued that current definitions of the condition were inadequate to allow accurate measurement of targeted performance improvement efforts. Also of note, SHM was offered a HICPAC seat, which will enhance our ability to further impact the development and evaluation of current and future metrics.
I was invited back to Washington in July to meet with Don Wright, MD, MPH, FAACP, HHS’ principal deputy assistant secretary for health. It’s obvious to me that HHS realizes that any effective campaign to reduce HAI incidence will require engaging hospitalists, and, interestingly, HHS has even heard from other professional societies that hospitalists are a key group to target if you plan to implement hospitalwide interventions that span the ED, hospital wards, ICUs, surgical patients, pediatrics, or any other nook or cranny in the hospital. Hospitalists and SHM appear to be at ground zero in the national effort to combat HAIs.
The Hospitalist’s Role
There are few medical conditions that impact more of SHM’s big tent of membership the way HAIs do. HAIs affect administrators, internists, family practitioners, pediatricians, physician assistants and nurse practitioners, nurses, residents, students, community practitioners, academics, and large management companies … the list goes on. Not surprisingly, efforts to combat HAIs will require teams composed of many of the groups highlighted above working together to create systems-based approaches in their own hospitals—in joint efforts to reduce the rate of preventable HAIs.
Take the most common HAI as an example: catheter-associated urinary tract infections. These infections affect patients in every hospital unit and are familiar to every care provider, regardless of background or practice setting. Administrators should care about CAUTIs in part because CMS no longer pays for a CAUTI when it complicates a hospitalization, but also because these infections adversely affect patient satisfaction. Efforts to reduce CAUTIs will need to address inappropriate catheter insertion, provide alternatives to catheter use (e.g., bladder scans), develop best practices for maintenance of necessary catheters, and facilitate timely removal of catheters no longer needed. Dealing with all of these issues will take a team-based systems approach.
I will not be surprised if hospitalists end up leading these initiatives across the country. Hospitalists will need to share best practices, collaborate in local or national initiatives, provide feedback to SHM and policymakers about what works and what doesn’t, and educate patients about HAIs and prevention. Every hospitalist in the country needs to understand the reasons HAIs develop, know strategies to prevent them, and work to implement these strategies in their hospitals.
Given the urgency, what can you expect next? The action plan is finalized, so HHS is turning its attention to implementation. HHS has reached out to SHM to see how we can get the word out to our members. Dissemination strategies include publication of key messages in The Hospitalist, the Journal of Hospital Medicine, Webinars, e-mail announcements, and presentations at our annual meeting.
And while HHS’ plan of action highlights the metrics, it does not provide detailed strategies to combat HAIs. Prevention tools will need to be developed, tested, and, if effective, disseminated. HHS has asked SHM to help in tool development and dissemination.
HHS will continue to work with CMS to align payment policies that incentivize prevention efforts, and SHM will need to follow these developments closely. In addition, AHRQ is dedicating substantial funds to support the development and dissemination of best practices to prevent HAIs.
HHS acknowledges we still have much to learn about HAIs and their prevention. I expect many hospitalists, as well as SHM, will be at the center of these initiatives. Healthcare-associated infections are a problem that can no longer be ignored. Prevention efforts need to be ramped up. Hospitalists around the country need to prepare to lead and champion these efforts. It is time to act. TH
Dr. Flanders is president of SHM.