2013 marks a turning point in the way hospitals are held accountable for the prevention of healthcare-associated infections (HAIs). It has been known for some time that HAIs are a serious cause of morbidity, with 1 in 20 hospital patients in the U.S. acquiring one. That represents 1.7 million Americans and accounts for about 100,000 lives lost each year. On a personal note, my father died of an HAI after surgery in 2000.
Now, with the Affordable Care Act coming into full swing, hospitals must get serious about preventing HAIs. This presents a major opportunity for hospitalists. There are three ways that hospitals will be affected:
- Since 2008, hospitals have not been reimbursed at a higher rate for vascular catheter-associated infections, catheter-associated urinary tract infections (UTIs), or surgical-site infections when acquired in the hospital.
- Over the next few years, Medicare’s Hospital Value-Based Purchasing (HVBP) program will begin to pay hospitals more or less, depending on how they perform, on six HAIs.
- Beginning in October 2014, in a roll-up measure for hospital-acquired conditions (which include infections), the worst-performing quartile of U.S. hospitals will be penalized 1% of their Medicare inpatient payments (see Table 1, below).
There are six HAIs that will be increasingly tied to hospital reimbursement. Each can be partially or completely prevented based on sets of practices, or care bundles, that require teamwork both in the planning stages and at the bedside. And, of course, the single most important way to reduce the spread of HAIs is to clean your hands before and after each patient encounter.
Clostridium-Difficile-Associated Disease (CDAD)
It is likely that your hospital has some type of CDAD prevention program. Here are a few things to keep in mind for CDAD prevention:
- Avoid alcohol-based hand rubs, because they do not kill C. diff spores. Vigorous hand washing with soap and water is the best approach.
- Use clindamycin, fluoroquinolones, and third-generation cephalosporins judiciously, as their restriction has been associated with reduced rates of CDAD.
- Place patients with suspected or proven C. diff infection on contact precautions, including gloves and gowns.
Methicillin-Resistant Staphylococcus Aureus (MRSA)
This includes hospital-acquired MRSA bacteremia. This topic will be discussed in future columns. Approaches to prevention include hand hygiene, cohorting patients, effective environmental cleaning, and antibiotic stewardship.
Central-Line-Associated Bloodstream Infection (CLABSI)
Adherence to the central-line insertion bundle has been conclusively shown to prevent CLABSI. It will become a process measure for HVBP in the near future. Prevention measures include hand hygiene, maximal barrier precautions during insertion, skin antisepsis with chlorhexidine, avoidance of the femoral vein, and daily assessment for readiness to discontinue the central line (which should involve every hospitalist).
Catheter-Associated Urinary Tract Infection (CAUTI)
CAUTI has been mentioned frequently in this column, and for good reason: It is the most common HAI. Although the evidence supporting practices that prevent CAUTI is not as strong as for CLABSI, every institution should have a bundle of practices embedded in nurses’ and doctors’ workflow to prevent CAUTI (see “Quality Meets Finance,” January 2013, p. 31).
Surgical-Site Infection (SSI)
For the most part, SSI can be left to the surgeons and other operating room professionals. However, with increasing involvement of hospitalists in surgical cases, we must have an understanding of how SSIs are prevented. The World Health Organization surgical checklist (www.who.int/patientsafety/safesurgery) is a great starting point for any organization.
Ventilator-Associated Pneumonia (VAP)
For hospitalists who provide critical care, adherence to a VAP prevention bundle includes:
- Elevation of the head of the bed;
- Daily “sedation vacation” and readiness to extubate;
- Oral care with chlorhexidine; and
- Peptic ulcer disease and venous thromboembolism prophylaxis.
In 2009, the U.S. Department of Health and Human Services (HHS) launched an action plan to prevent HAIs. As part of this effort, the Agency for Health Research and Quality (AHRQ) created a comprehensive unit-based safety program (CUSP) aimed at preventing CLABSI and CAUTI. The effort also focuses on safety culture and teamwork. For those interested in participating, visit www.onthecuspstophai.org.
Another way to get involved is to work Partnership for Patients, a public-private partnership led by HHS (http://partnershipforpatients.cms.gov), if a team at your hospital is participating. The Partnership for Patients seeks to reduce harm, including HAIs, by 40% by the end of 2013 compared with a 2010 baseline.
Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at email@example.com.