Surgical Products: Can you discuss how new health care legislation could affect hospital protocols for preventing infection? How will this change the standards hospitals have in place for preventing infection?
Crosby: The Patient Protection and Affordable Care Act contains a national quality improvement strategy that includes improving patient health outcomes such as infection rates. The Act also requires public reporting of hospital-acquired infections to the Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS). As part of the effort to make infection rates public, hospital infection rates among Medicare patients will be reported on the U.S. Health and Human Services Department website by 2014.
One of the biggest changes for hospitals will be adherence to universal patient outcomes established by the federal government and mandatory reporting of infection rates. Currently, patient outcomes are established within individual hospitals or as part of state or regional infection reduction initiatives. A hospital may establish target outcomes for infection rates based on its own unique incidence. For example, infection control protocols may pertain primarily to reduction of infection rates associated with orthopedic surgeries, or in response to infections associated with a particular pathogen such as Clostridium difficile. Universal patient outcomes will require broader infection control initiatives within all hospital departments and these outcome measures will be standardized for all hospitals.
Similarly, universally mandated reporting of infection rates will require establishment of reporting protocols within hospitals that do not currently report, and changes in the type of reporting among those that do. Only 27 states require reporting of infection rates right now and infection reporting requirements such as the type, amount and frequency of data collected may vary from state to state. Infection prevention protocols and standards must be adapted to meet requirements for government-mandated outcomes and reporting requirements. While we don’t yet know what specific measures hospitals will undertake to meet these requirements, reporting alone will help infection control specialists quantify the problem and devise corrective steps where they are needed.
Surgical Products: How does new legislation/regulations affect what happens to a hospital/health care facility if a patient contracts a hospital-acquired infection? With CMS no longer reimbursing hospitals for “never events” – including SSIs/HAIs – how does this make infection prevention that much more important?
Crosby: The new law establishes incentives and financial penalties associated with patient outcomes. Hospitals receive financial incentives to improve quality of care for outcomes such as reduction of certain types of infections. Conversely, starting in fiscal year 2015, Medicare payments will be reduced by 1% to hospitals with high rates of hospital-acquired conditions such as infections. A “never event” is generally defined as a serious adverse event that is “reasonably” preventable. The term also applies to hospital-acquired conditions, such as infections. In 2007, the CMS began denying reimbursement for hospital-acquired conditions and does not reimburse increased costs of care due to a never event. In addition, those increased costs of care cannot be passed along to the patient, and some large health insurers also began to adopt the same criteria as CMS to deny coverage for never events. Essentially, that means that hospitals bear sole financial responsibility for never events. Reducing the incidence of hospital-acquired infections is becoming a financial necessity for hospitals.
Surgical Products: What are some of the main causes of HAIs – specifically surgical site infections?
Crosby: Microorganisms from the patient’s skin are the number one pathogen that causesbloodstream infections (BSIs) and surgical site infections (SSIs). And, there are approximately 780,000 SSIs each year with annual costs ranging from $3.2 to $10 billion. SSIs may also be caused by microorganisms within the patient’s body or by those that are external to the patient, such as microorganisms on a surgical instrument, operating room table or surgical staff member.
There are many factors that affect a patient’s risk for developing an SSI, such as the type and virulence of bacteria present, the type of surgical wound (for example, whether it is contaminated) and the patient’s underlying health condition. But one of the most important preventive measures against SSIs are removing or killing microorganisms on the patient’s skin and on any surface or person that comes into contact with the patient.
Several evidence-based guidelines address other critical preventative measures such as prophylactic antibiotic timing, preoperative skin antisepsis, hand hygiene and barrier measures such as using optimal drapes, masks and gloves to reduce the patient’s risk of developing an SSI.
Surgical Products: What types of technology/products can hospitals use to help them prevent these infections?
Crosby: The risk of developing a SSI varies greatly according to the nature of the operative procedure and the specific clinical characteristics of the patient undergoing that procedure. General measures to prevent SSIs can be organized into those directed at the patient’s preoperative risk factors and those that relate to perioperative management of the patient, so different technologies and products are used prior to, during, and after surgery.
According to data obtained from the National Nosocomial Infections Surveillance System (NNIS), Staphylococcus aureus is the leading cause of nosocomial infections, including SSIs, and the incidence of methicillin-resistant S. aureus (MRSA) strains is rising dramatically. Because these skin dwelling flora are so prevalent, it is imperative that proper recommended protocols for preoperative patient preparation be followed.
There are numerous studies demonstrating the effectiveness of alcoholic chlorhexidine in helping to reduce intravascular device-related infection rates as part of a bundled approach. A multi-center study published in 2010 by Darouiche et al in the New England Journal of Medicine showed an overall reduction of SSIs with the use of alcoholic chlorhexidine for skin antisepsis..
Another part of proper skin antisepsis recommended by the CDC is patient preoperative showering with chlorhexidine gluconate soap to reduce the number of microorganisms on skin prior to surgery. Hospitals can provide chlorhexidine soap to patients prior to admission for surgery. Preoperative showering along with skin preparation with alcoholic chlorhexidine provides cumulative antimicrobial effects.
Another key aspect is appropriate hair removal, which is one of the measures currently monitored as part of the Surgical Care Improvement Project (SCIP), an initiative developed by a partnership of nongovernmental and government organizations, including the American College of Surgeons, CDC, and CMS. Shaving with a razor can cause tiny abrasions in the skin that allow microorganisms to enter the surgical wound. When hair removal is necessary, clippers should be used instead of razors. Clippers should have disposable, single-use blades to reduce risks of cross contamination, and a fully submersible handle for thorough disinfection. Other important products used to help reduce the risk of SSI include drapes that offer good adhesion and barrier protection during surgery, as well as masks and gloves.
Surgical Products: How are these new regulations affecting CareFusion’s plans moving forward in offering facilities solutions for infection prevention?
Crosby: New legislation will require hospitals to adhere to universal patient outcomes and mandatory infection rate reporting. Currently, however, there are significant differences in the way hospitals measure and report outcomes such as HAIs. A study by Lin et al published recently in the Journal of the American Medical Association found substantial variation of central line-associated bloodstream infection (CLABSI) rates among hospitals. Rates of infection reported by infection preventionists also varied substantially from computer algorithm reference standards, suggesting significant variation in the application of standard definitions of CLABSI. Lin et al identified several factors that complicate standardized reporting, such as different culturing practices, quality of medical documentation and oversight practices.
Similar results were reported by Niedner in a study of CRBSIs occurring in pediatric intensive care units. This study published in the American Journal of Infection Control found that all infection control practitioners reported using the CDC’s definition of CRBSI, but none actually did. Unless definitions and measurement criteria are standardized, accurate comparisons among hospitals will be extremely difficult. CareFusion is in a unique position to support facility efforts to address HAI risk with products, research initiatives and collaborative relationships to help with standardizing definitions and reporting processes. For example, CareFusion offers tools such as the MedMined™ Data Mining Surveillance service to help infection prevention professionals with data gathering and analysis. This tool could be adapted to hospitals’ existing systems to help identify infections in a standardized way, using an algorithm. In the study by Lin et al, computer algorithms identified more infections than infection preventionists.
CareFusion also has established relationships with organizations such as the Infectious Disease Society of American (IDSA), the Society of Hospital Epidemiology (SHEA) and the Association for Professionals in Infection Control and Epidemiology (APIC) and could partner with these organizations to establish standardized definitions. In addition, CareFusion provides training and in-service education and sponsors continuing education for healthcare personnel. We anticipate greater need for education in regards to reducing infection rates and adopting infection prevention protocols and actively work with organizations to provide educational tools for the healthcare professional. We also fund research with the goal of improving patient outcomes. The new legislation may offer opportunities for new partnerships with hospitals willing to participate in research as part of the increased focus on infection prevention. We will continue to develop products with the goal of continuous improvement of patient health outcomes.
Surgical Products: Anything else our readers should know about new health care legislation and its impact on infection control?
Crosby: The effort to standardize definitions and reporting of HAIs is a major initiative, but we have been thinking about these issues for some time and have begun the steps to outline programs and products to assist the healthcare community. The potential benefit in improving patient outcomes is significant. We are looking forward to participating in this process.