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Organizational issues for prevention of HAIs and the systemic nature of the problem

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You can't read anything about patient safety and quality or health reform without running into the topic of healthcare-associated infections (HAI). The issue tops a list of priorities for many health-related government institutions (e.g., Agency for Healthcare Research & Quality, CMS), nonprofit organizations (e.g., IHI, National Patient Safety Foundation), current research and publications, and patient advocacy groups. Popular media has recently been ­shining a light on the problem as well as the use of tools, such as checklists, as part of the solution for prevention.

Intense process improvement and research efforts in Michigan ICUs have gained a lot of ­attention for demonstrating significant reductions (and subsequent sustainability of those reductions) of HAIs. The work of Peter Pronovost, Atul Gawande, and others is quickly gaining traction. One of the troubling aspects of HAIs is the systemic nature of how they occur, the complex contributing factors, and the organizational issues of detecting and preventing them (not to mention their breadth of type and severity). HAIs are a problem wrought with cost and reimbursement pressures, challenges in allocating organizational resources, and care team performance factors.

Pressure and costs

Hospitals and other institutions are under obvious and immense pressure to improve quality and reduce costs. In fact, additional federal penalties and ­Medicare ­withholdings are anticipated on top of the current financial incentives to reduce infections. One of the current incentives in place-no CMS reimbursement for hospital-acquired conditions (HAC)-may not have been as strong of a penalty as initially thought due to certain coding mechanics. If a patient has any other complication or comorbidity not present on the HAC list, the hospital will still be reimbursed at a higher diagnosis-related group (DRG) rate.

That said, the hospital still incurs the cost of paying for the HAI, which can be extremely expensive. The average cost for a central line-associated bloodstream infection is $35,441-and this condition represents about 14% of HAI cases. As a comparison, catheter-associated urinary tract infections represent about 34% of cases, but the average cost per case is significantly less at $1,006.1 Ultimately, regardless of the cost, I think we can all agree that preventing an HAI is best for the patient.

It is becoming increasingly difficult for hospitals to allocate resources for data collection and organization in an attempt to evaluate the nature and extent of HAIs. Much of the information needs to be coordinated from direct observations (e.g., hand hygiene), laboratory administrative data, and clinical outcome data. There is sophisticated infection surveillance software available to support organizations, but these tools can sometimes pose issues with electronic health record integration and fragmentation of data. The costs of combing through data may rise as HAIs (hopefully) become less prevalent. Finally, the external reporting requirements (such as those required by CMS, the National Healthcare Safety Network of the Centers for Disease Control and Prevention, the ­National Database of Nursing Quality Indicators, and state departments of health) are a burden.

The importance of data

However, the data is what drives the clinical process improvement cycle. An organization that has real-time data has the power to adapt quickly and immediately modify actions at the bedside. Data that can be easily reported, interpreted, and evaluated in real time will become paramount for organization leaders to get the upper hand on HAIs. Latency in administrative data and resources required for observational data is a hindrance to timely action and response. Clearly, the goal is to be as proactive as possible, but good baselines and snapshots of current processes and rates are critical.

Interdisciplinary team performance and communication factors are also vital components in addressing HAIs. Nursing, physicians (or other advanced practitioners), respiratory therapists, radiologists, anesthesiologists, surgical services, peripherally inserted central catheter teams, sterile processing, environmental services, dietary staff, and administrative departments all play a collaborative role. The availability of information in real time is becoming much more of a requirement to drive best-practice care surrounding line insertion/removal, catheter care, selection of placement sites, and so forth. Information that implicitly guides the nurse with minimal education and training (photo and video) can be a powerful aid. Lastly, documentation of the care provided needs to be accurately done in real time and disseminated to all the members of the care team.

Interpersonal team performance is a big factor in prevention of HAIs. Each of the demonstration and research projects in which a checklist was utilized was heavily supported with team training (TeamSTEPPS® in many cases) or a program such as the Comprehensive Unit-Based Safety Program. The chaotic nature of the clinical environment leads to behaviors such as normalization of deviations, work-arounds, overlooking best practice, and complacency.

Nowhere are these challenges more clearly manifested than in hand hygiene practices. Team elements such as decision-making, mutual support, hierarchy, situational awareness, and divergent/convergent thinking all make an impact. These team dynamics are often not addressed during process improvement; however, they always present themselves in a root cause analysis.

The positive note for those working to prevent HAIs is the ever-growing body of research culminating in repeatable, scalable best practices that institutions can adopt. Although preventing HAIs may not be easy or immediate, demonstration projects with ­sustainable ­results prove that it is possible. This is good news as we march through the work it will take to get to zero harm.

1. U.S. Department of Health and Human Services' Action Plan to Prevent Healthcare-Associated Infections.