Healthcare-associated- infections (HAIs) are associated with high morbidity and mortality, as well as high direct and indirect costs. Healthcare-associated infections include central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), surgical site infections (SSI), Clostridium difficile infections (CDI), ventilator-associated pneumonia (VAP), and healthcare-associated acquisition of multidrug-resistant organisms (MDROs) including methicillin-resistant Staphylococcus aureus.
The scope of the problem of HAIs is dramatic. On any given day, about one in twenty five hospitalized patients in the United States (U.S.) has a healthcare-associated infection; roughly 1.7 million HAIs are diagnosed annually in the U.S. While methodologies to assess cost lead to different cost estimates, the direct and indirect costs of HAIs are undeniably substantial. Direct costs from CLABSI have been estimated as high as $45,000 per episode, CAUTI estimates approach $1,000 per episode, and CDI costs may be in excess of $10,000. The direct annual costs of HAIs, estimated at ~$6-9 billion, rival the cost of stroke and exceed the costs of diabetic complications and chronic obstructive pulmonary disease (COPD). While statisticians and economists may debate methodologies to generate estimates, to the practicing clinician it is likely adequate to observe that that HAIs are very costly.
The stakes for hospital administrators, and by extension for hospitalists, are also significant. Given the high costs of HAIs, the Centers for Medicare and Medicaid Services (CMS) instituted a policy in 2008 of no additional reimbursements for healthcare-associated conditions (HACs) that are "reasonably preventable," including CAUTIs and CLABSIs. Further, since 2011 CMS has required reporting of HAI data to the National Healthcare Safety Network (NHSN) of the Center for Disease Control and Prevention (CDC). A majority of states also require public reporting of HAI data. Additionally length of stay, a key performance metric for many hospitalists, is unsurprisingly increased for patients with HAI; a CLABSI may increase length of stay by more than ten days.
The most common device-associated infections encountered by hospitalists are catheter-associated urinary tract infections (CAUTI) and central line associated blood stream infections (CLABSI). Ventilator-associated pneumonia (VAP) and surgical site infections (SSI) are less often encountered by hospitalists. The challenge for hospitalists is to identify healthcare-associated infections that may be present on admission (e.g., Clostridium difficile colitis), and to assist in the prevention of healthcare-associated infections.
II. Identify the Goal Behavior
When it comes to HAIs, the old adage "prevention is the best medicine" is of the utmost importance. Efforts to prevent healthcare-associated infections are multidisciplinary and should occur simultaneously in two general ways: vertically, i.e. through efforts to reduce colonization with, infection from, and transmission of particular pathogens; and horizontally: i.e. through efforts to reduce risk for infections generally that are neither patient nor pathogen specific. A hospitalist should be familiar with both vertical approaches utilized within their institution – e.g., active surveillance and testing with isolation for specific pathogens such as MRSA or vancomycin resistant enterococci (VRE) - as well as advocate for and participate in effective horizontal approaches, such as widespread and consistent hand hygiene, effective antimicrobial stewardship at an institutional and individual level, and thorough environmental cleaning.
For hospitalists, the most relevant device-associated infections are CAUTIs and CLABSIs, so we will focus on these below. It is also critical for hospitalists to be familiar with the surveillance definitions for HAIs. While surveillance definitions do not necessarily correlate with clinical diagnoses, as these definitions change with some frequency an awareness of current definitions will help a hospitalist most effectively document their clinical assessment of a patient’s condition. We will define HAIs here per current NHSN criteria; the reader should ensure that these definitions remain current.
III. Describe a Step-by-Step approach/method to this problem.
CAUTIs are defined as a patient who meets all three of the following criteria:
1) “Patient had an indwelling urinary catheter that had been in place for > 2 days on the date of event (day of device placement = Day 1) AND was either:
Present for any portion of the calendar day on the date of event
Removed the day before the date of event
2) Patient has at least one of the following signs or symptoms:
costovertebral angle pain or tenderness
3) Patient has a urine culture with no more than two species of organisms identified, at least one of which is a bacterium of ≥105 colony forming units/milliliter (CFU/ml).
To prevent CAUTIs:
1) Ensure that indwelling urinary catheters are being used only when indicated, and leave in place only as long as needed. Commonly accepted indications for use include:
Acute urinary retention or obstruction,
Accurate measurement of urine output in the critically ill,
To assist in healing of open sacral or perineal wounds in those with incontinence,
Patients requiring prolonged immobilization (e.g., unstable spinal injury, pelvic fractures),
Comfort at the end of life, and
selected peri-operative use, especially for surgeries of the genitourinary tract or adjacent structures, surgeries of prolonged duration or with anticipated large volume infusions or diuretic use, and for those surgeries requiring close monitoring of intake and output.
The duration of catheter placement has the most significant effect on the likelihood of a CAUTI. It is worth noting that interventions prompting catheter removal—e.g., by daily review of necessity, by multidisciplinary review, or electronic reminders—have been shown to reduce device days. Reflection on the part of the hospitalist as to the true medical necessity of continued catheter use (e.g., impact of monitored urine output to ongoing medical decision making) may allow catheter removal and decrease patient risk.
2) Ensure that urinary catheters are inserted by properly trained personnel using aseptic technique and sterile equipment. Properly trained personnel usually means nurses who have formal training and regular refreshers in catheter insertion. Medical students, residents, fellows and attendings should NOT be inserting catheters unless they have undergone formal training and have regular refreshers. Such training can frequently be accomplished in simulation centers.
3) Ensure systematic documentation of physician order for catheter, indication for catheter, date and time of insertion, name of person inserting catheter, daily documentation of catheter presence and maintenance care, justification for continued use or removal, and date and time of removal.
4) Ensure that indwelling catheters are properly maintained. This includes keeping the catheter system "closed" (i.e. don't remove the bag from the catheter, and replace the entire system if a "break" in the closed system occurs), maintaining unobstructed urine flow (i.e. keep the catheter from kinking, keep the bag below the bladder and off of the floor, and empty the bag at regular intervals), performing routine daily hygiene in patients with catheters (though meatal cleaning is unnecessary).
5) Other critical recommendations include:
Use alternatives to indwelling bladder catheters when appropriate (e.g., intermittent catheterization, or condom catheters in cooperative men without urinary retention or obstruction).
Do not routinely use antimicrobial/antiseptic impregnated catheters.
Do not perform routine screening of catheterized patients for asymptomatic bacteriuria.
Do not treat asymptomatic bacteriuria in catheterized patients except before urologic procedures.
Avoid catheter irrigation.
Do not use prophylactic systemic antimicrobial therapy.
Do not routinely exchange catheters.
CLABSIs are defined as meeting the following criteria:
a laboratory confirmed primary bloodstream infection (i.e. infection not attributed to a separate source)
a central line (an intravenous [IV] line terminating at or close to the heart or in one of the great vessels) was in place for at least two calendar days
a central line was in place on the day of or the day before the event
It is important to note that if a patient is observed or suspected to have injected into a central line and is subsequently found to have a bloodstream infection, this would be considered a lab-confirmed bloodstream infection, but not a CLABSI requiring NHSN reporting, provided that suspected injection through the central line is documented. Thus, if a patient is observed or suspected to have injected through a central line, it is critical that the hospitalist document that confirmed or suspected behaviour.
Numerous guidelines exist from a variety of organizations regarding strategies to prevent CLABSIs. In general, strategies for CLABSI prevention can be divided into routine preventive practices and special approaches for more unique circumstances. Generally accepted routine strategies include:
Developing and adhering to lists of indications for central line use.
Requiring education and training of personnel involved with central line insertion and maintenance.
Chlorhexidine bathing on a daily basis for all adults intensive care unit (ICU) patients.
Standardizing processes (e.g., by checklists, use of all-inclusive insertion kits) to promote aseptic technique at time of catheter insertion.
Using maximum sterile barrier protections (mask, cap, gown, and sterile gloves for those placing catheters, and full-body sterile drape of the patient) at time of insertion.
Performing hand hygiene prior to catheter insertion or use.
Preparing skin with alcoholic chlorhexidine at time of catheter insertion.
Avoiding use of the femoral site in obese patients if catheter placement is planned and controlled.
Using ultrasound guidance for internal jugular catheter placement.
Maintaining appropriate nurse-patient ratios, especially in ICUs.
Disinfecting catheter hubs, connectors, and ports before catheter access.
Removing of non-essential catheters.
Changing dressings at appropriate intervals (5-7 days for transparent dressings, or 2 days for gauze) or sooner when dressing is visibly soiled, loose or damp.
Replacing administration equipment not used for blood, lipids, or blood products for more than 96 hours.
Applying antimicrobial ointments for hemodialysis catheter insertion sites.
Ensuring appropriate CLABSI surveillance in both ICU and non-ICU settings.
When CLABSI rates remain high despite appropriate implementation of routine strategies, special approaches for use in particular units or patient populations may be considered. Some of these approaches may have unintended consequences, associated adverse events, and may have cost impacts as well that should be considered before implementation. Special approaches may include:
Using antiseptic or antimicrobial-impregnated catheters.
Applying chlorhexidine-containing dressings.
Using antiseptic hubs, connectors, cap protectors or covers.
Utilizing antimicrobial catheter locks.
Using weekly tissue plasminogen activating factor after hemodialysis for patients dialyzed through central line.
It is worth noting that since the publication of the last edition of this text that substantial progress has been made in reducing the incidence of CLABSIs. Thanks to the adoption of strategies like those listed above, between 2008 and 2014 CLABSIs were reduced by 50% nationwide. Clearly there is still work to be done, but such a reduction should be seen as encouragement that the problem is not completely intractable.
IV. Common Pitfalls.
In the area of CAUTI prevention, ensure indwelling bladder catheters are placed only when necessary and maintained only when truly needed. Routine screening of catheterized patients for asymptomatic bacteriuria should be avoided. Systemic antimicrobials should be not used as prophylaxis to prevent CAUTI. Catheters should NOT be used: as a substitute for nursing care for the incontinent, to obtain samples for urinalysis or cultures in those who can provide clean-catch samples on their own, or for prolonged post-operative duration without indication (e.g., urethral repair, prolonged effect of epidural anesthesia).
In the area of CLABSI prevention, ensure central lines are placed only when needed, and removed when no longer necessary. If a central line infection is suspected, removal should occur immediately (e.g., don't wait until the end of rounds to remove a line if the team decides during the beginning of rounds to remove a line). Any patient observed or suspected of injecting through a central line should be appropriately documented. Peripherally-inserted central catheters (PICCs) should not be used as a CLABSI reduction strategy. Systemic antimicrobials should not be used for the purpose of CLABSI prevention. Central lines should not be routinely replaced or exchanged, though lines placed under emergent circumstances may be considered for replacement.
Infection control and prevention is an inherently multidisciplinary process, and it is important for the hospitalist to view their role in this context. Multiple team members—including but not limited to physicians, nurses, infection control and preventionists, epidemiologists, microbiologists, pharmacists, administrators, and information technology specialists—should work together with the common goal of reducing the risk for healthcare associated infections. Understanding the ways that the members of this diverse group each contribute to the prevention of hospital acquired infections, and the role of the hospitalist within hospital processes, will make the hospitalist more effective in providing safe care to their patients. Personal adherence on the part of a hospitalist to aspects of an individual’s direct patient care that can influence the likelihood of a patient acquiring a hospital acquired infection—effective handwashing, appropriate antimicrobial stewardship, limiting placement and duration of use of central lines or indwelling urinary catheters, to name a few—will also improve patient safety by reducing healthcare-associated infections. Additionally, while there are some generalizable strategies that have been shown to be of benefit, local particularities make efforts at local improvements essential. As a hospitalist identifies potential strategies to reduce healthcare-associated infections, working with the infection prevention team to “Plan, Do, Study, Act” upon these ideas may yield exciting new findings and improvements.
V. National Standards, Core Indicators and Quality Measures.
The federal government's "Partnership for Patients" has identified eleven core areas of focus. Five of those areas are HAIs: 1) CAUTI, 2) CLABSI, 3) SSI, 4) Ventilator-Associated Events, including Infection-related Ventilator-Associated Complications, and CDI. In addition, the Joint Commission includes prevention of HAIs in its 2017 National Patient Safety Goals (NPSG):
NPSG.07.04.01 recommends implementing “evidence-based practices to prevent central line–associated bloodstream infections.”
NPSG.07.06.01 recommends implementing “evidence-based practices to prevent indwelling catheter-associated urinary tract infections (CAUTI)
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