Home / Cover Story / Pa.’s hospital-acquired infection battle

Pa.’s hospital-acquired infection battle

Richard Shannon, M.D.

By Christopher Guadagnino, Ph.D.

Pa.’s hospital community, although supportive of HAI public reporting in principle, criticizes PHC4’s presentation of HAI data as misleading and lacking scientific validity. The PHC4 reports have nevertheless been a catalyst for public debate and – with their reminder that HAIs occur in patients who came to a hospital to get well – add moral urgency to a variety of HAI prevention efforts in Pa. Those efforts include infection control programs at individual hospitals, regional collaborations and participation in national infection control initiatives.

Reporting and Counting HAIs

The Centers for Disease Control and Prevention (CDC) estimates that HAIs account for two million infections, 90,000 deaths and $4.5 billion in excess health care costs annually. For over 30 years, the CDC’s National Nosocomial Infections Surveillance (NNIS) System has collected HAI information voluntarily reported by hospitals and, using a standardized set of 13 types of HAIs, establishes a national risk-adjusted benchmark for HAI rates and invasive device usage ratios and feeds back aggregate data to hospital infection control practitioners to help guide prevention efforts.

Public reporting of HAI frequency is a relatively new phenomenon, and Pa. is one of only a handful of states that mandates some form of it. The PHC4 was authorized to collect HAI data by the 1986 legislation that created the council, while legislation in 2003 that reauthorized the council added language to clarify and refine a focus on HAIs, according to PHC4 Executive Director Marc P. Volavka.

Beginning in January 2004, Pa. hospitals were required to submit four categories of HAI data to PHC4 on a quarterly basis, using definitions established by the CDC. Reportable infection types included surgical site infection (SSI), and three device-related infections: central line-associated bloodstream infection (CLAB), ventilator-associated pneumonia (VAP), and foley catheter-associated urinary tract infection.

The choice of CLABs and SSIs as categories for public HAI reporting is endorsed by the CDC because of their frequency, severity, preventability of outcomes, and likelihood that they can be detected and reported accurately. But May 2005 recommendations to the CDC by the Healthcare Infection Control Practices Advisory Committee (HICPAC) warned that including HAIs other than these two types in a public reporting system may result in invalid comparisons of infection rates and be misleading to consumers. HICPAC noted that VAPs have substantial morbidity and mortality, but are difficult to detect accurately, while catheter-associated urinary tract infections are associated with lower morbidity and mortality, and monitoring them likely has less prevention effectiveness relative to the burden of data collection and reporting.

In a July 2005 Research Brief, PHC4 noted that Pa.’s 173 acute care hospitals reported a total of 11,668 HAIs in 2004, and that 1,793 of those patients – or 15.4 percent – died, compared to a mortality rate of 2.4 percent for patients who did not have an HAI.

Urinary tract infections were reported the most frequently (6,139), followed by CLABs (1,932), VAPs (1,335), surgical site (1,317) and multiple infections (945). Mortality rates were highest – 31.9 percent – for patients reported as having VAP, followed by a mortality rate of 25.6 percent for CLAB, 9.4 percent for urinary tract infection and 3.1 percent for surgical site infection.

The brief noted that $2 billion in additional hospital charges and 205,000 additional hospital days in 2004 “were associated with” hospital admissions in which HAIs occurred – which the brief said were probably underestimates because Pa. hospitals likely underreported HAIs, based on a steady increase each quarter in number of HAIs reported and submission disparities among hospitals.

In a November 2005 Research Brief, PHC4 said that Pa. hospitals billed Medicare an extra $1 billion in hospital charges to treat patients with HAIs in 2004, billed Medicaid $371.6 million, and billed commercial insurers $603.8 million. The brief noted that average charges for Pa.’s Medicare patients with HAIs were about $160,000, compared with about $32,000 for those uninfected, while the average charges for Medicaid patients were more than $391,000 for those with HAIs and about $30,000 for those without.

PHC4 plans to release a third HAI report shortly, says Volavka.

As of Jan. 1, 2006, PHC4 is requiring Pa. hospitals to report all HAIs, using CDC’s 13 body-site categories, e.g., urinary tract, surgical site, pneumonia, bloodstream, bone and joint, central nervous system, cardiovascular, gastrointestinal, lower respiratory tract, reproductive tract, skin and soft tissue, and systemic. Because the incidence is so small for infections of the eye, ear, nose, throat or mouth, PHC4 has agreed not to collect data on those, says Volavka.

While PHC4 has received seemingly universal praise for its pioneering efforts to collect and report statewide HAI data, the hospital and medical community regards the format of the HAI frequency and cost data reported so far by the council as misleading, and lacking clinical credibility and usefulness. A meaningful understanding of HAIs requires knowing what the risk of infection is in vulnerable populations, according to Paula Bussard, senior vice president, policy and regulatory services of the Hospital & Healthsystem Association of Pennsylvania (HAP). A statewide aggregate tally of reported HAIs using “hospitalization” as a unit of analysis, and using the entire patient population as the “denominator” is too coarse a methodology to yield scientifically valid conclusions about HAIs, she says.

Gross comparisons of mortality and cost between patients with HAIs and patients without HAIs are not meaningful, says Bussard, because they are blind to underlying patient conditions and do not factor out costs associated specifically with HAIs. Complex and often elderly patients have weaker immune systems, are more susceptible to HAIs, and are inherently costlier to treat, while the PHC4 reports compare mortality, length-of-stay, and cost of care between HAI and non-HAI patient hospitalizations without separating the impact of the infection from the underlying disease or condition that brought the person to the hospital, notes Bussard.

HAP has communicated its criticisms in detail to the council, and has also articulated them in an editorial co-signed by 14 medical directors and chief medical officers of hospitals and health systems throughout Pa., including University of PennsylvaniaChief Medical Officer and Senior Vice President P.J. Brennan, M.D., who is chair of HICPAC and co-chair of PHC4’s HAI advisory panel.

Because PHC4 used hospital billing data to identify diagnoses that may indicate the presence of HAI, and then used overall hospitalization charges when comparing HAI and non-HAI patients, its reports grossly inflated the cost of HAI in several ways, maintains HAP: by not factoring out other treatment costs in patients with HAIs (which are often considerable); by not factoring out infections that were suspected and treated without actually being present; and by using hospital charges instead of actual reimbursement amounts – while an earlier PHC4 report acknowledged that Pa. hospitals are paid by insurers, Medicare and Medicaid at significant discounts averaging 71 percent less than charges.

By adapting its hospital performance report approach to HAI reporting, PHC4’s “effort-neutral” use of billing code data won’t help consumers and purchasers make sound decisions for several reasons, believes Brennan. Billing code data do not adequately distinguish HAIs from community-acquired infections, and a patient’s additional length-of-stay in a hospital may not be attributable to an HAI, he says. VAP is particularly prone to being overcounted as a bona fide HAI, as many conditions can mimic it and clinical staff will treat it as an infection, Brennan adds, while SSIs are vulnerable to an undercount, as 50 percent of them occur after a patient is discharged from a hospital, and will only be captured if a patient is readmitted.

Good cost accounting will require drilling down to data at the individual patient case level, Brennan says, noting that a member of PHC4’s HAI advisory panel did a detailed comparison between all urinary tract infection case data and billing code data at one hospital, and found only a 17 percent concordance between the two sets of data.

Because Pa. was the first state in the nation to begin collecting HAI data, HAP notes that there are no clinically validated benchmarks yet by which one can evaluate hospital-specific data, and it likely will be several years until valid and reliable methods can be developed to effectively compare hospital performance along the measures collected. Given the public, purchaser, and clinical interest in HAI data, however, HAP wants PHC4 to publicly release hospital-specific data and provide all hospitals with a 45-day review period to validate and verify the data and to provide comment that would be included in any public release, such as whether a hospital has implemented evidence-based infection reduction activities, and whether the hospital had few, if any, HAIs given the nature of care provided at these facilities.

Volavka maintains that PHC4’s reports of aggregate HAI data accurately reflect what hospitals submitted, using CDC definitions, and he says PHC4 will continue to use hospital billing data for HAI cost estimates.

Since last quarter, PHC4 has begun to collect a widely accepted proxy measure for risk-adjusting some HAI data – “device days” – which was recommended by PHC4’s HAI advisory panel and supported by HAP. For device-associated infections, a rate per 1,000 device days is calculated – for example, number of CLABs per 1,000 central line catheter days – and stratified by unit type, thereby producing “numerators and denominators” that offer meaningful benchmarking, even though they do not account for all potential confounding variables.

Volavka wonders whether mandatory device day reporting will be useful because there are still a significant number of Pa. hospitals “that don’t believe they want to provide it,” and CDC’s device day reporting definition has so far yielded disparate data by giving hospitals wide latitude on data capturing methods and time intervals, with some hospitals sampling daily and others weekly.

Last December, PHC4 asked the state Department of Health (DOH) to take action against 21 hospitals for failing to comply with mandatory reporting of HAIs. Volavka says the council identified those hospitals as under-reporting HAIs by noting large discrepancies between reported numbers and average expected numbers – which were derived by forming five peer categories stratified by hospital admission size and determining an average number for each peer group. Other than the enforcement request for data reporting compliance, PHC4 does not share HAI data collection or analysis with DOH, says Volavka.

Several of those hospitals have thus far provided additional data to PHC4 or reconciled their numbers. For example, DOH looked in detail at one hospital on the list, which was short 18 HAI reports, re-faxed those reports to PHC4, then dropped off the list of under-reporting hospitals, according to Richard Lee, DOH’s deputy secretary for quality assurance.

Nine hospitals remain suspected of underreporting HAIs, and DOH has asked PHC4 to investigate each facility to obtain case-specific information that demonstrates actual lack of reporting, because DOH cannot pursue deficiencies based on statistical comparisons of actual and expected rates, says Lee. DOH can then cite a hospital for failing to comply with a regulation of another Commonwealth agency and, if a follow-up survey shows no correction, DOH can determine an appropriate sanction, such as a fine or licensure action – which would require a legal proceeding, adds Lee.

DOH does not itself have a regulation that deals directly with HAIs and they are not specifically a red flag for inspections, although DOH oversight may be tangentially related, e.g., enforcing safety standards during hospital construction that impact cleanliness and sterility, inspecting appropriate use and disposal of linens and gowns, inspecting appropriate cleansing and sanitizing of operating rooms, and following up on cases of inappropriate care that are discovered either through a complaint or chart sampling during scheduled inspections, says Lee. Even the Patient Safety Authority’s reporting system for serious events, incidents and infrastructure failures do not address HAIs, per se, Lee adds.

DOH does not plan to seek an HAI data-sharing arrangement with PHC4, although Lee adds the qualifier that HAI data collection is in its infancy. For now, he adds, DOH’s role is to enforce regulations and assist PHC4’s efforts to get better data.

Hospitals Take the Initiative

Paralleling PHC4’s public reporting activities are fresh efforts being launched by Pa. hospitals to reduce HAIs, often in conjunction with regional and national collaboratives that seek to implement practices proven to be effective, and to share results.

A fundamental rationale behind PHC4’s mandatory public reporting requirements is that “sunshine spurs improvement,” and Volavka has noted that mortality rates for coronary artery bypass graft surgery (CABG) in Pa. have dropped 48 percent in the past 10 years, mirroring the years of PHC4’s public reports of CABG mortality at Pa. hospitals, and outstripping improvements in states without public reporting.

Pressure from consumers and purchasers may be less significant an inducement to improvement than is generally believed, however, as hospitals are always examining their care processes and making quality improvements. Despite perennial accolades and praise for PHC4’s mission with each of its published reports, businesses and consumers over the years have scarcely made use of PHC4 report data in their purchasing and provider selection decisions (as Physician’s News Digest has previously reported https://physiciansnews.com/cover/1003.html), while hospitals and physicians have become the chief consumers of the council’s data for quality improvement efforts.

“With or without the public data, hospitals can implement effective infection control interventions. They have the expertise, and what needs to be done is well-established. What is needed is leadership support,” according to Brennan, who adds that “public exposure makes it imperative to get the data right.”

The challenge of effective infection control is also becoming increasingly important for hospitals because evolving medical technologies permit treating sicker and more medically complex patients, while the incidence of antibiotic-resistant bacteria is rising, says Bussard.

Pioneering efforts begun in 1997 by the Pittsburgh Regional Healthcare Initiative (PHRI) demonstrated that dramatic reduction in HAIs was possible. PRHI hosted forums of health care experts from a large number of hospitals in western Pa. who shared and implemented best practices, resulting in the Pittsburgh region posting a 55 percent reduction in CLABs between 2001 and 2004, according to PRHI Managing Director Peter L Perreiah.

For example, CLAB countermeasures taken by one participant in the initiative, Monongahela Valley Hospital, included using transparent dressings and Chlorhexidine to cleanse the insertion site and during dressing changes, according to Kathy Liberatore, RN, Mon Valley’s infection control manager. Since Jan. 2003, the hospital has had zero infections in its cardiac care unit and four in its ICU, which are below CDC benchmark rates, she notes. The hospital has had zero urinary tract infections and zero VAPs in those units for six consecutive months, she adds.

Highmark is collaborating with PRHI in what Perreiah dubs an “enlightened” pay-for-performance program aimed at reducing CLABS, in which Highmark will compensate hospitals for using best practice standards – adapted from PRHI’s working groups – of how to insert and monitor central lines, and for maintaining and reporting data back to Highmark, says Perreiah. Fifteen hospitals in southwestern Pa. are participating in the program, which started last July, Perreiah notes.

In another initiative, the rate of hospital-acquired, methicillin-resistant Staphylococcus aureus (MRSA) was reduced by over 85 percent at the inpatient surgery unit at the VA Pittsburgh Healthcare System’s main hospital, adds Perreiah, after two years of implementing real-time problem solving methods from the Toyota production system. The approach used floor-based consulting to standardize work flow protocols, identify problems as they occur, apply countermeasures to prevent their recurrence, and improve communication to spread the countermeasures rapidly throughout the unit. The MRSA reduction was accomplished despite a 50 percent increase in the number of surgical enhanced care beds, and the effort is now being rolled out in other units and at the VA’s long-term care facility, Perreiah notes.

A key obstacle to implementing a real-time problem-solving approach to infection control is the intense amount of leadership required to make it work. “There will be resistance by accountants to save money, and by staff who have to make the changes, while hospital administrators have to get physicians on board,” says Perreiah. The approach requires a unit-by-unit team agreement to efficiently review each infection and examine circumstances of care, care environment and staff activities in order to identify sources of infection. Information is fed back to physicians and nurses within 24 hours so that key personnel begin to understand that infections can be prevented, he adds.

As challenging as it is to implement a successful real-time problem-solving approach to HAI reduction, Perreiah believes it is more effective than other approaches, such as signing on to a national, programmatic intitiative that uses a “formulaic bundle of best practices” and leaves short the engagement of caregivers, while leaving the possibility that local conditions – e.g., an inadequate supply system, or a staffing instability such as heavy reliance on agency nurses or other circulating caregivers – can defeat its full implementation.

A problem with traditional surveillance work by infection control experts, says Perreiah, is that data are not collated and analyzed for trends in a timely manner – often quarterly – and follow-up is typically a “look in the rear-view mirror,” long disconnected from the occurrence of an HAI, and often after the patient has already been discharged. Traditional data collection requires examination of lab data and patient charts, and talking to caregivers to determine if an infection was attributed to care in the hospital, while that data typically gets reported in the aggregate and lose the specific case detail, he adds.

The traditional surveillance approach is becoming enhanced by electronic reporting capabilities, shortening the reporting time-lag sometimes to only a few days, and adding “granularity” to HAI reports, for example, by attributing surgery infections to a specific care unit, step-down unit, or outpatient unit, says Perreiah. That improvement must not be diluted by continuing to report aggregate data in quarterly meetings, and hospitals should be committed to review data on a weekly or bi-daily basis, Perreiah urges.

It is very difficult to eliminate HAIs solely through retrospective surveillance, and real-time problem-solving approaches in Pa. are challenging that approach, says Ken Segel, former director of PRHI, and a principal of Value Capture LLC and the Value Capture Policy Institute. “With a purely surveillance approach, you can get lulled to sleep if your infection rates are within the bounds of the CDC’s national and peer benchmarks, although it helps you make sure you’re not missing a serious outbreak, and it may reveal aggregate patterns that guide thinking about possible institution-based changes,” adds Segel.

A goal of zero infections is needed to spur an institution to react to each infection, Segel believes, and leadership is needed to make it clear that infection control is the duty of every health care professional. “Not only is zero possible,” says Segel, “But the gains of pursuing zero – figuring out how to do something really important together, systematically – are worth their weight in gold in continuing to build great organizations.”

The notion that “we gave it to them” adds a moral dimension to a hospital’s goal of eliminating preventable HAIs in patients, Segel adds.

A relatively new organization, Value Capture consults with leaders of health care institutions to help them investigate problems when they occur, with the people involved in the processes that broke down, and design solutions as soon as a root cause is attained, notes Segel. The approach requires leaders to say, “we own this,” and to set a goal of zero for the problems they are addressing, and rejects the urge simply to put more effort into how they’ve done things in the past, including epidemiological approaches to infection control, Segel explains. The company is currently assisting LifeCare Hospitals of Pittsburgh in efforts to reduce medication errors and workplace injuries, he adds.

Jolting conventional wisdom that HAI prevention efforts are costly to hospitals, and that hospitals lack sufficient financial incentive to pursue them, a program spearheaded by Allegheny General Hospital (AGH) Department of Medicine Chair Richard Shannon, M.D. has virtually eliminated CLABs and VAPs in one year’s time, and made an economic profit for the hospital by doing so.

Reviewing data from July 2002 to June 2003, Shannon noticed that the two intensive care units he oversees at AGH – the medical ICU and coronary care ICU – had 5.1 CLABs per 1,000 central-line days, which he says was lower than CDC’s benchmarks for comparable ICUs but higher than the regional average, and that 47 total infections occurred in 37 patients, 19 of whom died.

“Those data were totally meaningless for starting improvement efforts,” Shannon says, because they didn’t offer case-specific information. Shannon says an economic analysis revealed that AGH lost an average of $26,839 on every CLAB, calculated as actual cost minus actual payment, while a similar analysis revealed an average loss of $24,435 for every VAP.

“With a central-line infection, we lose money. If there is no infection, we make money. How much, depends on the DRG,” says Shannon. For example, he says the hospital makes roughly $10,000 in revenue per obesity surgery, but loses roughly $16,000 (in cost minus revenue) if that surgery results in an infection – yielding a comparative loss of about $26,000 per infection.

“A hospital CFO looking at this sees that infections are making people worse, not better. Plus, the hospital is losing money. That’s a compelling case for trying to prevent the infections,” says Shannon.

AGH physicians, nurses and housestaff applied a form of real-time problem-solving by attacking variation as the breeding ground for error, says Shannon, and coming to consensus on best practices for six specific conditions related to placing and maintaining the central line, and care related to ventilator-associated pneumonia. It took three months for the care teams to agree to do the six things the same way all the time, thereby eliminating chaotic and individualized variation which made it impossible to isolate the best processes, says Shannon. By explicitly stating the steps in the care process, he says, a team of care providers can detect a problem when it occurs, isolate which step was missed, and fix the problem when it occurs.

“We now do any one of those things 90 percent of the time, and all six things 30 percent of the time, so there is still variation – but we’ve seen good results,” notes Shannon: from FY 2004 to FY 2005, CLABs dropped from 49 to six, and VAPs dropped from 45 to eight. AGH has since rolled out the approach to six ICUs, involving about 200 physicians, and has shared it with other hospitals in southwestern Pa., as well as with hospital consortiums in New York, Minneapolis and North Carolina, Shannon adds.

Impressed by Shannon’s success at reducing HAI frequency and costs, PHC4 has partnered with the Pittsburgh-based Jewish Healthcare Foundation to fund demonstration project grants for hospitals to see if the experience could be translated to other types of infections, says Volavka. Six hospitals around the state were selected for the grants, and have agreed to report back to PHC4 what the actual treatment and costs were for patients who get an HAI, data which PHC4 plans to share publicly in some form, Volavka adds.

One of the grant recipients is Erie’s Hamot Medical Center, which since November 2004 has been using an infection control database system with data mining capabilities that let it track in real-time positive cultures indicative of a CLAB, according to Emily McCracken, MPH, Hamot’s hospital epidemiologist and director of infection control. Hamot uses the system as an aggregate database for all ICU patients; is implementing a series of interdependent, scientifically grounded steps called the central line bundle; and will undertake a financial analysis of the program, adds McCracken.

Another grant recipient is Allentown’s Lehigh Valley Hospital, which is focusing its efforts on reducing catheter-associated urinary tract infections, according to Deborah Fry, MT(ASCP), MBA, CIC, the hospital’s infection control practitioner. One-quarter of patients admitted to the hospital may require a urinary catheter as part of their care, and up to 30 percent of them may become infected, while such infections account for 40 percent of all HAIs, notes Fry. While Lehigh Valley Hospital has for years been implementing best practice guidelines – such as using a closed drainage system, aseptic insertion techniques, using catheters only in patients for whom such use is truly indicated, and minimizing the time a catheter is in place – Fry says the hospital is using the PHC4 grant to investigate the impact on infection rates and care costs of using silver alloy-coated catheters exclusively. Although the special catheters are significantly more expensive, Fry hopes the trial – which is scheduled to conclude at the end of this month – will demonstrate an overall cost savings to the hospital through fewer infections.

Ironically, Lehigh Valley Hospital was one of the 21 hospitals that PHC4 believed was underreporting infections and that it referred to DOH for failing to comply with mandatory reporting of HAIs. Fry says that part of the problem was a glitch in some of the hospital’s computer programs, which failed to recognize admission identification numbers when they changed from eight digits to nine digits, and that the hospital has reconciled the omissions and sent the additional data back to PHC4.

A third PHC4 grant recipient is Philadelphia’s Thomas Jefferson University Hospital, which is performing a rapid-cycle work flow analysis of the materials, insertion and care of catheters inserted through the skull to relieve pressure on the brain of severe stroke patients, several hundred of whom Jefferson treats each year, according to Jonathan Gottlieb, M.D., Jefferson’s senior vice president for clinical affairs. A well-defined team of neurosurgeons, intensive care nurses, OR personnel and infection control professionals meet regularly to review best practice literature and actual work flow details, with the goals of standardizing the process to reduce unintended variation, says Gottlieb. The team has agreed upon five or six changes in the process so far, such as using one type of clipper – the gentlest – for shaving the head during site preparation, and reducing the frequency of spinal fluid sampling from the catheter, and hopes to identify a dozen changes to standardize by the time the project concludes six months from now, he adds.

Pa. hospitals are also participating in a variety of regional and national HAI control collaboratives.

The Partnership for Patient Care, a new three-year initiative, is an expansion of the Delaware Valley Healthcare Council’s (DVHC) Health Care Improvement Foundation, which began five years ago as a regional medication safety project involving 65 hospitals in southeastern Pa. in collaboration with the Institute for Safe Medication Practices and ECRI – a nonprofit health services research agency, according to DVHC President Andrew Wigglesworth. The Foundation program provided participating hospitals with educational programs and tools, ongoing reviews of practices, and assistance in developing individualized action plans to adopt 16 “action goals” regarding institutional culture, infrastructure, clinical practice and technology, efforts which have produced a 22 percent aggregate improvement across the 16 measures, Wigglesworth adds.

DVHC’s new Partnership project will focus its first year on reducing SSIs and CLABs, by sharing evidence-based practices identified by the National Quality Forum among southeastern Pa.’s hospitals, says Wigglesworth. With technical assistance from ECRI, the project will implement a Failure Mode and Effects Analysis methodology – a proactive risk assessment process designed to map out care processes, isolate what factors contribute to the risk of developing an HAI, and design intervention measures – and will offer forums for hospitals to share results gleaned from the experience.

Independence Blue Cross (IBC) is interested in assessing and improving adoption of National Quality Forum’s safe practice measures, and was involved in designing the Partnership project’s goals, says I. Steven Udvarhelyi, M.D., IBC’s senior vice president and chief medical officer. IBC also provided a three-year grant of $1.25 million to support the project. While HAIs are not the only patient safety or health care quality issue, they are preventable and expensive sources of morbidity and mortality, and it is important to bring stakeholders – including health insurers – together in collaborative efforts to identify their causes and opportunities to prevent them, he notes. While it is not delivering the care, IBC is “promoting traction through financial and thought leadership” on HAI prevention, Udvarhelyi adds.

While IBC does not have definitive plans to factor HAI prevention into its pay-for-performance programs, it is looking for the right performance metrics and, to the extent there is agreement that HAIs can be used, it will explore doing so, says Udvarhelyi.

In addition to regional collaboration, hospitals throughout Pa. are participating in a number of statewide and national HAI collaboratives.

Pa.’s Medicare quality improvement organization(QIO), Quality Insights of Pennsylvania, shares with physicians, hospitals and other health care organizations best practices resource materials – developed by Pa. hospitals themselves – and has four clinical priority areas, one of which is working on surgical infection prevention.

VHA East Coast and VHA Pennsylvania, part of a national alliance of more than 2,400 not-for-profit health care organizations, have recently focused on providing education and best practices for hospitals to implement the rapid response team concept – a group of hospital experts that can be called to a patient’s bedside to detect subtle early signs of cardiac arrest, respiratory failure, shock or sepsis, with the goal of preventing the need for more extensive emergency clinical interventions.

The CDC is in the process of integrating three patient and health care personnel surveillance systems – including the NNIS System – into a web-based National Healthcare Safety Network, which will include modules that allow reporting of several device related infections, surgical site and post-procedure infections, and data around antimicrobial use and resistance, according to Bussard. Unlike the CDC’s current surveillance system, she adds, the network will allow any hospital to report information into the new system and to capture data electronically, while the CDC has indicated that data collected within the system could be shared with other agencies.

More than 2,800 hospitals nationwide – including 126 Pa. hospitals (roughly three-quarters) – have pledged to participate in the Institute for Healthcare Improvement 100,000 Lives Campaign, and are implementing some or all of six best practice interventions recommended by the campaign to prevent avoidable deaths, including:

· Preventing central line infections by implementing a series of interdependent, scientifically grounded steps called the “central line bundle.”

· Preventing surgical site infections by reliably delivering the correct perioperative care.

· Preventing ventilator-associated pneumonia by implementing a series of interdependent, scientifically grounded steps called the “ventilator bundle.”

· Deploying rapid response teams at the first sign of patient decline.

· Delivering reliable, evidence-based care for acute myocardial infarction to prevent deaths from heart attack.

· Preventing adverse drug events by implementing medication reconciliation.

Hospitals submit their results for the Institute to track and measure the progress of their efforts, while HAP serves as a hub for coordinating participation in the campaign with other regional collaboratives, says Bussard, including Quality Insights of Pennsylvania, VHA East Coast and VHA Pennsylvania. Each organization has taken the lead on one of the best practice areas, says Bussard, and HAP is coordinating learning sessions at which participating hospitals and their physicians, nurses and other clinicians come together to share best practices, how to reduce barriers that prevent improvements, and lessons learned.

Geisinger Medical Center in Danville has participated in the campaign for over two years and, by implementing metrics such as elevating a patient’s head 30 degrees and attending to respiratory hygiene, and has seen its VAP rate – which was never above national norms – fall by 60 to 70 percent, according to Bruce Hamory, M.D., chief medical officer of Geisinger Health System.

The Surgical Care Improvement Project (SCIP), initiated recently by CMS and CDC in partnership with QIOs and other organizations, seeks to coordinate care by teams of surgeons, anesthesiologists, perioperative nurses, pharmacists and infection control professionals, with the goal of preventing surgical complications. Among the project’s interventions is using prophylactic antibiotics within one hour of incision and discontinuing their use within 24 hours, normothermia control (keeping a patient warm after surgery), and other best practice measures to prevent SSIs.

Reducing the risk of HAIs is also one of the national patient safety goals for 2006 set by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), which evaluates health care quality in hospitals, nursing homes, ambulatory surgical facilities and other health care settings.

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