Well-designed and executed health care infection prevention programs are successful in reducing device-associated infections such as CLABSI, CAUTI, VAP, and SSI and other invasive procedure-associated infections. They are also aimed at protecting patients and health care personnel from acquiring communicable diseases such as influenza and other respiratory virus infections, gastrointestinal illnesses, and infections with health care-associated pathogens such as CDI and MDRO (eg, MRSA,
) while receiving or giving health care. Infection prevention program activities can be divided into two main domains: surveillance for HAIs and prevention and control of HAIs.
Surveillance for Health care-Associated Infections
Surveillance is the process of collecting and analyzing data regarding HAIs and other health care-associated events to monitor trends in occurrence and to evaluate the effectiveness of strategies implemented to prevent adverse events and increase positive patient outcomes. Surveillance is the foundation of quality assurance, performance improvement, and prevention activities and is a major activity of the infection preventionist.
Surveillance for all HAIs is not feasible or necessary; thus, infection prevention program activities should include development of annual surveillance plans to prioritize surveillance activities based on the patient populations most at risk of adverse outcomes and that align with the overall quality improvement goals of the institution. Outcomes associated with high-volume and high-risk treatments and procedures should be considered for surveillance.
Surveillance plans must also accommodate federal and state HAI reporting requirements. The CMS value-based purchasing initiative is based in part on submission of selected HAI data to the NHSN, and facilities that fail to complete data entry into that system do not receive full reimbursement from CMS. Most states have also enacted laws requiring hospitals and other health care facilities to report certain HAIs. As of October 2017, 32 states have enacted laws mandating reporting of at least one HAI.15
The NHSN is a national HAI database maintained by the CDC and is the central repository of HAI data used to monitor national, state, and individual facility progress toward HAI reduction. It is also the system used to meet federal and state HAI reporting requirements. More than 17 000 health care facilities including acute care hospitals, LTAC hospitals, psychiatric and rehabilitation hospitals, dialysis centers, ASCs, and skilled nursing facilities participate in NHSN, and more facilities will enroll in the future as HAI surveillance expands to additional health care facilities.16
To track HAI occurrence over time at the national, state, and individual facility level, a standardized infection ratio (SIR) is used to compare the actual number of HAIs occurring at the state or facility level to the predicted number of infections, a risk-adjusted number calculated from NHSN aggregate data. The SIRs that are significantly higher than 1 indicate HAI occurrence worse than predicted, and SIRs significantly lower than 1 indicate HAI occurrence better than predicted. Because SIRs are based on risk-adjusted data, they have replaced the use of incidence rates as the preferred method to track and monitor trends in HAI occurrence over time.
Surveillance includes not only detecting outcomes (eg, HAIs) but also measuring compliance with processes implemented to achieve the desired outcome. Examples of HAI prevention processes that are typically measured to maintain or increase compliance include hand hygiene and influenza vaccination of health care personnel. Process measurement should be an integral part of HAI prevention efforts, and both outcomes and process surveillance data should be disseminated to facility staff, managers, and administrators to motivate further quality improvement.
Although surveillance activities are foundational to successfully reducing HAIs, the modern-day infection preventionist is increasingly burdened with surveillance-related tasks in response to reporting mandates and expansion of health care services and size of facilities. A 2015 survey conducted by the APIC determined that approximately 25% of infection preventionists’ work time is spent conducting surveillance, more than any other single task. This means that less time is available for participating in HAI prevention activities.17
Fortunately, technologic solutions such as installation of electronic medical records systems and development of automated surveillance algorithms have enhanced the efficiency and reliability of surveillance methods. These technologic trends are expected to continue to evolve and further enhance automated surveillance in the future.18
Prevention of Health Care-Associated Infections
Knowledge gained through HAI surveillance, outbreak investigations, and laboratory research has contributed to the dramatic evolution of HAI prevention science since the inception of infection control programs during the 1970s. Organizations such as the APIC and the CDC have developed evidence-based prevention guidelines based on that knowledge to improve patient safety by reducing HAI occurrence.
The Healthcare Infection Control Practices Advisory Committee (HICPAC) is a federal advisory committee that assists the CDC in the development of strategies to prevent device-associated infections and procedure-associated infections; reduce the prevalence of MDRO; prevent transmission of infectious agents among patients and health care personnel; and promote best practices in disinfection and sterilization, environmental infection control, and employee health. These evidence-based strategies are compiled into systematically reviewed guidelines containing multiple recommendations that should be practiced by all health care facilities to prevent HAI occurrence. The recommendations are categorized according to the strength of scientific evidence supporting the strategy or regulatory requirements (Table 49.4
Healthcare Infection Control Practices Advisory Committee categorization scheme for strength of evidence of recommendationsa
A strong recommendation supported by high- to moderate-quality evidence suggesting net clinical benefits or harms
A strong recommendation supported by low-quality evidence suggesting net clinical benefits or harms or an accepted practice supported by low- to very low-quality evidence
A strong recommendation required by state or federal regulation
A weak recommendation supported by any quality evidence suggesting a trade-off between clinical benefits and harms
No recommendation/unresolved issue
An issue for which there is low- to very low-quality evidence with uncertain trade-offs between the benefits and harms or no published evidence on outcomes deemed critical to weighing the risks and benefits of a given intervention
aData from Centers for Disease Control and Prevention.19
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