Danielle Scheurer, MD, MSCR Division of General Internal Medicine and Geriatrics Hospital Medicine June 2014
Learning Objectives Know the financial and clinical impact of HAIs Know the top 4 HAIs (in frequency of occurrence) Know the public reporting of the top 4 HAIs Know the major prevention strategies for the top 4 HAIs
1 in 25 hospitalized patients will develop HAI 750,000 a year 75,000 attributable deaths Introduction Top 4: CAUTI, CLABSI, VAP, SSI
Public Reporting VAP, CLABSI, CAUTI, and SSI are all publicly reported CLABSI and CAUTI are both a part of Hospital Value Based Purchasing, which is a program that financially rewards or penalizes hospitals for performance (SSI will be added FY 2017) Most are used in various quality rankings (US News and World Report, Leapfrog, UHC, Consumer reports) Estimated that 2/3 are preventable
VAP Cost $45K per infection 250,000 annually ~15% of those on vents get VAP Mortality ~10% Increases ICU LOS (4-13 days) Organisms Strep, Staph H.Flu Gram negatives (pseudomonas, acinetobacter)
NIPPV Maintenance VAP prevention HOB >30 degrees Oral care (brush q12 and swab q2) Dedicated equipment Early extubation Sedation vacation daily (controversial)
VAP at MUSC Insertion: NIPPV widely available Maintenance: Bundle checklist and audits from EMR Removal: Daily sedation vacations, mobility Others: Goals, monetary incentives
VAP at MUSC
VAP at MUSC
CAUTI 25% of all inpatients have an indwelling catheter Most common HAI (about 1/3 of all HAIs) Cost $6K per infection Most common organisms (in order) Ecoli Candida Enterococcus Pseudomonas Klebsiella Enterobacter
CAUTI Prevention Avoid catheters Post operative removal within 24 hours Appropriate insertion and maintenance Condom catheters in males Appropriate indications for indwelling catheters Urinary retention bladder outlet obstruction Accurate I/O in critically ill Perioperative Sacral perineal wound healing in incontinent End of life care
CAUTI at MUSC Insertion Epic CPOE insertion indications, inserter letters for early infection, PCT and nurse training on technique Maintenance Bag below bladder, bladder scanners, pericare Removal: PACU standing orders Nurse removal protocol and bladder scanners Other: Goals, monetary incentives, weekly rounding, audit-feedback, absorbent pads, exception based reporting
CAUTI at MUSC
CAUTI at MUSC
250,000 a year in the US Costs $25K per infection Etiology of organism Skin Hub Blood Most common organisms CNS Staph aureus Enterococcus Candida Gram negatives CLABSI
Insertion bundle Skin prep, sterile technique, upper extremity Maintenance bundle Daily necessity, limit access Early removal Other CLABSI prevention Goals, incentives, audit-feedback, exception based reporting PICC-IV team access
CLABSI at MUSC Insertion Sterile technique, inserter letters for early infections Maintenance Bundle checklist and audit in EMR, daily CHG bathing, reducing line accesses Removal Daily line necessity, PICC team availability, automatic femoral line removal at 72 hours Other Goals, monetary incentives, exception based reporting
CLABSI at MUSC
CLABSI at MUSC
Surgical Site Infection Cost $12K per infection Epidemiology Staph aureus CNS Enterococcus Ecoli
Preop SSI Prevention Skin prep, clipping, CHG bathing Periop Antibiotics, OR traffic, air exchanges, temperature, SPD Post op Antibiotics, wound care
SSI at MUSC Preop Bathing in preop, patient education, resident skin prep incentive Periop Room traffic, temperature maintenance, antibiotic choice and timing Postop Wound care Other CUSP program with Hopkins, SPD
HAIs are a major cause of morbidity and mortality at MUSC (and elsewhere) HAIs affect the financial viability of MUSC through nonreimbursement (HAC) and Value Based Purchasing 2/3 of these are preventable! Hand Hygiene Key messages Don t put it in, Take it out, Meticulous maintenance care!
Bibliography http://www.cdc.gov/hai/vap/vap_faqs.html http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm http://www.cdc.gov/hicpac/cauti/002_cauti_toc.html http://www.cdc.gov/hai/bsi/bsi.html http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf http://www.cdc.gov/hicpac/pdf/guidelines/ssi_1999.pdf