Healthcare-associated infections (HAIs) are a scourge of every hospital, harming patients, increasing costs and length of stay, and burdening busy healthcare providers. Three main risk factors contribute to HAIs; understanding them is the key to prevention.
First: Patient Risk Factors
Patients with compromised immune systems (young, elderly, diabetic, cancer patients undergoing chemotherapy, etc.) are naturally at a higher risk for HAIs. There's no way to change a patient's age, of course, but some patients can be medically optimized (by assisting diabetics in managing their disease, etc.), which may help reduce their chances of catching an infection.
This is an ideal option for patients undergoing an elective hospitalization or procedure. One of the areas that has the best data on pre-admission optimization is the orthopedic implant community. Numerous studies have shown that medical optimization of diabetes, tobacco abuse, anemia and malnutrition can reduce the incidence of a post-operative infection.1
Proper medical management is ideal for many reasons but in most cases, it isn't possible. You wouldn't stop chemotherapy for a cancer patient based on the risk of an HAI, nor delay the transfer of a critically injured patient to improve his or her nutrition status. Despite medical optimization being ideal, it's only practical in some elective admissions and has limited utility.
Second: Iatrogenic Risk Factors
The second method is reducing patient exposure to interventions that can lead to infections. In concept, this is almost comically simple. For example, patients who don't have central lines can't catch a CLABSI and patients who don't have surgery can't get an SSI.
But, in practice, this can be trickier to implement.
Multiple studies have documented that reducing the frequency and duration of urinary catheters reduces CAUTIs.2 The appropriate use of antibiotics, especially for those at risk for C. diff, is also key. One study found that a 30 percent reduction in broad-spectrum antimicrobials led to a 26 percent drop in C. diff infections.3
Along the same lines, another option for reducing the risk of CLABSI is choosing a site associated with a lower risk of HAIs. For example, putting the central line in the subclavian vein instead of the femoral vein is associated with a reduced risk of HAIs.4
Reducing patient exposure to these elements can diminish the chance of infection. However, that risk can't be eliminated reliably. Let's face it, there will always be more "experienced" surgeons who insist on Foleys and most non-surgeons will always lean toward not putting needles into a patient's chest.
Third: Process Factors
Some patients have uncorrectable risk factors and require procedures that may contribute to HAIs. Fortunately, however, putting systems and processes in place is the biggest and most consistent impact that hospitals can have in reducing HAIs.
Dr. Pronovost's checklist for reducing CLABSI, developed as a tool to ensure that the proper steps were followed in the appropriate order, is one of the most impactful interventions. It tremendously reduced infections, improving patient safety and saving countless lives.5
Infections can be spread through the environment due to a process called vertical transmission. Vertical transmission occurs when a patient has an infection, checks out of a room and the next patient coming into that room is infected with that HAI. There are a variety of strategies for preventing vertical transmission of infections - thoroughly disinfecting rooms between patients, utilizing UV robots or using a variety of methods to clean hard surfaces more methodically.
That said, the vast majority of HAIs occur through horizontal transmission, when infections are spread across adjacent rooms between patients who are in the hospital at the same time. In almost every case, the root cause is transmission by healthcare providers, especially on their hands. This is the reason that every credible organization in the infection control community says that proper hand hygiene is the foundation of infection prevention and the most important thing providers can do to prevent the spread of HAIs.
Education and reporting by direct observation are widely used methods but have limited success. Let's face it, we're still having the same conversations we've had about hand hygiene for the past 150 years. Hospitals that are serious about reducing HAIs are installing electronic hand hygiene reminder systems coupled with systematic processes to ensure that clinicians clean their hands when they're supposed to.
Reducing healthcare-associated infections requires these three actions:
1. Medically optimize patients whenever possible to reduce their susceptibility to HAIs.
2. Reduce exposure to factors that increase the likelihood of acquiring an HAI, such as catheters, central lines and antibiotics.
3. Establish processes and systems to ensure a reduction in the spread of HAIs.
Chris Hermann, PhD, is the Founder and CEO of Clean Hands – Safe Hands. Dr. Hermann started and led the multi-institution research collaboration that developed the core technology utilized in the CHSH system. Over the last 12 years, he led investigators from Children's Healthcare, Georgia Tech, Emory School of Medicine, the GA Tech Research Institute and the Centers for Disease Control and Prevention. Dr. Hermann earned a PhD in Bioengineering, a MS in Mechanical Engineering, a BS in Biomedical Engineering with High Honors from the Georgia Institute of Technology and is an MD candidate at Emory School of Medicine.
References:
1. Alamanda, V. and Springer, B. (2018). Perioperative and Modifiable Risk Factors for Periprosthetic Joint Infections (PJI) and Recommended Guidelines. Curr Rev Musculoskelet Med, (June 4, 2018).
2. Meddings, J., Rogers, M., Krein, S., Fakih, M., Olmsted, R. and Saint, S. (2014). Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. BMJ QualSaf, 23(4), pp.277-89
3. Saint, S., Krein, S. and Stock, R. (2015). Preventing Hospital Infections: Real-World Problems. Realistic Solutions.. New York, NY: Oxford University Press, p.114.
4. Timsit, J., Bouadma, L., Mimoz, O., Parienti, J., Garrouste-Orgeas, M., Alfandari, S., Plantefeve, G., Bronchard, R., Troche, G., Gauzit, R., Antona, M., Canet, E., Bohe, J., Herrault, M., Schwebel, C., Souweine, B. and Lucet, J. (2013). Jugular versus femoral short-term catheterization and risk of infection in intensive care unit patients. Causal analysis of two randomized trials. Am J Respir Crit Care Med, 188(10), pp.1232-9.
5. Pronovost, P. and Vohr, E. (2011). Safe Patients, Smart Hospitals. New York: Plume.