4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections: A challenge for change

Abstract

Hala Fawal, MPH, MBA, CICView Large Image Figure ViewerDownload Hi-res image Download (PPT) A compilation of the richly complex and diverse science that has evolved within the field of health care epidemiology and infection control during the past 30 years comprised the program for the 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections held March 5-9, 2000, in Atlanta, Ga. The conference sessions were consistently informative, often thought provoking, and persistent in presenting us with challenges to change our thinking and vision for the future. Sponsored by the Centers for Disease Control and Prevention (CDC), and cosponsored by the Association for Professionals in Infection Control and Epidemiology, Inc (APIC), the Society for Healthcare Epidemiology of America, Inc (SHEA), and the National Foundation for Infectious Diseases (NFID), the Decennial Conference attracted more than 2500 attendees from the United States and throughout the world. More than 750 scientific presentations and abstracts were presented on a wide range of topics: those traditionally associated with health care–associated infections and infection control (eg, surgical site infections, bloodstream infections, and urinary tract infections), newer issues having an impact on infection control and infection prevention (eg, medical device reuse, biofilms, water quality, and measurement of cost-effectiveness), and controversies at the forefront of the practice of infection control (eg, control strategies for antimicrobial use, vancomycin-resistant Enterococcus isolation, and infection control dogma). This 4th Decennial Conference was not only a review of our current state of knowledge; it also presented a strong message for change. We, as professionals in health care epidemiology and infection control, are in the midst of change. Significant changes are occurring now in response to the public and decision-makers' demands for improved patient safety in health care. Additional change is forthcoming as we examine how we can measurably and effectively contribute to improving health care quality. We may need to reassess and repackage our roles and how we view our impact on patient health care quality and infection prevention for the future. What are the forces of change that are present and having an impact on our profession and our business? In her opening remarks, Dr Julie L. Gerberding, director of the CDC's Hospital Infections Program, set up several premises for the Decennial Conference. She described how health care and the practice of health care epidemiology have evolved during the past 4 decades as a result of “change drivers,” major forces that change societal perspectives and expectations. Currently, the change drivers affecting health care delivery are:1.The increasing emphasis on health care value purchasing2.The increasing complexity of the health care delivery system3.The rapidly changing and exigent information age These change drivers resulted in several themes that were highlighted throughout the Decennial Conference: (1) the need to measure value, prevention impact, and cost-effectiveness of our infection prevention activities, (2) the need to develop quality promotion and infection prevention activities across the continuum of the health care system, and (3) the need for further development of information networks, knowledge-based systems, and computer decision-support systems. It was through those themes that the challenges for change were presented. The Institute of Medicine (IOM) released a report in November 1999 entitled “To Err is Human,” which is already having an impact on the practice of infection control and prevention as we know it today.1Institute of Medicine To err is human. Advance copy. National Academy Press, Washington (DC)1999Google Scholar In the Decennial keynote address, Dr John Eisenberg, director of the federal Agency for Healthcare Research and Quality (AHRQ) (formerly the Agency for Healthcare Policy and Research), discussed the implications of the IOM report on health care quality promotion and patient safety. The report described the current state of health care delivery as a system in which medical errors and adverse events occur too frequently, which contributes significantly to patient morbidity and mortality. Much of the resulting discussion within the health care community and the media after the release of the IOM report has focused on medication and diagnostic errors. However, as Dr Eisenberg indicated in his address, “It's not just drugs or diagnostic errors, but also failure to order the right test in the first place. It's nursing procedure—simple things—like forgetting to pull the bed rails up. It's simple things like making sure the patient gets the right blood transfusion rather than somebody else's. And of course, it's infections in the hospital as well.” To respond to the IOM report, President Clinton and Vice President Gore charged the federal agencies with a stake in health care quality to provide a report to clarify what the government can do to address the problem. The Quality Interagency Coordination Task Force report was submitted to the president, who announced the elements of the federal response plan on February 22, 2000.2Quality Interagency Coordination Task Force Report to the president on medical errors: doing what counts for patient safety.http://www.quic.govDate: 2000Google Scholar Among the elements of the plan are requirements for:1.the creation of a national goal to reduce the number of medical mistakes by 50% during the next 5 years2.establishing a Center for Quality Improvement and Patient Safety at AHRQ3.developing a nationwide system of medical error reporting that includes both mandatory and voluntary components4.directing all health care facilities to have strong, clear, visible patient safety programs How is this changing our practice? Infection control professionals are being held accountable for providing proof that their prevention and intervention activities are successfully contributing to improving health care quality and patient safety. Integration of infection control programs into more broad-based programs designed to address patient safety and quality improvement may be imminent. Health care stakeholders, including the Joint Commission on Accreditation of Healthcare Organizations, the National Committee for Quality Assurance, the CDC, APIC, and SHEA, are all examining how to best promote their demonstrated scientific contributions to make an impact in improving patient care and promoting patient safety. The CDC's Hospital Infections Program has been addressing health care quality throughout its history of monitoring infections, developing evidence-based guidelines, and promoting clinical performance improvement at the local level. Dr Eisenberg described how the CDC's National Nosocomial Infection Surveillance (NNIS) system represents a model of success for developing and implementing voluntary systems for reporting adverse health events. A report published in the Morbidity and Mortality Weekly Report on March 3, 2000, illustrated a significant decline in device-associated infection rates in hospitals participating in the NNIS system from 1990-99.3Centers for Disease Control and Prevention Monitoring hospital-acquired infections to promote patient safety, United States, 1990-1999.MMWR Morb Mortal Wkly Rep. 2000; 49: 149-153PubMed Google Scholar The critical elements of the NNIS system that make it a model for other systems aimed at improving health care quality include (1) the use of standardized methodology, (2) targeted monitoring, (3) risk adjustment, (3) participation by trained professionals (ICPs), and (4) a link between the disseminated data and prevention efforts. Also forcing rapid changes in our hospitals and health care systems are societal demands for information exchange and improvements in information technology. In a Decennial Conference session that addressed the issues of health care information management, the developments that are changing our ability to access information were elucidated. The common message was that the control of information is central to the practice of infection control in this new century. Dr Walter Hierholzer described the changes occurring as health care systems develop needed health care-based information systems for quality promotion and infection prevention. Because our computer use in hospitals and health care systems at this time is often limited by many “stand-alone” systems, we need to identify our primary data needs (eg, pharmacy and laboratory) and integrate data and systems wherever possible (even if that integration is only partially complete). We need to develop systems to provide not only patient-specific information, but also to provide needed numerators and denominators and include components of error monitoring. Although our knowledge gap regarding intrinsic patient risk is more a problem of science than informatics, Dr Hierholzer challenged the audience to develop methods to use existing and changing data systems to gain a better understanding of patient intrinsic risk factors, which are largely responsible for contributing to the occurrence of infections and other adverse events and result in negative patient outcomes. Dr John Burke described how decision-support systems can greatly contribute to our efforts in quality promotion and infection prevention. “Decision support” refers to the use of computer technology to help reduce uncertainty in the clinical decision-making process. Critical to development of decision-support systems is integration of information systems within our health care systems. As described by Dr Burke, “Integration is the Holy Grail of clinical computing, and requires systems that allow individual departments and separate health care functions to communicate.” Currently, only 4% of US hospitals have the capacity for complete systems integration and decision support. Because many newly developed software and integration tools are coming on the market without proven track records, Dr Burke warned the audience to encourage potential purchasers of health care information software to visit another site where the new system is already operating to ensure that it can produce the desired results. Many problems that have traditionally been our focus for prevention and intervention efforts in infection control programs will undergo changes as we reevaluate our potential for impact. Dr Jean Carlet asked the question “Does ventilator-associated pneumonia (VAP) really affect patient outcomes?” In a comprehensive review of the literature, he described how VAP is a heterogenous disease. Early onset VAP, treated as soon as suspected, is associated with a low rate of mortality. Late onset VAP has been shown to be a result of different types of pathogens (eg, Acinetobacter and Pseudomonas species) and may be associated with increased mortality. Dr Carlet concluded that the impact of VAP on mortality may be overestimated as a result of limitations in study designs in assessing patient severity of illness. Past studies failed to adequately address case-mix problems, specifically, failures to control for persistent or worsening severity of illness throughout the stay in the intensive care unit. Recognizing our limited knowledge of the preventable impact of VAP and our questionable potential for intervention and prevention should encourage us to develop new paradigms for monitoring and addressing this problem in our critical care patients. How we address another problem familiar to infection control—improving compliance with hand hygiene—requires renewed assessment of where we can make changes to improve impact. Dr Elaine Larson provided a thorough review of hand ecology. She described studies that have contributed to our knowledge of how the skin flora of health care personnel is affected by hand care and hand hygiene products. Changes to be considered include incorporating the use of alcohol-based hand products and encouraging the use of suitable hand lotion products for health care personnel. Dr Larson concluded: More of the same is not better. More scrubbing, more brushing, more antiseptics are not necessarily better. Improved skin health is good for patients as well as staff. We need to minimize scrubbing and skin shedding. There are promising advances in technology with hand degermers, barrier creams, and new delivery mechanisms. And just because it feels good doesn't mean it's bad. Dr John Boyce described the studies addressing access to and acceptability of hand hygiene products and processes. Dr Didier Pittet challenged us to change the way we think of improving compliance among health care workers by moving the focus away from “handwashing” to increased emphasis on “hand hygiene” by using alcohol-based hand rubs or rinses. He described a systemic, comprehensive approach to improve hand hygiene compliance through institutional participation, feedback of hand hygiene compliance rates, and easing access to hand hygiene products. The consistent message from each speaker in this session is the need to change our thinking about hand hygiene issues based on a critical review of the evidence of the past 30 years. Change will occur as we take on new partners in our efforts to promote health care quality through infection prevention. Dr Richard Platt described how health maintenance organizations (HMOs) might be new partners. In his presentation, Dr Platt attempted to answer the question “Can managed health care help us manage health care-associated infections and should it?” He described the similarities between HMOs and public health systems: both address defined populations; both are responsible for overall health of its members (including preventive medicine); both have limited resources; both collect and use data to make decisions; and both are relatively information rich. By using data from ongoing CDC-sponsored studies, Dr Platt described several examples in which HMOs have already successfully collaborated with the infectious diseases community: (1) better management and compliance with guidelines for the prevention of Group B Streptococcus in neonates, (2) identification and public health reporting of patients with Mycobacterium tuberculosis, and (3) identification of surgical site infections posthospital discharge. HMOs may be able to provide many of the characteristics we are looking for to make systems improvements in health care delivery. They are able to assess the patients they cover, determine the services they offer, monitor outcomes of care across delivery sites, and intervene to improve care. Dr Platt concluded that managed care can help manage health care-associated infections by making infection control a priority, collaborating in epidemiologic research, enhancing surveillance and data management, and implementing control programs. However, APIC, SHEA, and the CDC need to:1.prove that infection control is sufficiently important to displace another important activity,2.advocate for active collaboration3.commit to a sustained engagement with managed care plans HMOs may have a lot to offer, but the relationship between managed care and infection control still needs to be built. As we form new partnerships, changes in the way we communicate are also necessary. Dr Julie Gerberding pointed out that although we are often talking about the same problems and issues, health care epidemiologists and infection control professionals often use terminology unfamiliar to other stakeholders, patients, and purchasers. We continue to describe one of our major activities as “surveillance and response”; instead, we need to change to “performance measurement, performance improvement, or reporting and learned response.” We monitor “infections and adverse health events”; we need to adopt the terminology “quality indicators” and “medical errors.” “Nosocomial,” a term understood by few people outside of hospital infection control, should be replaced with “health care-associated.” We should not describe—nor be content with—activities of “quality assurance,” but rather practice “quality promotion.” Finally, the community of health care epidemiologists and infection control professionals needs to incorporate the concepts that the public and our patients are also active partners in our business. Both Drs Eisenberg and Gerberding encouraged the conference attendees to ensure that our programs in quality promotion, infection prevention, and patient safety are designed with patient involvement and address patient needs. In her closing address, Dr Gerberding posed a challenge for change by imploring all conference attendees to “Put the ‘caring' back in health care.” The Decennial Conference addressed where we have come in infection control during the past 30 years and where we need to move in the next 10. Many of the conference presenters mapped out for us how change can be achieved. Our challenge is to recognize the forces that present new opportunities and embrace change in the way we practice quality promotion through infection prevention.