Improving Patient Safety: Resource Availability and Application for Reducing the Incidence of Healthcare‐Associated Infection
Objective. VHA Mountain States conducted a survey and analysis of infection control (IC) staffing resources, organizational structures, and clinical processes related to reducing the incidence of healthcare‐associated infections (HAIs) in community healthcare facilities.
Methods. Member participation was solicited for 2 study components. The first was a survey of demographic characteristics regarding the type and size of the facility and the structure and functions of IC departments. The second was an observational study of infection prevention practices related to general hand hygiene (GHH), ventilator‐associated pneumonia (VAP), catheter‐related bloodstream infection (CRBSI), and catheter‐related urinary tract infection (CRUTI).
Results. A total of 31 not‐for‐profit community healthcare facilities submitted data; the number of beds in participating centers ranged from less than 50 beds (1 facility) to more than 500 beds (7 facilities). IC department staffing ranged from 0.3 to 5.0 full‐time equivalents. There was a positive correlation between average daily census and IC staffing (
; 
). Observational studies revealed that compliance with the use of alcohol‐based hand rubs (77%) was significantly better than compliance with the use of soap and water (64%; 
). Seven (30%) of 23 organizations observed 90% or better compliance with VAP process measures; 7 of 27 (26%) observed 90% or better compliance with guidelines for preventing CRBSI; and 14 (56%) demonstrated proper placement of urinary drainage bags at least 90% of the time.
Conclusions. There was variation in IC department structure and processes among the participating organizations. Infection prevention practices were inconsistent. These findings emphasize the need for more‐effective implementation of current evidence‐based recommendations for preventing HAIs and reducing the risk of harm to patients.
Received October 27, 2004; accepted August 31, 2005; electronically published March 6, 2006.
Recent reports from the Institute of Medicine and heightened attention to the promotion of safe healthcare environments have encouraged leading regulatory, accreditation, and quality‐monitoring organizations to target healthcare‐associated infection (HAI) as a preventable adverse event and an issue of patient safety.1,2 These preventable infections contribute an estimated $4.5 to $5.7 billion annually to patient care costs and are associated with mortality rates as high as 35%.3‐5
Much has been written about the important role of infection control (IC) practices in preventing HAIs.6,7 Successful implementation of these IC practices depends on well‐trained and experienced practitioners who are responsible for identifying and controlling outbreaks of infection, monitoring trends in antimicrobial resistance, educating clinical staff about strategies to prevent infection, and developing and implementing evidence‐based standards of IC practice. Because of their expertise in epidemiology, IC professionals (ICPs) are frequently called on to participate in quality‐improvement initiatives. In addition, the national defense against the growing threat of bioterrorism relies on these hospital‐based ICPs as coordinators of the first line of support.8 At the same time, however, the availability of IC resources has decreased.9 The challenge today, therefore, is a conflict between the imperative to minimize the risk and incidence of HAIs and the limited availability of resources for managing infection prevention and control activities in hospitals and communities.
To evaluate the extent to which community healthcare facilities are prepared to meet these challenges with appropriate IC resources, infrastructure, and related clinical‐care processes for reducing the incidence of HAI, we designed and conducted this descriptive study beginning in early spring 2004 within VHA, a nationwide network of not‐for‐profit community‐based healthcare facilities.
Methods
VHA is a national alliance of more than 2,400 not‐for‐profit healthcare organizations. Voluntary participation in this study by VHA facilities was solicited by e‐mail and telephone communication. The invitation for participation was forwarded to a total of 93 healthcare facilities across several different regions of VHA member organizations. Commitment to participate was submitted via e‐mail registration. Study materials, data collection tools, and instructions were forwarded to participants, and orientation was provided through conference calls.
Participants had the option to complete and return a data form for either or both of 2 different study components. The first component was a questionnaire designed to elicit demographic characteristics of the organization, such as type and size; items also addressed the structure and functions of the IC department. The second component was an observational study of evidence‐based practices for reducing the incidence of infection, including general hand hygiene (GHH) and practices for patients with ventilator‐associated pneumonia (VAP), catheter‐related bloodstream infection (CRBSI), or catheter‐related urinary tract infection (CRUTI). Participants were instructed to make 30 random observations of IC practices for each of the 4 areas of focus (GHH, VAP, CRBSI, and CRUTI). These observations were to be of healthcare professionals in the process of performing direct patient‐care activities. Participants were to observe multiple subjects on different units, shifts, or both and to assess compliance with the recommended IC practice for each infection type.
Elements of GHH process measures followed the recommendations and guidelines of the Centers for Disease Control and Prevention (CDC).10 For this study, appropriate GHH required application of an alcohol‐based hand rub to the palm and rubbing the hands together, covering all surfaces of the hands and fingers until dry. Alternatively, if soap and water were used, the process required wetting hands with water first; rubbing the product into the hands for at least 15 seconds, covering all surfaces; and using a towel to turn off the faucet. GHH was monitored before procedures and before and after direct patient contact. Influence on the performance of GHH was minimized by encouraging participants to conduct observations whenever possible without informing the subject.
Indicator specifications for VAP, CRBSI, and CRUTI followed the National Quality Forum Consensus Performance Measures Set, which is supported by the Joint Commission on Accreditation of Healthcare Organizations, the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid Services (CMS), and the CDC.11‐15 Process measures for the prevention of these infections were based on recommendations from national experts and on guidelines from professional organizations, including the Healthcare Infection Control Practices Advisory Committee, the Society for Healthcare Epidemiology of America, the Association for Professionals in Infection Control and Epidemiology, and the Infectious Diseases Society of America.16‐18
Process measures for reducing the incidence of VAP included elevating the head of the bed to angle of at least 30 degrees for patients currently receiving mechanical ventilation; performing a daily weaning trial; ensuring that the patient was kept at an appropriate level of sedation, as assessed at least once during a 24‐hour period by his or her ability to follow commands; and using particular agents to provide prophylaxis against stress ulcer disease (SUD). Measures for reducing the incidence of CRBSI included the use of maximal sterile barrier precautions during catheter insertion, application of occlusive dressings to the insertion site, appropriate site care, and duration of central venous catheter (CVC) placement beyond clinically indicated time of use. Measures for reducing the incidence of CRUTI included a physician’s order for initiating and discontinuing the use of an indwelling urinary catheter and the placement of the urinary catheter drainage bag (ie, whether placement promoted unrestricted urinary flow).19
Results
Component 1
Data were received from 31 (33%) of 93 solicited not‐for‐profit community hospitals and affiliated organizations in 13 states. Four of the respondents reported data from extended‐care facilities; the remainder reported data from acute‐care hospitals and healthcare systems. Four organizations were affiliated with the National Nosocomial Infections Surveillance System. The number of beds in participating centers ranged from less than 50 beds (1 facility) to more than 500 beds (7 facilities). The average (ie, mean) daily census (±SD) across the group was 
patients (range, 18‐680 patients). Notably, the average (ie, median) daily census was 153 patients; this value reflects the number of relatively small organizations that contributed data (Table 1).
Organizational staffing devoted to IC ranged from 0.3 to 5.0 full‐time equivalent ICPs. Only 1 of the participating organizations indicated that the IC department received data‐management support. There was a significant positive correlation between the average daily census and overall ICP staffing hours (
; 
) (Figure). The largest portion of ICP time (30%) was allocated to surveillance, followed by communication (16%), prevention of transmission (13%), and education or training (13%). Other activities included identifying infectious diseases processes, conducting investigations, and controlling transmission.
Figure. The relationship between the average daily census (ADC) and the number of full‐time equivalents (FTEs) of infection control professionals (ICPs) for each responding VHA facility, demonstrating a positive correlation (
; 
).
Additional survey items were related to specific product use, policies, and procedures. Responses revealed that most organizations (23 [74%] of 31) used chlorhexidine skin preparation for CVC insertion; 6 (19%) of 31 used povidone iodine. Twenty (65%) of the 31 organizations favored transparent dressings for the CVC site, whereas 2 (7%) favored gauze. Seven organizations (23%) used chlorhexidine‐impregnated sponges. Sixteen (52%) used antibiotic‐ or antiseptic‐impregnated CVC products; 9 (56%) indicated that such products were used primarily for high‐risk patients. Ten organizations (32%) used silver hydrogel urinary catheters; 8 (80%) indicated that such catheters were used primarily for high‐risk patients (Table 2). Six (19%) of the organizations reported having a team designated to insert CVCs, and 18 (58%) required physician’s privileges for CVC insertion. Most organizations (29 [94%] of 31) reported having a written IC plan in place as required by regulatory agencies. Of these 29 organizations, 25 (86%) also had a formal program evaluation process (Table 3). Reported measures of IC program effectiveness for 2003 included incidence rates of surgical‐site infection, VAP, and CRBSI. The most common area of focus identified for 2004 was surgical infection prevention, followed by GHH compliance and reducing the incidence of CRBSI and VAP. Other areas of attention for 2004 included creation of severe acute respiratory syndrome (SARS) surveillance and influenza vaccination programs. The most frequently cited barrier to program success was lack of adequate resources.
Component 2
The second component of this study involved the observation of process measures for reducing the incidence of HAIs. The observational component was organized into 4 areas of focus (Table 4). The first area involved compliance with GHH measures; the second, measures for reducing the incidence of VAP; the third, measures for reducing the incidence of both central and peripheral CRBSI; and the fourth, measures for reducing the incidence of CRUTI.
Twenty‐six organizations submitted data from a total of 34 different units (ie, patient‐care areas) for some or all of the GHH measures. Overall, mean compliance with the use of the alcohol‐based hand rubs (77%) was significantly better than compliance with the use of soap and water (64%; 
). The poorest compliance related to GHH (60%) was in decontaminating hands before direct contact with patients.
Twenty‐three organizations submitted data on some or all of the VAP measures. Seven organizations (30%) observed 90% or better overall compliance with the VAP process measures as a group. The highest overall mean compliance rate in this group was 82% for SUD prophylaxis. There was 77% compliance with elevation of the head of the bed; the poorest overall mean rating was for compliance with daily weaning trials (64%).
Of the process measures related to reducing the incidence of CRBSI, the best overall mean compliance (94%) was with the use of maximal sterile barrier precautions during CVC insertion; however, only 8 organizations submitted data on this measure. The poorest level of compliance associated with the management of CVCs and peripheral intravenous lines was related to dating insertion site dressings according to organizational policy (79% for CVCs and 44% for peripheral intravenous lines). Overall, 7 (26%) of 27 organizations observed 90% or better compliance with the CRBSI process measures as a group.
Of the 24 organizations reporting data related to CRUTI measures, the best compliance (87%) was with placing the urinary catheter drainage bag below the bladder and checking the catheter line for kinks, to ensure appropriate drainage of urine. Fourteen participants (56%) observed that the urinary drainage bag was properly placed at least 90% of the time.
Discussion
Component 1
It should be emphasized that the small sample of VHA organizations and the variance in participation in the different aspects of this study limit the generalizability of our findings. Overall, however, our results demonstrate variations in IC structure and processes across the participating VHA facilities. On the basis of the responses from the organizations participating in this study, it appears that 3 primary areas of activity occupy nearly 60% of ICPs’ time: surveillance, communication, and prevention of transmission. Substantial time is also spent on education and training. These results support earlier time estimates of ICP activities.9 The scope of responsibility for IC is expanding: the related activities are increasing in breadth as new diseases and threats emerge.8 Activities such as SARS surveillance and bioterrorism preparation were not previously listed as IC responsibilities. One would also expect increased attention to surveillance of emerging pathogens and pathogens for which resistance is an issue, particularly those associated with adverse clinical outcomes.
The correlation between average daily census and ICP staffing indicates that 10 participating organizations (approximately 30%) were not staffed at the recommended level of 1 full‐time equivalent ICP per 100 occupied beds.9 Surprisingly, only 1 organization reported that the IC department had data‐management support. Given the current surveillance documentation and analyses required of IC departments, one might expect to see dedicated data‐management resources. The cost‐reduction focus that is so prevalent in the healthcare environment today requires strong rationales in support of appropriate staffing levels. As mentioned above, the lack of attention to adequate IC staffing can translate into increased costs and poor outcomes.3‐5 Our findings can assist the ICP in building the business case with hospital administrators for enhancing IC resource allocation.
Participants’ responses to the issue of IC planning for 2004 raised several points of interest. The emphasis on surgical infection prevention is likely to continue because the CMS has focused on this initiative nationally. The respondents emphasized hand washing, but this activity has not yet been identified as a measure of the effectiveness of IC programs. Two areas of focus most frequently identified were reducing the incidences of VAP infection and CRBSI, which will be part of the national performance measure set for intensive care unit quality. A number of organizations provided favorable comments regarding the support received from organizational administrators and medical directors; however, an important barrier to success mentioned by respondents was the lack of support from physicians. This finding raises the question of whether physician support is related to payment for relevant services and suggests that physician leaders should consider becoming more involved in IC practices and oversight.
The reported use of site‐preparation products for CVC insertion demonstrates an opportunity for further adoption of best‐practice measures by healthcare organizations. Evidence indicates that a 2% chlorhexidine‐based preparation is the preferred choice for preparing a CVC site for patients older than 2 months.16 A promising new product is chlorhexidine‐impregnated dressing.20 One participant anecdotally reported a reduction in the incidence of CRBSI when this product was used for dressing care at CVC insertion sites (Nancy Iversen, RN, CIC, oral communication, June 2004). Despite the proven effectiveness of this new product, only a few of the organizations participating in our study reported using it.
Component 2
Results from the process observations in this study demonstrated variability across participating organizations in adherence to evidence‐based infection prevention strategies, which are the least expensive and least complicated practices with the greatest opportunity for improvement. This finding is not surprising, because adherence to even such basic practices as GHH has historically been a challenge. Education, forcing functions, and multifaceted interventions have been shown to promote improved compliance with GHH principles, yet repeated intervention appears to be required for sustaining these improvements.10 Recent studies show that physicians comply more poorly with GHH recommendations than do other healthcare professionals involved in patient care.21,22 This study did not gather information about adherence to the GHH recommendations according to healthcare occupation; such information could be helpful in developing specific targeted interventions.
VAP is a complex disease; this complexity is underscored by the lack of national consensus about what constitutes a case of VAP. Increasingly, experts are recognizing that the prevention of VAP is equally complex and is best accomplished by the simultaneous application of multiple interventions. Interventions aimed at preventing VAP are designed to reflect better care practices for intubated patients and typically include positioning the patient such that the risk of aspiration pneumonia is decreased (ie, by elevating the head of the bed), SUD prophylaxis, and promotion of rapid extubation (weaning trials and appropriate sedation). Of these practices, the best mean compliance documented in this study involved SUD prophylaxis; however, the choice of prophylactic agent varied. Interestingly, the CDC makes no recommendations about the preferential use of sucralfate, H2 antagonists, or antacids for SUD prophylaxis in patients receiving mechanical ventilation.18
The process measures for the management of intravenous insertion sites offer additional opportunities for improvement. Checklists and other tools for monitoring CVC insertion procedures have been successfully implemented, along with staff empowerment for interrupting the procedure if appropriate practices are not being followed. CVC placement is an invasive procedure with a risk of complications, yet few of the organizations that participated in this study require specific credentials for performance of this procedure. Opportunity exists for promoting expertise in this area of practice by requiring specific training and the performance of a minimal number of CVC insertion procedures each year before privileges for performing the procedure are granted.
Practices for reducing the incidence of CRUTI include maintaining adequate drainage of urine. This goal can be accomplished simply by positioning the urinary drainage bag below the level of the patient’s bladder and avoiding kinks in the drainage tubing.19 Observations for this practice revealed that slightly more than half of the organizations achieved at least 90% compliance. Again, an inexpensive intervention, such as proper bag positioning, can make a substantial contribution to patient safety. Ten (32%) of the 31 participating organizations reported the use of silver hydrogel urinary catheters. Although these catheters are more expensive than standard catheters, they have proved to be effective in reducing the incidence of nosocomial UTIs and may be useful for those organizations that cannot consistently use less expensive prevention strategies because of staff shortages.
Summary of Study
Our study had several limitations. Participation was voluntary and limited to VHA member organizations; thus, selection bias may exist, because only not‐for‐profit community organizations took part. It is also possible that VHA organizations with adequate resources and effective IC departments were confident in their performance and had no interest in participating. Alternatively, there is evidence that some organizations were interested in participating but did not have available resources to provide data for the study. Another limitation was study design. Although we provided an abstraction guide, detailed instructions, and orientation, differences in the interpretation of survey items prompted variation in responses. Missing data points and variations in the numbers of observations reported per indicator were evident, although these factors were considered in the calculation of compliance rates. Another threat to validity might be the difficulty of conducting random, unobtrusive observations for capturing realistic practice behaviors.
With a total sample size of 31 organizations, generalizing our findings is difficult. Although the differentiation in size and the variation in organizational structure and function are noted and may support adequate sample representation, caution should be used in analyzing data from such a small number of respondents. Sample size also limits the types of analyses that can be performed and the conclusions that can be inferred, such as a correlation between ICP staffing or allocation of ICP time and adherence to recommended IC practices. We cannot conclude from our findings whether the levels of support and resources allocated to IC were appropriate, yet the issue was raised in the participants’ responses and should be studied further. Future studies should also include a larger number of healthcare organizations so that these preliminary findings can be validated. Additional value would come from the opportunity to analyze any correlation between staffing, adherence to evidence‐based practices for reducing the incidence of HAI, and outcomes data, such as the incidence of VAP, CRBSI, and CRUTI. On the basis of these limited study findings, however, we have identified some common themes for improvement opportunities and have underscored the need for more‐effective and consistent implementation of currently recommended strategies for preventing HAI, reducing the risk of harm to patients, and reducing costs.
Acknowledgments
We gratefully acknowledge the following additional members of the project steering committee for their expertise and assistance in indicator development and initial survey design: Kent Crossley, MD, Minneapolis VA Medical Center, Minneapolis, MN; and Christine Nightingale, RN, CIC, and Camilla Saberhagen, MD, private practice, Missoula, MT. We also thank Allan Prochazka, MD, for his guidance and support of this work. This article has been presented in part at the 44th Interscience Conference on Antimicrobial Agents and Chemotherapy, October 31–November 2, 2004; Washington, DC; abstracts 2156 and 2194.
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