GENERAL CONCEPTS AND EPIDEMIOLOGY
Before the advent of the patient safety movement, the hospital epidemiology and other infection control staff were largely responsible for the prevention of hospital-acquired infections. Attempts to engage clinicians in prevention efforts were often unsuccessful. Branding healthcare-associated infections (HAIs) as a patient safety problem (which by extension rendered failure of clinicians to engage in appropriate infection control practices a form of medical error) has elevated the importance of preventing these infections in the minds of providers, leaders of healthcare organizations, and policymakers.
Gratifyingly, evidence is accumulating that healthcare organizations can markedly decrease the frequency of HAIs. Some hospitals, having religiously implemented a variety of prevention strategies, are reporting intervals of months, even years, between previously commonplace infections such as ventilator-associated pneumonias (VAP), methicillin-resistant Staphylococcus aureus (MRSA), and central line–associated bloodstream infections (CLABSI) (Figure 10-1).
Depicts mean rate of central line-associated bloodstream infections for 121 intensive care units from 73 hospitals from March 2004 through December 2013. (Reproduced with permission from Pronovost PJ, Watson SR, Goeschel CA, Hyzy RC, Berenholtz SM. Sustaining reductions in central line-associated bloodstream infections in Michigan intensive care units: a 10-year analysis. Am J Med Qual 2016;31:197–202.)
If we consider HAIs resulting from failure to adhere to evidence-based practices preventable adverse events, then HAIs may well be the most common source of serious and preventable harm in healthcare. In the United States, HAIs are tracked and reported through the Center for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN). Based on the HAI Prevalence Survey, the CDC estimates that in 2011 there were about 722,000 HAIs in U.S. acute care hospitals, and that approximately 75,000 patients with HAIs died during their hospitalizations.1 In addition, preventing HAIs is associated with significant cost savings. Indeed, it has been estimated that the federal government may have saved more than $1 billion in ICU-related costs alone from CLABSIs averted between 1990 and 2008.2 Beginning in 2008, Medicare began withholding payments to hospitals for the care of certain HAIs (CLABSI, catheter-associated urinary tract infections [CAUTIs], and Clostridium difficile infections) it considered largely preventable (Chapter 20 and Appendix VIII).3
For many HAIs (and other complications of healthcare, see Chapter 11), a variety of process or structural changes appear to be correlated with improvement. In the past, infection control experts and regulators underscored the need to increase adherence to individual prevention elements—for example, if there were five strategies thought to be effective in preventing a certain type of infection, a hospital might get “credit” for achieving 100% adherence on one of the five elements, 80% on another, and 50% on the other three. The Institute for Healthcare Improvement (IHI) has promoted a “bundle” approach, emphasizing that the chance of preventing complications seems to improve with ...