Before the patient safety movement began, the prevention of hospital-acquired infections was seen as the job of the hospital epidemiologist and other infection control staff, who tried (often unsuccessfully) to engage clinicians in prevention efforts. Branding healthcare-associated infections (HAIs) as a patient safety problem (which by extension rendered failure to engage in appropriate infection control practices a form of medical error) has elevated the importance of these infections and propelled prevention into the mainstream.
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).
Marked decrease in catheter-related bloodstream infections after implementation of safety practices at Johns Hopkins Hospital. (Reproduced with permission from Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004;32:2014–2020.)
If we consider HAIs resulting from failure to adhere to evidence-based practices preventable adverse events (a position I endorse), then HAIs may well be the most common source of serious and preventable harm in healthcare. The Centers for Disease Control and Prevention (CDC) estimates that 1 in 10–20 hospitalized patients will develop an HAI, that HAIs are responsible for approximately 100,000 deaths per year in U.S. hospitals, and that these infections are responsible for $30 to 40 billion in attributable costs.1,2 Beginning in 2008, Medicare began withholding payments to hospitals for the care of certain HAIs (CLABSI, healthcare-associated urinary tract infections, 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 processes or structural changes appear to be correlated with improvement. In the past, infection control experts and regulators have 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 chances of preventing complications seem to improve with complete adherence to a “bundle” of preventive strategies.4 Under this model, institutions receive credit for their quality and safety efforts only for above-threshold adherence (i.e., >80%) on all of the preventive strategies, not just some. This approach rests on the theory that not only does better adherence to the individual elements increase the chances of prevention but also achieving high bundle adherence rates usually requires reengineering the entire clinical process of care. Changes ...