Keeping Infections Out

Health care-associated infections still plague hospitals across the country. Properly protecting against and preventing them is the key to lowering the annual number of illnesses and deaths.

• By Jamie Friedlander
• Sep 01, 2014

When acute care hospitals in the United States reported their data on health care-associated infections (HAIs) in 2011 to the Centers for Disease Control and Prevention, the survey found in that calendar year alone, the hospitals reported roughly 722,000 HAIs. Roughly 75,000 of those HAIs resulted in the death of a patient. In addition, more than half of the HAIs occurred outside the intensive care unit.

Various factors have contributed to the evolving HAI landscape over the last few years, including a continuum of care that extends beyond the hospital and into other areas, such as long-term care facilities, dialysis centers. and ambulatory surgery centers. "We're learning more and more about health care delivery areas outside the hospital," said Dr. Michelle Hulse-Stevens, M.D., the medical director for 3M's Infection Prevention division. "How they're all linked together is an important metric that has come into play in the past few years particularly."

"I think infection prevention and control is an incredibly complex area, and it has come a long way in the last 15 years," Hulse-Stevens said. "And there's a lot more work that still needs to be done."

New types of antibiotic-resistant infections have also contributed to changing HAI landscape recently. Hulse-Stevens pointed out that while any type of infection that occurs in a health care facility is of importance, multi-drug resistant gram negative rods have become particularly significant during the past few years. "What has evolved over the last five to ten years has been a group of organisms called multi-drug resistant gram negative rods. They are a type of bacteria that is very common. Gram-negative rods are part of the normal micro biome in your gut and of the environment," she explained. Increased antibiotic exposure with use in humans, animals, and agriculture has created antibiotic pressure that has resulted in the evolution of antibiotic-resistant bacteria, which includes gram negative bacteria. "There has been tremendous exposure to antibiotics, and that has contributed significantly to the pressure and evolution of antibiotic resistance that occurs in bacteria," said Hulse-Stevens. "There are infections occurring in patients that we no longer have any antibiotics for, and that is of great concern not only for the hospitals, but for global health biosecurity in general."

New Routes of Transmission
The HAI landscape also has changed because of new fomites, or substances and objects that carry infectious organisms. These fomites include hospital computers, cell phones, and other new technologies not seen 10 or 20 years ago. "It has been recognized that the keyboards for the computers on wheels were potential fomites for transmission as they went from room to room and people were touching the keyboard and then maybe touching the environment for a patient," said Hulse-Stevens. "I think cell phones are in that same category."

Other common fomites in hospitals include doorknobs, food, and bathroom surfaces.

In order for a hospital to protect its employees and patients, a highly functioning infrastructure needs to be in place. "The most important thing is for hospitals to have a basic infection control infrastructure," Hulse-Stevens said. "You can't overlay a technical solution on a system that isn't functioning very well."

She said a series of factors contribute to a solid infrastructure, including administrative controls— such as a program for infection prevention and policies to address how to deal with certain circumstances. Hospitals also need to have hand hygiene programs, a sterilization and disinfection department, and ways to check competencies for staff and allied health personnel in the hospital. "So, assuming you have the context and those engineering and administrative controls in place, then you can start talking about what else you need to do to try to mitigate risk of infections occurring," she said. "I think the majority of hospitals do try really hard to educate their staff. Does that mean that they're perfect? I don't think anybody’s perfect. But I think that everybody is trying."

The Importance of PPE
Once proper infrastructure is in place, hospitals can then address what else they can do to help control the spread of infection in the event that it occurs, which includes ensuring that adequate personal protective equipment is on site and being used properly. "PPE is important for certain types of circumstances, and in health care there are [various] types of transmission," she said. "If you talk about something that could be spread via contact, then wearing gowns and gloves would be important. If there's a potential for a splash to occur, then wearing a mask and eye protection would be important."

Airborne infections are a very specific category because there not many infectious pathogens spread via the airborne route, she added. In the event that there is an airborne infection—such as measles or chicken pox—all staffers entering a room who are not immune need to use N95 respirators. For tuberculosis, any person entering the room of a potentially infectious patient should don an N95. Masks, on the other hand, should be used when there is the potential for droplet transmission of an infection.

One challenge Hulse-Stevens has seen is employees not using N95 respirators at the right time. "What I see happen more often than not is that if an N95 is needed, it's not being used," she said. "There are so few infections where an N95 is required and they don't occur often in most facilities, so it's a matter of not having it happen often enough to remember when it needs to be used."

SHEA Whitepaper Maps Next Steps
Recently, the Society for Healthcare Epidemiology of America (SHEA) published a whitepaper titled "The Evolving Landscape of Healthcare-Associated Infections: Recent Advances in Prevention and a Road Map for Research." According to the whitepaper, HAIs "continue to pose a major challenge to healthcare professionals in all healthcare settings." The whitepaper addresses the current HAI landscape and proposes steps that need to be taken during the next several years in order to prevent HAIs, such as increasing international collaboration, securing funds to create an infrastructure that can provide funding for important projects, and developing a process to collaborate effectively with industry.

"We anticipate that the next decade will be a productive time with generation of new knowledge critical to lead HAI prevention effectively," the whitepaper concludes.

SHEA also collaborated with the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission to produce new guidelines meant to reduce the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals. The guidelines were published in the July 2014 issue of Infection Control and Hospital Epidemiology. "Many hospitals have made inroads in preventing health care-associated MRSA through essential prevention strategies, but some hospitals need additional intervention. This guidance provides a roadmap for prioritizing and implementing strategies," said Dr. David Calfee, M.D., MS, co-lead author of the guidelines with Dr. Cassandra Salgado, M.D., MS.

This article originally appeared in the September 2014 issue of Occupational Health & Safety.