To the Editor—Hospital-acquired or nosocomial infections are infections that patients develop during the course of their hospitalization.Reference Horan, Andrus and Dudeck1 Patients who develop HAIs are usually infected exogenously when exposed to a healthcare facility, procedure, staff, visitors, and/or other patients such that “prevention of hospital-acquired infection is central to providing safe and high-quality health care.”Reference Murni, Duke, Kinney, Daley and Soenarto2 An estimated 1.7 million patients in the United States are diagnosed with a HAIs annually. Nearly 5.8% of those patients, ~100,000 individuals, will die.Reference Klevens, Edwards and Richards3 The annual national cost of HAIs is between ~$28 and ~$45 billion in the United States.Reference Scott4 Most of the cost of HAIs stems from increased hospital stays and use of medical resources.Reference Graves, Halton and Jarvis5 However, the cost of reducing HAIs can also be very expensive and requires investment in staff, technology, and other resources. Many studies on improving hand hygiene to reduce HAIs have been publishedReference Pittet6-Reference Hübner, Hübner and Kramer9; however, many other important interventions have been studied, particularly those that are more systematic and involve multiple stakeholders.Reference Wenzel, Osterman, Hunting and Gwaltney10 Here, we summarize the successful efforts of a regional health system to reduce HAIs without increasing operational costs.
Methods
In our regional health system, we sought to create an intervention that provides high-quality, safe, and cost-effective health care across multiple healthcare facilities. We identified the reduction of the HAI standardized international ratio (SIR) as a primary measure of our goal of providing safe health care to our New England population. The Trinity Health of New England (THONE) healthcare system spans Connecticut to Massachusetts, with 5 hospitals and multiple outpatient sites across all major subspecialties. In this study, we included all of the HAIs that the National Healthcare Safety Network (NHSN) mandates that our health system tracks.
Our primary goal was to reduce the SIR to <1.0 within 3 years. To achieve this goal, the infection control team performed a literature review for infection prevention best practice and performed a gap analysis of current practices versus best practices. The challenges identified included a lack of standardized best practices and compliance with current policies. To address these opportunities, the hospital focused on some key areas of infection discussed here.
Surveillance
The primary goal of the new surveillance system was to provide quality and timely data in accordance with National Healthcare Safety Network (NHSN). The secondary goal was to help hospital staff appreciate the process of surveillance and enhance the use of data to drive change. A dashboard was created that would contain updated HAI unit data that would be accessible to all hospital employees and would provide the unit-based surveyors the means to monitor their data independent of the infection prevention department.
Prevention
A best-practice bundle across the region was implemented in December 2018. Because many hand hygiene compliance protocols have proven effective historically,Reference Pittet6-Reference Hübner, Hübner and Kramer9 a hand hygiene compliance program was implemented as an additional intervention. Also, the program was redesigned to allow individual units to decide how they would improve compliance metrics and respond to negative trending. Thus, the staff could take ownership of patient care and could more directly invest in the efforts of by their unit.
Environmental cleaning was identified as another opportunity for improvement. An environmental cleaning audit revealed <45% compliance when the program was introduced. In 2019, a >40% increase in the proper cleaning of high-touch areas was achieved. Lastly, the hospitals collaborated with the information technology team to implement processes that would automatically place an isolation order.
Early and accurate diagnosis
Another opportunity revealed by the initial analysis was the number of hospital-onset infections that occurred due to timing of testing. The staff had a knowledge deficit regarding the importance of early detection and treatment of infections. The hospitals addressed this deficit by providing education and clinical guidance through algorithms in the hospital computer system. Providers were educated through computer-based training modules, educational sessions, and one-on-one meetings. Infection prevention staff worked with the infectious disease department to create evidence-based diagnostic tools such as algorithms for diagnosing UTI and a workflow for the proper management of acute diarrhea. This approach could be helpful in decreasing hospital-onset CDI detected after 4 days with symptoms present at time of admission.
Results
After regional standardization of infection prevention interventions, the SIR decreased from a baseline of 0.772 in calendar year 2018 to 0.474 in calendar year 2019 (P < .05 χReference Murni, Duke, Kinney, Daley and Soenarto2 test) (Fig. 1). Reductions in infection rates were observed for catheter-associated urinary tract infection (CAUTI), central-line–associated bloodstream infection (CLABSI), and Clostridium difficile infection (CDI), whereas increases were observed for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and surgical site infection (SSI).
Fig. 1. Hospital-acquired infection (HAI) standardized infection ratio (SIR) during the preintervention period (calendar year 2018) and the postintervention period (calendar year 2019). Note. CAUTI, catheter-associated urinary tract infection; CLABSI, central-line–associated bloodstream infection; MRSA, methicillin-resistant Staphylococcus aureus bacteremia; SSI, surgical site infection; CDI, Clostridium difficile infection.
Discussion
After regional standardization of best-practice bundles, there was a significant decline in HAIs across all hospitals within our regional healthcare system. In 2014, we started our program with the introduction of a dynamic antimicrobial stewardship based on the Centers for Disease Control and Prevention (CDC) tool kit. The program was led by the chief of infectious disease, the director of infection prevention, and the stewardship pharmacist. All 3 departments collaborated effectively to create policies that would influence best practice. We focused on reducing antibiotic use through education, policy change, and formulary restrictions. We recognize this multipronged approach as the pillar of our success, and we cannot overstate its importance. In fact, the program’s entire success is based on the multiple relationships and culture that we have created on this journey. Although many different models exist to reduce HAIs, the best-practice bundle described here was implemented without any major additional cost or capital purchases in an urban hospital managing a large, disproportionate-share, patient population. This team-based, multipronged effort can likely be implemented reliably in other hospital settings.
Acknowledgments
Financial support
No financial support was provided relevant to this article.
Conflicts of interest
All authors report no conflicts of interest relevant to this article.
