Surprising Victories Against Old Foes: Preventing HealthcareAssociated Infections

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Surprising Victories Against Old Foes Preventing
Healthcare-Associated Infections

• John A. Jernigan, MD, MS
• Division of Healthcare Quality Promotion
• Centers for Disease Control and Prevention
• May 14, 2008

Nothing to Disclose
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What is the Preventable Fraction of Healthcare
Associated Infections?
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What is the Preventable Fraction of Healthcare
Associated Infections?

• Study on the Efficacy of Nosocomial Infection
  Control (SENIC) study results
• 1971-1976
• Suggested 6 of all nosocomial infections could
  be prevented by minimal infection control
  efforts, 32 by well organized and highly
  effective infection control programs
• Harbarth et al at least 20 of infections are
  preventable J Hosp Infection 200354258

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What is the Preventable Fraction of Healthcare
Associated Infections?

• Some may have interpreted these data to mean that
  most healthcare associated infections are
  inevitable
• What impact has this had on the psychology of
  prevention?
• How has this influenced the way infection control
  programs operate?
• Difficult to define success when achievable
  results unknown-what should the goal be?

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Eliminating catheter-related bloodstream
infections in the intensive care unit
Berenholtz, S et al. Critical Care Medicine.
32(10)2014-2020, October 2004.
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Semi-Annual Central Line-associated Bloodstream
Infection Rates in Medical-Surgical Intensive
Care Units Participating in the Southwest
Pennsylvania Collaborative and NNIS, 2001-2005
pNS

plt0.001
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Michigan Keystone ICU Project
Provonost et al. NEJM 20063552725-2732
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Source Burton et al., abstract presentation,
SHEA 2008
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Source Burton et al., abstract presentation,
SHEA 2008
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Regional distribution of MRSA bacteraemia rates,
April 2001 to September 2007 , United Kingdom
Introduction of national target
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MRSA Incidence, Veterans Affairs Pittsburgh
Medical Center, 1999-2007
MRSA per 1000 Patient Days
Month
Source Ellingson et al., abstract presentation,
SHEA 2008
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MRSA Incidence, Veterans Affairs Pittsburgh
Medical Center, 1999-2007
Difference between pre- and post-intervention
slopes (p0.0055)
MRSA per 1000 Patient Days
Month
Source Burton et al., abstract presentation,
SHEA 2008
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MRSA Incidence, Veterans Affairs Pittsburgh
Medical Center, 1999-2007
1.4 (95CI, 0.8-1.8) decrease in MRSA per
Month(plt0.0001)
MRSA per 1000 Patient Days
Month
Source Burton et al., abstract presentation,
SHEA 2008
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MRSA Incidence, Veterans Affairs Pittsburgh
Medical Center, 1999-2007
MRSA 77
MRSA 56
MRSA per 1000 Patient Days
Month
plt.001
Source Burton et al., abstract presentation,
SHEA 2008
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Hospital-wide Incidence Density Based on
Intervention Effect, MRSA Prevention
Collaborative Hospitals , 2004-2007
Incidence per 1,000 Patient days
B
A
C
Month
Pooled Effect 2.9 reduction per month (95 CI,
7.9 to -2.3, p.27)
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Maybe the Preventable Fraction is Much Larger
than we Thought?
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There is a growing body of evidence suggesting
that the preventable fraction of
healthcare-associated infections is much larger
than previously appreciated
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Most of these successes are achieved by
successful implementation of prevention practices
that are not novel
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How to improve implementation of existing
recommendations?

• By changing the way front-line healthcare workers
  think and act regarding prevention of adverse
  healthcare events
• Social/cultural change
• Behavior change

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The crucial determinants of suboptimal patient
care and approaches to improving care are limited

• Need to build multidisciplinary research programs
• Epidemiologists
• Social scientists
• Behavioral scientists
• Basic scientists
• Others
• Usual tools (e.g. randomized controlled trials)
  may be inappropriate for studying the complex,
  unstable, nonlinear social changes needed to
  improve quality
• Berwick DM JAMA 20082991182-1184

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Different Organizational Theories of Healthcare
Delivery

• Traditional Organizational Theories
• Healthcare facilities viewed as machine-like,
  replaceable parts, if each part doing its job
  things will go smoothly
• well oiled machine
• Organizational theory based on complexity science
• Healthcare facilities viewed as dynamic, living,
  social systems, or Complex Adaptive Systems

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Stacey R.D. Complexity and Creativity in
Organizations. San Francisco, CA
Berrett-Koehler, 1996
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Complex Adaptive Systems

• A collection of individual agents that have the
  freedom to act in ways that are not always
  totally predictable, and whose actions are
  interconnected so that one agents actions
  changes the context for other agents

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Complex Adaptive Systems

• Diverse fields of science have found value in
  complexity theory
• Chemistry, Physics, Physiology, Mathematics,
  Sociology, Economics, Metorology
• Examples of systems that have been studied as a
  Complex adaptive systems
• immune system
• Human brain
• a colony of social insects such as termites or
  ants
• the stock market
• almost any collection of human beings

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Complex Adaptive Systems

• System implies
• Multiple Agents
• Agents are Interdependent and Connected
• Complex implies
• Diversity
• Many Elements
• Large Number of Connections
• Adaptive implies
• Capacity to Alter or Change

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Complex Adaptive Systems

• Agents
• e.g. People, processes, hospitals
• Interconnections
• Agents interact and exchange information,
  creating connection among all agents in the
  system
• Self organization
• Agents can adjust behaviors in ways needed to
  cope with changing environmental circumstances
• Emergence
• Development of novel and coherent patterns and
  properties during the process of
  self-organization
• Co-evolution
• As complex adaptive systems change, they change
  the environment around them. CAS and their
  environments co-evolve such that each
  fundamentally influences the development of the
  other

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• Complex adaptive systems depend upon
  interconnection to adapt, change, and transform
• If healthcare facilities behave like complex
  adaptive systems, then they should benefit
  greatly from collaboration

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Quality Improvement Collaboratives Are Popular

• Northern New England Cardiovascular Disease Study
  Group
• SunHealth Alliance Internal Group Benchmarking
  Projects
• UniHealths Collaborative on Joint Replacement
• Vermont-Oxford Neonatal Network
• Institute for Healthcare Improvement Breakthrough
  Collaboratives
• Pittsburgh Regional Healthcare Initiative
• Michigan Keystone
• Veterans Health Affairs
• Health Disparities Collaborative (HRSA)
• United Kingdoms National Health Service
• Institute for Clinical Systems Improvement
• Rochester Health Commission
• Wisconsin Collaborative on Healthcare Quality

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Does Participation in a Quality Improvement
Collaborative Actual Improve Quality?
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Limitations of Evidence Base

• Demand-induced bias
• Most often published in management- and
  practitioner-oriented journals whose mission and
  readership attract practical guidance and insight
  from successful efforts
• Methodologic Weakness
• Commonly uncontrolled pre-post test analyses
• Measures of process and outcome often rely on
  participants unvalidated self-reports, lack of
  standardized surveillance methods/definitions
• Often measured for short periods of time
  immediately following the intensive collaborative
  period

Mittman BS Ann Intern Med 2004140897-901
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Controlled Studies of Quality Improvement
Collaboratives

• Collaborative Intervention to improve care of
  HIV-infected patients Landon BE, et al. Ann
  Intern Med 2004140887-896
• no statistical difference between intervention
  and control
• Cluster randomized trial to improve surfactant
  treatment in pre-term infants Horbar JD et al.
  BMJ 20043291-7
• Treatment improved significantly in intervention
  arm
• Cluster randomized controlled trial of
  collaborative dementia care management program
  Vickrey BG et al. Ann Intern Med 2006145713-26
• Higher adherence go guidelines in intervention
  group
• Cluster randomized trial to test the impact of
  quality improvement collaborative on improvements
  in the pre-operative antimicrobial prophylaxis
  process (TRAPE) TRAPE study group, in press
• No difference in intervention and control group

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Why the heterogeneity of Results?

• Possibilities
• Collaboration has no benefit
• Benefit is modest
• Effects are unpredictable
• Intervention incorrectly or incompletely
  implemented in some cases
• when you see one quality improvement
  collaborative, youve seen one quality
  improvement collaborative

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• Whether or not participation in a quality
  improvement collaborative actually improves
  quality, successful quality improvement
  collaboratives may have great impact on what
  other healthcare facilities do by
• Demonstrating preventability across wide spectrum
  of healthcare facilities
• Opportunity for innovation, hypothesis
  generation, and pilot testing

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Overall rate reduction of 68
MMWR 2005541013-6
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Michigan Keystone ICU Project
Provonost et al. NEJM 20063552725-2732
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National Healthcare Safety Network a valuable
tool for supporting healthcare-associated
infection prevention collaboratives
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Conclusions

• There is a growing body of evidence suggesting
  that the preventable fraction of
  healthcare-associated infections is much larger
  than previously appreciated
• Our understanding the precise determinants of
  this success are limited
• Need multidisciplinary research
• Facilitating successful collaborative
  demonstration projects may be an important
  strategy for influencing global changes in
  practice in ways that improve quality

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Acknowledgments

• Rachel Gorwitz
• Kate Ellingson
• David Kleinbaum
• Val Gebski
• Jonathan Edwards
• Pei-Jean Chang
• Alexander Kallen
• Scott Fridkin
• Monina Klevens
• Jeff Hageman
• Fred Tenover
• Melissa Morrison
• Teresa Horan

• Robert Muder
• Rajiv Jain
• Dawn Sievert
• Deron Burton
• Alicia Hidron
• Dan Pollock
• Curt Lindbergh