The Guide to Patient Safety for Health Care–Associated Infections
Authors: Sanjay Saint, Jennifer Meddings, Karen E. Fowler, Valerie M. Vaughn, Jessica M. Ameling, Jeffrey M. Rohde, Kyle J. Popovich, David P. Calfee, Sarah L. Krein, Vineet Chopra
Journal: Annals of Internal Medicine (2019)

Supplement: STRIVE1 October 2019The Guide to Patient Safety for Health Care–Associated InfectionsFREESanjay Saint, MD, MPH, Jennifer Meddings, MD, MSc, Karen E. Fowler, MPH, Valerie M. Vaughn, MD, MSc, Jessica M. Ameling, MPH, Jeffrey M. Rohde, MD, Kyle J. Popovich, MD, MS, David P. Calfee, MD, MS, Sarah L. Krein, PhD, RN, and Vineet Chopra, MD, MScSanjay Saint, MD, MPHUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (S.S., V.M.V., S.L.K., V.C.)Search for more papers by this author, Jennifer Meddings, MD, MScUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System,Ann Arbor, Michigan (J.M.)Search for more papers by this author, Karen E. Fowler, MPHCenter for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (K.E.F.)Search for more papers by this author, Valerie M. Vaughn, MD, MScUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (S.S., V.M.V., S.L.K., V.C.)Search for more papers by this author, Jessica M. Ameling, MPHUniversity of Michigan Medical School, Ann Arbor, Michigan (J.M.A., J.M.R.)Search for more papers by this author, Jeffrey M. Rohde, MDUniversity of Michigan Medical School, Ann Arbor, Michigan (J.M.A., J.M.R.)Search for more papers by this author, Kyle J. Popovich, MD, MSRush University Medical Center/Stroger Hospital of Cook County, Chicago, Illinois (K.J.P.)Search for more papers by this author, David P. Calfee, MD, MSWeill Cornell Medicine, New York, New York (D.P.C.)Search for more papers by this author, Sarah L. Krein, PhD, RNUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (S.S., V.M.V., S.L.K., V.C.)Search for more papers by this author, and Vineet Chopra, MD, MScUniversity of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (S.S., V.M.V., S.L.K., V.C.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M18-3443 SectionsSupplemental MaterialAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Health care–associated infection (HAI) remains a common and costly patient safety problem, affecting about 1 in 25 hospitalized patients in the United States (1). Certain HAIs—such as catheter-associated urinary tract infection (CAUTI) and central line–associated bloodstream infection (CLABSI)—seem to be especially preventable, given the high fraction of avoidable device placements (2) coupled with successful regional and national collaboratives targeting such infections (3–5). Despite the readily available evidence to prevent such infections (6), not all U.S. hospitals have been able to consistently reduce CAUTI and CLABSI rates, or successfully prevent other potentially lethal HAIs, such as Clostridioides difficile infection (CDI) and methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection. One potential reason for variable success is differences in applying the evidence at the bedside. A tool that guides infection preventionists and other hospital staff in how to troubleshoot problems, overcome barriers, and consistently implement evidence-based practices is therefore needed.Identifying BarriersTo better understand why some hospitals have been more successful than others in reducing HAI, we first used a rigorous qualitative assessment to identify implementation barriers and possible solutions (7). Formal hospital site visits were conducted across the United States to better understand issues with implementing HAI prevention practices. Several recurring issues emerged regardless of the hospital, many of which were related to socioadaptive (that is, human or behavioral) aspects of prevention; for example, physician champions were absent, physicians and nurses resisted change in practice, and project managers lacked dedicated time for HAI prevention. Although hospital site visits are a useful strategy for providing tailored HAI prevention guidance to an individual facility, conducting formal visits is both time-consuming and resource-intensive. Each visit requires at least 1 full day of meetings with hospital personnel, plus travel-related funds. Thus, visiting the approximately 5500 hospitals in the United States—let alone those worldwide—would be impractical.Developing and Validating a CAUTI GPSTo help hospitals conduct their own “site visits,” we constructed a CAUTI-specific guide to patient safety (GPS) to help hospitals detect their potential internal challenges and identify approaches for overcoming such barriers (Supplement) (8). Specifically, the CAUTI GPS was developed as an online tool consisting of 13 yes/no questions followed by automated feedback, including tailored solutions based on the answers provided. This initial tool, as previously described, was developed on the basis of 21 site visits and interviews with over 400 stakeholders in CAUTI prevention (8).A validation study involving 8 units (half medical-surgical and half intensive care) at 4 hospitals demonstrated that the results of the CAUTI GPS assessment tool, as completed by the unit nurse manager, generally corresponded with findings from qualitative interviews with nurses and physicians conducted during a site visit (9). Nurse managers in particular found the GPS helpful and comprehensive (9). Moreover, this study highlighted the potential utility of the GPS assessment tool for stimulating discussion of implementation-related issues among key stakeholders.Expanding to CDI, CLABSI, and MRSAOn the basis of our success in developing the CAUTI GPS, we undertook 3 simultaneous but separate processes to develop infection-specific guides for CDI, CLABSI, and MRSA, which included a literature review and expert consultation (Appendix Figure 1). Each GPS is envisaged as a tool that can be broadly deployed. Our guiding principles for each were that they had to be 1) developed by experts in the infection targeted for prevention; 2) concise (none having more than 13 yes/no questions); and 3) actionable, assisting a hospital or unit in pinpointing their specific barriers to successfully preventing a given infection.Appendix Figure 1. Overview of development of infection-specific GPSs.CAUTI = catheter-associated urinary tract infection; CDI = Clostridioides difficile infection; CLABSI = central line–associated bloodstream infection; GPS = guide to patient safety; MRSA = methicillin-resistant Staphylococcus aureus.* Available at www.catheterout.org/cauti-gps.html.† Available at http://psep.med.umich.edu/gpscdi.html.‡ Available at www.improvepicc.com/gpsclabsi.html.§ Available at http://psep.med.umich.edu/gpsmrsa.html. Download figure Download PowerPoint We modified the validated CAUTI GPS to make it applicable to the other HAIs. For example, questions specific to selection and appropriateness of central venous catheters were added to the CLABSI GPS. However, several questions are similar for all 4 of the GPS tools, such as: those focusing on having a well-functioning team, a project lead with dedicated time, an effective physician champion, and senior leadership support; collecting infection-related data; and routinely sharing those data with frontline staff.Each GPS includes brief instructions on how to use the respective infection-specific tool. For example, the information provided to hospitals or units attempting to reduce CDI is provided in Appendix Figure 2.Appendix Figure 2. Instructions for the CDI GPS.CDI = Clostridioides difficile infection; GPS = guide to patient safety. Download figure Download PowerPoint Because each GPS is intended to be simple to use, the questions were intentionally structured with yes/no answers. This facilitated our ability to provide automated, yet tailored, answers when data are submitted by using an online electronic version. Specifically, “no” answers lead to specific advice (including suggested links) on how to overcome the problems identified. For example, if a unit attempting to reduce CLABSI answers “no” to “Do you have a team leader with dedicated time to coordinate your CLABSI prevention activities?” the unit is then taken to the following information:You indicated that either you do not have a team leader or that the one you have does not have appropriate time for CLABSI prevention. The team leader is responsible for coordinating the CLABSI prevention efforts—collecting data, organizing reports, presenting outcomes and tracking progress. It is their responsibility to keep the improvement moving forward and coordinate all the moving pieces between stakeholders. It is unlikely that the CLABSI prevention initiative is the only responsibility of the team leader, and because of this, there may not be enough time devoted to the prevention efforts. Creating that dedicated time is imperative to a successful initiative.The sites on which the GPS are hosted (www.catheterout.org and www.improvepicc.com) also provide tools and resources for further reading, such as information on the top 10 characteristics of great project managers, materials on team building, and core competencies of team members. These additional resources allow teams to further explore and develop key strategies in preventing a specific infection.The MRSA GPS has 13 questions, including several that are not included in the other GPS tools. One example is, “Do you have a system in place for communicating confirmed MRSA-positive cultures to frontline care staff?” If the unit answers “no,” they will then see the following automated response:You indicated that your hospital does not have a system in place, or the existing system does not function well, for communicating confirmed cases of MRSA to frontline care staff. An important component of preventing MRSA is early identification of patients with MRSA and notification of those involved in the care of that patient. Early identification and notification allows for the placement of these patients into Contact Precautions and modifications to daily patient care activities. Thus, it is imperative that frontline staff are aware of a patient's MRSA status. Nursing champions can play a pivotal role in helping ensure a communication system is in place and properly followed.In addition, they are provided with information and links that will assist them in overcoming this barrier to effective MRSA prevention.All 4 GPS tools can be found in the Supplement.ConclusionFirst developed and validated for addressing CAUTI, our automated, online GPS is a tool that can now be used by any hospital in the world to also prevent CDI, CLABSI, and MRSA. Preventing infection often depends on socioadaptive interventions, such as behavior change (10). Although formal qualitative assessment involving site visits are the gold standard for identifying unit-specific barriers and solutions, such an approach is both time- and resource-intensive. We envision that the infection-specific GPS will obviate the need for formal site visits for most hospitals, because the automated system will analyze the responses given and provide the user with personalized and tailored feedback. Knowing that hospital units have varying resources and use different processes, the responses include multiple suggestions and online resources. In fact, online tools can facilitate pinpointing issues that can then be explored in further detail, either through self-learning or expert consultation. Our hope is that these infection-specific tools will allow hospitals to self-diagnose problems and empower them to institute solutions that will lead to fewer infections and enhance patient safety.References1. Magill SS, O'Leary E, Janelle SJ, et al; Emerging Infections Program Hospital Prevalence Survey Team. Changes in prevalence of health care-associated infections in U.S. hospitals. N Engl J Med. 2018;379:1732-44. [PMID: 30380384] doi:10.1056/NEJMoa1801550 CrossrefMedlineGoogle Scholar2. Umscheid CA, Mitchell MD, Doshi JA, et al. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011;32:101-14. [PMID: 21460463] doi:10.1086/657912 CrossrefMedlineGoogle Scholar3. Saint S, Greene MT, Krein SL, et al. A program to prevent catheter-associated urinary tract infection in acute care. N Engl J Med. 2016;374:2111-9. [PMID: 27248619] doi:10.1056/NEJMoa1504906 CrossrefMedlineGoogle Scholar4. Saint S, Fowler KE, Sermak K, et al. Introducing the No Preventable Harms campaign: creating the safest health care system in the world, starting with catheter-associated urinary tract infection prevention. Am J Infect Control. 2015;43:254-9. [PMID: 25728151] doi:10.1016/j.ajic.2014.11.016 CrossrefMedlineGoogle Scholar5. Berenholtz SM, Lubomski LH, Weeks K, et al; On the CUSP: Stop BSI program. Eliminating central line-associated bloodstream infections: a national patient safety imperative. Infect Control Hosp Epidemiol. 2014;35:56-62. [PMID: 24334799] doi:10.1086/674384 CrossrefMedlineGoogle Scholar6. Yokoe DS, Anderson DJ, Berenholtz SM, et al; Society for Healthcare Epidemiology of America (SHEA). A compendium of strategies to prevent healthcare-associated infections in acute care hospitals: 2014 updates. Infect Control Hosp Epidemiol. 2014;35:967-77. [PMID: 25026611] doi:10.1086/677216 CrossrefMedlineGoogle Scholar7. Krein SL, Kowalski CP, Harrod M, et al. Barriers to reducing urinary catheter use: a qualitative assessment of a statewide initiative. JAMA Intern Med. 2013;173:881-6. [PMID: 23529627] doi:10.1001/jamainternmed.2013.105 CrossrefMedlineGoogle Scholar8. Saint S, Gaies E, Fowler KE, et al. Introducing a catheter-associated urinary tract infection (CAUTI) prevention guide to patient safety (GPS). Am J Infect Control. 2014;42:548-50. [PMID: 24576604] doi:10.1016/j.ajic.2013.12.019 CrossrefMedlineGoogle Scholar9. Fletcher KE, Tyszka JT, Harrod M, et al. Qualitative validation of the CAUTI guide to patient safety assessment tool. Am J Infect Control. 2016;44:1102-09. [PMID: 27339790] doi:10.1016/j.ajic.2016.03.051 CrossrefMedlineGoogle Scholar10. Saint S, Howell JD, Krein SL. Implementation science: how to jump-start infection prevention. Infect Control Hosp Epidemiol. 2010;31 Suppl 1:S14-7. [PMID: 20929360] doi:10.1086/655991 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: University of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (S.S., V.M.V., S.L.K., V.C.)University of Michigan Medical School and Veterans Affairs Ann Arbor Healthcare System,Ann Arbor, Michigan (J.M.)Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (K.E.F.)University of Michigan Medical School, Ann Arbor, Michigan (J.M.A., J.M.R.)Rush University Medical Center/Stroger Hospital of Cook County, Chicago, Illinois (K.J.P.)Weill Cornell Medicine, New York, New York (D.P.C.)Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Centers for Disease Control and Prevention, the American Hospital Association, or the Department of Veterans Affairs.Acknowledgment: The authors thank the Health Research & Educational Trust Health Care-Associated Infection team, as well as the National Program Team and all members of the Centers for Disease Control and Prevention STRIVE collaborative.Financial Support: Additional support was received from the Agency for Healthcare Research and Quality (K08 HS19767) and the Department of Veterans Affairs (Health Services Research & Development Service RCS 11-222, and National Center for Patient Safety Ann Arbor Patient Safety Center of Inquiry).Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-3443.Corresponding Author: Sanjay Saint, MD, MPH, George Dock Professor of Internal Medicine, University of Michigan Department of Internal Medicine, 2800 Plymouth Road, Building 16, Room 430W, Ann Arbor, MI 48109-2800; e-mail, [email protected]umich.edu.Current Author Addresses: Drs. Saint and Meddings: University of Michigan Department of Internal Medicine, 2800 Plymouth Road, Building 16, Room 430W, Ann Arbor, MI 48109-2800.Ms. Fowler and Dr. Krein: Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, PO Box 130170, Ann Arbor, MI 48113-0170.Dr. Vaughn: University of Michigan Department of Internal Medicine, 2800 Plymouth Road, Building 16, Room 472C, Ann Arbor, MI 48109.Ms. Ameling: University of Michigan Department of Internal Medicine, 2800 Plymouth Road, Building 16, 4th Floor, Ann Arbor, MI 48109-2800.Dr. Rohde: University of Michigan Department of Internal Medicine, 1500 East Medical Center Drive, Ann Arbor, MI 48109.Dr. Popovich: Rush University, 600 South Paulina, Suite 143, Chicago, IL 60612.Dr. Calfee: Weill Cornell Medicine, 525 East 68th Street, New York, NY 10065.Dr. Chopra: University of Michigan Department of Internal Medicine, 2800 Plymouth Road, Building 16, Room 432W, Ann Arbor, MI 48109-2800.Author Contributions: Conception and design: S. Saint, J. Meddings, K.E. Fowler, V.M. Vaughn, J.M. Ameling, J.M. Rohde, D.P. Calfee, S.L. Krein, V. Chopra.Analysis and interpretation of the data: S. Saint.Drafting of the article: S. Saint, K.E. Fowler, V. Chopra.Critical revision of the article for important intellectual content: S. Saint, J. Meddings, K.E. Fowler, V.M. Vaughn, J.M. Ameling, J.M. Rohde, K.J. Popovich, D.P. Calfee, S.L. Krein, V. Chopra.Final approval of the article: S. Saint, J. Meddings, K.E. Fowler, V.M. Vaughn, J.M. Ameling, J.M. Rohde, K.J. Popovich, D.P. Calfee, S.L. Krein, V. Chopra.Obtaining of funding: S. Saint, V. Chopra.Administrative, technical, or logistic support: K.E. Fowler, J.M. Ameling.This article is part of the Annals supplement “States Targeting Reduction in Infections via Engagement (STRIVE),” which was supported by the Health Research & Educational Trust and built upon work made possible by the Centers for Disease Control and Prevention, STRIVE Program (contract 200-2015-88275). 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Rolle, MPH, and Vineet Chopra, MD, MSc 1 October 2019Volume 171, Issue 7_SupplementPage: S7-S9KeywordsBacteremiaInfectious disease controlMethicillin-resistant staphylococcus aureusSafetyStaphylococcal infectionUrinary tract infectionsVeteran care ePublished: 1 October 2019 Issue Published: 1 October 2019 PDF downloadLoading ...