Reducing Health Care–Associated Infection: Getting Hospitals and Health Systems to Zero
Authors: Jay Bhatt, Sue Collier
Journal: Annals of Internal Medicine (2019)

Supplement: STRIVE1 October 2019Reducing Health Care–Associated Infection: Getting Hospitals and Health Systems to ZeroFREEJay Bhatt, DO, MPH and Sue Collier, MSN, RNJay Bhatt, DO, MPHHealth Research & Educational Trust, American Hospital Association, Chicago, Illinois (J.B., S.C.) and Sue Collier, MSN, RNHealth Research & Educational Trust, American Hospital Association, Chicago, Illinois (J.B., S.C.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M18-3441 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail On any given day, 1 in every 25 hospitalized patients has a health care–associated infection (HAI) (1). These infections affect patient care, add costs to the U.S. health care system, and challenge hospitals that struggle to achieve substantive reductions in infection rates. Several national efforts, including collaborations among the Health Research & Educational Trust (HRET), the University of Michigan, and other partners (2, 3), have focused on HAI prevention. Overall, hospitals and long-term care facilities have made enormous progress in driving down preventable HAIs. However, hospitals must work to close the remaining performance gaps, and to identify novel and sustainable approaches to addressing this issue.The HAI National Action Plan goals framed the Centers for Disease Control and Prevention (CDC) vision for the STRIVE (States Targeting Reduction in Infections via Engagement) program (4). This 3-year program (2015–2018) focused on improving infection control practices and strengthening key stakeholder relationships to improve infection control efforts at the hospital and statewide levels. The HRET recruited 462 hospitals in 28 states and the District of Columbia, with 443 hospitals completing the 12-month program. STRIVE used evidence-based HAI reduction strategies and relationship-based methods to address HAI rates in hospitals with a high cumulative attributable difference rate in Clostridioides difficile and at least one other HAI (central line–associated bloodstream infection, catheter-associated urinary tract infection, or methicillin-resistant Staphylococcus aureus infection). The HRET collaborated with the CDC, Association for Professionals in Infection Control and Epidemiology, American Society for Health Care Engineering, Society of Hospital Medicine, University of Michigan, and other experts to provide technical assistance and guidance. This national program team built a structured, stepwise curriculum for all enrolled hospitals to reduce HAIs and, in doing so, developed new alliances. The curriculum emphasized horizontal (called "foundational") infection prevention strategies, such as hand hygiene and environmental cleaning, that cut across all HAIs (5), as well as socioadaptive solutions, such as team building and leadership engagement, to address the attitudinal and cultural changes that must occur to ensure consistent application of evidence-based guidelines (6). STRIVE also encouraged statewide collaboration on HAI reduction efforts for hospitals by bringing together state hospital associations, state health departments, and quality innovation networks/quality improvement organizations.The STRIVE materials and techniques focused on embedding evidence-based infection prevention practices across teams. For example, one module in the curriculum promoted team engagement across multiple departments. Program education emphasized changing traditional communication methods in order to break the cycle of infections. Standardized protocols to promote accountability and reduce the spread of nosocomial infections were emphasized throughout. A dedicated patient and family engagement module highlighted how patients and families can be active partners to improve care. The curriculum reinforced the importance of using standardized processes in a complex system, such as a hospital, to ensure patient safety.Results showed some hospitals realized some improvements in outcome and process measures, and some maintained or achieved zero infections during the intervention period. However, in aggregate, there was no statistically significant change over time during the program intervention period compared with the baseline period for any of the HAIs (7–10). So we asked, "Why not?" Various explanations, including limitations of data collection and analysis as well as inconsistent engagement due to competing priorities and high staff turnover, are possible. Also, because some hospitals began with low HAI rates, the ability to see a statistically significant change over time may have been reduced. Qualitative findings did show stronger stakeholder relationships had been established that could align and sustain HAI prevention across the entire patient continuum of care (11).Did our program accelerate the journey to zero preventable HAIs? Although all hospitals worked hard at this effort, some achieved greater success than others. This reality begs the question: Why is HAI prevention so difficult? Many reasons have been cited in the literature that include the immense financial and workforce challenges and staff turnover experienced by participating hospitals. These challenges can be especially difficult for hospitals that need resources to educate staff on standardized, evidence-based practices shown to reduce HAIs. Access to HAI consistent staff training and development and other evidence-based guidelines and systems to easily implement them and review data sounds like a simple solution, but in reality, HAI prevention is challenging, especially for hospitals that may struggle with numerous technical and socioadaptive barriers in the environment (12).How, then, do we advance this important safety agenda? We need to redouble our efforts to standardize HAI prevention processes throughout the U.S. health care system. Every health care delivery organization should be able to implement evidence-based HAI prevention processes. We need to enhance the resources and knowledge of hospital teams to prevent HAIs. This commitment includes educating health care workers in HAI prevention, robust processes to measure infection rates, and continuous use of evidence-based practices with every patient in every setting by all clinicians and team members. Other commitments may include coordinated federal and state funding support across all agencies; tools and resources for infection control leadership in every hospital; consistent collection, analysis, management, reporting, and sharing of HAI incidence rates; rigorous implementation of known and effective policies and procedures to prevent HAI, such as hand hygiene, environmental disinfection, antimicrobial stewardship, and engagement of patient and family advisors in prevention teams; consistent training and retraining of team members; and use of medical technologies and devices designed to prevent infections and identify patients colonized or infected with HAI-associated pathogens.The STRIVE program engaged leading experts, clinicians, community leaders, and trusted partners to prevent and reduce HAIs, and assumed that safe, high-quality care can be delivered in all environments. We must unite to implement evidence-based medicine to realize the ultimate goal of zero HAIs. We must continue to evaluate all programs and interventions for achievements and failures in order to drive improvement in health outcomes. Every hospital, every program, and every initiative matters when we learn to improve together. Everyone wins when we are all moving ahead together.References1. 2017 National and State Healthcare-Associated Infections Progress Report. Atlanta: Centers for Disease Control and Prevention; 2016. Accessed at www.cdc.gov/hai/data/portal/progress-report.html on 21 November 2018. Google Scholar2. 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 Scholar3. Mody L, Greene MT, Meddings J, et al. A national implementation project to prevent catheter-associated urinary tract infection in nursing home residents. JAMA Intern Med. 2017;177:1154-62. [PMID: 28525923] doi:10.1001/jamainternmed.2017.1689 CrossrefMedlineGoogle Scholar4. Bell MR, Kuhar DT. An introduction to STRIVE. Ann Intern Med. 2019;171:S1. doi:10.7326/M18-3440 LinkGoogle Scholar5. Septimus E, Weinstein RA, Perl TM, Goldmann DA, Yokoe DS. Approaches for preventing healthcare-associated infections: go long or go wide? Infect Control Hosp Epidemiol. 2014;35:797-801. [PMID: 24915206] doi:10.1086/676535 CrossrefMedlineGoogle Scholar6. Saint S, Krein SL, Stock RW. Preventing Hospital Infections: Real-World Problems, Realistic Solutions. New York: Oxford Univ Pr; 2014. Google Scholar7. Patel PK, Greene MT, Jones K, et al. Quantitative results of a national intervention to prevent central line–associated bloodstream infection. A pre–post observational study. Ann Intern Med. 2019;171:S23-9. doi:10.7326/M18-3533 LinkGoogle Scholar8. Meddings J, Manojlovich M, Ameling JM, et al. Quantitative results of a national intervention to prevent hospital-acquired catheter-associated urinary tract infection. A pre–post observational study. Ann Intern Med. 2019;171:S38-44. doi:10.7326/M18-3534 LinkGoogle Scholar9. Dubberke ER, Rohde JM, Saint S, et al. Quantitative results of a national intervention to prevent Clostridioides difficile infection. A pre–post observational study. Ann Intern Med. 2019;171:S52-8. doi:10.7326/M18-3545 LinkGoogle Scholar10. Calfee DP, Davila S, Chopra V, et al. Quantitative results of a national intervention to prevent hospital-onset methicillin-resistant Staphylococcus aureus bloodstream infection. A pre–post observational study. Ann Intern Med. 2019;171:S66-72. doi:10.7326/M18-3535 LinkGoogle Scholar11. Fowler KE, Forman J, Ameling JM, et al. Qualitative assessment of a state partner–facilitated health care–associated infection prevention national collaborative. Ann Intern Med. 2019;171:S75-80. doi:10.7326/M18-3477 LinkGoogle Scholar12. Vaughn VM, Saint S, Krein SL, et al. Characteristics of healthcare organisations struggling to improve quality: results from a systematic review of qualitative studies. BMJ Qual Saf. 2019;28:74-84. [PMID: 30045864] doi:10.1136/bmjqs-2017-007573 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Health Research & Educational Trust, American Hospital Association, Chicago, Illinois (J.B., S.C.)Acknowledgment: The authors thank Louella Hung and Cynthia Greising for their support in editing this opinion piece and the HRET Health Care-Associated Infection team, as well as the National Program Team and all members of the CDC STRIVE collaborative.Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-3441.Corresponding Author: Jay Bhatt, DO, MPH, 155 North Upper Wacker Drive, Suite 400, Chicago, IL 60606; e-mail, [email protected]org.Current Author Addresses: Dr. Bhatt: 155 North Upper Wacker Drive, Suite 400, Chicago, IL 60606.Ms. Collier: North Carolina Healthcare Foundation, 2400 Weston Parkway, Cary, NC 27513.Author Contributions: Conception and design: J. Bhatt, S. Collier.Analysis and interpretation of the data: J. Bhatt, S. Collier.Drafting of the article: J. Bhatt.Critical revision of the article for important intellectual content: J. Bhatt, S. Collier.Final approval of the article: J. Bhatt, S. Collier.Obtaining of funding: S. Collier.Administrative, technical, or logistic support: J. Bhatt, S. Collier.Collection and assembly of data: J. Bhatt.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). Previousarticle Advertisement FiguresReferencesRelatedDetails Metrics 1 October 2019Volume 171, Issue 7_SupplementPage: S81-S82KeywordsBacteremiaEvidence based medicineHealth careHygieneInfectious disease controlInterleukinsPatientsSafetyUrinary tract infectionsVision ePublished: 1 October 2019 Issue Published: 1 October 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...