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1
Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries.
Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America.
© Jennifer Meddings, Vineet Chopra, and Sanjay Saint 2021
First Edition published in 2015 Second Edition published in 2021
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above.
You must not circulate this work in any other form and you must impose this same condition on any acquirer.
Library of Congress Cataloging-in-Publication Data
Names: Meddings, Jennifer author. | Chopra, Vineet author. | Saint, Sanjay author. Title: Preventing hospital infections : real-world problems, realistic solutions / Jennifer Meddings, Vineet Chopra, Sanjay Saint.
Description: Second edition. | New York, NY : Oxford University Press, [2021] | Preceded by Preventing hospital infections / Sanjay Saint, Sarah L. Krein. 2015. | Includes bibliographical references and index.
Identifiers: LCCN 2020047013 (print) | LCCN 2020047014 (ebook) | ISBN 9780197509159 (paperback) | ISBN 9780197509173 (epub) | ISBN 9780197509180
Subjects: MESH: Cross Infection—prevention & control | Catheter-Related Infections—prevention & control | Clostridium Infections—prevention & control | Equipment Contamination—prevention & control | Infectious Disease Transmission, Professional-to-Patient—prevention & control | Infection Control Practitioners | Guideline Adherence
Classification: LCC RC683.5.I5 (print) | LCC RC683.5.I5 (ebook) | NLM WX 167 | DDC 617/.05—dc23
LC record available at https://lccn.loc.gov/2020047013
LC ebook record available at https://lccn.loc.gov/2020047014
This material is not intended to be, and should not be considered, a substitute for medical or other professional advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances. And, while this material is designed to offer accurate information with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical and health issues is constantly evolving and dose schedules for medications are being revised continually, with new side effects recognized and accounted for regularly. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulation. The publisher and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material. Without limiting the foregoing, the publisher and the authors make no representations or warranties as to the accuracy or efficacy of the drug dosages mentioned in the material. The authors and the publisher do not accept, and expressly disclaim, any responsibility for any liability, loss, or risk that may be claimed or incurred as a consequence of the use and/or application of any of the contents of this material.
DOI: 10.1093/med/9780197509159.001.0001
9 8 7 6 5 4 3 2 1
Printed by Marquis, Canada
To my parents, Betty and Leo Meddings, for their endless support, and to my patients and their families for the privilege of caring for them.
Jennifer Meddings
To Palak, Vyaan, and Priya. Thank you for making me complete.
Vineet Chopra
To my nursing colleagues throughout the world: Thank you for your tireless efforts in caring for patients.
Sanjay Saint
CONTENTS
Preface ix
About the Authors xiii
1. An Effective Strategy to Combat Hospital Infections 1
2. Committing to an Infection Prevention Initiative 10
3. Types of Interventions: Catheter-Associated Urinary Tract Infection 24
4. Types of Interventions: Central Line–Associated Bloodstream Infection 40
5. Building the Team 52
6. The Importance of Leadership and Followership 69
7. Common Problems, Realistic Solutions 87
8. Joining a Collaborative 118
9. Toward Sustainability 131
10. Taking on Clostridioides difficile 141
11. The Future of Infection Prevention 158
APPENDICES
A. Ann Arbor Criteria for Urinary Catheters in Hospitalized Medical Patients 183
B. Michigan Appropriate Perioperative (MAP) Criteria for Urinary Catheter Use 195
C. Two-Tier Approach to Prioritize Interventions for CatheterAssociated Urinary Tract Infection (CAUTI), Central Line–Associated Bloodstream Infection (CLABSI), and Clostridioides difficile Infection (CDI) 199
D. Guide to Patient Safety (GPS) Tools for CAUTI, CLABSI, and CDI 201
E. Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) Criteria 225
References 229 Index 245
Nearly 2 million Americans develop a healthcare-associated infection each year, and some 100,000 of them die as a result. Yet healthcare-associated infections are reasonably preventable through hospitals’ adoption and implementation of evidence-based methods that offer sizable potential savings—in terms of both lives and dollars. A major stumbling block exists between these preventive methods and their full implementation, namely, the failure of large numbers of healthcare personnel to put the methods into practice.
First, though, we would like to pause a moment to acknowledge the altered healthcare environment into which this book is being launched. We had no idea when we set forth on the new edition that it would appear while the world was still reeling from the effects of a very different kind of infection. Our hearts go out to those whose lives have been torn apart by the novel coronavirus pandemic.
There is no shortage of books that address healthcare-associated infection and its prevention. Most of them, however, are primarily focused on identifying and describing the various types of infection and on the “technical” aspects of prevention—the sanitary conditions or the latest device that will stop germs from spreading. The “adaptive aspects”—the acceptance and use of preventive measures by clinical personnel—receive relatively little attention.
This book, now in its second edition, is primarily devoted to that very issue, providing detailed guidance for dealing with the human equation
in a hospital quality improvement initiative. We address that challenge in every element of an initiative, from the decision by senior leaders to proceed, to the selection of a project manager and physician and nurse champions, to the piloting of the initiative on a single medical unit and its rollout to the entire hospital or system, to the sustaining of the project’s gains. There are chapters that pinpoint the main categories of resistance to an initiative and how to cope with them, that analyze the role of leadership in a change initiative, and that explore the future of infection prevention. All of the chapters have been carefully updated since the first edition, with new (or expanded) material on the technical aspects of preventing several types of hospital infection; tools and algorithms that can be used by front-line providers as well as more senior managers; appropriateness criteria for using invasive urinary and vascular access devices; recent results of several large collaborative infection prevention studies; novel approaches, including mindfulness and motivational interviewing to change behavior; and the role of the patient and family in preventing infection. We have been greatly appreciative of the positive feedback we received on the first edition; we hope this latest iteration continues to meet the needs of our readers. In order to provide a fresh perspective, we have added two new authors, each with deep expertise in this topic. We are also extremely grateful to Dr. Sarah Krein for her work on the first edition; much of the material in this book reflects her important contributions.
The book follows an infection prevention initiative as it might unfold in a model hospital. Because the initiative we use addresses catheterassociated urinary tract infection (CAUTI), it involves the entire hospital and the whole range of clinical staff, rather than being limited to, say, the emergency department or the intensive care unit. As a result, we believe its lessons can be applied to many other kinds of quality improvement efforts, such as those to prevent venous thromboembolism and falls.
The book is relatively concise and written in a conversational style. Its content largely reflects our findings and the work that we have been engaged in over the last two decades in trying to understand why some hospitals
are more successful than others in preventing healthcare-associated infection. This includes research and prevention-related activities funded by the Department of Veterans Affairs (VA), the National Institutes of Health (NIH), the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), the Health Research & Educational Trust (HRET) of the American Hospital Association, the Blue Cross Blue Shield of Michigan Foundation, and the Michigan Health and Hospital Association’s Keystone Center.
In addition to the valuable support of our funders, we have been fortunate to work with a superb group of individuals who share our goal of preventing infection and enhancing patient safety. We are ever grateful to our dedicated project staff, including Karen Fowler, Jessica Ameling, Latoya Kuhn, Martha Quinn, Molly Harrod, Debbie Zawol, David Ratz, Michele Mazlin, and Rachel Ehrlinger. We have benefited greatly from our fruitful collaborations with a large number of individuals from different parts of the world, including Sarah Krein, Molly Harrod, Jane Forman, Valerie Vaughn, Tim Hofer, Mohamad Fakih, Russ Olmsted, Milisa Manojlovich, Lona Mody, Todd Greene, Sam Watson, Scott Flanders, Hugo Sax, Benedetta Allegranzi, Alessandro Bartoloni, Akihiko Saitoh, Anita Huis, Didier Pittet, Laraine Washer, Anucha Apisarnthanarak, Bob Wachter, Jay Bhatt, and Yasuharu Tokuda. We are especially grateful for the contributions to this work provided by Robert Stock— his quick eye and even quicker pen are greatly appreciated.
We also value the support we have received from our employers: the VA Ann Arbor Healthcare System and the University of Michigan. Both organizations are committed to excellence in all that they do, and we are honored to call both organizations our home. We remain grateful to our many supervisors through the years who have provided us with the support and encouragement to conduct our work, including Rod Hayward, Larry McMahon, John Carethers, Mark Hausman, Eve Kerr, Eric Young, Ginny Creasman, and Robert McDivitt. We also thank the many healthcare providers and administrators who participated in our interviews and shared with us their stories (trials, tribulations, and successes) as they
worked to prevent infections in their organizations. It is these individuals and their counterparts in hospitals across the United States and the world for whom this book is primarily intended as we collectively strive to improve the safety of hospitalized patients.
Let the journey continue!
Jennifer Meddings
Vineet Chopra
Sanjay Saint
ABOUT THE AUTHORS
Jennifer Meddings, MD, MSc, is an associate professor of internal medicine and pediatrics at the University of Michigan Health System and the VA Ann Arbor Healthcare System. Much of her recent research has focused on evaluation and development of evidence-based interventions for prevention of catheter-associated urinary tract infection (CAUTI). She has performed several systematic reviews involving interventions to reduce unnecessary catheter use, including meta-analyses demonstrating that the use of urinary catheter reminders and stop orders can reduce CAUTIs by over 50%. Her work has informed the development and evaluation of educational interventions in multiple national collaboratives to reduce CAUTI in the acute care and long-term care settings. She developed and led a project using the RAND/UCLA Appropriateness Method to formally rate the appropriateness of three types of urinary catheters (indwelling, intermittent straight, and external) for hundreds of clinical scenarios commonly encountered in hospitalized adults on medical services; this work was published in Annals of Internal Medicine. She also applied the RAND/UCLA Appropriateness Method to generate the Michigan Appropriate Perioperative Criteria for common procedures in general surgery and orthopedics, published in BMJ Quality & Safety. Her work has also focused on the evaluation of measures of urinary catheter use for surveillance and public reporting and the challenges in implementing value-based purchasing programs that use metrics involving urinary catheter use and pressure ulcer development. She received her Medical
Doctorate from the University of Michigan, completed a medical residency and chief residency at the Ohio State University, and obtained a Master of Science in Health and Healthcare Research from the University of Michigan.
Vineet Chopra, MD, MSc, is chief of the Division of Hospital Medicine, associate professor of internal medicine at the University of Michigan, and a research scientist at the VA Ann Arbor Healthcare System. Dr. Chopra is an internationally recognized expert in patient safety. His research on the appropriateness of vascular access device use and its outcomes has informed clinical policies and protocols for countless hospitals and health systems. He is the recipient of numerous teaching and research awards, including the 2016 Kaiser Permanente Award for Clinical Teaching and the 2019 Distinguished Mentor Award from the Michigan Institute for Clinical and Health Research. Dr. Chopra has published over 200 peerreviewed articles in journals such as JAMA, Annals of Internal Medicine, BMJ, Lancet, Infection Control and Hospital Epidemiology, and Clinical Infectious Diseases; the majority of these articles focused on preventing infectious and noninfectious complications from the use of vascular access devices.
Sanjay Saint, MD, MPH, MACP, is the chief of medicine at the VA Ann Arbor Healthcare System, the George Dock Professor of internal medicine at the University of Michigan, and the director of the VA/University of Michigan Patient Safety Enhancement Program. His research focuses on enhancing patient safety by preventing hospital infection and translating research findings into practice. He has authored over 375 peer-reviewed papers, approximately 110 of which appeared in the New England Journal of Medicine, JAMA, Lancet, or the Annals of Internal Medicine. He is an international leader in preventing CAUTI. He is a special correspondent to the New England Journal of Medicine, an editorial board member of BMJ Quality and Safety, an elected member of the American Society for Clinical Investigation and the Association of American Physicians, and an international honorary fellow of the Royal College of Physicians
(FRCP). He received his Medical Doctorate from UCLA, completed a medical residency and chief residency at the University of California at San Francisco, and obtained a master’s in public health (as a Robert Wood Johnson Clinical Scholar) from the University of Washington in Seattle. He has been a visiting professor at over 100 universities and hospitals in the United States, Europe, and Asia.
An Effective Strategy to Combat Hospital Infections
The hospital is altogether the most complex human organization ever devised.
Peter Drucker
We were interviewing staff members at a dozen hospitals that had taken part in a campaign to reduce healthcare-associated urinary tract infections. The goal was to make sure that indwelling urinary catheters were only used when medically necessary and were removed promptly when no longer needed, which sounded simple enough. But, in reality, it turned out to be infinitely complex and confusing.
We discovered, for example, that there were two sets of nurses who were worried about their patients taking a fall. One set wanted the catheter out as soon as possible because it interfered with patient mobility, and they feared that their patients, especially those who are a bit confused and do not even realize the catheter is in place, might trip on the tubing. “They are going to try and get out of bed and injure themselves,” one nurse said.
Another set of nurses favored maintaining the catheter in place as long as possible because it tended to keep their patients in bed. A nurse put it this way, “Well, do I really want this person hopping out of bed, and can
I really be sure that they’re going to call me to help them? We don’t want there to be any falls.”
Two groups of nurses that were both concerned about their patients’ well-being; one group gladly cooperated with an infection prevention program, while the other group was, at best, reluctant. As is so often true when a hospital embarks on a campaign to control infection, the human dimension intruded.
There is universal agreement within the nation’s hospitals that the prevention of healthcare-associated infection (HAI) is an absolute necessity for both humane and financial reasons. And there is no shortage of evidence-based strategies that can take us closer to that goal. Multiple studies1–6 have demonstrated that at least 20% of all HAIs can be prevented, and some researchers have suggested that the figure might reach 70%; preventability appears to vary by the type of HAI and the clinical setting (within or outside an intensive care unit [ICU], for example). Yet many of the efforts that hospitals have made to implement these proven strategies have fallen short of their goals. Why? Our research spanning two decades has shown that a principal reason is the failure of the hospitals to win their staff’s active support of infection prevention initiatives. In their focus on the technical aspects of an initiative, some hospitals have given short shrift to the human aspects imperative for improving patient safety.
We offer a field-tested framework for organizing and implementing a hospital-based initiative to combat infection. It includes descriptions and explanations of some evidence-based infection prevention procedures, but the major focus is on ways to inspire full-scale adoption of these practices—essentially, to change behavior. We answer this central question: Given all the complexities of the hospital operation—the hierarchical arrangements, the competing priorities, the web of personal relationships—how do you get the people of a hospital to truly buy in to an infection prevention initiative?
The stakes are high, and they can be quickly stated. A multistate point prevalence study published in 2018 estimated that in 2015 there were 687,200 hospital-acquired infections in US hospitals.3 The infections create physical and emotional distress for hundreds of thousands of
patients annually. They also take a psychological toll on the staff of a hospital and on its culture, constant reminders of their failure to live up to their credo, primum non nocere first, do no harm.
Hospitals have not been ignoring the problem—far from it. Spurred on by a consumer-driven patient safety movement, they have undertaken hundreds of programs to combat HAI, providing a classic example of the translation of medical research findings into clinical practice and better care for the patient. And the programs have had an impact: The Centers for Disease Control and Prevention (CDC) infection and fatality figures previously cited are considerably lower than earlier estimates. Specifically, in a national point prevalence study applying the CDC’s HAI definitions in approximately 200 hospitals, 3% of patients had HAIs in 2015 compared to 4% in 2011 using the same research methods,3 primarily due to reductions in surgical site infections and urinary tract infections. More recent national data published using hospital-reported National Healthcare Safety Network data for changes reported between 2017 and 2018 indicated central line–associated bloodstream infection (CLABSI) had decreased 9% overall and 11% in the ICU; catheterassociated urinary tract infection (CAUTI) had decreased 8% overall and 10% in the ICU; and hospital-onset Clostridioides difficile (formerly known as Clostridium difficile) infection (CDI) has decreased 12% overall. However, there has been no significant change in ventilator-associated pneumonia or surgical site infection for the 10 monitored procedures and no change in hospital-onset methicillin-resistant Staphylococcus aureus (MRSA) bacteremia.7
At one hospital, the scene of a campaign to reduce infections caused by central venous catheters, we interviewed an infection preventionist who wanted to extend the campaign from the ICU to the operating room. At a management Christmas party, over cocktails, he asked the head of anesthesiology whether he was aware that, with the ICU project in full swing, the operating room was now the source of all of the hospital’s central venous catheter infections. The anesthesiologist was surprised and chagrined and, in short order, a convert to extending the campaign to his bailiwick.
“My philosophy,” the preventionist said, “has always been: What if it’s your mother, your father? We always want the best care for those that we love, and we try to bring that home to everyone in the hospital.”
But our hospitals as a whole have a long way to go before they realize their infection prevention goals. Although some hospitals do publish successes6 in prevention of CAUTI and CLABSI in the ICU setting, two recent large collaboratives that focused on ICUs with elevated rates of CLABSI and CAUTI did not demonstrate improved outcomes.8–10 Overall, reported staff adherence to prevention practices for CLABSI and CAUTI, two of the most common device-related infections, was variable and, in some cases, depressingly low. For CLABSI, reported adherence to prevention policies was nearly 100% for two key recommended practices (maximum sterile barrier precautions during central line insertion and chlorhexidine gluconate for insertion site antisepsis), with adherence to use of chlorhexidine antimicrobial dressing ranging from 86% to 92%. The use of antimicrobial catheters, however, ranged from just 36% to 45%.11 For CAUTI, though large improvements in key preventive practices were seen compared to the prior 2017 assessment, there remains much room for improvement in basic preventive strategies. The use of portable bladder scanners to avoid unnecessary catheterizations, for example, ranged from 69% to 77%. The use of urinary catheter reminders or discontinuation by nurses ranged from 72% to 79%, and just 23% to 31% reported routine use of external condom catheters in men as an alternative to indwelling urinary catheters.11
Difficulties with adherence to standard prevention approaches remain, and educational interventions focused on both technical and even socioadaptive strategies to prevent HAIs too often falter. A recent large collaborative funded by the CDC for hospitals struggling with HAI rates provided and deployed HAI-specific self-assessment and educational materials in multiple formats for CAUTI and CLABSI, as well as for two other common HAIs, CDI and MRSA.8,9,12,13 Though it failed to reduce HAI rates significantly, new tools were developed that may be of interest to hospitals on the journey to reducing HAIs—more detail is provided on this in the chapters to come.
In addition, there have been government initiatives on state and federal levels. In 2009, for example, the Department of Health and Human Services launched a national action plan, increasing its financial support of HAI-related projects and setting 5-year goals for a major reduction of five of the most serious hospital-acquired infections.14 The Centers for Medicare & Medicaid Services (CMS) has stopped reimbursing hospitals for the extra costs involved in treating a number of hospital infections.15,16 Starting in 2014, all CMS payments to hospitals “that rank in the lowestperforming quartile of hospital-acquired conditions,” including some infections, were reduced by 1%.17 And CMS requires that hospitals report their infection rates for several HAIs,18 information that is critical for understanding how best to target such infections.
We (all three authors of this book) have, individually and jointly, closely observed, participated in, and published academic papers about a number of effective efforts to combat hospital infections. Jennifer Meddings, MD, MSc, is an associate professor of internal medicine and pediatrics at the University of Michigan, who has performed several systematic reviews focused on the impact of interventions to prevent CAUTI.6,19,20 She developed and led a project using the RAND/UCLA Appropriateness Method to develop the Ann Arbor Criteria for urinary catheter use in hospitalized medical patients, as well as the Michigan Appropriate Perioperative Criteria for common procedures in general surgery and orthopedics.21,22 Vineet Chopra, MD, MSc, is the chief of the Division of Hospital Medicine and associate professor of medicine at the University of Michigan, Ann Arbor. He was the lead author for the 2015 Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) criteria that define when use of a peripherally inserted central catheter is appropriate.23 Sanjay Saint, MD, MPH, MACP, is the chief of medicine at the VA Ann Arbor Healthcare System and the George Dock professor of medicine at the University of Michigan, Ann Arbor. He was the lead author of the 2016 article4 in the New England Journal of Medicine that detailed the findings of a large-scale collaborative addressing CAUTI in hospitals throughout the United States, which is discussed in more detail in Chapter 3.
Healthcare-associated infections caused by such indwelling devices are especially common—and preventable. They have thus become the
leading edge of efforts to combat HAI. In this book, we focus on examples involving two of the most common medical devices: the indwelling urinary catheter and the central venous catheter.
• The indwelling urinary catheter is also known as a Foley. Infections associated with this catheter, known as CAUTI, though generally less dangerous than other conditions, create serious pain and discomfort for patients and are among the most common device-associated infections in the United States. Among the estimated 62,700 healthcare-associated urinary tract infections each year, 62% (38,585) are CAUTIs in US hospitals, based on medical record reviews in 2015.3
• The central venous catheter is commonly referred to as a central line. CLABSIs associated with the use of these catheters are life threatening, particularly because these devices remain in the bloodstream for several weeks or more. Among the estimated 83,600 healthcare-associated bloodstream infections in the United States, 73% (61,092) are CLABSIs occurring annually in hospitals, based on 2015 medical record reviews.3
Peripherally inserted central catheters (PICCs) are a unique type of central venous catheter; these are inserted in peripheral veins of the upper arm but terminate in central veins of the chest. They are thus a central line placed through a peripheral vein. PICCs are inserted by specialized vascular access teams at the bedside and are commonly used outside the ICU. As a result of growing PICC use, more complications from central lines now occur outside critical care settings.
“Bundles” of clinical interventions for preventing infection have been developed for both indwelling and central line catheters. Though these interventions vary in their details, they share the common goal of removing the device as soon as possible. * * *
The infection prevention framework we present in the chapters to come is primarily focused on CAUTI and CLABSI, with later examples describing how lessons learned and challenges related to prevention of CAUTI and CLABSI apply to other HAIs, such as CDI and MRSA, as well as emerging threats such as Candida auris. 24 We have chosen CAUTI as our primary focus because hospitals have found CAUTI far more resistant to quality improvement efforts than other infections, particularly in the ICU setting.4,10 We also believe that the CAUTI prevention framework can serve a larger purpose: as a model for coping with challenges beyond HAIs, including the prevention of falls and antimicrobial stewardship.
In the quotation that opens this chapter, Peter Drucker marvels at the complexity of the hospital as an organization. The CAUTI model can help us unravel some of that complexity and gain a better understanding of hospitals’ operations.
Why is a CAUTI prevention framework an apt model for this larger role? Several reasons are the following:
• CAUTI’s impact on patients has long been felt throughout the hospital, from the emergency department to the medical–surgical floor to the ICU and from the inpatient rehab unit to the nursing home.
• CAUTI prevention involves a broad spectrum of hospital personnel, including nurses, physicians, infection preventionists, administrators, nursing aides, and microbiologists.
• CAUTI can easily fly under the radar in an environment governed by the rule of rescue, where heart attacks and other lifethreatening events trump all else. The same is true of several other hospital-acquired conditions.
• The CAUTI model relies heavily on widely applicable socioadaptive concerns, rather than on technical elements that vary with each target problem. As is true of many other quality improvement efforts, the success of a CAUTI initiative relies on the full engagement of front-line clinicians and on positive communication between nurses and physicians.
