Health care-associated infections (HAI) occur in a variety of settings and are caused by a variety of pathogens. They occur in ambulatory, institutional, hospital, and home-based settings. Four primary categories of HAIs exist, most of which are seen in acute care settings: surgical site infections, central line-associated blood stream infections, ventilator-associated pneumonia, and catheter-related urinary tract infections.  (Together, these 4 categories of infections account for 75% of HAIs each year.) HAIs are among the leading cause of death in the United States, accounting for more than 100,000 deaths annually. Overall, there are nearly 2 million HAIs reported each year.

Now, the federal government is making infection control surveillance another priority. Funding will, of course, be provided by the recently passed American Reinvestment and Recovery Act. $50 million of the Act is assigned to prevent HAIs. Specifically, $10 million of that $50 million will focus on HAI prevention in ambulatory care settings. The new survey plan will be launched as a joint effort of the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC). Officials from the Department of Health and Human Services (HHS), which has ultimate oversight of the program and its budget, asserts that ambulatory care centers will be inspected and surveyed every 3 years. The expectation is that these inspections will be deterrents to relaxed infection control practices and, thus, will lead to a reduction in HAIs.

The survey process has already been tested in 3 states in 2008, and the results were promising, according to HHS, though specific data is lacking. They predict national reductions of 10-20% in HAIs within 2 years of the nationwide program’s initiation. As part of the surveillance plan, the CDC plans to create state agencies that will collaborate with hospital associations, quality improvement organizations, and state health departments to develop coordinated prevention strategies.

While the goal of the federal government is admirable, and HAIs are inarguably a major concern in health care delivery today, the solution may be more straightforward than they would like to think. They may not see the forest for the trees, or the hand in front of their face, as the case may be. Hand hygiene has been proven the simplest and most effective control measure of HAIs. Many HAIs occur from direct contamination by the hands, clothing, or equipment used by a health care provider. Recent studies have shown that only 40% of health care worked followed hand hygiene recommendations after patient contact. Nurses and allied health professionals have better compliance than physicians, but no group complies with hand hygiene recommendations more than 70% of the time. Unfortunately, intensive care units –- the area with the highest risk of adverse outcomes from infections –- showed the poorest compliance.

The last 30 years have seen a shift from health care as a science to health care as a business. When formal infection control programs were initiated in most hospitals in the 1970s to combat the emergence of antibiotic-resistant organisms, the programs were effective. But, as budgets were trimmed and personnel were downsized in cost-cutting measures, infection control programs also fell by the wayside, since they were not considered revenue-generating. At the same time, the growth of outpatient and ambulatory clinics and home-based health care skyrocketed owing to the improved efficiency and cost-effectiveness of health care delivery compared to traditional inpatient settings. Also, patient care has moved from physicians and nurses only to a variety of allied health and other health care professionals and technicians, meaning that patients see more health care workers than ever before, increasing the chance for disease transmission. For these, and other reasons, HAIs are on the rise again. However, infection surveillance is complicated in an outpatient setting. Patients are harder to trace, and monitoring multiple centers is more cumbersome than monitoring a single acute-care setting. Also, standardization of surveillance methods is challenging across all locales and populations. Further, participation in a surveillance network, as well as confidentiality and adequate and timely feedback need to be addressed by a nationwide, federally-directed surveillance program.

Will private outpatient clinics or hospitals receive sufficient time and funding to educate health care workers on new infection control practices? Who are the inspectors and will they use standardized benchmarks and quality outcomes for measuring infection control? What kind of accountability will the inspectors have for their reports? (The United States has recently suffered a number of food-borne illness outbreaks thanks to inadequate and irresponsible inspectors assigned to keep the public safe.) Finally, should CMS –- an organization that clearly has managerial and budgetary issues of its own –- administer a program intended to keep Americans healthy? The federal government may have good intentions, but it would cost a lot less than $50 million to teach Americans to wash their hands.

References

Banfield, K., Kerr, K., Jones, K., & Snelling, A. (2007). Hand hygiene and health-care-associated infections The Lancet Infectious Diseases, 7 (5), 304-304 DOI: 10.1016/S1473-3099(07)70088-9

HHS Action Plan to Prevent Healthcare-Associated Infections: U.S. Department of Health & Human Services; 2009.

Goldman L. Cecil Medicine. 23rd ed: Elsevier Health Sciences; 2007.

Cohen J, Powderly W. Infectious Diseases. 2nd ed: Elsevier Health Sciences; 2004.