Healthcare-Associated Infections: Prevention and Clinical Management

Background and Definition

Healthcare-associated infections (HAIs) are acquired by patients while undergoing treatment for their medical conditions. They occur in virtually all healthcare settings, including surgery and acute care centers, outpatient facilities, and long-term care facilities such as rehabilitation and nursing homes. HAIs are associated with multiple causes, including the use of medical devices like ventilators and catheters, post-surgical complications, transmission between healthcare workers and patients, and overuse of antibiotics, among others.

Healthcare-associated infections, along with other serious adverse events, continue to result in high morbidity and mortality among patients in U.S. healthcare facilities and cost the nation billions of dollars in healthcare expenses. Although advances have been made in understanding HAI prevention through implementation of existing guidelines, current prevention strategies remain limited by the state of scientific knowledge. Not all HAIs can be prevented, even when all recommended protocols are followed. Investment in HAI prevention research is critical to improving existing strategies and moving toward HAI elimination.

Clinical Problem and Epidemiology

The Centers for Disease Control and Prevention conducted a prevalence survey that provides current estimates of the scope of the HAI problem in U.S. hospitals. Using a large sample of acute care facilities nationwide, the survey reports that on any given day, approximately one in every twenty-five hospitalized patients has an HAI. Approximately 722,000 cases of HAI occurred in acute care hospitals in the United States, with approximately 75,000 of these patients dying while hospitalized. At least half of these infections occurred in intensive care units (ICUs).

Modern healthcare employs many invasive procedures and devices to aid patient recovery. Infections can be directly linked to devices used in various procedures, including ventilators and catheters. The resulting HAIs include catheter-associated urinary tract infections (CAUTIs), line-associated bloodstream infections, and ventilator-associated pneumonia. Infections can also develop at surgical incision sites, referred to as surgical site infections. The CDC actively monitors and works toward preventing these infections because they pose a direct threat to patient safety.

A surgical site infection occurs at the location where a surgical procedure was performed. These infections can sometimes be superficial, affecting only the skin. Other surgical site infections may be serious, penetrating body tissue beneath the skin, affecting organs, or compromising implants. Central line-associated bloodstream infections (CLASBIs) cause thousands of deaths annually and cost the healthcare system billions of dollars. Ventilator-associated pneumonia is a lung infection that develops in individuals using a ventilator—a device that helps patients breathe by supplying oxygen through a tube inserted in the nose or mouth, or sometimes through an opening in the neck. Infection can occur when bacteria enter the lungs through the tube.

Urinary tract infections (UTIs) can affect any part of the urinary tract, including the ureters, bladder, kidneys, and urethra. They are the most commonly reported type of HAI in the National Healthcare Safety Network (NHSN). Of hospital-acquired UTIs, approximately 75 percent are associated with indwelling urinary catheters—tubes used to drain urine from the bladder. It is estimated that 15 to 25 percent of hospitalized patients use urinary catheters during their stay. The most significant risk factor for developing a CAUTI is prolonged catheter use. Catheters should therefore be employed judiciously and not left in place longer than necessary.

Impact on Patients, Nurses, and Organizations

The Iowa Department of Public Health recognizes that HAIs pose a major challenge to the healthcare sector and acknowledges the need to monitor and reduce preventable infection rates. The CDC reports that nearly two million patients acquire HAIs in U.S. hospitals annually. Approximately 99,000 deaths result from these infections, and the CDC estimates that the problem costs the nation between $28 billion and $33 billion annually. The Iowa Department of Public Health emphasizes that patients should never anticipate acquiring infections during their hospital care. Eliminating HAIs from the healthcare system is essential to ensure safety for all patients. These infections cause preventable deaths annually and impose unnecessary financial hardship on patients and families.

The story below illustrates the profound impact of healthcare-associated infections on an individual patient and family. A 72-year-old woman was enthusiastic about undergoing hip replacement surgery so that she could resume dancing with her husband. After enduring hip pain for several years and hearing about successful outcomes from friends, she was eager to proceed. The surgery was successful and her recovery was progressing well until the third postoperative day, when fever developed while she awaited transfer to a rehabilitation facility. Tests ruled out pneumonia and bloodstream infection, but revealed a urinary tract infection. The surgeon attributed the infection to the urinary catheter that had been in place. Four days after returning home, her condition deteriorated dramatically. The surgical incision became severely inflamed with reddish-yellow drainage. Her surgeon readmitted her to the hospital and reopened the incision in the operating room, diagnosing a surgical site infection. Culture testing identified an organism matching the one found in her urine, suggesting the surgical site infection had been seeded from the earlier urinary tract infection.

The subsequent months were extraordinarily difficult for this patient. She experienced prolonged hospital stays, multiple surgeries to clean the wound, and ultimately required removal of the newly implanted hip. She was transferred to a skilled nursing facility to allow the wound to heal sufficiently for reimplantation. Depression set in, and she became unwilling to participate in physical therapy. She stopped eating and experienced significant weight loss, necessitating placement of a feeding tube. Three months later, when the surgeon replaced her hip, she was no longer the same person who had come for the initial surgery. Her suffering was compounded by financial strain. Her care was not fully covered by Medicare or supplemental insurance, and her husband depleted their savings to cover medical bills that exceeded $200,000.

This case exemplifies how healthcare-associated infections, such as the CAUTI in this patient, can profoundly affect lives. HAIs cause substantial morbidity, costs, and mortality. The CDC estimates that two million HAIs occur in United States hospitals annually, resulting in 99,000 deaths. The nation experiences approximately 4.5 HAIs per hundred hospital admissions. In intensive care units, the rate rises to 9.3 infections per thousand patient-days, and surgical site infections occur in two per hundred operations. These infections cost the nation five to six billion dollars annually, with an average incremental cost of $8,832 per patient. CAUTIs account for the largest number of HAIs in U.S. hospitals. In 2002, nearly 450,000 CAUTIs were identified in United States hospitals. With an average cost of approximately $1,000 per infection in 2007, the total annual cost estimate reaches a staggering $450 million.

The PICOT (Population, Intervention, Comparison, Outcome, Time) question format provides a structured method for developing researchable and answerable clinical questions. Although writing PICOT questions may seem straightforward, formulating effective ones significantly simplifies the entire evidence evaluation process. Determining what to search for to achieve the desired outcome can be challenging. Clearly defining the desired outcome streamlines the evidence-searching process. Importantly, evidence represents more than just the outcome desired; it is through evaluation of evidence that meaningful outcomes are achieved.

Evidence-Based Problem Analysis

Key questions in determining HAI prevention priorities include:

1. Which patients are most likely to be affected by HAI problems?
2. What intervention or solution measures should be considered?
3. Are there alternatives to proposed intervention methods?
4. What outcomes are desired?

Current Evidence-Based Practice Standards

The term evidence-based practice (EBP) has become increasingly prevalent in healthcare. Evidence-based practice comprises multiple steps. First, one must evaluate the available research evidence. Second, the resulting information is integrated with available resources and clinical experience. Finally, patient preferences are considered to provide the best possible care. A primary goal of the EBP movement is to accelerate the integration of research findings into patient care.

The Iowa Model uses key triggers focused on knowledge or clinical problems to guide clinicians in applying the model's components. Clinicians initially generate a question derived from either research findings or an identified clinical problem. The second step involves determining whether the question aligns with organizational priorities. If relevant, the next step assesses whether sufficient evidence exists to answer the question. Following evidence examination, if evidence is sufficient, a pilot practice change is implemented. If evidence is insufficient, the model directs gathering additional evidence through additional research. The Iowa Model thus produces two potential outcomes: if the pilot demonstrates that practice change is appropriate, the institution implements the change based on available research; if the pilot does not support change, practice remains unchanged pending further evidence.

Conclusion