Tracking of Healthcare-Acquired Infections Continues to Evolve

The monitoring and tracking of healthcare-acquired infections (HAIs) has evolved over time based on national and local guidelines and regulations. Formal standard definitions for HAIs were first developed by the Centers for Disease Control and Prevention (CDC) through the network of hospitals that participated in the National Nosocomial Infection Surveillance (NNIS) program.¹ This network was a voluntary group of facilities that used the definitions to standardize the collection of HAI data and also report to a national database where analysis was completed and disseminated. This national data surveillance program provided a method for benchmarking HAI events with the advantage of having consistent definitions and data collection methodologies.

Facilities could determine what HAIs they would actively track and report, leaving it to the discretion of the infection control program, facility leadership, and assessment of specific population risk factors. Therefore, each facility could be tracking different infections, but all would be using the same definitions for data collection and determination of HAI status. Eventually, the NNIS evolved into the National Healthcare Safety Network (NHSN) and the HAI definitions transitioned over to the NHSN division of the CDC. Currently, HAI definitions in the United States are standardized to the NHSN criteria and infection prevention (IP) programs to use those definitions as their surveillance strategy.

Risk More Noticed

Over time, the tracking of HAIs became more regulated. State governments were passing legislation mandating public reporting of select HAIs, thereby forcing IP programs to focus efforts on those particular HAIs that were publicly reported. Each state would have different HAIs required, however the majority focused on device associated infections, such as central line associated bloodstream infections (CLABSIs), or various surgical site infections.² As the risk and impact of HAIs became more noticed in the public media, the federal government established the reporting requirements through the Centers for Medicare and Medicaid Services (CMS) of several HAIs, starting with CLABSI and adding more indicators.1 Currently there are 6 HAIs that are federally publicly reportable: CLABSI, catheter associated urinary tract infections (CAUTI), surgical site infections (SSI) for colon procedures, SSI for total abdominal hysterectomies, and laboratory based measures for Clostridium difficile infections and Methicillin resistant Staphylococcus aureus (MRSA) bacteremia infections. The public reporting of these HAIs impacted the way IP programs define their surveillance plans and tied hospital reimbursement directly to performance on these indicators.

As public reporting became a reality for IP programs, the focus of the surveillance shifted from what would be more individualized to each facility to these 6 specific HAIs. The efforts of IP programs had to meet the reporting need, and also were more visible as a financial impact to hospitals. IP programs also were pressured from hospital leadership when reviewing cases to determine if they met NHSN definitions, and would then be reported and potentially result in CMS penalties.

These aspects of the mandatory reporting were new experiences for IP programs, and the task of describing an event as hospital-associated or not, suddenly became much more at the forefront of the role performed by infection preventionists (IPs). Meanwhile, the requirement for public reporting meant that surveillance became more important and a higher priority for IP programs; therefore, other important program functions, such as rounding, education, process improvement projects, construction and biopreparedness all had to be set aside for the time to monitor and report HAI data.

Resources need to be provided for IP programs that can help ease the burden of reporting, and also free up time for IP staff to perform other tasks. Surveillance and data mining systems that can automate much of the reporting requirements would be ideal for IP programs. Also, as mandatory reporting continues, it would be essential to have input from IPs on what items should be included or added to the reporting requirements. IP staff input would allow federal and state legislators to understand the time and resource requirements of mandatory reporting and be a voice to advocate for changes in legislation that would improve reporting.

The coronavirus disease 2019 (COVID-19) pandemic has impacted HAIs across the country. Not only were IP programs stretched during the pandemic as part of the public health response, but also the HAI reporting was still being done. IP staff had to figure out how to manage all the workload of the pandemic response and continue to keep surveillance and data reporting current and active.

The work of HAI prevention was also impacted similarly, with less time for IPs to do rounding and focus on the elements that contribute to HAIs. As the national data is analyzed and released in coming months, it will be interesting to see if HAIs were impacted by COVID-19 and to understand exactly how a pandemic influences HAI prevention efforts. Anecdotally, patients with COVID-19 were seen to be high risk for HAIs, particularly CLABSI and CAUTI, due to long lengths of stay, duration of ICU admissions, proning treatments to help with respiratory function and other unique aspects of care.³

Pathways

As IPs work toward a future that includes COVID-19, there will continue to be a resource pull away from traditional infection prevention work to help focus continued efforts toward pandemic response, vaccination of staff and patients and public health collaboration. Compounding this work is the increased risk for HAI events with COVID patients. IP programs can work with nursing and medical staff to develop COVID-19 pathways for patients to help address concerns around HAIs and other healthcare-associated complications, such as pressure injuries and falls. These pathways can include specific interventions that are based on current best practice, such as chlorhexidine bathing, daily assessment of devices, and use of external urinary catheters, but make modifications that would further help mitigate risk for these patients who are at increased risk.

The impact of COVID-19 on HAI identification and reporting is still to be seen. Perhaps more reporting will be required of other respiratory illnesses, such as influenza or pertussis, as well as hospital onset COVID outbreaks. Perhaps COVID status will be part of routine reporting to NHSN as a risk factor. However, the regulations around reporting may change, IP programs will need to continue to incorporate pandemic response into their daily routines, while working to maintain a presence with HAI prevention. All this puts a strain on IP programs, and increased resources or new collaborations and partnering across programs will be essential for success, and ultimately for patient and staff safety.

REBECCA LEACH, RN, BSN, MPH, CIC, has been an infection preventionist since 2010, with a background in nursing and epidemiology. Leach, a member of Infection Control Today®’s Editorial Advisory Board, currently works at a healthcare system in Phoenix that includes 5 hospitals and more than 100 outpatient treatment centers.

References:

1. Dixon RE. Control of healthcare associated infections, 1961-2001. MMWR. October 7, 2011. Accessed September 10, 2020. https://www.cdc.gov/mmwr/preview/mmwrhtml/su6004a10.htm​
2. Infectious Disease Advisor. Mandatory public reporting of hospital acquired infections. Accessed September 12, 2020. https://www.infectiousdiseaseadvisor.com/home/decision-support-in-medicine/hospital-infection-control/mandatory-public-reporting-of-hospital-acquired-infections/​
3. Bean M. How the pandemic is affecting HAI rates: 5 things to know. Becker’s Hospital Review. Published August 5, 2020. Accessed September 12, 2020. https://www.beckershospitalreview.com/infection-control/how-the-pandemic-is-affecting-hai-rates-5-things-to-know.html​