National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination

FRAMEWORK^[1]

I. Introduction

A. Magnitude of the Problem

Healthcare-associated infections (HAIs) are infections that people acquire while they are receiving treatment for medical or surgical conditions in a healthcare setting.  HAIs can be acquired anywhere healthcare is delivered, including but not limited to inpatient acute care hospitals; outpatient settings such as ambulatory surgical centers (ASCs) and end-stage renal disease (ESRD) facilities; and long-term care (LTC) facilities, such as nursing homes and rehabilitation centers.

Healthcare-associated infections are linked with a variety of risk factors, including but not limited to, the use of indwelling medical devices such as bloodstream, endotracheal, and urinary catheters; having a surgical procedure; receiving injections; contamination of the inanimate environment, such as table surfaces; and transmission of communicable diseases between patients and healthcare workers.  The overuse of antimicrobial agents increases the likelihood of some infections (e.g., Clostridium difficile HAI) and especially the risk of infection with an antimicrobial resistant microorganism.  HAIs may be caused by any type of infectious agent, including bacteria, fungi, and viruses.

Healthcare-associated infections exact a significant toll on human life.  Even if only those infections which have their onset in hospitals are measured, HAIs are a significant cause of morbidity and mortality.  At any given time, about one in every 20 inpatients has an infection related to their hospital care.  In LTC facilities, about 1.6 to 3.8 million infections occur annually.^[2]  There are no reliable overall estimates at the time of this publication of the total burden of infections which occur as a result of treatment in outpatient settings.

Based on 2002 data, nearly 80 percent of all hospital-acquired HAIs are caused by four types of infections.  Urinary tract infections (UTI) comprise the highest percentage (34% of all hospital-acquired HAIs) followed by surgical site infections (SSI) (17%), bloodstream infections (14%), and pneumonia (13%).^[3]

The cost to the American economy is also steep.  Based on 2002 estimates of the numbers of HAIs, hospital-acquired HAIs alone were responsible for $28 to $33 billion dollars in excess healthcare costs in 2002.^[4]  A recent report using different methodology from the U.S. Department of Health & Human Services (HHS) Office of the Inspector General estimated that hospital care associated with adverse and temporary harm events, including hospital-acquired HAIs, cost Medicare an estimated $324 million in October 2008.^[5]

It has been known for many years that some HAIs are largely preventable and that the occurrence of these infections can be drastically reduced in order to save lives and avoid excess costs.  Today, there is a growing consensus that the aspirational goal should be the elimination of HAIs.  The growing demands on the healthcare system, coupled with increasing concerns about antimicrobial-resistant pathogens and steadily rising healthcare costs, reinforce the imperative to address this issue.

B. Background/Context

To maximize the efficiency and improve the coordination of prevention efforts across the Department, HHS established in 2008 a senior-level Steering Committee for the Prevention of Healthcare-Associated Infections.^[6]  Members of the Steering Committee include clinicians, scientists, and public health leaders who are high-ranking officials within their Operating and Staff Divisions. Among the Divisions contributing to the effort are the Agency for Healthcare Research and Quality (AHRQ), Administration on Aging (AoA), Centers for Disease Control and Prevention (CDC), Centers for Medicare & Medicaid Services (CMS), Food and Drug Administration (FDA), Health Resources and Services Administration (HRSA), Indian Health Service (IHS), National Institutes of Health (NIH), and from within the HHS Office of the Secretary (OS), the Office of the Assistant Secretary for Health (National Vaccine Program Office (NVPO) and Office of Healthcare Quality (OHQ)), Office of the Assistant Secretary for Planning and Evaluation (ASPE), and Office of the National Coordinator for Health Information Technology (ONC).  Later, the Steering Committee expanded beyond HHS to include the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DOD).

Since its inception, the Steering Committee has marshaled extensive and diverse resources (see Table 4), formed public and private partnerships, and initiated discussions that enhanced new approaches and worked towards identifying new approaches to HAI prevention and collaborations.  In 2009, the HHS Assistant Secretary for Health created the OHQ to support and carry out the Steering Committee’s mandate to improve healthcare quality by reducing HAIs.^[7]

Table 4. Departmental & HHS Operating Division Roles and Activities in Implementing the National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination

Through late 2008 and 2009, the Steering Committee, along with scientists and program officials across the government, developed the HHS Action Plan to Prevent Healthcare-Associated Infections, providing a roadmap for HAI prevention in acute care hospitals.  In the first iteration of the Action Plan, the Steering Committee chose to focus on infections in acute care hospitals because the associated morbidity and mortality was most severe and the scientific information on prevention and capacity to measure improvement was most complete.  Thus, prevention of HAIs in acute care hospitals became the first phase, or Phase One, of the Action Plan (Figure 1).

Figure 1. Organizational Structure of the HAI Steering Committee

Given the substantial breadth and depth of HAIs and the complexity of addressing these problems, the Steering Committee, at the time of its formation in 2008, decided to concentrate its activities and the content of the initial Action Plan on six high priority HAI-related areas within the acute care hospital setting.  In addition, the Steering Committee included in the Action Plan five-year goals for nine specific measures of improvement tied to the six HAI prevention priority areas (see Table 5).  Focusing on these six high priority and high burden areas allowed for a concentration of resources and effort during the initial phases of Action Plan implementation.  It also allowed the Steering Committee to take advantage of the substantial expertise and experience both within and outside HHS in HAI prevention in the acute care hospital setting.

Table 5. HHS Action Plan to Prevent Healthcare-Associated Infections (2009) Priority Areas and Five-Year Goals

Thus, Phase One of the Action Plan addressed the most common infections in acute care inpatient settings and outlined: specific recommended optimum clinical practices to prevent the infections; a prioritized research agenda; an integrated information systems strategy; policy options for linking payment incentives or disincentives to quality of care and enhancing regulatory oversight of hospitals; and a national messaging and communications plan to raise awareness of HAIs among the general public and HAI prevention strategies among healthcare personnel.

The plan was initially released in January 2009 for public comment.  A final version that incorporated additional content and responses to comments was released in June 2009.^[8]  The Steering Committee clearly articulated the need to maintain the Action Plan as a “living document,” developing successor plans in collaboration with public and private partners to incorporate advances in science and technology, shifts in the ways healthcare is delivered, changes in healthcare system processes and cultural norms, and other factors.

C. Action Plan Expansion

Over the past five decades, the dramatic changes in medical care and the health system in the U.S. have allowed patients with complex health problems to be managed outside the acute care hospital, rather than requiring extensive inpatient stays.  Thus, patients at risk for HAIs are now managed at home, have surgical procedures of many types done on an outpatient basis at free-standing clinics, and may have intravascular and urinary catheters as well as other indwelling medical devices in place for extended periods outside the hospital.  At the same time, there is a growing proportion of individuals admitted to nursing facilities for Medicare Part A short-term rehabilitation and post-acute care.

Movement of patients between their homes, community based-settings, outpatient facilities, acute care hospitals, and LTC facilities occurs frequently and continuously.  Infection control and the prevention and elimination of HAIs can no longer be compartmentalized within the time span from a patient’s date of admission to date of discharge at any one particular facility.  The chain of transmission may have multiple links connecting to the intensive care unit, not just to other wards in the hospital but all the way to the patient’s home.

The healthcare and public health communities are then increasingly challenged to identify, respond to, and prevent HAIs across the continuum of settings where healthcare is delivered.  The public health model’s population-based perspective can increasingly be deployed to enhance the prevention of HAIs, particularly given the shifts in healthcare delivery from acute care settings to ambulatory and LTC settings.^[9]

Thus, following publication of the initial Action Plan in 2009, the Steering Committee quickly moved to expand the scope of its activities to include both the outpatient environment and role of healthcare personnel in ensuring optimal patient outcomes.  In late 2009, the Steering Committee approved an expansion of the Action Plan through the addition of three new modules or chapters:

1. Prevention of HAIs in Ambulatory Surgical Centers;
2. Prevention of HAIs in End-Stage Renal Disease Facilities; and
3. Increasing Influenza Vaccination Coverage of Healthcare Personnel.

These chapters comprise the second phase of the Action Plan, extending its scope to the outpatient environment and addressing the health and safety of healthcare personnel, as well as the risks of influenza transmission from healthcare personnel to patients (see Action Plan Chapters 4, 5, and 6).

Ambulatory surgical centers and ESRD facilities were selected as areas of focus because of the complexity of care delivered in those settings, their continued growth in terms of number of patient care encounters, the infection control challenges faced in those settings, and in the case of ASCs, recent large-scale outbreaks which demonstrate the urgency of addressing infection control and prevention for patients in that setting.  Similarly, recent experiences in which public health authorities needed to consider the risk of influenza and persistent concerns about sub-optimal rates of healthcare personnel vaccination against seasonal influenza led the Steering Committee to request a report on that subject.  Drafts of these additional sections were released for public comment in September 2010.^[10]  These sections, revised based on public comments, have now been incorporated in the overall Action Plan.

In 2012, the Steering Committee will consider and decide upon additional components to constitute the third phase of Action Plan development.

D. Partnership for Patients

On April 12, 2011, HHS launched a new public–private initiative, entitled Partnership for Patients: Better Care, Lower Costs, to help to improve the quality, safety, and affordability of healthcare for all Americans.  The Partnership for Patients brings together leaders of major hospitals, employers, physicians, nurses, and patient advocates along with state and federal governments in a shared effort to make hospital care safer, more reliable, and less costly.

The two goals of this new partnership are to:

• Keep patients from getting injured or sicker.  By the end of 2013, preventable hospital-acquired conditions would decrease by 40% compared to 2010.  Achieving this goal would mean approximately 1.8 million fewer injuries to patients with more than 60,000 lives saved over three years.
• Help patients heal without complication.  By the end of 2013, preventable complications during a transition from one care setting to another would be decreased so that all hospital readmissions would be reduced by 20% compared to 2010.  Achieving this goal would mean more than 1.6 million patients would recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge.   

Achieving these goals will save lives and prevent injuries to millions of Americans and has the potential to save up to $35 billion dollars across the healthcare system, including up to $10 billion in Medicare savings, over the next three years.  Over the next ten years, it could reduce costs to Medicare by about $50 billion and produce billions more in Medicaid savings. 

The Partnership for Patients is committed to addressing all forms of harm that can affect patients in hospitals.  Addressing all causes of harm means tackling safety and quality in every care setting and embedding a new ethos into the system and the culture of care.  As a starting point, the Partnership for Patients has identified nine focus areas including four HAIs: catheter- associated urinary tract infections (CAUTI), central line-associated bloodstream infections (CLABSI), SSI, and ventilator-associated pneumonia (VAP).

As a component of the Partnership for Patients, success in achieving the Action Plan goals will strongly align with and vitally contribute to the success of the Partnership for Patients.  Joining our accumulated HAI knowledge base and other resources developed since 2008 to the Partnership’s foci, energies, and additional resources promises escalated action in the fight for patient safety and healthcare quality and against preventable human and economic costs.  

E. Key Partnerships

The breadth and complexity of the healthcare delivery and public health systems require that a national initiative to eliminate HAIs be a shared responsibility of practicing healthcare professionals and their representative organizations, the healthcare industry, federal, state and local governments, and consumers.  The growth of a proactive, highly engaged healthcare consumer movement has been one of several factors that greatly accelerated the patient safety movement since the publication of the Institute of Medicine report To Err is Human in 1999.^[11]

The Action Plan goals cannot be achieved without a broad-based network of partners comprising all segments of the healthcare and public health enterprise in the United States.  In recognition of this, the Steering Committee committed to widespread stakeholder engagement and input into the development of the first iteration of the Action Plan.  In September 2008, HHS, through the CDC, convened a meeting of key stakeholders from academia, federal and state governments, professional provider organizations, consumer groups, and others with the purpose of soliciting individual input on the setting of potential national prevention targets regarding HAI elimination.  At this meeting, participants identified near- and long-term process and outcome measures for benchmarking progress in the prevention of HAIs.

Since that initial meeting, HHS and its component Operating and Staff Divisions have held numerous stakeholder meetings to continue proactive engagement with groups and individuals throughout the U.S. involved in HAI elimination.^[12]  The result of this ongoing engagement has been the development of a network of organizations comprising a broad range of private and public sector groups coordinated through OHQ.  This network, initially established through the Steering Committee to more closely link HHS Operating and Staff Divisions, has joined together governmental and non-governmental partners by leveraging established contacts already existing within each of the HHS component organizations.  The network achieved rapid success in filling a clearly recognized need for better communication and bridging between bureaucratic and organizational silos both within and outside the Federal government, as well as at the state-level and among various components of the healthcare system.

As the revised Action Plan is reviewed and as the Steering Committee seeks to achieve the Action Plan goals, the federal government will increasingly look to its multidisciplinary partners to co-develop and amplify key messages, increase the adoption of recommended practices, and serve as local, state, regional, and national leaders in a coordinated effort to eliminate HAIs.  More progress can and will be accomplished together, focused on the end goal of eliminating preventable infections and their associated consequences.

F. Setting Elimination as an Aspirational Goal

Since the publication of To Err is Human in 1999, experts in the field of patient safety have discussed the concept and feasibility of not just reducing, but eliminating HAIs.  Scientific advances, a changing culture of safety within the healthcare system, and the proven success of smaller scale prevention initiatives have now led to a consensus of the foremost experts in the field that the elimination of HAIs is a worthy aspirational goal and that the elimination of HAIs is possible.^[13],[14]  The Steering Committee, through the Action Plan, subscribes to that challenge and seeks to continue to provide leadership to move the field as far as possible towards HAI elimination.

II. Changing Landscape

A. Introduction

The publication of the 2009 HHS Action Plan to Prevent Healthcare-Associated Infections was a milestone in national efforts to address this serious public health problem and provided a roadmap for HHS activities in this area.

The Action Plan also described the process by which the Steering Committee has been monitoring progress toward the success of the effort through regular reporting by the Steering Committee’s various Working Groups and the HHS Operating and Staff Divisions; building HAI prevention infrastructure at the regional, state, and local/community levels; on-going input from and dialogue with stakeholders; formalized independent evaluation by external consultants; and, most importantly, measurement using identified metrics towards corresponding five-year national HAI prevention targets.

B. Progress Toward Achieving Five-Year National Prevention Targets

Progress toward achieving the nine goals established in the 2009 Action Plan (Table 5) was presented during the Steering Committee’s meeting “Progress Toward Eliminating Healthcare-Associated Infections” held in September 2010 in Arlington, Virginia.

Overall, national HAI prevention efforts resulted in decreases in the national incidence rates of some HAIs when compared to baseline data:

• 33% decrease in CLABSI when 2009 and 2010 data is compared to a baseline established according to 2006-2008 data;
• 18% decrease in invasive MRSA infections when 2009 and 2010 data is compared to a baseline established according to 2007-2008 data;
• 10% decrease in SSIs when 2009 and 2010 data is compared to a baseline established according to 2006-2008 data; and,
• 7% decrease in CAUTI when 2010 data is compared to a baseline established according to 2009 data.

Increases in national rates of adherence to specific processes to reduce the risk of SSIs using CMS SCIP measures were also reported.  Experts also reported that the national rate of hospitalizations with C. difficile infection were on the rise.  Progress data for the remaining 2009 Action Plan measures were not available as national baselines were still in the process of being established.  A more complete summary of the data illustrating progress toward achieving the 2009 Action Plan goals is available on the OHQ website.^[15]

C. Recent Advances

Since the publication of the 2009 Action Plan, a number of developments have served to greatly accelerate and facilitate the HAI prevention effort.  The Steering Committee’s activities in themselves have successfully leveraged both existing and new investments in prevention and monitoring throughout HHS.  The Steering Committee’s Working Groups (Figure 1) regularly report on each group’s progress in implementing the components of the Action Plan and provide leadership and support to the public health and healthcare delivery communities in working toward the achievement of the five-year Action Plan targets.

In addition, each of the HHS Divisions conducts far-reaching programs in accord with its individual mission for the prevention of HAIs.  All of these entities have achieved significant accomplishments in their domains.  Some of the highlights include:

• CDC’s Prevention Epicenter research network addressed priority gaps in prevention knowledge.
• Scientific evidence and past experience have highlighted the importance of employing appropriate strategies to implement guidelines and recommendations for the prevention of HAIs.  Efforts such as AHRQ’s spreading the use of CUSP, aimed at preventing CLABSI, have demonstrated the improvements that are achievable when CDC guidelines and recommendations for care are coupled with practical and explicit implementation approaches for use by hospitals and other healthcare delivery organizations.^{[16],[17],[18]}  The CUSP approach was designed to improve the culture of safety and help clinical teams learn from mistakes by integrating safety practices into the daily work of a unit or clinical area.  CUSP, which was first shown to be effective in reducing CLABSI through the AHRQ-supported Keystone Project in Michigan Intensive Care Units (ICUs), has been implemented at a large number of organizations and has achieved significant reductions in CLABSIs.  AHRQ is currently expanding this effort to the prevention of other forms of HAIs (i.e., CAUTI, SSI, VAP), as well as to patient care areas of the hospital other than ICUs.
• A new supply chain of HAI data has been launched.  As a first step in implementing the Affordable Care Act (ACA), data from CDC’s NHSN will be supplied to CMS’s Hospital Inpatient Quality Reporting Program.  NHSN is providing CLABSI data for the CMS Hospital Inpatient Prospective Payment System for acute care hospitals.  As a result of the CDC-CMS collaboration, NHSN will serve as a national data source for publicly reported HAI data, beginning with CLABSI data in 2011, which are to be included in the healthcare quality measurement data made publicly available on the Hospital Compare website.  This initial data collection will be followed in January 2012 by the collection and reporting of CAUTI data. Additional HAI measures may be added to the program in subsequent years.  These new achievements in HAI systems integration and data standardization are occurring at the same time that new federal efforts, funding through the HITECH Act and guided by ONC and CMS, are supporting accelerated adoption of electronic health records (EHRs).  With more ubiquitous use of EHRs on the near-term horizon, new opportunities are arising for HHS agencies and their partners to catalyze and coordinate the transition from manual to electronic methods of HAI detection and reporting.
• AHRQ and CDC have also worked together to assure that HAI data standards are applied to the new patient safety reporting program established by AHRQ that will enable voluntary and confidential HAI reporting to designated Patient Safety Organizations (PSOs).  Healthcare providers voluntarily work with PSOs to report non-identifiable patient safety event data to the Network of Patient Safety Databases using AHRQ’s Common Formats that includes HAIs using CDC definitions.
• In terms of coverage, over 5000 healthcare facilities have enrolled in NHSN as of January 2011 and there are currently 80 listed PSOs in 30 states and the District of Columbia.

D. Building Sustainability: Infrastructure and Stakeholder Network

The Action Plan’s overall coordinating structure seeks to bring into alignment the disparate agencies, programs, and organizations at the national, regional, state, and local levels that can together significantly reduce HAIs.  The Steering Committee pursues an overall multi-level, multi-system approach to HAI prevention.

1. National Level

   A critically important component of the initiative has been the development of an informal national network of organizations comprising a broad range of public and private sector groups.  This network, which initially connected HHS Divisions, rapidly expanded to include non-governmental partners by leveraging the established contacts already existing within each of the HHS components.  This network quickly became effective because it filled a clearly recognized need for better communication and bridging between bureaucratic and systemic silos both within and outside the federal government.

   In the current economic, regulatory, and scientific environment, this informal network served the needs of all parties to have structured lines of communication and the capacity for on-going interaction which was created under the auspices of the Steering Committee.  These structures soon evolved a wide array of secondary and tertiary communication channels which provided to all participants the means to interact with greater facility.  The Steering Committee and OHQ, on behalf of the Steering Committee, continues to maintain the basic infrastructure of the network.

2. Regional Level

   HHS is currently sponsoring regional pilot projects implemented by the HHS Regional Offices.  The projects evaluate new programs and leverage state activities across multiple states in a region.  Through the development and implementation of these projects, state coordination across the regions has strengthened, in addition to coordination between local, state, regional and national-level efforts and activities.

3. State Level

   The Action Plan outlines strategies needed to achieve and sustain progress toward reducing HAIs at the national level.  However, measurable progress depends on the leadership of states in coordinating prevention efforts at the state and local levels.  Many state health agencies have been leaders in advancing HAI prevention through public reporting, survey and certification quality assurance processes, and outreach and training for healthcare personnel.

Investments in State Activities

The American Recovery and Reinvestment Act (ARRA) of 2009 provided a total of $50 million in funding for state level HAI prevention activities.  The funding created opportunities for strengthening and building the state-level infrastructure for HAI prevention.  As determined by the Steering Committee, the HAI ARRA program was administered by CDC and CMS.  In addition, other HHS funds from annual appropriations to AHRQ, CDC, CMS, and OHQ are being used to directly support state efforts.

The CDC-administered ARRA program built state health departments’ HAI prevention capacity.  CDC provided technical assistance to states for surveillance and prevention of HAIs, collaboration initiatives, workforce training activities in HAI prevention, and measurement of outcomes.  States, the District of Columbia, and Puerto Rico have begun implementation of their State Action Plans and have hired HAI state coordinators to implement prevention collaboratives and pursue validation of data to improve HAI measurement and reporting.

Many states have shown successes in HAI prevention, including progress toward goals set in Phase I of the Action Plan.  States are also furthering HAI prevention efforts outside acute care settings including ESRD facilities, ASCs, and LTC facilities.  Recovery Act investments have not only accelerated these efforts, but also supported new, successful HAI prevention programs in states without previous programs.

The CMS-administered ARRA program was designed to support State Survey Agencies in their efforts to enhance the inspection process of Medicare-participating ASCs, specifically to include case tracer methodology and a CDC-CMS developed infection control assessment tool in surveys.  Initial findings from the enhanced inspection process include that over two-thirds of the facilities surveyed in the pilot phase of the project had lapses in infection control and prevention and half of the facilities had not undergone a full inspection in more than five years.^[19]

Through CMS’ policy setting mechanism, all states were required to use the enhanced inspection process and survey one third of ASCs in FY 2010.  Prior to the ARRA-funded program, ASCs were inspected at an average frequency of every 10 years.  The goal with the program is to inspect facilities every three years.

In efforts to support state level HAI collaboration, AHRQ involves State Hospital Associations in implementing the Action Plan. Funds from AHRQ have awarded projects that address critical implementation science gaps that are in alignment with the Action Plan and demonstrate generalizability and feasibility for widespread implementation.  CUSP is one such program that has been supported by these funds and has demonstrated how a structured strategic framework for safety can result in dramatic improvements in patient care.  AHRQ is currently expanding the successful program across the country.

Federal funds have had a considerable impact in supporting state advancements, but significant challenges remain.  Enhanced investment in staffing at various levels, research, communication and health information technology, and investigation of human and organizational factors that contribute to the occurrence of HAIs are necessary to overcome these challenges.  State officials have expressed concern that sustaining state based efforts may prove challenging without the availability of a long-term, sustainable funding mechanism.

State Action Plans

The 2009 Omnibus Appropriations Act required states receiving Preventive Health and Health Services Block Grant funds to certify that they would submit a plan to reduce HAIs to the Secretary of HHS in order to receive the full allotment of grant funds.  The Secretary received plans from all 50 states, the District of Columbia, and Puerto Rico in January 2010.

The purpose of the State Action Plans was primarily to outline strategies to leverage and enhance state capacity to reduce and prevent HAIs, focusing on achievement of the Action Plan goals.  In addition, states were encouraged to establish statewide HAI prevention leadership through the formation of multidisciplinary groups or State HAI Advisory Councils led by State Health Departments.

States were asked to address four areas in their State Action Plans:

• Program Infrastructure;
• Surveillance, Detection, Reporting, and Response;
• Prevention; and,
• Evaluation, Oversight, and Communication.

Through the State Action Plans, states had the opportunity to articulate areas of strength and areas requiring support in their HAI programs; identify which stakeholders to engage in HAI prevention activities; and set benchmarks for future activities.  States outlined a uniform way of addressing HAI prevention focusing not only on acute care facilities but, when possible, on other healthcare settings, complementing the expanding scope of the national Action Plan.  By having each state identify its own goals based on the level of infrastructure and resources presently in place, HHS has been able to gather valuable information that is further guiding prevention efforts.

State Action Plans Report to Congress

The Healthcare-Associated Infections: FY 2010 State Action Plans Report to Congress^[20] addressed the adequacy of the state plans for achieving state and national goals for reducing HAIs.  Based on a review of the 52 State Action Plans received, HHS reported that each State Action Plan submitted was consistent with the national Action Plan, and where appropriate, included measurable five-year goals and interim milestones for reducing the infections.

The Report to Congress described the great degree of variability across states regarding current prevention activities and resources available to support HAI prevention.  Some states had more mature HAI prevention programs and demonstrated excellent understanding of the necessary scope for an effective and ambitious prevention program.  These states had not only identified target initiatives, but had begun implementation several years ago and were already involved in multiple prevention collaboratives.  States with the strongest HAI programs indicated that they had completed extensive efforts to validate HAI data submitted by facilities.  These states were also progressing towards interoperability of electronic systems and lab capacity enhancements to improve HAI reporting.  Although some States had longstanding programs in place, others were just beginning to launch HAI prevention programs and still need support to strengthen basic program infrastructure, communications, lab capacity, and data collection systems.

State Based HAI Reporting

State-Specific HAI Summary Data Reports^[21] (May 2010 and March 2011) include both national CLABSI and SSI data and state-specific data for states mandated by law to report.  Additional, regular reporting of state level HAI data is planned for the remaining Action Plan measures.

E. An On-Going, National Dialogue with Partners

To ensure that the Action Plan is representative of the needs of the many partners and participants in the national effort to prevent HAIs, each of HHS’ component Operating and Staff Divisions sponsored and conducted numerous engagement activities to ensure an on-going and vibrant dialogue with the many sectors within public health and healthcare, as well as with the general public.  Examples of engagement activities include:

• Public Comment Periods (Periodic): With the release of each version of the Action Plan, the Steering Committee requests and carefully reviews written comments from the public on plan content.  Public comments provide HHS with important feedback from individuals, professional societies, businesses, advocacy groups, and others.  Comments have prompted revisions and additions to subsequent versions of the Action Plan and provided guidance for future HAI prevention work.
• Action Plan Stakeholder Meetings (June to September 2009): The Steering Committee hosted a series of engagement meetings in Washington, District of Columbia, Denver, Colorado, Chicago, Illinois, and Seattle, Washington in mid-2009 to engage the public and gather feedback on the Action Plan.
• HAI Recovery Act State Grantee Meetings (October 2009, 2010, and 2011): This annual meeting gathers State HAI Coordinators and others working at the state-level to discuss best practices in HAI prevention.  The meeting is one opportunity to link national, regional, and state-level perspectives in HAI prevention and progress.
• Fifth Decennial International Conference on Healthcare-Associated Infections (March 18-22, 2010): Hosted by the CDC and the Society for Healthcare Epidemiology of America in partnership with Association for Professionals in Infection Control and Epidemiology and the Infectious Diseases Society of America, provided a review of accomplishments in the field over the past decade and proposed a scientific agenda for the next decade, including an expert consensus on the prospect of eliminating HAIs.^[22]
• Progress Toward Eliminating Healthcare-Associated Infections (September 23-24, 2010): National-level expert meeting and workshop reviewed progress toward achieving the nine five-year national HAI prevention targets for reducing the incidence of specific HAIs, and how to accelerate the prevention, reduction, and eventual elimination of HAIs.  The content of the discussions provided input for this revision of the Action Plan.
• AHRQ Healthcare-Associated Infections Investigator Meetings (September 26, 2010 and September 18, 2011): Hosted by AHRQ as a component of the AHRQ Annual Conference, these meetings gathered together contractors (2010, 2011 meetings) and grantees (2011 meeting) conducting HAI-related work to discuss on-going efforts and the broader initiative to prevent HAIs across HHS.
• Public Health Collaboration Models for Infection Prevention in Licensed Healthcare Settings A Focus on Ambulatory Surgical Centers (October 20, 2010): This meeting continued the national-level discussion during the ASC-focused session at the September meeting, Progress Toward Eliminating Healthcare-Associated Infections, among those working at the state level.
• Accelerating Healthcare-Associated Infection Elimination: Health System, Hospital, and Government Leadership Collaboration (October 28, 2010): In response to the need for an enhanced partnership between the federal government and healthcare facility and health system senior leadership, OHQ collaborated with the Texas Medical Institute of Technology’s Greenlight Program Healthcare to host a meeting of hospital quality leaders from across the nation regarding the key role of leadership in eliminating HAIs.
• State-Level Partners Collaborating to Eliminate Healthcare-Associated Infections (September 15-16, 2011): This meeting gathered state-level organizations (e.g., State Health Departments, QIOs, PSOs, private payers) working on HAI to discuss national and state programs and policies affecting state-level prevention efforts and next steps to sustain state-level programs.

In addition to these highlighted activities, many of the organizations with representation on the Steering Committee, as well as each of the Steering Committee’s Working Groups maintain communication and interaction with a vast array of interested parties.

F.  External Independent Evaluation

As part of the national effort outlined in the original Action Plan, AHRQ, CDC, and OHQ contracted with an independent evaluation group to conduct a three-year evaluation of all activities associated with the Action Plan and the impact of the initiative.  The iterative, longitudinal, and comprehensive evaluation uses context, input, process, and product evaluations to measure the initiative’s effectiveness in reducing HAIs nationwide.

The goals of the evaluation are to:

• Record the content and scope of the Action Plan, how it is designed now, and what it will add in the future;
• Provide feedback on how to strengthen on-going assessments of the scope of HAIs and interventions, to reduce them, and to begin to understand the effectiveness of those interventions; and
• Provide strategic insights from on-going processes and outcomes to identify high yield opportunities to reduce HAIs.

The report Longitudinal Program Evaluation of the Healthcare-Associated Infections (HAI) HHS Action Plan Year 1 Report^[23] (September 2010) summarizes initial recommendations.  The report gives information on using identified strengths and weaknesses to inform what the HAI initiative should accomplish (the context evaluation) and how it should be accomplished (the input evaluation).

At the state level, the evaluation will not only monitor the progress and impact of the individual State HAI Action Plans and initiatives linked to the plans, but also examine other activities that are taking place within states performed by health departments, state hospital associations, QIOs, and other entities.

G. A National Focus on Improving Healthcare Quality and Patient Safety

ACA, passed in 2010, seeks to increase access for all Americans to high-quality, affordable healthcare and includes an array of provisions designed to enhance coordination, innovation, efficiency, and the quality of healthcare.

To help guide and coordinate public and private sector activities, ACA calls on the HHS Secretary to establish a National Strategy for Quality Improvement in Healthcare (the National Quality Strategy).^[24]  The National Quality Strategy is a plan for improving the delivery of healthcare services, achieving better patient outcomes, and improving the health of the U.S. population.  It pursues three broad aims used to guide and assess local, State, and national efforts to improve the quality of healthcare:     

• Better Care: Improve the overall quality, by making healthcare more patient-centered, reliable, accessible, and safe.
• Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care.
• Affordable Care: Reduce the cost of quality healthcare for individuals, families, employers, and government.

The Partnership for Patients initiative, launched in 2011, carries out the broad aims in the National Quality Strategy by implementing a broad multi-year program to significantly reduce harm in hospitals and preventable readmissions.  Despite decades of work to improve patient safety and despite daily efforts by committed caregivers, patients are still harmed by the healthcare system.  The initiative combines broad incentives and programmatic supports to address preventable harm and readmissions.

Existing policy levers and programs, as well as new programs (e.g., supports for state and local cooperative learning networks; programs to engage patients and family members in the care process) are included in the initiative.  In addition to HAIs, the harm events targeted for reduction include pressure ulcers, adverse drug events, obstetrical adverse events, injuries from falls, and post-surgical venous thromboembolisms.

Under the framework created by both the National Quality Strategy and the Partnership for Patients, the Action Plan provides a roadmap to specifically reduce the burden of HAIs in U.S. healthcare facilities.  Data measures and goals across the Partnership for Patients, Action Plan, and other related programs have been aligned to reduce confusion. ACA clearly demonstrated the importance of preventing HAIs as a critical component in ensuring quality healthcare and patient safety.  The law links payment to quality outcomes and established the Hospital Value-Based Purchasing program in Medicare.  This program offers financial incentives to hospitals to improve the quality of care provided. Hospital performance is required to be publicly reported, beginning with measures relating to heart attacks, heart failure, pneumonia, surgical care, and HAIs.  HAI specific reporting began in January of 2010 with CLABSIs and became publicly available on the Hospital Compare website in January of 2012.  Also in January 2012, CMS will require reporting to include SSIs.  In 2015, CMS will include reporting of MRSA bacteremia, Clostridium difficile infection, and healthcare personnel influenza vaccination, and intends to propose VAP, post-procedure pneumonias, and multi-drug resistant organisms (e.g., Klebsiella, Acinetobacter) in the future.  Payments will begin to apply for discharges occurring on or after October 1, 2012.

Also established by ACA, the Center for Medicare and Medicaid Innovation at CMS is a new entity aimed at helping transform Medicare, Medicaid, and the Children’s Health Insurance Program through improvements in the healthcare system, thereby ensuring better healthcare, better health, and reduced costs for beneficiaries, and ultimately enhancing the healthcare system in the United States.  The new center has the resources and charge to rapidly test innovative care and payment models and encourage widespread adoption of practices that support better healthcare at lower cost.

III. Ten Themes for Translating Strategy to Action

A. Background

A national effort to achieve and exceed the Action Plan goals will occur as a result of activities and initiatives within all parts of the health system and as a result of actions by every individual and group, including consumers and their families, concerned with the quality of healthcare in the United States.  At the September 2010 meeting “Progress Toward Eliminating Healthcare-Associated Infections,” experts identified key themes in HAI prevention strategies that are central to creating and sustaining core capacities of HAI prevention.

Although there is no simple formula that will lead to the prevention and elimination of HAIs in every setting and every facility and for every patient, well-established strategies to prevent and eventually eliminate HAIs have been tested and proven.  These strategies include actions taken during patient care in the clinic and at the bedside; actions taken by executives, managers and administrators of facilities and health systems; and broad-based system changes that involve focused and concerted efforts by everyone.

B. Ten Themes for Translating Strategy to Action

Frontline Clinicians

• Reduce Inappropriate/Unnecessary Device Use: A large proportion of HAIs are associated with the use of indwelling medical devices, especially intravascular catheters, urinary catheters, and devices associated with mechanical ventilation.  Although optimal practices concerning insertion, maintenance, and care of such devices greatly reduces the risk of HAIs, avoiding the insertion of such devices and their prompt removal as soon as clinically appropriate is the best strategy for preventing device-associated infections.
• Improving Adherence to Hand Hygiene and Barrier Precautions: Mechanically preventing the spread of pathogenic microorganisms, especially to high-risk patients and particularly for antimicrobial resistant microorganisms, is a simple and powerful prevention tool that requires the consistent and universal adoption of these proven prevention practices in every patient interaction and in ongoing vigilance of the environment.
• Implementing and Improving Antimicrobial Stewardship: Antimicrobial stewardship programs have been shown to be an important factor in reducing the overall prevalence of antimicrobial resistant microorganisms in the hospital environment.  Efforts to ensure optimally appropriate antimicrobial use have been a hallmark of quality improvement activity in both inpatient and outpatient care setting in recent decades.  Ongoing research is allowing for greater precision and understanding of the best use of antimicrobial agents balancing clinical necessity and optimal patient care with the negative consequences of overuse and inappropriate use of antimicrobial agents, including the spread of antimicrobial resistant pathogens, adverse drug reactions in patients, and excess financial cost.  Providers and patients must partner to use antibiotics only when needed and completing scheduled doses appropriately.

Clinical Leaders, Executives, and Administrators

• Engaging Leadership Support at the Highest Levels of the Facility: A central role for leadership in supporting practice improvements is vital to efforts in preventing HAIs and other adverse patient safety events.  Strong support, both in terms of personal commitment and allocated resources, from healthcare executives and administrators is frequently cited by front-line healthcare workers as one of the most important factors in implementation of successful HAI prevention strategies in healthcare facilities and health systems.
• Implementing a Culture of Safety: All parts of the health system need to move towards a culture of safety that includes patients and families as members of the healthcare team.  The broadening of responsibility and accountability for patient safety, including recognition of a role for patients and their families, has been one of the most impactful developments in the patient safety movement.  Making the prevention of HAIs as important a part of the clinical decision-making process as any other aspect of patient care, and continuing to acknowledge the role of consumers as partners in prevention – even, and perhaps especially – in clinical settingscan have a profound impact on our ability to eliminate HAIs.  Further, all members of the healthcare team must feel secure in their ability to contribute to the recognition of the risks and correction of sub-optimal practices without fear of adverse consequences.

Government, Advocates, Clinical Leaders, and Administrators

• Enhancing Financial Incentives and Regulatory Oversight: The growth of the patient safety and HAI prevention and elimination effort has both prompted, and been advanced by, an increasing alignment of financial incentives by public and third party payers.  These incentives provide a greater margin of reimbursement for care that does not incur adverse healthcare events such as HAIs.  Similarly, accreditation, certification, and other regulatory oversight increasingly incorporate adherence to proven HAI prevention practices in the inspection process.  This has promoted adherence to best practices and facilitated decision-making that rewards prevention.
• Implementing System-Based Approaches and Evidence-Based Guidelines: A number of authors and organizations have demonstrated the value of system-based approaches to improving healthcare and preventing medical errors and adverse healthcare events, including HAIs.  These approaches, based on human factors research in the social sciences as much as on the traditional medical sciences, have led to significant improvements in patient outcomes in many different types of facilities in a variety of settings.  Introducing checklists and standardizing care or protocols for procedures associated with HAI incidence (i.e., catheter insertion) have been helpful in reducing infections and promoting stronger healthcare teams.
• Achieving Better Use of Technology: Technological advances are very powerful tools in the effort to eliminate HAIs.  Improvements in medical devices, supplies, equipment, and antimicrobial compounds can impede colonization of indwelling catheters, improve the effectiveness of barrier precautions, enhance compliance with and the effectiveness of hand hygiene, and decrease the risk of cross-infection due to contamination of the environment.

The advance of information technology and the rapidly increasingly application of digital technologies to medical records, healthcare management, and healthcare administration are of particular importance now.  Thoughtful applications of computer-based records and systems (e.g., computerized physician order entry) have shown their value in improving patient care and patient safety, including HAI prevention and elimination.

In addition, information technology tools need to be appropriate for smaller, rural, or under-resourced hospitals and the timeliness of data feedback must be improved for real-time improvements.

• Improving Public Reporting of Credible Data: Elimination of HAIs will require “a clear national will to succeed in this area.”^[25]  Public reporting of HAI data has been a vital factor in focusing the attention of both the general public and healthcare professionals and administrators on the scope and magnitude of the problem.  Assuring the validity of reported and published data is a responsibility of all parties in the data collection and reporting process.  The continued dissemination of trusted, reliable, and credible data can provide an ongoing stimulus for the HAI prevention effort.  The goal is to report actionable, timely data that multi-sector stakeholders can readily use for multiple purposes.
• Enhancing Traditional and Non-Traditional Partnerships: The modern patient safety movement has succeeded in engaging the attention of everyone who works in or seeks care from the health system.  Continuing awareness of this problem is prompting an ever-growing network of committed individuals and organizations.  Some of these partners have been traditional advocates for infection control for many decades; others, including consumers, are newly empowered and exercising an increasingly important role.  The network and partnerships involving care providers, health professionals, public health officials, academia, industry, payers, employers, and patients and their families have provided both the capacity and commitment that has led to the call for the elimination of HAIs.  Meaningful partnerships across sectors could uncover innovative ways to improve patient safety across the continuum of care.

IV. Conclusion

Within the healthcare and public health arenas, the emphasis on healthcare quality, patient safety, and particularly on the prevention and elimination of HAIs continues to grow in prominence.  The past two years (2008-2010) have seen dramatic growth in the health system’s capacity to measure and improve the health and safety of patients and healthcare personnel alike with significant improvements in care, reductions in morbidity and mortality, and substantial cost savings from infections prevented.

Continuing this progress and achieving the goal of HAI prevention and progressing towards elimination will require on-going commitments of action, energy, and resources on the part of all members of the broad-based HAI prevention network that has grown and been strengthened through the national coalition since 2008.