Chapter 2 Introduction

Healthcare-associated infections, commonly referred to as HAIs, are infections that patients acquire during treatment for conditions within a health care setting, such as a hospital, ambulatory surgical center, nursing home, or outpatient care center. HAIs are one of the major types of complications or adverse events that can occur when receiving medical treatment in a health care facility. These infections can be relatively minor and easily treatable (such as a minor skin infection) or can be devastating to both patients and their families due to lost time and wages, the need for additional treatment, additional days in the hospital, and increased medical costs. Act 52 was enacted in 2007 to reduce the devasting impact and burden that HAIs have on Pennsylvania health care consumers, their families and the health care system.

In 2007, Pennsylvania was one of the first states to pass HAI legislation assigning specific responsibilities for implementation to the Department of Health (Department) as well as the Pennsylvania Safety Authority (PSA) and Pennsylvania Health Care Cost Containment Council (PHC4). The Department continues work to reduce HAIs per requirements of Act 52, which include tracking HAIs; distributing quarterly validation reports to hospitals; publishing Pennsylvania HAI data, guidance and technical support to health care facilities regarding NHSN and HAI reduction strategies; and reviewing infection control plans for newly opened hospitals, long term care facilities, and ambulatory surgical facilities. Recently, the Department transferred the responsibility for HAI prevention from Quality Assurance to the Department’s Bureau of Epidemiology and expanded its’ role through work with the Centers for Disease Control and Prevention (CDC), engagement with health care facilities and collaboration with other health partners committed to patient safety, health care quality, and HAI reduction. These expanded roles include:

• Conducting on site assessments of infection prevention and control practices;
• Making recommendations for practice changes to fill gaps in implementation of national guidelines;
• Assisting facilities with outbreak response to prevent additional HAIs;
• Coordinating laboratory testing to identify multidrug resistant organisms; and
• Raising awareness about and educating providers and facilities about antimicrobial stewardship principles.

While Pennsylvania continues to see a statewide reduction in HAIs, they continue to be an important patient safety concern being addressed by the Department and CDC. In 2015, CDC reported there were an estimated 687,000 HAIs in United States acute care hospitals and about 72,000 deaths associated with HAIs.¹ In a 2009 report published by CDC, it was estimated that the direct costs of HAIs to US hospitals was in excess of 28 billion dollars, of which 70% was estimated as preventable.³ In 2009, HHS issued a 5-year National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination⁴ for hospitals. In 2016, it was updated to establish new target reduction goals and defined a new 5-year period for measure (2015-2020). This 2017 Pennsylvanian HAI report focuses on 5 important types of HAIs benchmarked in Pennsylvania and targeted by HHS for reduction in the HAI National Action Plan. These infections include:

1. Central line-associated bloodstream infection (CLABSI);
2. Catheter-associated urinary tract infection (CAUTI);
3. Surgical site infection (SSI) [for seven procedure types];
4. Laboratory-identified bloodstream infection (LabID) events caused by MRSA; and
5. Laboratory-identified infection (LabID) events caused by Clostridioides difficile (CDI).

This report is generated by the Department as a requirement of Act 52 and serves as a resource for health care providers and for the general public seeking information about HAI prevention and reduction progress. Hospitals can use the data presented to benchmark against themselves to assess their HAI reduction strategies and progress. Health care consumers in Pennsylvania can use this report to get an overview of how a specific hospital ranks in preventing infections and to heighten their awareness of HAI risk at the hospital they may choose.

This is the second report to use an online format. This report identifies how hospitals in Pennsylvania are performing regarding HAI prevention by displaying how many HAIs each hospital reported during January 1, 2017, through December 31, 2017. However, the number of infections alone cannot be used to determine how well a facility ranks in their efforts to prevent infections.

2.1 Catheter-Associated Urinary Tract Infection (CAUTI)

A urinary tract infection (UTI) is an infection involving any part of the urinary system, including the urethra, bladder, ureter, and kidney. Among UTIs acquired during a hospitalization, approximately 75% are associated with an indwelling urinary catheter, a tube inserted into the bladder and left in place to drain urine.⁵ These UTIs are classified as a catheter-associated UTI (CAUTI) when an infection is identified after a urinary catheter that was inserted into the urinary bladder has been in place for more than 2 calendar days.⁶ Between 15% and 25% of hospitalized patients receive urinary catheters during their hospital stay; many catheters are not needed and/or stay in place longer than needed.

The most effective way to reduce CAUTIs is to reduce unnecessary urinary catheter placement by establishing clear indications for use and minimizing the length of time it remains in place by removing it as soon as the medical necessity no longer exists. Each day that a patient has a catheter in place increases the risk for developing a CAUTI by 3% to 7%.^{7 ,8} The Centers for Medicare and Medicaid Services (CMS) no longer reimburses hospitals for additional costs generated by CAUTIs.

Many resources are available for health care providers that outline strategies and guidelines for prevention of CAUTIs including those published by the Society for Healthcare Epidemiology of America (SHEA)⁷ and the Association for Professionals in Infection Control and Epidemiology (APIC). Strategies to prevent CAUTIs are discussed in CDC’s Healthcare Infection Control Practices Advisory Committee (CDC/HICPAC) document, Guideline for Prevention of Catheter-Associated Urinary Tract Infection.⁹

A central line is a device used to administer fluids, medications, blood, and nutrition, or to collect blood needed for laboratory testing or to measure a patient’s status. Unlike short peripheral intravenous catheters, these catheters are inserted to access major vessels that are located near the heart and are placed via a large vein in the neck, chest, groin, or through veins in the arms. A central line can stay in place for weeks to months.¹⁰

When a bloodstream infection occurs after bacteria or other organisms enter a patient’s bloodstream directly through the central line, it is categorized as a CLABSI. When an infection occurs elsewhere in the body (e.g. the lungs or skin) and later moves to the bloodstream, it is not considered a CLABSI.

CLABSIs continue to be a serious patient safety issue as well as an economic burden to health care facilities even though United States CLABSI rates decreased 46% from 2008-2013.¹¹ An estimated 30,100 CLABSIs still occur in United States hospitals each year. Each CLABSI is estimated to cost $70,696 (2012 dollars).¹² The CMS no longer reimburses hospitals for additional costs generated by CLABSIs.¹³ Research indicates that between 65% and 70% of CLABSIs are preventable by implementing evidence-based strategies. Compared to other HAIs, CLABSIs are associated with the highest number of preventable deaths.¹⁴

CLABSI prevention strategies are available in published guidelines. Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals is published by SHEA and is based upon a collaboration of experts.¹⁵ APIC’s 2015 Implementation Guide to Preventing Central Line-Associated Bloodstream Infections¹⁰ and the CDC/HICPAC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011¹⁶ are also evidenced-based guidelines.

2.2 Surgical Site infections (SSIs)

Surgical site infections (SSIs) are infections that are attributed to a surgical procedure and vary in complexity and infection depth. The depth ranges from minor superficial incisional infections to those located deep into muscle and those penetrating the organ space.⁶

Patients with an SSI have a 2 to 11 times higher risk of death compared with operative patients without an SSI. The number of SSIs in the United States has significantly decreased since 2011¹ and account for 20% to 22% of all HAIs.¹⁵ In 2002, Klevens et.al.¹⁷ estimated there were 290,485 SSIs. By 2011, the estimated SSIs decreased to 157,500¹⁸ and, by 2015, the number further decreased to 110,800.¹ Between 2006 and 2008, the SSI rate from all procedure types in 39 states was 1.9%.¹⁹ Similar data from 2010-2012 determined the SSI rate to be 0.82%²⁰ or 0.97%.¹⁸ By 2015, the national SSI rate dropped to 0.56%.¹

Surgical site infections are associated with human and financial costs related to lost work time, increased days in the hospital (on average an added 9.7 days),²¹ added treatment costs including return to the OR, emergency department visits, and readmissions to the hospitals. Per CDC’s 2017 Guideline for the Prevention of Surgical Site Infection, the cost of an SSI ranges from $10,443 to $25,546 per infection, and costs can exceed $90,000 when the SSI involves a prosthetic joint implant or antimicrobial-resistant organism.²²

About half of SSIs are estimated to be preventable by the application of evidence-based strategies.¹⁴ Therefore, facility SSI reduction efforts as recommended in APIC’s 2015 Implementation Guide: (Infection Preventionist’s Guide to the OR) should include resources so that hospital infection prevention and control programs can support the perioperative team to implement the most current and evidence-based surgical infection prevention and control strategies, as well as tracking and communicating surgical infection rates to the perioperative team. Recently published SSI prevention guidelines and evidence-based recommendations include CDC’s updated Guideline for the Prevention of Surgical Site Infection,²² and the American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update.²¹ CDC recommends that facilities incorporate new and updated evidence-based strategies into a comprehensive surgical quality improvement program to improve patient safety.

2.3 Clostridioides difficile infection (CDI) in the stool

Clostridioides difficile, formerly defined as Clostridium difficile, is an anaerobic, Gram-positive, spore-forming bacillus (bacteria) that can produce 2 exotoxins, toxin A and toxin B. It was considered nonpathogenic until 1978 when it was first identified as the primary cause of pseudomembranous colitis after antibiotic exposure.²³ C. difficile infection (CDI) is the leading cause of antibiotic-associated diarrhea in the United States¹ and has become the most commonly identified cause of HAIs in United States adults, is a major health threat to hospitalized patients, and, in recent years, has become established as a community acquired pathogen.

The development of CDI most commonly requires 2 components: exposure to antibiotics and new acquisition of C. difficile from the ingestion of spores (fecal-oral transmission). Antibiotics suppress or disrupt the normal bowel microbiota (bacteria) that allow for C. difficile to flourish when spores are ingested. In the health care setting, exposure to C. difficile spores occur via the hands of health care personnel contaminated with C. difficile spores or contact with contaminated environmental surfaces or equipment. A significant risk factor for CDI is occupying a room where a prior occupant had CDI.²⁴ The most important modifiable risk factor is exposure to antibiotics. Other risk factors for CDI are advanced age, long hospitalization stays, and severe underlying illness.

A study funded by the CDC to assess the United States burden of C. difficile in 2011 estimated that C. difficile was responsible for almost 500,000 infections and associated with approximately 29,000 deaths. Fifty-eight percent (N=293,300) of the infections were healthcare-associated, meaning that onset followed a visit to a health care setting. Thirty-seven percent of the healthcare-associated infections were estimated to occur during a hospital visit (hospital onset). Thirty-six percent were classified as occurring in nursing homes (nursing home onset) and 27% were classified as having onset dates in the community after the patient had recently visited a health care facility (community onset). Of the patients with hospital onset, community onset after hospital stay, or nursing home onset, the rate of death within 30 days was 9.3%. The mortality rate was about 10 times higher among people aged 65+ compared with those aged 45-64.²⁵ Recent United States hospital discharge data indicate that the number of hospital discharges with a diagnosis of CDI plateaued at historic highs between 2011 and 2013.²⁶ Approximately 1.9 million and 600,000 patients discharged from United States hospitals across 6 study years had a C. difficile infection as a discharge and principal diagnosis, respectively in 2004 and 2014. C. difficle-associated fatality decreased from 3.6% in 2004 to 1.6% in 2014, but the mean hospital charges increased from 2004 ($24,535) to 2014 ($35,898).²⁷ In a Canadian study, patients with CDI had an increased hospital stay of 6 days.²⁸ Approximately 14% to 26% of individuals experience CDI recurrence, despite successful treatment after the initial episode. In those patients who experienced a single recurrence, the risk of additional recurrences may be as high as 65%²⁹.

SHEA and the Infectious Diseases Society of America (IDSA) updated their clinical practice guidelines for C. difficile in 2017.²⁶ In 2013, APIC developed their Guide to Preventing Clostridium difficile Infections.³⁰

2.4 Methicillin-resistant Staphylococcus aureus (MRSA) found in the blood

Staphylococcus aureus is a bacteria often called “staph” that is commonly found on the skin and does not typically cause an infection. However, when staph enters the bloodstream, it can cause a serious infection and even death. Staph infections that cannot be treated with the antibiotic methicillin are named methicillin-resistant Staphylococcus aureus (MRSA). About 2% of people carry MRSA in their nose or skin.³¹ MRSA can be spread by persons who are infected or colonized with MRSA to another person through direct contact or contact with equipment or shared personal items. Outbreaks of MRSA have occurred in daycare centers, on sports teams, in group homes, and health care facilities. In hospitals, MRSA can be passed from one person to another through hands of health care workers and on surfaces contaminated with MRSA, such as bedrails or medical equipment. Anyone can get MRSA, but persons living in or involved with activities that take place in crowded settings (i.e. athletes, military barracks), as well as hospitalized patients who have surgery, have received broad spectrum antimicrobials, have had devices inserted into their bodies, or have been admitted into a room in which the previous occupant was colonized or infected with MRSA are at an increased risk for acquisition of MRSA.³² Per the CDC, persons who inject drugs are 16 times more likely to develop a serious staph infection³³ and of all patients treated in United States hospitals, 5% carry MRSA in their nose or on their skin, which is known as being colonized.³¹

A study published in MMWR in 2019 reported that MRSA bloodstream infections in health care settings decreased nationally by approximately 17% each year from 2005 until 2013.³⁴ Recent NHSN data show only an 8% decline in MRSA bacteremia standardized infection ratios (SIR) between 2016 and 2017³⁵.

MRSA infection prevention and control remains a priority for the CDC because MRSA is estimated to cause more than 70,000 severe infections and 9,000 deaths per year.³⁶ Based on the current evidence, CDC continues to recommend the use of contact precautions for MRSA-colonized or infected patients.³⁷ As facilities and the public review the MRSA data presented in this report, it is important to know that some hospitals in Pennsylvania have stopped using contact precautions (isolation) for this population, opting instead to reinforce strict adherence to standard precautions and enhanced hand hygiene monitoring. This is contrary to SHEA recommendations³⁸. Consumers are encouraged to question their providers about infection prevention and control practices at the hospitals when they seek care. Health care facilities and infection preventionists are encouraged to monitor MRSA community and admission prevalence rates and health care data to determine which prevention strategy to implement, as well as to evaluate the effectiveness of their infection prevention and control practices.