Frances A. Griffin

‘Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured

Identification and measurement of adverse medical events is central to patient safety, forming a foundation for accountability, prioritizing problems to work on, generating ideas for safer care, and testing which interventions work. We compared three methods to detect adverse events in hospitalized patients, using the same patient sample set from three leading hospitals. We found that the adverse event detection methods commonly used to track patient safety in the United States today-voluntary reporting and the Agency for Healthcare Research and Qualitys Patient Safety Indicators-fared very poorly compared to other methods and missed 90 percent of the adverse events. The Institute for Healthcare Improvements Global Trigger Tool found at least ten times more confirmed, serious events than these other methods. Overall, adverse events occurred in one-third of hospital admissions. Reliance on voluntary reporting and the Patient Safety Indicators could produce misleading conclusions about the current safety of care in the US health care system and misdirect efforts to improve patient safety.

Strategies to prevent surgical site infections in acute care hospitals.

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals to implement and prioritize their surgical site infection (SSI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.1. Burden of SSIs as complications in acute care facilities.a. SSIs occur in 2%-5% of patients undergoing inpatient surgery in the United States.b. Approximately 500,000 SSIs occur each year.2. Outcomes associated with SSIa. Each SSI is associated with approximately 7-10 additional postoperative hospital days.b. Patients with an SSI have a 2-11 times higher risk of death, compared with operative patients without an SSI.i. Seventy-seven percent of deaths among patients with SSI are direcdy attributable to SSI.c. Attributable costs of SSI vary, depending on the type of operative procedure and the type of infecting pathogen; published estimates range from

Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals

3,000 to

Strategies to Prevent Catheter‐Associated Urinary Tract Infections in Acute Care Hospitals

29,000.i. SSIs are believed to account for up to

Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals

10 billion annually in healthcare expenditures.1. Definitionsa. The Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System and the National Healthcare Safety Network definitions for SSI are widely used.b. SSIs are classified as follows (Figure):i. Superficial incisional (involving only skin or subcutaneous tissue of the incision)ii. Deep incisional (involving fascia and/or muscular layers)iii. Organ/space

A compendium of strategies to prevent healthcare-associated infections in acute care hospitals.

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their central line–associated bloodstream infection (CLABSI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.1. Patients at risk for CLABSIs in acute care facilitiesa. Intensive care unit (ICU) population: The risk of CLABSI in ICU patients is high. Reasons for this include the frequent insertion of multiple catheters, the use of specific types of catheters that are almost exclusively inserted in ICU patients and associated with substantial risk (eg, arterial catheters), and the fact that catheters are frequently placed in emergency circumstances, repeatedly accessed each day, and often needed for extended periods.b. Non-ICU population: Although the primary focus of attention over the past 2 decades has been the ICU setting, recent data suggest that the greatest numbers of patients with central lines are in hospital units outside the ICU, where there is a substantial risk of CLABSI.2. Outcomes associated with hospital-acquired CLABSIa. Increased length of hospital stayb. Increased cost; the non-inflation-adjusted attributable cost of CLABSIs has been found to vary from 29,000 per episode

Strategies to prevent clostridium difficile infections in acute care hospitals.

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their catheter-associated urinary tract infection (CAUTI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion. 1. Burden of CAUTIs a. Urinary tract infection is the most common hospital-acquired infection; 80% of these infections are attributable to an indwelling urethral catheter. b. Twelve to sixteen percent of hospital inpatients will have a urinary catheter at some time during their hospital stay. c. The daily risk of acquisition of urinary infection varies from 3% to 7% when an indwelling urethral catheter remains in situ. 2. Outcomes associated with CAUTI a. Urinary tract infection is the most important adverse outcome of urinary catheter use. Bacteremia and sepsis may occur in a small proportion of infected patients. b. Morbidity attributable to any single episode of catheterization is limited, but the high frequency of catheter use in hospitalized patients means that the cumulative burden of CAUTI is substantial. c. Catheter use is also associated with negative outcomes other than infection, including nonbacterial urethral inflammation, urethral strictures, and mechanical trauma.

Strategies to Prevent Transmission of Methicillin-Resistant Staphylococcus aureus in Acute Care Hospitals

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their ventilator-associated pneumonia (VAP) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.1. Occurrence of VAP in acute care facilities.a. VAP is one of the most common infections acquired by adults and children in intensive care units (ICUs).i. In early studies, it was reported that 10%-20% of patients undergoing ventilation developed VAP. More-recent publications report rates of VAP that range from 1 to 4 cases per 1,000 ventilator-days, but rates may exceed 10 cases per 1,000 ventilator-days in some neonatal and surgical patient populations. The results of recent quality improvement initiatives, however, suggest that many cases of VAP might be prevented by careful attention to the process of care.2. Outcomes associated with VAPa. VAP is a cause of significant patient morbidity and mortality, increased utilization of healthcare resources, and excess cost.i. The mortality attributable to VAP may exceed 10%.ii. Patients with VAP require prolonged periods of mechanical ventilation, extended hospitalizations, excess use of antimicrobial medications, and increased direct medical costs.

Development and Evaluation of the Institute for Healthcare Improvement Global Trigger Tool

Preventable healthcare-associated infections (HAIs) occur in US hospitals. Preventing these infections is a national priority, with initiatives led by healthcare organizations, professional associations, government and accrediting agencies, legislators, regulators, payers, and consumer advocacy groups. To assist acute care hospitals in focusing and prioritizing efforts to implement evidence-based practices for prevention of HAIs, the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America Standards and Practice Guidelines Committee appointed a task force to create a concise compendium of recommendations for the prevention of common HAIs. This compendium is implementation focused and differs from most previously published guidelines in that it highlights a set of basic HAI prevention strategies plus special approaches for use in locations and/or populations within the hospital when infections are not controlled by use of basic practices, recommends that accountability for implementing infection prevention practices be assigned to specific groups and individuals, and includes proposed performance measures for internal quality improvement efforts.

Rethinking emergency department visits.

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their Clostridium difficile infection (CDI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion. 1. Increasing rates of CDI C. difficile now rivals methicillin-resistant Staphylococcus aureus (MRSA) as the most common organism to cause healthcare-associated infections in the United States. a. In the United States, the proportion of hospital discharges in which the patient received the International Classification of Diseases, Ninth Revision discharge diagnosis code for CDI more than doubled between 2000 and 2003, and CDI rates continued to increase in 2004 and 2005 (L. C. McDonald, MD, personal communication, July 2007). These increases have been seen in pediatric and adult populations, but elderly individuals have been disproportionately affected. CDI incidence has also increased in Canada and Europe. b. There have been numerous reports of an increase in CDI severity. c. Most reports of increases in the incidence and severity of CDI have been associated with the BI/NAP1/027 strain of C. difficile . This strain produces more toxins A and B in vitro than do many other strains of C. difficile , produces a third toxin (binary toxin), and is highly resistant to fluoroquinolones.