In October 2008, Congress appropriated $17 million to the Agency for Healthcare Research
and Quality (AHRQ) for projects to help further reduce and eliminate healthcare-associated infections (HAIs). This fact sheet provides brief descriptions
of each project.
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Introduction
Acronyms
Addressing Healthcare-Associated Infections
Addressing Central Line-Associated Blood Stream Infections
Addressing Methicillin-Resistant Staphylococcus aureus Infections
Addressing Clostridium Difficile Infections
Addressing Surgical Site Infections
Addressing Carbapenem-Resistant Enterobacteriaceae Infections
Addressing Catheter-Associated Urinary Tract Infections
For More Information
Introduction
Healthcare-associated infections (HAIs) are infections that patients get
while receiving treatment for another condition in a health care facility.
A study of patients in 2002 estimated that HAIs account for an estimated 1.7
million infections and 99,000 associated deaths annually, making them the most
common complication of hospital care. The added financial burden attributable
to HAIs is estimated to be between $28 billion to $33 billion each year.
To address this growing problem, AHRQ has funded and collaborated with other
Federal agencies, including the Centers for Disease Control and Prevention
(CDC), to develop and launch projects that prevent and reduce HAIs. These projects
are primarily funded through existing AHRQ mechanisms.
In October 2008, Congress appropriated $17 million to the Agency for Healthcare
Research and Quality (AHRQ) for projects to help further reduce and eliminate
HAIs. This fact sheet features details of projects that AHRQ funded in fiscal
year 2009 to address various infections, including central line-associated
blood stream infections (CLABSIs), methicillin-resistant Staphylococcus
aureus (MRSA) infections, Clostridium difficile infections (CDIs), surgical
site infections (SSIs), Carbapenem-resistant enterobacteriaceae (CRE)
infections, catheter-associated
urinary tract infections (CAUTIs), and blood stream infections (BSIs).
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Acronyms
ACTION—Accelerating Change and Transformation in Organizations
and Networks
AHRQ—Agency for Healthcare Research and Quality
BSI—blood stream infection
CAUTI—catheter-associated urinary tract infection
CDC—Centers for Disease Control and Prevention
CDI—Clostridium difficile infection
C. difficile—Clostridium difficile
CLABSI—central line-associated blood stream infection
CRE—Carbapenem-resistant enterobacteriaceae
CUSP—Comprehensive Unit-based Safety Program
HAI—Healthcare-associated infection
HHS—U.S. Department of Health and Human Services
HCUP—Healthcare Cost and Utilization Project
ICU—intensive care unit
KPC—Klebsiella pneumonia carbapenemase
MRSA—methicillin-resistant Staphylococcus aureus
SSI—surgical site infection |
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Addressing Healthcare-Associated Infections
Medical devices and surgical procedures can cause BSIs, CAUTIs, SSIs, and
ventilator-associated pneumonia, all of which can lead to extended hospital
stays, increased care costs, and higher risk of death. Many of these infections
are caused by antimicrobial-resistant pathogens, such as MRSA or CRE, which
are related to overuse of antibiotics and frequent patient-to-patient transmission
of microorganisms. Although not related to a medical device or surgical
procedure, Clostridium difficile (C. difficile) is a frequent cause
of an intestinal infection that is spread in health care settings and infects
patients who have recently received antibiotics. Preventing and reducing these
infections can be a challenge for individuals who provide patient care. To
address this issue, AHRQ supports many activities focused on preventing and
reducing HAIs. They are summarized below.
Reducing the Overuse of Antibiotics by Primary Care Clinicians in Ambulatory
and Long-Term Care Settings
A critical step in limiting the number of infections caused by the multidrug-resistant
bacteria present in health care settings is to reduce the overuse of antibiotics.
This project will design and test interventions aimed at reducing inappropriate
use of antibiotics in primary care settings and disseminate findings widely.
It also will define modifiable factors that appear to contribute to primary
care clinicians' overuse of antibiotics when caring for residents of
long-term care facilities.
AHRQ Program: Practice-Based Research Networks
Institutions: Medical University of South Carolina, Charleston,
SC; Children's Hospital of Philadelphia, PA; University of Colorado Health
Sciences Center, Denver, CO; and University of North Carolina at Chapel Hill,
NC
Project Nos.: HHSA-290-2007-10015 task order 3; HHSA-290-2007-10013
task order 3; HHSA-290-2007-10008 task order 7; and HHSA-290-2007-10014 task
order 6
Project Period: 8/09-8/11
Total Funding: $2,000,000
Standardizing Antibiotic Use in Long-Term Care Settings
Antibiotics are commonly prescribed in long-term care facilities, and the
proportion of inappropriate antibiotic prescriptions can be as high as 75 percent
in this setting. Optimizing use of antibiotics in long-term care facilities
will reduce the incidence of C. difficile colitis and the emergence
of multidrug-resistant organisms that pose major morbidity and mortality risks
for residents. This effort, called SAUL, for standardizing antibiotic use in
long-term care settings, includes two projects that will first assess current
antibiotic utilization practices in a group of long-term care facilities using
the Loeb "minimum criteria" as a standard and then develop new
approaches to optimize antibiotic prescribing practices in a subset of facilities.
AHRQ Program: Accelerating Change and Transformation in Organizations
and Networks (ACTION)
Institutions: Abt Associates, Cambridge, MA; and American
Institutes for Research, Washington, DC
Project No.: HHSA-290-2006-00011I and HHSA-290-2006-0019I
Project Period: 9/09-3/12
Total Funding: $2,000,000
Producing Rapid National-, Regional-, and State-Level Estimates to Evaluate
the Impact of Interagency HAI Initiatives
This project will build on an initial investment to produce rapid national,
regional, and State estimates of HAIs, including C. difficile, MRSA,
CLABSIs, and SSIs, acquired in the acute care setting. Researchers will
establish a baseline and subsequent rates of HAIs in the acute care setting
following interventions funded through this and earlier initiatives.
AHRQ Program: Healthcare Cost and Utilization Project (HCUP)
Institution: Thomson Reuters, Santa Barbara, CA
Project No.: HHSA-290-2006-00009C
Project Period: 9/09-12/10
Total Funding: $500,000
Implementing Teamwork Principles for Frontline Health Care Providers
This project will use a national training and support network called the National
Implementation of Team Strategies and Tools to Enhance Performance and Patient
Safety (TeamSTEPPS™) Project, developed by AHRQ and the Department of
Defense. Researchers will use an evidence-based teamwork system aimed at optimizing
patient outcomes by improving communication and teamwork skills among health
care professionals. The project will focus on high-risk areas, such as hospital
surgery centers, ambulatory care centers, emergency departments, labor and
delivery units, and other health care settings. Researchers will work to reduce
MRSA, CAUTIs, CLABSIs, and other HAIs by using resources at five Team Resource
Centers located at Duke Medical Center, Durham, NC; Carilion Clinic, Roanoke,
VA; University of Minnesota Fairview Medical Center, Minneapolis, MN; Creighton
University Medical Center, Omaha, NE; and University of Washington Medical
Center, Seattle, WA.
AHRQ Program: Patient Safety
Institution: American Institutes for Research, Washington,
DC
Project No.: HHSA-290-2006-0019 task order 3
Project Period: 9/09-9/11
Total Funding: $1,000,000
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Addressing Central Line-Associated Blood Stream Infections
Often referred to as a central venous catheter, a central line is a tube placed
in a large vein in a patient's neck, chest, or groin to administer medication
or fluids or to collect blood samples. According to CDC, each year, an estimated
250,000 cases of CLABSI occur in U.S. hospitals, and an estimated 30,000 to
62,000 infected patients die. AHRQ's latest projects to address CLABSIs
are summarized below.
Expanding the Comprehensive Unit-Based Patient Safety Program to Reduce
Central Line-Associated Blood Stream Infections
The following projects build on the national implementation of the 3-year-long
Comprehensive Unit-based Safety Program (CUSP) to reduce CLABSIs in intensive
care units (ICUs) that began in 100 hospitals from 10 States in 2008. The program
includes tools to help health care professionals identify opportunities to
reduce potential HAIs and implement policies to make care safer in the ICU.
- Since the initial implementation of the CUSP-CLABSI initiative in 10 States,
additional hospitals in those States have expressed interest in participating
in the program. This project will increase the number of participating hospitals.
Total Funding: $1,000,000
- This project expands the CUSP-CLABSI initiative to 22 States, the District
of Columbia, and Puerto Rico. As a result of this additional funding from
AHRQ and a private foundation, all 50 States, Puerto Rico, and the District
of Columbia are now participating in the Keystone Project. In an 18-month
period, the Keystone Project reduced the rate of BSIs from intravenous lines
by two-thirds within 3 months in more than 100 ICUs in Michigan and helped
the average ICU decrease its infection rate from 4 percent to 0.
Total Funding: $3,000,000
- Because CLABSI is a significant problem in hospitals and in settings other
than the ICU, this project expands the CUSP-CLABSI initiative to general
medical and surgical hospital units. Current CUSP resources will be
modified so they are applicable to a non-ICU environment.
Total Funding: $2,000,000
AHRQ Program: ACTION
Institution: Health Research & Educational Trust
Project No.: HHSA-290-2006-00022I task order 7
Project Period: 9/09-09/12
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Addressing Methicillin-Resistant Staphylococcus aureus Infections
Although there is evidence to suggest that the number of CLABSIs caused by
MRSA, specifically, as well as CLABSIs, overall, are decreasing, MRSA remains
one of the most common pathogens responsible for HAIs. Moreover, according
to the AHRQ-sponsored HCUP database (http://www.hcup-us.ahrq.gov/reports/statbriefs/sb35.jsp),
the number of MRSA-associated hospital stays more than tripled after 2000,
reaching 368,600 in 2005. Patients hospitalized for MRSA infections have longer
hospital stays and are more likely to die than patients who do not have MRSA
infections. These HAIs are especially common in hospital ICUs. AHRQ's
latest project that addresses MRSA infections is summarized below.
Evaluation of Strategies to Eliminate MRSA in Intensive Care Units
Recent interest in preventing MRSA infections has led to the widespread practice
of screening patients in ICUs for MRSA to guide additional infection control
practices, such as isolation and application of MRSA-decolonization regimens.
Screening patients for MRSA is labor intensive, costly, and may have limited
impact on other important pathogens. In contrast, universally bathing ICU patients
with chlorhexidine, a practice increasingly employed in U.S. hospitals, has
yielded promising results in reducing bacterial skin colonization and central-line
infections from all pathogens, and the strategy may be simpler to implement.
This project proposes a large, simple, cluster-randomized trial to compare
the relative effectiveness of screening and isolation with two novel approaches:
1) screening plus decolonization regimens for MRSA carriers and 2) universal
decolonization regimens for all ICU admissions in the absence of screening.
The study may help identify a more cost-efficient and effective alternative
to what has become a very popular approach to preventing hospital-associated
MRSA infections. The project also will answer quality improvement questions
through the use of practical, pragmatic, cluster-randomized trials that take
advantage of the existing clinical care infrastructure.
AHRQ Program: Developing Evidence to Inform Decisions about
Effectiveness
Institution: Harvard Pilgrim Health Care, Harvard Medical
School, Boston, MA
Project No.: HHSA-290-2005-0033I task order 11
Project Period: 9/09-3/11
Total Funding: $1,500,000
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Addressing Clostridium Difficile Infections
C. difficile-associated infections occur most often when antibiotic
therapy suppresses the normal bacteria in the patient's colon. According
to AHRQ's HCUP database (http://www.hcup-us.ahrq.gov/reports/statbriefs/sb50.jsp),
there were more than 2 million cases of C. difficile in U.S. hospitals
between 1993 and 2005; two out of three infected hospital patients in 2005
were elderly. On average, patients with C. difficile were hospitalized
almost three times longer than uninfected patients, and the in-hospital death
rate for patients with C. difficile was 9.5 percent compared with
2.1 percent overall. A summary of AHRQ's latest project that addresses C.
difficile infections follows.
Reducing Clostridium Difficile Infections in a Regional Collaborative
of Inpatient Health Care Providers
Building on the Keystone Project's successful reduction of bloodstream
infections, this project aims to reduce CDIs along with their associated morbidity,
mortality, and costs in a cohort of regional inpatient facilities. Participating
facilities have patients with frequent health care contacts before and after
hospitalization, such as acute care facilities, associated nursing homes, long-term
care facilities, and ambulatory care settings, such as emergency departments. Interventions
for reducing CDI rates will include decreasing unnecessary antimicrobial prescribing
and improving infection control. Prevention measures will be bundled according
to the clinical processes and personnel most affected by their implementation
(e.g., measures impacting environmental services or facilities maintenance
versus nursing care or other clinical care). Investigators will conduct both
quantitative and qualitative research, including interviews, focus groups,
and periodic surveys to identify barriers that either impede prevention measure
implementation or make it expensive. As a result of this project, researchers
will develop an implementation toolkit and manual to assist other regional
prevention collaboratives in reducing CDI rates.
AHRQ Program: ACTION
Institution: Boston University School of Public Health, Boston,
MA
Project No: HHSA-290-2006-0012I task order 10
Project Period: 9/09-9/11
Total Funding: $1,000,000
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Addressing Surgical Site Infections
SSIs are a substantial cause of morbidity and mortality among hospitalized
patients. Based on survey data from 2002, SSIs accounted for approximately
16 percent of an estimated 1.7 million HAIs and 8,205 of the 98,987 HAI associated
deaths, for a mortality rate of 3 percent. The financial burden attributable
to these largely preventable infections is also significant, with an estimated
hospital cost of $25,546 per infection and approximately $7 billion annually. A
summary of AHRQ's latest project that addresses SSIs follows.
Improving Measurement of Surgical Site Infection Risk Stratification and
Outcome Detection
Feedback on surgeon-specific SSI rates is considered to be the cornerstone
for preventing these infections. For feedback to be effective, however, surgeons
must believe that the rates are reliable for comparing their performance to
that of their peers. Unfortunately, many surgeons believe that current surveillance
methods are unreliable because of limitations in patient risk adjustment and
event detection. This multihospital study will employ sensitive electronic
detection algorithms to determine SSI rates in a large number of specific high-risk
procedures and will design and test methods to risk stratify on data elements
that can be optimized for electronic collection. Investigators will propose
a risk-adjusted model in a set of procedures and then verify the model's
predictive value in a second patient pool. Finally, investigators will assess
surgeon acceptance of the surveillance methodology using the risk-adjusted
models with sensitive event-detection methods.
AHRQ Program: ACTION
Institution: Denver Health, Denver, CO
Project No.: HHSA-290-2006-00020 task order 8
Project Period: 09/09-03/11
Total Funding: $413,000
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Addressing Carbapenem-Resistant Enterobacteriaceae Infections
CRE is another bacterial agent that is emerging as a challenge in health care
settings. One type of CRE—Klebsiella pneumoniae carbapenemase
(KPC) producing organisms, also known as carbapenem-resistant Klebsiella
pneumoniae—poses significant treatment challenges because it is
resistant to almost all available antimicrobial agents. As a result, these
infections have been associated with higher mortality, longer hospital stays,
and increased health care costs. The emergence and spread of KPC-producing
organisms and other types of CRE are worrisome public health developments
and underscore the immediate need for aggressive detection and control strategies.
AHRQ's latest project that addresses these infections is summarized
below.
Reducing Infections Caused by Carbapenem-Resistant Enterobacteriaceae through
Application of Recently Developed Recommendations
The goal of this project is to demonstrate the efficacy of aggressive, CDC-recommended
infection control interventions to halt the emergence of KPC-producing organisms. A
second goal is to develop an implementation toolkit and manual to assist facilities
in implementing aggressive infection control approaches to reduce the spread
of KPC-producing organisms.
AHRQ Program: ACTION
Institution: Boston University
Project No.: HHSA-290-2006-00012 task order 9
Project Period: 09/09-09/11
Total Funding: $500,000
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Addressing Catheter-Associated Urinary
Tract Infections
The urinary tract is the most common site of HAIs, accounting for more than
30 percent of infections reported by acute care hospitals. Complications associated
with CAUTIs cause patient discomfort, prolonged hospital stays, and increased
cost and mortality. Each year, more than 13,000 deaths are associated with
urinary tract infections. A summary of AHRQ's latest project that addresses
CAUTIs follows.
Catheter-Associated Urinary Tract Infection Demonstration Project Using
the Comprehensive Unit-Based Patient Safety Program
The success of CUSP in reducing CLABSIs has increased pressure to apply the
program to other HAIs, including CAUTIs; thus, this project initiates a demonstration
of the CUSP concept as applied to CAUTIs. Investigators will first modify CUSP
materials so they apply to CAUTI and then use the materials in 10 hospitals
in each of 10 States, for a total of 100 hospitals, to demonstrate CUSP's
utility in reducing CAUTIs.
AHRQ Program: ACTION
Institution: Health Research & Educational Trust
Project No.: HHSA-290-2006-00022 task order 8
Project Period: 9/09-9/11
Total Funding: $1,000,000
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Addressing Blood Stream Infections in Hemodialysis
According to CDC, in 2006 approximately 330,000 patients were maintained on
hemodialysis in the United States. Infection, most often of the bloodstream,
is the second leading cause of death for hemodialysis patients. BSIs are most
frequently experienced by patients with indwelling vascular catheters. A summary
of AHRQ's latest project to address BSIs is below.
Prevention of Blood Stream Infections for Outpatients Undergoing Hemodialysis
This study will use CUSP to examine the comparative effectiveness of standard
recommended practices with antibiotic catheter locks and antiseptic catheter
locks for preventing BSIs in hemodialysis patients. Secondary evaluations will
include screening assessments for changes in antimicrobial resistance and evaluating
the development of toxicities related to the use of catheter locks.
AHRQ Program: ACTION
Institution: Yale University, New Haven, CT.
Project No.: HHSA-290-2006-00015 task order no. 3
Project Period: 9/09- 3/12
Total Funding: $1,000,000
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For More Information
For more information about AHRQ's HAI initiatives, visit http://www.ahrq.gov/qual/hais.htm or
contact:
William B. Munier, M.D., M.B.A.
Director
AHRQ's Center for Quality Improvement and Patient Safety
540 Gaither Road
Rockville, MD 20850
Phone: 301-427-1327
E-mail: william.munier@ahrq.hhs.gov
Fact sheets on AHRQ-funded projects are also available for:
Information on the Comprehensive Unit-based Safety Program—which has been expanded to include all 50 States, Puerto Rico and the District of Columbia, to include other settings in addition to intensive care units, and to address other types of HAIs—is available at Using a Comprehensive Unit-based Safety Program to Prevent Healthcare-Associated Infections.
AHRQ Publication Number: 09(10)-P013-1
Current as of October 2009
Internet Citation:
AHRQ's Efforts to Prevent and Reduce Healthcare-Associated Infections: FY 2009 Projects. October 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/haify09.htm
540 Gaither Road Rockville, MD 20850 