Invisible Threat

From the Winter 2018 edition of Vanderbilt Medicine Magazine

Protecting patients from infection is the top priority for Tom Talbot, MD, MPH, and Vicki Brinsko, MSN, RN. Photo by John Russell.

 

Every day, a team of epidemiologists, infection preventionists and data analysts report to work at Vanderbilt University Medical Center (VUMC) with a mission: to track invisible trails of microscopic clues, dissect data, analyze lab results, pore over patient medical records and ferret out possible hiding places of disease-causing microbes that could lead to dangerous infections.

Sometimes their search leads to surprising locations such as construction zones, which are plentiful on the sprawling medical campus.

Trading a microscope for a protective hardhat, Vicki Brinsko, MSN, RN, director of Infection Prevention, joins a construction crew surrounded by scaffolding and gets to work, with one goal in mind: patient safety.

“We actually do have our own construction hats, and we go on ‘construction rounds’ several times a week,” Brinsko said. “We visit major project sites where you see the huge cranes outside and smaller reconstruction projects where, for example, they’re adding a new doorway. We’re involved in all of it, making sure that these construction teams — whether it’s a contracted construction company or our own facilities management employees — follow the same rules to protect our patients.”

If it seems surprising that infection prevention specialists are involved in construction, it shouldn’t be. The Infection Prevention team at VUMC, which includes six epidemiologists, eight infection preventionists (IPs) and a data analytics team, is involved at every step of construction, from planning to final punch list. They examine issues such as if the proposed system of air handling is suitable, whether materials are easy to disinfect and if construction dust is well contained so it won’t harm patients.

“There are many things that happen at a medical center that you may not directly connect to infection risk and that are not part of any mandated report,” said Chief Hospital Epidemiologist Tom Talbot, MD, MPH. “There is no one out there asking how well we monitor construction projects, but it’s important. Similarly, if a new medical

device is brought into the Medical Center, we have to make sure there is no unintended consequence. We ask how the device is cleaned and if it might spew anything into the air that people could inhale. We focus not just on the institution’s Pillar Goals and ensuring that the reports that everyone sees outside of these walls look good; all of these other things that can potentially cause harm are important, too.”

 

“We’re fixers”

The role of infection prevention at hospitals and healthcare facilities has been increasing steadily in the United States, especially in the years following World War II as new discoveries in microbiology and immunology led to better understanding and reduction of healthcare-associated infections (HAIs).

In 2014, the Centers for Disease Control and Prevention (CDC) released results from its Healthcare-associated Infection (HAI) Prevalence Survey, and the results were staggering. On any given day, one in 25 hospital patients contracted at least one HAI. In 2011, an estimated 722,000 Americans developed HAIs in U.S. acute care hospitals, and about 75,000 hospital patients with HAIs died during hospital stays. HAIs cost the healthcare system nearly $6.5 billion annually, according to the CDC.

In 2008, Congress mandated that the Centers for Medicare and Medicaid Services (CMS) stop providing payments to hospitals for the treatment of “reasonably preventable” infections acquired by patients during hospitalizations. In 2010, Congress incorporated HAI prevention into the value-based purchasing program of the Affordable Care Act, leading to even greater accountability for healthcare facilities.

Changes in the regulatory landscape that mandate HAI reporting have also raised the importance of detection and response to HAIs. And in the past decade, electronic surveillance systems have enabled infection preventionists to more quickly identify infections and the presence of multi-drug resistant organisms, resulting in improved patient safety and rapid initiation of infection control measures.

The epidemiologists, infection preventionists and data analysts on the Infection Prevention team are part of the Quality, Safety and Risk Prevention (QSRP) office at VUMC so they work closely with other QSRP staff members, as well as other teams throughout the Medical Center campus that directly impact patient care and safety.

“We’re like the CSI (Crime Scene Investigation) for Vanderbilt,” laughed Talbot. “Well, I guess we’re more like a mini-CDC for the hospital. People that go into this field, well, we’re fixers. We want to fix everything, but we also have to realize that we’re not empowered to fix everything. We are the experts that support the people on the front line that can get in there and fix anything that needs to be fixed.”

Talbot and his team are well aware that every infection statistic is much more than a number on a spreadsheet. The number represents an individual — someone’s parent or child — and successful infection prevention saves lives. Not only does the team investigate suspected infections, they also educate medical staff, develop and enforce infection control policies, and measure the effectiveness of ongoing infection control efforts.

They pay attention to the story the data tell and are watchful for any unusual illness that could signal an outbreak or a new type of infection. But they are also closely connected to the much more personal aspect of infection prevention. They check on medical staff members’ patient care practices, participate in medical rounds in patients’ rooms and attend unit meetings so care teams can tell them directly what’s working and what needs more attention.

While there is much about their jobs that can appear routine, there are times when a rapid, but well-thought out, response can contain a potential outbreak, detouring what could have escalated into a health crisis into an isolated incident. Minutes can mean the difference between life and death, especially when it comes to highly contagious and antibiotic-resistant infections. Members of the Infection Prevention team are on call 24 hours a day, seven days a week, and can be consulted by anyone working on the frontline of patient care.

In 2014, when there was a threat of the deadly West Africa Ebola Virus Disease (EVD), the VUMC Infection Prevention team, working in conjunction with the CDC and with several internal VUMC groups, reacted quickly, communicating detailed information to clinicians on how to evaluate patients for Ebola and what to do if Ebola was suspected, including how to isolate patients. The Medical Center ran multidisciplinary drills to teach clinicians how to safely put on, take off and dispose of coveralls, gloves and face shields.

“Each time we have a major event, we learn a lot,” Talbot said. “We’re fairly nimble. We have great support teams and partners, and we have regular event drills to practice our response. We’re a big place, so it’s somewhat like steering an ocean liner, but we do a good job. We also have people on our staff like Bill Schaffner (VUMC’s first Hospital Epidemiologist and frequent national spokesman on infectious diseases), Vicki and myself, who are linked up closely with national experts, so we can see if we need to change anything we’re doing.

“Since I’ve been in this role, there have been a couple of big keystones. There was SARS (severe acute respiratory syndrome) in the early 2000s and the H1N1 pandemic of 2009-2010. We learned a lot from SARS, we did a lot of preparations, and we thought we were ready. Then Ebola shows up, and we had to develop a plan of action for that. What’s worth learning from all of these is that you’ll get hit quickly by things that are not what are expected at all. The ability to adapt is invaluable.”

 

National Recognition

Sustained success in infection prevention is a big reason VUMC was honored in 2017 as the first hospital system in the nation to receive the Association for Professionals in Infection Control and Epidemiology (APIC) Program of Distinction designation. The designation is the culmination of an intense review by an APIC survey team that observed infection prevention practices at Vanderbilt University Adult Hospital and Monroe Carell Jr. Children’s Hospital at Vanderbilt, as well as numerous off-site locations.

APIC is the leading professional association for infection preventionists in the United States, with more than 15,000 members. APIC’s Program of Distinction designation measures excellence in existing infection prevention policies and procedures and ongoing quality improvement efforts, as well as compliance with federal regulations.

“We’re incredibly honored to be the first institution in the country to receive this designation,” said Talbot. “One of the big things the surveyors cited was that it is not just the Infection Prevention team that contributed to the effectiveness of our infection prevention programs. This achievement validates our institution-wide dedication to patient safety, our collaboration and teamwork, and every individual’s effort in implementing and consistently following best practices to prevent healthcare-associated infections.”

Because VUMC is an American College of Surgeons-verified Level 1 Trauma Center, the Medical Center cares for critically injured individuals — everyone from gunshot victims to those in serious car accidents. VUMC patients also include those with compromised immune systems especially vulnerable to infection, such as patients receiving cancer treatment and organ transplants. This means the numbers of infections can tend to be higher here than other medical centers that don’t serve these complex patients, but that is not a “fall back” excuse, Talbot said.

“When you look across all hospitals, who we take care of is different,” he said. “We do take care of the sickest of the sick patients. We always aim for zero infections, but can we get there? The good thing is that our focus on the prevention of infections is everywhere in our Medical Center, from public reporting to payments. That’s been a really positive part of our culture here at Vanderbilt because it’s really driven resources to the right places to do the right thing and to reduce all preventable harm.”

VUMC’s healthcare-associated infection (HAI) rates overall are trending in a positive direction, Talbot said. For example, from 2009 to 2017 (estimated with six months of data in 2017), central line associated blood stream infections (CLABSI) in the intensive care units (ICU) were reduced by 79 percent, and non-ICU CLABSIs were reduced by 71 percent. From 2010 until 2017, there was an estimated 61 percent increase in the healthcare worker influenza vaccination rate. From 2009 until 2017, there was an estimated 81 percent increase in hand-hygiene compliance.

“The entire VUMC organization demonstrated commitment to actively integrating infection prevention into routine patient care practices,” said Terrie Lee, RN, MS, a member of the APIC Program of Distinction survey team. “We noted that Infection Prevention and Quality have been working collaboratively to address issues in a highly successful manner. There were also obvious forward-thinking, ‘wow!’ moments identified when we reviewed their methods of instrument reprocessing (high-level disinfection and sterilization), as well as the surveillance and data management system, antibiotic stewardship program, and their unit for care of patients with highly infectious diseases.”

 

Success Story

A spike in surgical site infections among patients who had colorectal surgeries, a population that is already at higher risk for infection due to the nature of the surgeries, spawned a successful infection prevention initiative at VUMC that has since guided the perioperative procedures for other types of surgeries.

A colorectal SSI task force began meeting twice a month to solve the problem. They reviewed scientific literature and examined other institutions’ practices.

Lack of consistency in how surgeries were handled, from before patients went into surgery until they were released home, seemed to be a key factor playing into the increasing infections, said Senior Quality and Patient Safety Advisor Barbara Martin, MBA, RN, who was part of the taskforce.

“It wasn’t that we weren’t doing things right, it was that we weren’t doing things in a standardized fashion,” she added. “If (infection preventionist) Mary DeVault and I both have the same idea about doing something, but we implement it in different ways, then we’re going to have different outcomes.”

A surgical care bundle, or a defined set of practices to improve outcomes, was developed and implemented for colorectal surgeries.

Elements included pre-surgery bowel preparation and oral antibiotics, using chlorhexidine gluconate cleansing wipes before surgery, the replacement of gowns/gloves in the operating room once the bowel is surgically closed, maintaining a set level of oxygenation, controlling glucose levels, and using wound protection after surgery.

“We started this with every case in colorectal in early 2013 and by June 2013, we had proved that it worked,” said Timothy Geiger, MD, director of Colon and Rectal Surgery. “Every member of the team is critical when it comes to preventing infection, and this was a very collaborative effort between administration, infection prevention, nursing, anesthesia and surgery. This is a nice realization of the fact that from the minute a patient hits the clinic door until the minute they’re discharged, every part of that hospital visit affects their outcome.”

Talbot agrees that one of the most significant factors for success when it comes to infection prevention is having a team that understands the value of every action and is willing to be accountable.

“You have to have people that you partner with that will take the ball and run with it,” Talbot said. “We have the knowledge, the guidelines and the expertise, and we can reach out to peers, but if that receiver on the other end isn’t accepting, then it’s not going to happen. You might get a little success, but you’re not going to get sustained success.”