Minimizing Hospital-acquired Conditions

Educational Objectives

The goal of this program is to improve prevention of hospital-acquired conditions (HACs). After hearing and assimilating this program, the clinician will be better able to:

1. Evaluate the impact of HACs on patient outcomes and health care costs.
2. Implement strategies to prevent HACs.

Summary

Hospital-acquired conditions (HACs): surgical site infections (SSIs) — account for the majority (≈20%) of HACs; the incidence of SSI is 0.5% to 3%; SSIs increase each admission cost by ≈$20,000 and are associated with a 2- to 11-fold increase in mortality; central line-associated bloodstream infections (CLABSIs) — diagnosed in ≈250,000 patients each year, ≈100,000 of whom are in the intensive care units (ICU); the incidence of CLABSI is 0.4 to 12 per 1000 ICU days; the prevalence is 18%; CLABSIs cost ≈$46,000 per case and cause ≈28,000 ICU deaths each year; ventilator-associated pneumonia (VAP) — the definition widely varies; the incidence is 1 to 17 per 1000 ventilator days; costs $10,000 to $40,000 per case; contribute to 13% to 14% of deaths in the United States

Consequences: overall — include increased length of stay, health care costs, morbidity, and mortality, delayed return to work, loss of employment days, increased productivity costs, and decreased community contributions; SSIs — include, eg, delayed or impaired wound healing, abscesses, osteomyelitis, sepsis, and thrombotic complications, multisystem organ failure, pain, death; CLABSIs — include, eg, sepsis, thrombotic complications, need for additional vascular access, multisystem organ failure, pain, death; VAP — include, eg, increased ventilator days, ICU stays, use of surgical airways, and cerebrovascular accidents (associated with 2-fold higher incidence of death)

Prevention

Handwashing: according to the World Health Organization, there may be reason to suggest handwashing or use of alcohol-based hand rubs (ABHRs) ≥300 times/hr at anesthesia work stations; the recommendation is to frequently change gloves and complete ≈8 hand decontaminations per hour; noncompliance rate is 50% to 80%

Anesthesia work area decontamination: readily accessible ABHRs can significantly improve hand hygiene compliance among anesthesia providers; personal clip-on dispensers lead to a 27-fold increase in compliance (Koff et al [2009])

Sterile ultrasonography probe covers: while commonly used for vascular access, their use in regional anesthesia and blockade is less common

Disposable laryngoscopes and fiberoptic bronchoscopes: reduce decontamination time, costs, and patient risk

Double-gloving for airway interventions: reduce SSIs occurring within 30 days after surgery (Andoh et al [2022]) and reduce disease transfer on operating room (OR) doors

OR measures: include maintaining normothermia and normoglycemia (to optimize perfusion and immune function), decontamination, and following principles for medication administration and port discipline (ie, 1 syringe, 1 medication, 1 patient; accessing ports, valves, and vials after wiping them)

Antibiotic prophylaxis: use the appropriate antibiotic for a specific surgical site; administer antibiotic prophylaxis 60 min prior to incision; vancomycin is typically given 120 min prior to incision; repeat intraoperative dosing as needed; good antibiotic stewardship involves ensuring discontinuation of antibiotics after 24 to 48 hr to reduce the risk for antibiotic resistance

Benefits associated with minimizing HACs: include avoidance of financial penalties, improved physician quality reporting metrics and stewardship, increased value-added propositions, and strengthened job contract negotiations and leverage for future requests (for additional, eg, equipment, staffing)

Readings

Andoh AB, Francis AA, Abdulkarim AA, et al. Routine sterile glove and instrument change at the time of abdominal wound closure to prevent surgical site infection (ChEETAh): a pragmatic, cluster-randomised trial in seven low-income and middle-income countries. Lancet. 2022;400:1767-1776. doi:10.1016/S0140-6736(22)01884-0; Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. doi:10.2146/ajhp120568; de Lissovoy G, Fraeman K, Hutchins V, et al. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control. 2009;37(5):387-397. doi:10.1016/j.ajic.2008.12.010; Gould DJ, Moralejo D, Drey N, et al. Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev. 2017;9(9):CD005186. doi:10.1002/14651858.CD005186.pub4; Haque M, McKimm J, Sartelli M, et al. Strategies to prevent healthcare-associated infections: a narrative overview. Risk Manag Healthc Policy. 2020;13:1765-1780. doi:10.2147/RMHP.S269315; Koff MD, Loftus RW, Burchman CC, et al. Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a novel device. Anesthesiology. 2009;110(5):978–85; Mouajou V, Adams K, DeLisle G, et al. Hand hygiene compliance in the prevention of hospital-acquired infections: a systematic review. J Hosp Infect. 2022;119:33-48. doi:10.1016/j.jhin.2021.09.016; Simmons CG, Hennigan AW, Loyd JM, et al. Patient safety in anesthesia: hand hygiene and perioperative infection control. Curr Anesthesiol Rep. 2022;12(4):493-500. doi:10.1007/s40140-022-00545-x.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Maani was recorded at Texas Society of Anesthesiologists 2024 Annual Meeting, held September 5-8, 2024, in San Antonio, TX, and presented by the Texas Society of Anesthesiologists. For information on upcoming CME activities from this presenter, please visit tsa.org. Audio Digest thanks the speakers and Texas Society of Anesthesiologists for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

AN664701

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.