A first: Infection control draft guidelines emphasize performance measures’
CDC also revising approach to resistant bugs
The Centers for Disease Control and Prevention (CDC) is revising its patient isolation guidelines to add new "performance measures" that may be adopted as national quality indicators by patient safety groups, Hospital Infection Control has learned.
The CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC) reviewed a draft of the new guidelines at a Feb. 25-26 meeting in Atlanta. In updating the 1996 patient isolation guidelines, the CDC and its advisors discussed and revised the second draft of a new Guideline to Prevent Transmission of Infectious Agents in Healthcare Settings.1,2
There was much discussion of the proposed performance measures, particularly since patient safety groups such as the National Quality Forum in Washington, DC, are beginning to work with HICPAC to add such measures to their quality indicators. The proposed infection control performance measures include administrative directives such as conducting "an annual review of effectiveness of [the] procedures to prevent transmission of infectious agents."
The measures, in part, are an effort to reinforce "administrative support for implementation and deployment of these particular recommendations," said Emily Rhinehart, RN, MPH, CIC, CPHQ, a consultant to the HICPAC committee and vice president of AIG Consultants in Atlanta. In addition, by breaking out such measures for possible adoption by other quality groups, the guidelines may further solidify the role of the infection control professional in the national patient safety movement.
"Certainly, nosocomial infection is a [patient] safety issue, and this adds one more piece to that puzzle," said Jane Siegel, MD, professor of pediatrics at the University of Texas Southwestern Medical Center in Dallas, the HICPAC member spearheading the new guidelines. "[This] picks out the recommendations that we think are the most important to monitor and use as quality indicators. We are really picking out what we think are the three to five most important, high-impact things and then having a measure for that to see if institutions are doing that."
There was some discussion of letting individual facilities select from a list of performance measures, but the prevailing argument was that there should not be an option of selecting some measures and opting out of others.
"[I] thought that this was a distilling of the document to those things — that if you do nothing else — you should be doing to make sure that you’re getting the most out of the guidelines," said Robert Weinstein, MD, HICPAC chairman and epidemiologist at Cook County Hospital in Chicago. "I think that having a large menu and saying, Choose some of these,’ really defeats that purpose. This is the first set of guidelines where we are doing this, so I think we will learn as we go."
In revising the 1996 CDC isolation guidelines, HICPAC is trying broaden the recommendations across the continuum of care. The old guidelines, for example, focus almost exclusively on acute care settings. "Accordingly, the revised guideline addresses the entire spectrum of health care delivery sites: acute care settings, special care units within hospitals, long-term care facilities, ambulatory clinics, medical offices, and private residences," the draft guidelines state.
The guidelines strongly underscore the concept of standard precautions for all patients in all settings. With its emphasis on hand hygiene and appropriate use of gloves and other protective equipment, standard precautions form "the essential foundation" for infection control during patient care. Beyond that, additional measures include droplet precautions (e.g., wear mask within 3 feet of patient with pertussis); contact precautions (e.g., place patient with Clostridium difficile in private room if possible); and airborne precautions (e.g., tuberculosis patient placed in negative-pressure room vented to outside). While very similar to the 1996 recommendations for "transmission-based" precautions, the additional measures now are called "enhanced" precautions. The change involves more than semantics, as the draft document states that "in acute care, an overemphasis on additional transmission-based precautions . . . can diminish the adherence to standard precautions."
Indeed, the emphasis on standard precautions extends to multidrug-resistant organisms, (MDROs), some of which have been treated under contact precautions at many hospitals. The new draft de-emphasizes the necessity of that, stating that contact precautions may be required for drug-resistant infections "in settings with outbreak, unusually vulnerable patients or wounds that cannot be contained with dressings."
In its new view of resistant infections, the CDC is trying to go to a more generic infection control approach instead of issuing guidance for individual pathogens such as the 1995 recommendations for vancomycin-resistant enterococci.
"One of the biggest changes is the way we are trying to present management of [MDROs]," Siegel told Hospital Infection Control. "We think it should have practical application, and we are hoping that it will help people to make decisions for their [individual] settings. When we broadly recommended very strict precautions for certain organisms in all settings, it was very difficult to implement and they didn’t always control the organisms."
The draft notes that "the experiences of health care facilities with specific MDROs span a spectrum that ranges from no prior isolations on one end to full-blown outbreaks on the other." A wide variety of other facilities fall between these extremes, making a single approach to the problem very difficult.
"We realized that there is not the same solution to the MDRO problem in every setting with every organism," she said. "So [this guideline] gives people some principles upon which they can walk through the process and make decisions as to how they will manage the patients in their setting."
The generic approach represents a "breakthrough" in how the CDC views special pathogens, said Julie Gerberding, MD, director of the CDC division of healthcare quality promotion. At the same time, however, she reminded the committee that new and emerging organisms such as vancomycin-intermediate Staphylococcus aureus (VISA) warrant special attention and enhanced communication between clinicians and health departments.
"We are not breaking [VISA] out and giving it specific recommendations," Siegel said. "But I think what we will include in response to her comment is some discussion about the fact that when one has a new pathogen for which the epidemiology has not been clearly defined, then it would be prudent to use contact precautions until we know more about that pathogen."
In general, ICPs should have a high index of suspicion and a low threshold for investigation to contend with drug-resistant pathogens, the draft recommends. For example, frequent monitoring of susceptibility patterns for problem pathogens may indicate a problem when the percentage of methicillin-resistant S. aureus (MRSA) isolates rises from less than 10% to more than 30%. "Similarly, two or three infections during the course of a month on certain patient care units may signal the advent of an outbreak in some settings, as would even a single infection when colonization rates are known to be increasing," the draft states.
The guidelines acknowledge — but do not really embrace — the myriad additional efforts ICPs are using to combat drug-resistant pathogens. For example, attempts to identify and decolonize asymptomatic patients are "controversial because there are no controlled trials to evaluate the benefit of one strategy vs. another," the draft states. "Given the uncertainty about the optimal strategy, individual facilities must select approaches that address their specific problem within the context of their overall goals, available resources, and standards promulgated by state and national organizations."
Despite calls for the CDC to recommend routine patient screening to better identify and control resistant organisms, the HICPAC draft does not endorse the practice.1 (See HIC, December 2001 under archives at www.HIConline.com.) A key section of the draft guidelines states that "because of their expense and the consequences of their use, e.g., stigmatization of carriers, most authorities would limit their use to problematic situations where their results will dictate a different course of action, e.g., use of contact precautions or cohorting schemes."
And with the guideline trying to extend recommendations across the spectrum of care, the committee is concerned that any recommendations for routine screening will require the resources and the availability of hospital epidemiologists and ICPs to resolve key issues. Those include which patients should be cultured, how should the tests be done, and at what intervals should they be given. "Because of these complexities, routine recommendations for surveillance cultures cannot be issued at this time," the draft concludes.
References
1. Strausbaugh L, Jackson M, Rhinehart, et al, and the Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee. Guideline to Prevent Transmission of Infectious Agents in Healthcare Settings 2002. Draft #2. Feb. 15, 2002.
2. Garner JS, Hospital Infection Control Practices Advisory Committee. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996; 17:53-80, and Am J Infect Control 1996; 24:24-52.
3. Farr BM, Salgado CD, Karchmer TB, et al. Can antibiotic-resistant nosocomial infections be controlled? Lancet Infect Dis 2001; 1:38-45.
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