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Analysis Bolsters VA's Leadership Role in HAI Prevention: Public Health Watch

FEB 19, 2020 | BRIAN P. DUNLEAVY
When it comes to the prevention of health care-associated infections (HAIs), the US Veterans’ Administration (VA) “has always been ahead of the curve,” Valerie Vaughn MD, MSc, an assistant professor of hospital medicine at University of Michigan Medical School, recently told Contagion®.

Vaughn practices in the VA Ann Arbor Healthcare System, so she’s not exactly an unbiased observer. However, she also has the data to back up the claim.

In a study, published February 5th in JAMA Network Open, Vaughn and her colleagues found that the use of 12 different infection-control practices increased in VA hospitals between 2005 and 2017. In all, since 2013, 92% to 100% of the VA hospitals included in their analysis indicated that they routinely used key infection-prevention protocols for Clostridioides difficile infection (CDI) and central line-associated bloodstream infection (CLABSI) to reduce incidence. In contrast, adoption of many practices to prevent catheter-associated urinary tract infection (CAUTI), while increasing, have lagged behind.

To derive these figures, the team surveyed 320 infection preventionists at VA hospitals every 4 years over the course of a 12-year period.

“The real reason I wanted to look at the VA was to see whether the national policies and strategies that had been implemented had driven an increase in infection prevention,” Vaughn noted. “And we found that, for the most part, they did. I really hope that other integrated health systems and hospitals can take note and institute their own policies to improve patient safety and reduce health care-associated infection.”

Though not as robust, there were improvements in other areas as well. For example, 97% of participating VA hospitals reported using semirecumbent positioning to prevent ventilator-associated pneumonia (VAP) in 2017, compared to 89% in 2005, while 65% indicated that they use subglottic secretion drainage to control VAP during the more recent year, compared to just 23% in the first year of the study. The use of other prevention practices, such as daily interruptions of sedation (85% in 2009 vs 87% in 2017) and early mobilization (81% in 2013 vs 82% in 2017), increased only slightly over the course of the study.

Notably, antibiotic stewardship programs were reported by nearly every VA hospital surveyed (97%). However, Vaughn et al added, some hospitals indicated that their microbiologic testing practices for HAIs—for example, 22% of respondents use routine urine culture testing—may “contribute to antibiotic overuse.”

“Hospitals need to start thinking about diagnostic stewardship—or practices to reduce unnecessary use of microbiologic testing,” Vaughn said. “By reducing inappropriate testing, you can prevent patients from being incorrectly diagnosed with an infection they don’t have. Luckily, there is already some great work in the VA and beyond looking at strategies to improve testing—to make sure that, for example, urine cultures are only ordered in patients who have symptoms of a urinary tract infection.”

When asked what, if any, changes, she’d like to see at a policy level based on her findings, Vaughn said, “Since national policy may drive adoption of infection prevention and stewardship practices, I’d like to see policies that target some of the needs we found. These include diagnostic stewardship, but also policies to improve infection prevention strategies for CAUTI and VAP. Notably, many of the things that can help in VAP are great for patients for other reasons: early mobilization can help improve mobility and prevent blood clots, sedation vacation can reduce time on the ventilator and maybe even cognitive functioning. So many of these strategies are important for patients generally.”

Food for thought at a time when HAIs remain a significant public health challenge.
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