Far Away, So Close: Successful Reduction of Hospital-Associated Infections in Patients Admitted to an Accredited, Verified Burn Center, from 2002-2012
Charles S. Hultman, MD, MBA, Jon Friedstat, MD, David J. Weber, MD, David van Duin, MD, PhD, Samuel Jones, MD, Bruce A. Cairns, MD.
University of North Carolina, Chapel Hill, NC, USA.
Introduction: Despite governmental mandates and institutional initiatives to decrease hospital associated complications over the past decade, hospital acquired infections (HAIs) continue to compromise clinical outcomes, especially in critically ill patients. Most plastic surgery patients have a low incidence of perioperative infection, but burn patients remain a challenging cohort to manage, due to the frequent occurrence of ventilator-associated pneumonia (VAP), catheter-associated urinary tract infections (CAUTI), central line-associated bloodstream infections (CLABSI), and surgical site infections (SSI). To date, very few studies have addressed the incidence and outcome of HAIs in burn patients. The purpose of this project was 1) to determine the efficacy of programmatic interventions, designed to reduce occurrence of HAIs in burn patients and 2) to create a financial model for cost savings, through decreased length of stay (LOS).
Methods: We performed an observational, retrospective analysis of data collected prospectively for the National Burn Repository (NBR), Surgical Care Improvement Project (SCIP), and National Surgical Quality Improvement Program (NSQIP). This study included all patients admitted to an accredited, verified, regional burn center, from 2002-2012. Interventions to decrease the incidence of HAIs in burn patients included: 1) full barrier precautions for bedside procedures in 2002, 2) changing central lines every 3 days in 2003, 3) early removal of urinary catheters in 2007, 4) adoption of Institute for Healthcare Improvement (IHI) bundles in 2007 (head of bed elevation, stress ulcer prophylaxis, tight glucose control, early ventilator weaning, sedation holidays), 5) semi-quarantine of patients with multiple drug resistant (MDR) HAIs in 2008, 6) monitored hand-washing in 2008, 7) full contact precautions for all ICU and floor patients in 2008, and 8) diagnostic and therapeutic broncho-alveolar lavage for VAP patients n 2008.
Results: From 2002 through 2012, we admitted 8,815 patients to our burn center, with 3,181 direct ICU admissions. Mean TBSA was 9.41%, mean age was 33.2 years, mean hospital LOS was 12.9 days, and mean hospital charges were $58,665. Mean length of ICU stay for patients admitted to the ICU was 31.7 days. Total HAIs (expressed as infection rate / 1000 patient days) decreased from 11.7 to 6.5, CAUTIs decreased from 5.4 to 1.4, and CLABSIs decreased from 11.0 to 2.2, but VAPs increased from 2.8 to 4.1 (all differences p<0.01). SSIs (expressed as % of admitted patients) doubled from 5.3% in 2002 to 10.7% in 2004, but dropped to <1% by 2008. Most common pathogens were Acinetobacter, Pseudomonas, Staphylococcus aureus, and Enterobacter, in that order. Financial modeling indicated that each additional day of hospitalization would increase the cost of care by $5,199 per patient. The added costs to treat HAIs range from <$1000 for CAUTI, to $36,396 for SSI, to $72,791 for VAP.
Conclusions: Patients with significant burn injury remain at risk for HAIs, but programmatic medical, surgical, and nursing interventions have dramatically reduced the incidence of specific infections, such as CAUTI, CLABSI, and SSI, over the past decade. VAP remains a particularly challenging problem, in terms of prevention, and is associated with a considerable increase in the cost of care.
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