On any given day, approximately one in 25 US patients has at least one infection contracted during the course of their hospital care.¹ Health care-associated infections (HAIs) can be acquired anywhere health care is delivered, including inpatient acute care hospitals; outpatient settings, such as ambulatory surgical centers and end-stage renal disease facilities; and long-term care facilities, such as nursing homes and rehabilitation centers. The impact of HAIs on the morbidity and mortality of patients, and on reimbursement for health care facilities, is significant and well documented. By collaborating with infection prevention teams; participating in antibiotic stewardship; adhering to regulations regarding cleanrooms, personal protective equipment (PPE), and hygiene practices; and remaining current on related issues and processes, hospital pharmacists can position themselves to significantly impact the occurrence and course of HAIs.

Current State of HAIs
The Centers for Disease Control and Prevention’s HAI Progress Report¹ describes meaningful reductions at the national level in 2013 for nearly all HAIs, including:

• A 46% decrease in central line-associated bloodstream infections (CLABSI) from 2008 to 2013
• A 19% decrease in surgical site infections (SSIs) related to the 10 select procedures tracked in the report between 2008 and 2013
• A 10% decrease in hospital-onset Clostridium difficile infections from 2011 to 2013
• An 8% decrease in hospital-onset methicillin-resistant Staphylococcus aureus (MRSA) bacteremia from 2011 to 2013

Despite this progress, the nation did not reach the 2013 goals established by the HAI Action Plan in 2009.² Furthermore, a 6% increase in catheter-associated urinary tract infections (CAUTI) from 2009 to 2013¹ indicates that additional work is necessary at every level of health care to improve patient safety and eliminate infections that threaten hospitalized patients. Research shows that when health care facilities, care teams, and individual health care workers are aware of the possibility of infections and take specific preventative steps, rates of certain HAIs (eg, CLABSI) can decrease by more than 70%.¹

Reimbursement Implications
Under the traditional fee-for-service reimbursement structure, health care facilities were reimbursed for care provided, including care administered to patients who acquired an infection or developed another complication while in the hospital. But under the new pay-for-performance structures, hospitals are no longer reimbursed for care provided to resolve such problems; the rationale is that a hospital functioning at its best does not permit an HAI to occur in the first place. Facilities are now penalized according to quality-based outcome measures. There have been many recent examples of facilities with high rates of CAUTI or CLABSI having a portion of their reimbursement withheld by the Centers for Medicare and Medicaid Services (CMS); this results in the loss of millions of dollars for the penalized health care facilities. Consequently, all disciplines in health care, including pharmacy, must collaborate in an effort to reduce HAIs and improve patient care and outcomes.

Collaborating with Infection Prevention
Developing a reciprocal relationship between infection prevention and pharmacy departments is important for both parties. The pharmacy can work with infection preventionists to develop pharmacy’s infection prevention strategies, such as establishing proper hand washing technique and verifying the appropriate PPE for the cleanroom, including the correct order for donning PPE. Starting with simple topics before moving to more complicated ones often helps to speed and ease the development of a partnership.  

Another key project is to establish periodic rounds in the pharmacy. Rounds can be scheduled to occur weekly, biweekly, or monthly depending on the need. Weekly rounds make good sense when the goal is to monitor process improvement projects. Weekly meetings can be kept short; 15 to 30 minutes is usually sufficient to update participants on progress, and the meetings can roll directly into pharmacy rounds. The rounding team should include infection prevention, a pharmacist, and a pharmacy technician. Ad hoc members who attend as needed may include those from facility safety or environmental services. During rounds, note staff behaviors and practices. For example:

• Are staff members performing hand hygiene every time they should and executing it effectively?
• Is staff wearing the appropriate PPE (eg, gown, gloves, mask) and donning it correctly?
• What are staff members’ practices when mixing medications? Can you identify any opportunities for contamination?

Lastly, remove any notions of infection prevention being like the police; the infection preventionist should be a partner, not an enforcer.

Antibiotic Stewardship
Once a relationship is developed, pharmacy and infection prevention can collaborate to improve patient outcomes. For example, by reviewing culture reports, pharmacists help ensure that patients are receiving the correct antibiotics for the organisms identified. Promptly notifying nursing staff and/or treating physicians if changes are required prevents patients from being exposed to incorrect antibiotic treatment for an unnecessary period of time, thus reducing resistance and the overgrowth of superbugs, such as MRSA and C. difficile.

In addition to pharmacy’s review of cultures, antibiotic stewardship efforts should utilize the facility’s antibiogram, which compares antibiotic usage to the resistance patterns of the organisms found in patients in that facility. This comparison yields important information, which can then inform the prescribing practices of the hospital’s physicians of antibiotic misuse or resistance. Certain antibiotics may be restricted, and physicians may be required to obtain the approval of pharmacy or an infectious disease physician before prescribing those agents. Over time, restricted access helps reduce the resistance of specific organisms to specific antibiotics and also may decrease a facility’s antibiotic spending.

Clean Versus Dirty
Another way to reduce HAIs is to keep clean items away from contaminated ones, a separation that is not always clearly understood. For example, cardboard boxes should not reside on the same shelves as items that have been removed from boxes; the shipping boxes are considered contaminated, or dirty, while the items inside are clean. Comingling these items on the same shelf threatens the cleanliness of the items that will be used in the care of patients.

Hand hygiene, another important element that often is overlooked, is the single most effective way to prevent the spread of infection. Even though pharmacy staff members often do not have physical contact with patients, the risk arises when they prepare medications that are administered to patients. Thorough hand hygiene should be performed before handling any medications, before and after wearing gloves, before and after eating, after using the restroom, and anytime hands are visibly soiled.

Maintaining the sterility of the cleanroom is central to preventing HAIs. Pharmacists must adhere to all regulations regarding the structure of the room and air exchanges, as well as ensuring that the correct PPE is used consistently. Infection outbreaks have occurred as a result of medications becoming contaminated during drug compounding. Duke University Hospital investigated an outbreak of Burkholderia cepacia in 2012.³ Researchers found that the outbreak was caused by a contaminated continuous fentanyl infusion prepared by the institution’s compounding pharmacy. Seven patients received compounded fentanyl via patient-controlled analgesia or continuous infusion while ventilated, for the purposes of pain control or sedation, in the 24 hours preceding onset of bacteremia. An intensive evaluation revealed B. cepacia complex in the anteroom sink drain and pH probe calibration fluid from the compounding cleanroom. Possible mechanisms for contamination from surfaces, equipment, and gloves in the compounding room included: gloves were not changed between compounding steps (instead gloves were disinfected using alcohol and then used to manipulate sterile items); the pH probe calibration fluid was not changed routinely; and the pH probe was submerged in the entire volume of the preparation instead of testing small aliquots at a time.

It is extremely difficult to connect a patient infection to a compounded product unless several patients who received the same product develop the same infection. One way to identify these infections is by reviewing the organisms involved. Two of the first questions that infection preventionists will ask are: Is a common contaminant the culprit? Is the responsible organism one that is common in water? They also will investigate particularly unusual or rare organisms because their presence usually indicates that something out of the ordinary has occurred. Although the infection preventionist is primarily responsible for the investigation, a second set of eyes always is useful for identifying unusual occurrences. The pharmacist can assist in this regard while reviewing isolate reports to determine the appropriateness of proposed antibiotics. By partnering with infection prevention in this way, there is less chance a key organism or important event will be missed.

Contamination can occur during any step in the compounding process, and the risk of contamination increases exponentially any time staff does not adhere to appropriate cleaning or PPE standards in the cleanroom. The most common cause of contamination in compounded products is improper cleaning techniques in the cleanroom. Perhaps the room is not appropriately disinfected, the number of air exchanges is incorrect, or the air filters require replacement. Contamination can result from something as simple as supplies being opened but not immediately used; instead, they are saved for the next time they are needed. However, once the package is opened, the cleanliness and sterility of the supplies can no longer be guaranteed. Anytime supplies are opened and not used, they must be discarded.

To minimize the chance of contamination, infection prevention should partner with pharmacy to perform weekly, biweekly, or monthly assessments of the cleanroom in addition to the annual cleanroom certification assessment. Such periodic reviews can help identify issues in advance of the certifier’s visit so that challenges can be resolved ahead of time. It is important to conduct this assessment while usual compounding is underway in order to assess actual staff practices and evaluate if there are opportunities to decrease the risk of contamination.

Education
Remaining current on HAI control and prevention strategies should be a priority for pharmacy. The infection prevention team should be viewed as a resource for education regarding hand hygiene, standard precautions, needle safety, compounding processes, cleanroom cleaning, etc. Keep in mind that education on sharps safety is an Occupational Safety and Health Agency requirement upon hire and annually thereafter.

Conclusion
Despite some recent decreases in HAI rates, these dangerous infections are far from eliminated, and health care facilities have yet to achieve the goals delineated in the National Action Plan. Reaching these goals and eliminating HAIs throughout the health care environment requires interdepartmental collaboration. Pharmacists are uniquely positioned to affect change through antibiotic stewardship efforts and vigilant management of the pharmacy and cleanroom.

References

1. Centers for Disease Control and Prevention. National and State Healthcare-Associated Infections Progress Report. http://www.cdc.gov/HAI/pdfs/progress-report/hai-progress-report.pdf. Accessed August 4, 2015.
2. Office of Disease Prevention and Health Promotion. National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination. http://www.health.gov/hcq/prevent_hai.asp#hai_plan. Accessed August 4, 2015.
3. Moehring RW, Lewis SS, Isaacs PJ, et al. Outbreak of bacteremia due to Burkholderia contaminans linked to intravenous fentanyl from an institutional compounding pharmacy. JAMA Intern Med. 2014;174(4):606-612.

Brenda Helms, RN, BSN, MBA/HCM, CIC, CPHQ, is currently the regional director of clinical compliance and accreditation at Baylor Medical Center in McKinney, Texas. She has been an infection preventionist for 9 years and has worked in health care for over 20 years. Brenda is a past president of the Dallas/Fort Worth chapter of the Association of Infection Prevention, Control, and Epidemiology (APIC) and of the Texas Society of Infection Control and Prevention (TSICP). In 2015 she received the Gerry Haynes award for excellence in infection prevention from the TSICP.