Hospitalists Lead Charge Against HAIs

It reads like the alphabet soup of healthcare: CDI, MRSA, CAUTI, and VAE. Those letters all fall under the category of hospital or healthcare-acquired infections (HAIs), and they can wreak havoc on patient care. On any given day, about 1 in 31 hospital patients has at least one HAI, according to the Centers for Disease Control and Prevention (CDC). The good news: As of 2023, the numbers demonstrated an improvement from the decade prior, but even a single HAI case is one too many.

Most HAIs manifest within 48 hours after hospital admission. They are not only a patient-specific problem but also a community-based problem. Some HAIs — like methicillin-resistant Staphylococcus aureus — are linked to multidrug resistance. Preventing and minimizing the spread of these infections are essential to public health. Risk comes down to a facility’s infection control practices, a patient’s immune status, and the prevalence of pathogens in a given community.

“Healthcare-acquired infections should be a focus for all hospitals and institutions,” said Reina A. Patel, DO, pediatric hospitalist at Phoenix Children’s Hospital, Phoenix. “Any and all of them can be serious, depending on the host and what all they have going on at the time.”

When it comes to HAIs, hospitalists are often at the front line of care. Therefore, it’s essential that hospitalists understand how to best work with their team to prevent, identify, and optimally treat patients presenting with HAIs.

Prevention as the Best Line of Defense

The most common HAIs hospitalists encounter include pneumonia, surgical site infections (SSIs), gastrointestinal infections, urinary tract infections, and catheter-associated bloodstream infections. According to the National Institutes of Health, Clostridium difficile is the leading cause of infections, followed by S aureus and Escherichia coli. Transmission is complex and occurs from a wide variety of sources or combinations thereof.

The best line of treatment, according to Patel, is prevention. Care bundles encourage consistent, evidence-based standard practices aimed at preventing HAIs. When implemented together, they can often lead to success. They involve three to five simple, clear steps. The key is that every member of the care team uses them, records it, and does so consistently. While that’s ideal, it doesn’t always happen.

“If I’m going to take care of a central line, there are certain steps I need to follow,” said Patel. “I need to think about all those steps and whether they are clinically indicated. That knowledge is power and can make a difference.”

In addition to care bundles, regular, consistent training on infection control is key. The CDC created its STRIVE curriculum to address both the technical and foundational elements of HAIs. Hospitals can use the modules in new hire training, or annual or periodic training, in the case of rising infection rates.

Lora Sparkman, an RN and clinical leader with Relias, a workforce education and enablement solutions provider, has spent the past 5 years focused on virtual reality training, with a special focus on HAI control. “In a perfect world, every member of the healthcare team is following the critical steps to prevent infection,” she said. “But you’re rapidly reassessing and reformulating the emergency in front of you. Steps get missed and you’re only as good as your next infection.”

Sparkman views the key to prevention as education and, in this case, changing how hospitals carry out that education. In a collaborative effort, Relias and Emory University launched Project Firstline, the CDC’s national training collaborative for healthcare infection control. The training turns the traditional didactic approach on its head and, instead, implements virtual reality training. “Telling people to wash their hands and watching PowerPoints hasn’t moved the dial,” said Sparkman. “With VR [virtual reality] training, clinicians can ‘see’ the virtual germs that cause infection, which heightens their awareness. They can also see where they might have missed a step in their prevention steps.”

The training is assessment-based and designed for hospitals to use more frequently than traditional annual training and in smaller chunks of time. “The approach creates recall in the brain so that you’re carrying it with you longer and better,” said Sparkman. “When training is faster and to the point, you’re also more likely to get doctors to the table.”

When Prevention Fails

While prevention is ideal, it’s still not always successful. In most cases, when a patient acquires an infection, it swiftly complicates their situation. “You’re treating for one condition and now adding another, which increases length of stay,” said Patel. “As first line of defense, hospitalists are often the first to notice something is amiss.”

The key to treating HAIs when they arise is co-management, said Patel. If you’re dealing with an SSI, for instance, your co-manager in the patient’s care will be the surgeon. But a hospitalist and a surgeon may have different approaches to care, which is where collaboration comes into play. “A surgeon will think about the surgical site, which they should,” Patel said. “But a hospitalist might be on the floor and available, and a nurse will reach out because a patient has a fever. A hospitalist will think of the reasons why that fever is there.”

Hospitalists, then, have an advantage in HAI care; they are readily available to jump in at the first indication of infection. They can draw blood cultures, send them to the lab, order imaging, and prescribe treatment, if needed. If the infection is related to a surgery, “reach out to the surgeon and ask to be there to see the site,” said Patel. “That way you have a baseline of what the site looks like and can monitor it. If you don’t do that, you might only have nurses or surgeons looking at the site in a silo.”

That’s a mistake because hospitalists are typically the physician with the most touch points with patients. Another member of the care team should be the infectious disease specialist. “Often there’s a decision to make, like how long you need to treat an infection before you can resume treating through a central line, for instance,” said Patel. “It’s definitely coordinated care.”

Most institutions are focused on lowering their HAI rates and recognize it’s a multidisciplinary approach. For example: In 2023, Patel’s institution implemented a two-step bathing process prior to surgery. Six months on and with high compliance, the hospital has dramatically lessened its SSI rates. “Anyone thinking about HAI prevention should consider all the different angles and services that interact with the patient,” Patel said. “How do we engage everyone to make a difference?”

The answer may lie with hospitalists, who regularly interact with many members of the care team. “The role of the hospitalist is the specialist in the hospital,” said Sparkman. “They are on staff around the clock, and they cut across the entire hospital.”

Patel agreed. “How you conduct your rounds, whether by yourself or with a group of learners, is critical,” she said. “It should be a family-centered rounding, including nurses, pharmacists, and hospitalists, and you should always be thinking about what more you can do for infection control.”