In the mid 1800s, the British obstetrician Sir James Young Simpson argued that infections after surgical procedures were closely related to deficiencies in hospital design, ventilation, and management. Simpson had previously observed the negative effects of overcrowding in hospitals and studied the correlation between poor hospital conditions and mortality rates. He used the term hospitalism to describe “the hygienic evils which the system of huge and colossal hospital edifices has hitherto been made to involve.” John Aiken, another eighteenth century physician, suggested that hospitals might be “gateways to death.”
Today, we benefit from healthtech innovations, advances in identifying the causes and treatments of infectious diseases, and widespread adoption of antiseptics and antibiosis practices. Nevertheless, about one in 31 hospital patients develops a healthcare-associated infection (HAI) in the United States on any given day. Worse still, 99,000 patients die of HAIs each year. 1,2
HAIs (also known as nosocomial infections) are infectious diseases not present or incubating at admission and contracted within a healthcare environment. They are caused by viral, bacterial, and fungal pathogens, and transmission usually occurs via medical interventions, hospital equipment, and healthcare worker and patient exposure. The most common sites of infection are the bloodstream (central line-associated bloodstream infections or CLABSI), lungs (ventilator-associated pneumonia or VAP), urinary tract (catheter-associated urinary tract infections or CAUTI), and surgical wounds (surgical site infections or SSI).
Though any bacteria may cause HAIs, there is an alarming rate of multidrug-resistant organisms (MDRO) causing HAIs. This increase is due to the misuse and overuse of antibiotics as well as poor hygiene measures and compliance. Commonly seen HAI-causing pathogens include methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and Clostridioides difficile (C. difficile). 3
A C. difficile infection (CDI) is of great concern because people with other illnesses, people taking antibiotics, or the elderly are at a greater risk of experiencing adverse health outcomes after contracting it. C. difficile is a bacterium that causes an infection of the large intestine, leading to severe diarrhea and colitis. It also forms highly resistant spores that easily persist in the affected person and disseminate through fecal-oral routes despite routine and terminal cleaning of hospital settings. Antibiotics that fight bacterial infections by killing bad microorganisms can disturb the balance of good microorganisms that populate the large intestine and would normally protect the body against harmful infections like CDI. This conundrum allows C. difficile to grow and release toxins that cause colon inflammation. The longer a patient is on antibiotics (which affects the levels of good microorganisms), the greater the risk of developing CDI.
Although the epidemiology of CDI has evolved over time, age has emerged as one of the most important risk factors for CDI in healthcare settings in recent years. The reasons for this correlation are multifaceted and include factors such as lower immune response, comorbidities, and antibiotic exposure. It has been suggested that the incidence of CDI in persons > 65 years of age contributed to over 80% of all deaths from CDI in recent years – an alarming and disproportionally high figure. 4,5
Effective prevention and control measures require active monitoring of HAI trends. For instance, COVID-19 led to significant increases of CLABSIs, CAUTIs, and VAEs in 2020 compared with 2019. These increases were likely due to the larger number of patients who needed ventilators and other COVID-19 related procedures. As more surgeries are expected in the coming months of 2021 and in 2022, these trends will continue to evolve.
Emerging HAI-causing pathogens are also of concern. Candida auris (C. auris) is a multidrug resistant (also called superbug) fungus that can lead to invasive infections and is associated with high mortality. C. auris can only be identified in highly specialized laboratories and is hard to eliminate and treat. Patients generally remain colonized with this potentially deadly pathogen for long periods, sometimes indefinitely, while shedding the fungus and contaminating their immediate environment. 948 new C. auris clinical cases were reported in the United States from May 1, 2020, to April 30, 2021, and screening identified 2,193 colonized patients. Again, COVID-19 may have played a role in driving these numbers since some patients required intubation and other invasive procedures that put them at higher risk of infection. 6,7
Patient Safety and Societal Impact
The Centers for Disease Prevention and Control (CDC) estimate that 1 in 31 hospital patients has an HAI, with more infections also occurring in other healthcare settings. HAIs account for an estimated 1.7 million infections and 99,000 associated deaths each year in the United States. Of these infections, approximately 32 % are CAUTI, 22 % are SSI, 15 % are VAP, and 14% are CLABSI. Patients who acquire SSIs spend, on average, an additional 6.5 days in the hospital. They are also five times more likely to be readmitted, 60% more likely to require admission to a hospital’s intensive care unit, and twice as likely to die. 8
The economic, direct medical costs of HAIs in hospitals is $28.4 billion each year, with an estimated additional $12.4 billion in societal costs from early deaths and lost productivity. The economic costs derive primarily from analyses of fixed and variable costs that directly impact hospital finances as they relate to medical care, such as labor, treatments, and supplies. Societal impact estimates encompass indirect and intangible costs such as lost wages, mortality, and diminished quality of life. The societal impact of HAIs is challenging to measure because of the economic magnitude and long-term impact of physical and cognitive disability. Some of these negative consequences manifest as reduced mobility; the necessity of home care; stays in long-term facilities; lost labor and leisure time; and out-of-pocket costs. Although most studies exploring the burden of HAIs focus on direct hospital costs, this perspective is far too limiting, and one must move past the statistics to comprehend the real, unmeasurable cost of HAIs.
As is the case for other patient safety issues, HAIs create suffering and additional stresses for patients and their families. HAIs prolong hospital stays and increase antibiotic resistance. They can also lead to long-term disability while generating unanticipated costs for patients and their caregivers, which represents a great financial burden for the healthcare system at large. Furthermore, HAIs account for 99,000 unnecessary deaths each year. These adverse outcomes and statistics are unacceptable in view of the fact that HAIs are largely preventable. 9, 10
In October 2014, the Centers for Medicare and Medicaid Services (CMS) began reducing Medicare fee-for-service payments for hospitals that rank in the worst-performing quartile with respect to hospital-acquired condition quality measures, including HAIs. These hospitals are subject to a 1% payment reduction. It is estimated that these penalties far exceed the potential cost savings accruing from a 1%-20% reduction in hospital-acquired conditions, including HAIs, that might result from hospitals’ efforts to improve patient care.11
A New Standard of HAI Prevention
In hospitals, infections can be limited through careful prescription and use of antibiotics, strict adherence to infection prevention and control protocols, and surveillance. The CDC advises hospitals on the use of chemical disinfectants, including alcohols, chlorine and chlorine compounds, formaldehyde, glutaraldehyde, ortho-phthalaldehyde, hydrogen peroxide, iodophors, peracetic acid, phenolics, and quaternary ammonium compounds. Although chemical disinfectants are essential to control communicable diseases in hospitals, excessive use of hospital-grade disinfectants also represents a potential health hazard to patients and staff.12
Germicidal ultraviolet-C light (UVGI) is a disinfection strategy that has received renewed interest during the COVID-19 pandemic after decades of use in advanced water disinfection systems across the globe. UVGI is a region of the UV-C spectrum that has been known to inactivate microorganisms by damaging their deoxyribonucleic acid (DNA) or ribonucleic acid (RNA). When UVGI is absorbed by DNA/RNA, the resulting photodamage renders the target microorganism incapable of replicating and harmless. UVGI can be used to disinfect air, water, and surfaces.
In a randomized, controlled clinical investigation funded by the CDC, researchers observed a significant reduction in the relative risk of colonization and infection when UVGI was paired with standard disinfection protocols for terminal room disinfection. The incidence of MRSA, VRE, CDI, and multidrug-resistant Acinetobacter was 30% lower among exposed patients after adding UVGI to standard cleaning strategies. Several before-and-after controlled clinical studies have also demonstrated the efficacy of UVGI systems for reducing HAIs. One study saw a 53% reduction in CDI rates after incorporating UVGI into terminal room disinfection protocols in a community hospital. The researchers also reported a dramatic reduction in deaths and colectomies attributable to CDI. 13
Although the majority of these studies used robotic UVGI systems deployed in unoccupied rooms, various studies starting in the 1960s have demonstrated that upper-room UVGI fixtures have also proven safe and effective to operate in occupied spaces. Upper-room UVGI fixtures are installed above people in rooms so that it creates a disinfection zone of UV-C energy that inactivates airborne pathogens released in the room without exposing the people below the disinfection zone to UV-C. The effectiveness of upper-room UVGI increases as air mixes between the upper and lower room. The CDC has long endorsed upper-room UVGI use in healthcare for Mycobacterium tuberculosis control and recommends the use of upper-room UVGI to help control SARS-CoV-2 and other infections. 14-17
Achieving (R)Zero Preventable Deaths
Implementation of sustainable HAI prevention programs remains an ongoing priority for American hospitals. The COVID-19 crisis has challenged these institutions to rethink their approaches to infection prevention and control. Traditional preventive measures to reduce HAIs include hand hygiene, antibiotic stewardship, contact precautions, appropriate antimicrobial prophylaxis, and the correct application of basic precautions during invasive interventions. Monitoring the local determinants of HAI burden, observing global trends, and promoting healthcare worker education/accountability are also key means of managing HAIs.
Despite advances in the prevention of HAIs over the years, the human cost of preventable hospital infections remains too high. At R-Zero, we collaborate with top healthcare organizations to modernize their infection prevention and control solutions to achieve zero preventable deaths or patient harm. UV-C disinfection will play a key role in the future of infection prevention by enabling disinfection that directly combats the high human costs of HAIs to achieve better patient outcomes. R-Zero is committed to leading that charge in the fight against these microscopic foes.
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