Patient Safety Q&A with Arjun Srinivasan

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Arjun Srinivasan, MD, Centers for Disease Control and Prevention
Arjun Srinivasan, MD, Centers for Disease Control and Prevention

Arjun Srinivasan, MD is Associate Director for Healthcare – Associated Infection (HAI) Programs in the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention’s (CDC) National Center for Emerging and Zoonotic Infectious Diseases. He also is a Captain in the U.S. Public Health Service. An infectious disease doctor, Dr. Srinivasan oversees several CDC programs aimed at eliminating HAIs and improving antibiotic use. For much of his CDC career, he ran the health care outbreak investigation unit, helping hospitals and other health care facilities track down bacteria and stop them from infecting other patients. Today, Dr. Srinivasan leads CDC’s work to improve antibiotic prescribing and works with a team of CDC experts researching new strategies to eliminate HAIs. As Assistant Professor of Medicine in the Infectious Diseases Division at the Johns Hopkins School of Medicine and as a staff physician, Dr. Srinivasan founded the Johns Hopkins Antibiotic Management Program. He carried his passion for combating antibiotic resistance to CDC, where he leads the Get Smart” program that teaches patients and clinicians alike what they need to know to ensure antibiotics are used appropriately. A graduate of the Vanderbilt University School of Medicine, Dr. Srinivasan is a member of the Alpha Omega Alpha medical honor society. He completed an internal medicine residency and infectious disease fellowship at Johns Hopkins University Hospital. He is an adjunct assistant professor of medicine at Emory University Medical Center and sees patients at the Atlanta Veteran’s Affairs Medical Center. Dr. Srinivasan has authored numerous articles in peer-reviewed journals, is a member of the Association for Professionals in Infection Control and Epidemiology, the Infectious Diseases Society of America, and the Society for Healthcare Epidemiology of America (SHEA). He was named to the Johns Hopkins Society of Scholars and won the SHEA’s 2008 Investigator Award for his landmark work in infection control.

Q. What have been some the most notable achievements in HAI reduction in the past year, and where is there room for improvement?

I think we’ve seen progress in a number of areas over the past year. Historically, we had struggled to reduce catheter-associated urinary tract infections (CAUTI), but now we’re reaping the rewards of our efforts and seeing some encouraging improvements, both inside and outside of the intensive care unit. We’ve seen moderate reductions in Clostridium difficile (C. diff), which is another major focus area. While our gains have been modest, and there still is a lot of room for progress, we are encouraged to see some positive indicators. The big front where we have seen only modest gains and need bigger improvements is antibiotic resistant infections. These are a compilation of HAIs, central-line associated bloodstream infection (CLABSI), CAUTI, etc., but as a group, they pose particular challenges with respect to how we can treat them. They represent a threat to patients. CDC and other agencies are very focused on this issue right now. We can do a lot more if we can muster the will and resources.

Q. What are some of the successful approaches and strategies that high-performing hospitals are employing in HAI reduction?

We’re seeing a number of hospitals employing approaches where they take individually effective strategies and combine them as a bundle. This technique was pioneered in the CLABSI setting and now is being applied to CAUTI and seeing some successes there. Hospitals are looking to bundling to combat other infections as well. What we’re really seeing at high-performing hospitals is a cultural element underlying their HAI reduction efforts. The hospitals that are most successful are the ones that are making HAI prevention a top priority for everyone – not just for the infection prevention or epidemiology department. Everyone needs to be part of the effort, including patients, leadership, the corporate office, the surgical and nursing staff; hospitals need to take the issue seriously at all levels. If you have a culture of safety, you will be successful.

Q. What are your perspectives on how best to tackle HAIs in the nursing home, skilled nursing and assisted living settings?

I think the nursing home and skilled nursing settings are beginning to get the attention they need. We know that HAIs and antibiotic resistance are big issues there; however, there’s a limit to what we know about the specifics within each setting. We need to know more about the extent of the problem and what the biggest challenges are. We are beginning to learn that and to work with community partners on strategies. It’s important to note that HAI reduction strategies that have been effective in the hospital setting can’t necessarily be copied and pasted to the nursing home setting. Long-term care facilities have different staff, different resources and different patient populations, so they need a different approach. Currently, we are figuring out how to tailor or adapt proven hospital strategies, so they are effective in the nursing home environment.

"The hospitals that are most successful are the ones that are making HAI prevention a top priority for everyone – not just for the infection prevention or epidemiology department." 

Q. Tell us a bit about the CDC’s antibiotic stewardship programs, which are designed to support the White House’s National Strategy for Combating Antibiotic-Resistant Bacteria.

Antibiotic stewardship is a key issue for us here at CDC. We feel strongly that improving antibiotic usage has to become part and parcel of all of our efforts to combat HAIs and antibiotic resistance. If we don’t improve antibiotic use, there is only so far we can go in improving resistance. By improving our usage of antibiotics, we also can have an impact on other areas like reducing C. diff, improving patient outcomes, reducing complications from antibiotic use, etc. It’s an intervention whose time has come. We’re trying to improve antibiotic use across the spectrum of health care and across care settings. CDC has best practices for both hospitals and nursing homes. We are working on a similar list of best practices for the outpatient setting as well. This is not just a hospital issue or a nursing home issue; there is a lot of antibiotic overuse period. Our goal is to get stewardship up and running everywhere in order to develop an infrastructure to prevent HAIs. The White House’s National Action Plan for Combating Antibiotic Resistant Bacteria, which was released last year, and the subsequent White House Forum on Antibiotic Stewardship brought together all key stakeholders to address the issue. That was truly a transformative event. This coalition has stuck together and expanded in the past year.

Q. How is the CDC partnering and collaborating with CMS Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) in this work?

We’ve had a long history of collaboration with QIN-QIOs, and it’s been a wonderful partnership. We can’t thank them enough for the work they do to prevent HAIs, improve patient safety and, now, to improve antibiotic use. They’ve been an important implementation group. QIN-QIOs are the ones out there working with hospitals to improve practices and to identify ones that are struggling and to bring solutions to them. We consider ourselves close partners with QIN-QIOs; when they’re out there and see facilities that are struggling, they connect us with those facilities. Jointly, we share lessons learned with other hospitals. One collaborative strategy we’re particularly excited about is our Targeted Assessment for Prevention (TAP) Strategy. QIN-QIOs told us they wanted to hone in on the hospital units with the most infections, so the CDC designed a strategy that uses data collected by hospitals to show the units with the largest numbers of excess infections. We know our HAI prevention efforts are most effective when they’re targeted at the areas that are most in need; the TAP Strategy allows QIN-QIOs to focus additional resources in the right areas. We worked closely with them to pilot the strategy and now are implementing it nationally.

Q. Are there any new CDC HAI reduction tools or resources you would you like to tell us about?

We have some important reports coming out in March 2016. First, our CDC Vital Signs report on HAIs, which will focus on where we’ve seen progress in HAI reduction and where we need to see more progress. Second, our annual HAI Progress Report , which will incorporate data from 2014 and provide an update on progress toward eliminating HAIs. Finally, we’ll publish our Patient Safety Atlas – an interactive web-based feature where you can learn more about antibiotic resistance.

Q. Anything else you would like QIO News readers to know?

What I would like readers to know is that we want to be here for you; we value our partnerships with other health care stakeholders, and we want to know how we can help them. We learn a lot from our mutual interactions. We encourage everyone to reach out to us and to let us know both how to help you and about your successes.