Healthcare’s Dirty Secret

What is the contracting professional’s role in reducing the incidence of infection in his hospital or IDN? Plenty. No, he can’t single handedly change the clinical and hygiene practices of caregivers. However, working with infection control professionals, contracting professionals can help demonstrate the potential impact that various products and technologies can have on the rate of healthcare-acquired infections. By sharpening their pencils, they can help make an economic case for instituting good infection control practices in their facilities.

The cat’s out of the bag on one of healthcare’s dirtiest secrets, that is, that hospitals are health hazards. Things couldn’t get more public than the June 6, 2005, New York Times op-ed piece “Coming Clean,” by Betsy McCaughey, former lieutenant governor of New York and founder of the Committee to Reduce Infection Deaths. Or ABC’s October 2003 “Primetime Live” report describing the death by infection of television sports reporter and author Dick Schaap following hip replacement surgery.

Indeed, the situation has become so bad that many states are calling for hospitals to publicize rates of healthcare-acquired infections. In fact, at press time, six states (Illinois, Pennsylvania, Missouri, Nevada, Virginia and Florida) had enacted legislation to that effect, and an additional 31 were considering doing the same, according to the Association for Professionals in Infection Control and Epidemiology Inc. in Washington. The issue, called “mandatory reporting,” has captured the attention of the public and professional organizations as well. In fact, the Consumers Union, publisher of Consumer Reports, operates a program called, the goal of which is “to help consumers find the best quality of care by promoting the public disclosure of hospital infection rates,” according to the Web site.

Meanwhile, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has made the reduction of healthcare-acquired infections a National Patient Safety Goal. The Centers for Disease Control and Prevention (CDC) now considers healthcare infections to be a patient safety issue.

How bad is it?
The statistics are enough to frighten anybody away from a hospital. The CDC says at least 2 million healthcare-acquired infections occur each year, resulting in 90,000 deaths Ð a third of which are preventable. About one of every 10 hospital patients gets an infection.

The most common hospital-acquired infections include those of the urinary tract (30 percent), bloodstream (18 percent), surgical site (16 percent) and pneumonia (15 percent), according to the National Surgical Infection Prevention Project, a collaboration of the Centers for Medicare & Medicaid Services and the CDC.

No one would dispute the profound emotional toll that healthcare-acquired infections have on patients and their families. But such infections also are disastrous from an economic point of view.

According to the CDC, healthcare infections cost the U.S. healthcare system an estimated $4.5 billion. A serious bloodstream infection increases a hospital stay by 11 days and adds, on average, $57,000 to a patient’s hospital bill, according to a study in the October 2003 issue of the Journal of the American Medical Association. And ventilator-associated pneumonia costs more than $40,000 per case to treat, according to research compiled by Sage Products in Cary, Ill.

Hospital infections add as much as 8 million excess patient days, adding, on average, eight days to a patient’s length of stay, says Bill Brandmeyer, director of marketing for Medi-Flex in Leawood, Kan. Surgical site infections increase lengths of stay an average of seven and one-half days, according to CDC’s National Nosocomial Infections Surveillance system. Each incidence of surgical site infections costs between $2,734 and $26,019 to treat, or between $130 million and $845 million per year.

What’s going on?
Is the situation worse than it was 10 or 15 years ago? That’s hard to say. Mandatory reporting might clarify that picture over time.

But it’s accepted that many patients in hospitals today are sicker than those who checked in years ago. “As patients become more immunocompromised and sicker, they’re more susceptible to infections and have a harder time fighting them off,” says Brandmeyer.

Some observers think the problem has simpler roots. With the influx of antibiotics on the market, they say, caregivers have gotten careless about the basics of infection control: frequent hand washing and glove changing, and simply keeping the hospital environment clean. Instead, they figure patients can take antibiotics if they develop infections.

There’s a big flaw in that line of reasoning, however. Many bacteria have developed a tolerance to even the strongest antibiotics on the market. A case-and-point is Staphylococcus aureus, which has developed a tolerance to the antibiotic methicillin. Patients with methicillin-resistant Staphylococcus aureus, or MRSA, often spend months in the hospital and endure several operations to cut out infected tissue, according to McCaughey. In 1974, 2 percent of staph infections were from MRSA; today, experts estimate that number is closer to 60 percent.

In some cases, technology has become so good at sustaining life that it is actually increasing the potential for healthcare-acquired infections. Ventilator-associated pneumonia is a case-and-point. According to a report in the American Journal of Critical Care, “One of the most critical risk factors for ventilator-associated pneumonia is microbial colonization of the oropharynx.” Bacteria that cause nosocomial respiratory disease colonize the oropharyngeal area, including dental plaque. These pathogens can be aspirated into the lungs and cause infection. Patients receiving continuous mechanical ventilation have six to 21 times greater risk of developing hospital-associated pneumonia than patients not on mechanical ventilation. Ventilator-associated pneumonia occurs in 10 percent to 65 percent of ventilated critical care patients, with mortality rates between 20 percent and 70 percent.

‘No’ to the status quo
Hospitals and IDNs can beat healthcare-acquired infections, but to do so, they have to execute some changes in behaviors and product usages. (See “Executive Interview,” p. 6, in which Pittsburgh Regional Healthcare Initiative Chairperson Karen Feinstein, Ph.D., says a group of Pittsburgh-area hospitals pooled information to reduce central line infections by 60 percent, and that a medical-surgical unit in a Veterans Affairs facility brought MRSA virtually to zero.)

Many times, beating healthcare-acquired infections simply means refusing to accept the status quo. That’s what the intensive care unit at Porter Valparaiso (Ind.) Hospital did.

“For years, we felt that mechanically ventilated patients were very sick and high risk,” says Terri Gingerich, critical care unit educator at the hospital, which is part of Porter Memorial Health System. “The fact that they developed pneumonia while on the ventilator was part of the package. But, recently, we realized that this is something we could controlÉso it became a matter of educating staff and bedside caregivers that this is a preventable condition, and that we have to do everything we can to prevent patients from being harmed in the ICU.”

The caregivers at Porter Valparaiso weren’t traveling solo, however. In 2003, the hospital joined “The Transformation of the ICU,” a national initiative of Irving, Texas-based VHA. “They provided us the help and processes to deliver evidence-based medicine,” says Gingerich. The department collected baseline data on key indicators (including mortality, bloodstream infections, length of time on ventilators and length of time in the ICU); examined the evidence regarding infections; created care protocols based on the science; educated the staff and physicians; and then implemented and monitored the changes.

Based on the evidence in the literature, Porter’s caregivers raised the heads of their ventilator patients 30 degrees or more. Why? Gingerich says studies indicated that when mechanically ventilated patients lie flat on their backs, organisms in the stomach can migrate into the mouth and then become aspirated into the lungs. In addition, the staff began consistently brushing these patients’ teeth with Sage Products’ oral care products. “Bacteria grows on dental plaque,” she says. “By brushing their teeth, we reduced the risk of microorganisms migrating down into the lung.”

Addressing the risk of ventilator-associated pneumonia was merely one aspect of Porter Valparaiso’s approach to reducing infection rates. “It isn’t just one intervention, but rather, looking at the patient as a whole,” says Gingerich.

Surgical site infections
The fight against surgical-related infections demonstrates how a combination of scientific evidence, the judicious use of products and a concerted effort to change clinicians’ practices can dramatically reduce healthcare-related infections.

Almost 40 percent of all healthcare-acquired infections in surgical patients are surgical site infections, according to the CDC’s National Nosocomial Infections Surveillance system. Between 4 percent and 16 percent of all healthcare-acquired infections among hospitalized patients are surgical-site infections. And between 2 percent and 5 percent of patients who undergo surgery develop a surgical site infection.

The science is relatively simple, says Brandmeyer, whose company, Medi-Flex, makes topical antiseptics. He points out that whenever the skin is broken, bacteria have an opportunity to enter the body. Although such bacteria are harmless when on the skin, it can lead to infection in the body, especially among sicker patients. But the risk of infection can be significantly reduced by proper aseptic technique, says Brandmeyer. That means proper barrier protection (gowns, masks and gloves) for caregivers and skin antiseptic for the patient.

Other efforts are being made to reduce the incidence of post-surgical infection, some of them product-related, some not. For example, studies indicate that tight control of diabetics’ blood glucose levels (to between 80 and 110 mg/unit) can eliminate post-surgical infections. Of particular interest is the deep sternal wound infection known as mediastinitis, according to research published by the Pittsburgh Regional Healthcare Initiative.

In addition, caregivers are being instructed to administer prophylactic antibiotics prior to surgery (a practice which, by itself, can prevent between 40 percent and 60 percent of surgical site infections), guarding against hypothermia among surgical patients, maintaining high levels of inspired oxygen, and avoiding shaving the operative site (which can nick the skin and allow bacteria to enter), according to the Institute for Healthcare Improvement in Cambridge, Mass.

Bloodstream infections
As many as 28,000 patients die each year in the United States because of catheter-related bloodstream infections, but doctors and nurses who implement simple and inexpensive interventions can cut the number of deaths to nearly zero, according to a study by Johns Hopkins researchers in Baltimore.

The simple interventions, which include a system for educating nurses and doctors about infection control, streamlining the catheter insertion process, and a safety checklist, are believed to have prevented more than 40 infections and eight deaths. The interventions also are believed to have saved nearly $2 million in additional healthcare costs during the four-year study, according to Sean Berenholtz, M.D., assistant professor of anesthesiology and critical care medicine and of surgery at Johns Hopkins, and the lead author of the study published in the October 2004 issue of Critical Care Medicine.

The heat will stay on
Success stories such as these, as well as continued bad press for hospitals that fail to improve their infection rates, will probably keep the issue of hospital-acquired infections in the public eye. For its part, the JCAHO intends to keep applying pressure to hospitals to stay vigilant.

“The joint commission’s position that deaths and disabilities associated with healthcare-acquired infections were sentinel events Ð that they required analysis and intervention, even for individual cases Ð did not sit well with many healthcare organizations and practitioners,” said JCAHO President Dennis O’Leary, M.D., in opening comments at JCAHO’s Infection Control Conference, November 2003 in Chicago. “They argued that the required root cause analyses were a labor-intensive exercise in futility for a problem that is inherent in the delivery of care. But the joint commission respectfully disagreed, and we still do.”

Beginning in January 2004, JCAHO has insisted that all accredited organizations be in compliance with the CDC’s hand-washing guidelines, and that all unanticipated deaths associated with organization-acquired infections be managed as sentinel events. “One root cause of these sentinel events is clearly inattention to hand washing,” said O’Leary at the conference. “That simply must change.” In addition, JCAHO demands that:

Leaders of healthcare organizations bear responsibility for the effectiveness of their infection control programs, including adequate staff training in infection control

When problems are identified, the healthcare institution will begin a timely intervention:

Institutions engage in ongoing risk assessment
Institutions have adequate numbers of competent infection control practitioners
Institutions’ infection control programs are monitored by meaningful performance measures.

Some hospitals have found that well-planned and well-executed infection control programs benefit not only patients, but also their own staffs.

“It has had a huge impact on our staff; they’re much more motivated,” says Terri Gingerich. “When nurses get into this profession, they know they will work hard, and they’re willing to do that. But there’s nothing more frustrating than to work hard and yet feel that you’re not giving the best care you can.” Results of Porter’s infection-fighting efforts are shared with the staff, so they can buy into the process and celebrate their successes. “They need to see it and to know it’s working,” says Gingerich.

That carrot might be stronger than any stick in reducing infection control rates in the country’s hospitals.

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