Hospitals should provide pertussis vaccines to their health care workers free of charge, but should still treat employees with antibiotics if they have unprotected exposure to patients with pertussis and work with patients at high risk, such as young infants, a federal vaccine advisory panel says.
This recommendation represents a re-emphasis of the importance of immunization with the Tdap vaccine and post-exposure prophylaxis of health care workers.
“I think the big message to hospitals is to get your health care personnel vaccinated against pertussis. It’s a very effective vaccine,” says Alexis Elward, MD, assistant professor of pediatrics at the Washington University School of Medicine in St. Louis and a representative of the Healthcare Infection Control Practices Advisory Committee (HICPAC) to the Advisory Committee on Immunization Practices (ACIP). ACIP made the pertussis recommendation to the Centers for Disease Control and Prevention.
A study of two outbreaks in Minnesota found that health care workers are at risk. In one outbreak, only 12% of cases were among health care personnel, but many of the exposed employees had received prophylaxis. In another outbreak, 52% of cases were among health care workers, who contracted the disease from co-workers or patients. There were no cases identified of transmission from health care workers to patients.1
Pertussis epidemics are cyclical, and the disease is particularly dangerous for neonates who have not yet had their first pertussis vaccine. The CDC warned about the “continued resurgence of pertussis” in a February “Health Alert,” advising health care providers on using PCR tests to confirm the diagnosis. In 2010, there were 8,383 cases in California alone, including 10 deaths of infants. There also were significant outbreaks in Michigan and Ohio. ACIP expanded the recommendation for pertussis vaccination to include people 65 and older, so it encompasses all health care workers. Vaccination should include volunteers, especially those working in pediatric hospitals or with pediatric patients, says Elward.
Yet even vaccinated health care workers need to be evaluated for post-exposure prophylaxis, ACIP decided. An exposure is defined as being within six feet of coughing patients with pertussis for five minutes without wearing a mask.
Special update from our sister publication, Hospital Employee Health
1. Leekha S, Thompson RL, and Sampathkumar P. Epidemiology and control of pertussis outbreaks in a tertiary care center and the resource consumption associated with these outbreaks. Infect Control Hosp Epidemiol 2009; 30:467-473.
Preventing health care associated infections (HAIs) has emerged as a top priority in the U.S. Department of Health and Human Services (HHS) Strategy for Quality Improvement in Health Care (National Quality Strategy).
The March 21, 2011 report to Congress was called for under the Affordable Care Act. According to the HHS, it is the first effort to create national aims and priorities to guide local, state, and national efforts to improve the quality of health care in the United States.
Infection prevention was cited as a national priority, with HHS emphasizing that HAIs “harm millions of American patients each year and needlessly add billions of dollars to health care costs”. The report notes that at least 1.7 million HAIs occur each year and lead to 99,000 deaths.
“Health care providers should be relentless in their efforts to reduce the risk for injury from care, aiming for zero harm whenever possible and striving to create a system that reliably provides high-quality health care for everyone,” the HHS report states. “This isn’t easy. Such a system requires, for example, the design of standard operating procedures, a workforce with diverse yet complementary skills, workloads that allow enough time for errors to be corrected or mitigated and leadership that promotes continuous improvement. But this kind of system can also make a big difference in improving care, whether it’s by preventing serious medication events or eliminating healthcare associated infections and other preventable conditions.”
Dramatic reductions in central line associated blood stream infections (CLABSIs) were cited by the HHS as an example of such infection prevention approaches. That underscores the growing national perception that CLABSIs – which have mortality rates in the 12% to 25% range – are preventable and should be prevented. The central line infections were decreased by 58% in intensive care unit patients from 2001 to 2009 in national surveillance data reported by the Centers for Disease Control and Prevention.
Money talks when it comes to infection prevention, particularly if it’s coming out of your wallet. That appears to be the lesson thus far of an infection control policy taken to an unusual extreme.
As of this writing, a punitive policy in place at the University of Pittsburgh Medical Center (UPMC) – a vanguard institution in infection prevention – calls for fines of up to a $1,000 for physicians who ignore a hand washing edict. Second offenses could mean a temporary loss of hospital privileges. With varying fines for other health care workers, the policy was enacted amid a persistent outbreak of multidrug resistantAcinetobacter baumannii(MDR-Ab).
How did we come to such a place, we ask rhetorically, knowing full well many infection preventionsts will answer, “Well, we’ve tried everything else!” But are such punitive approaches counterproductive, breeding worker resentment in the name of patient safety?
Surprisingly there has been little “pushback” thus far, in part because no fines have had to be levied, explains Carlene Muto, MD, MS, UPMC's medical director for infection control.
“We’ve had the support of our entire team – our physicians, our nurses, our [administration] and medical executives,” she says. “I think people want to do the right thing. They intend to do the right thing, but for lots of reasons they don’t. They are in a hurry; they didn’t see the sign, whatever. But they get it – they know these organisms are very problematic and that patients can die from them. We just needed something to bring it home.”
And make no mistake, the system was set up with every intention of follow-through on the first offense.
“This fine thing – there’s been a lot of talk over the years about whether the carrot or the stick is better,” she says. “We’ve tried a lot of things with rewards, and I do think it gets you some improvement in behavior. But the bottom-line is we want the right behavior every time.”
For more on this story see the April 2011 issue of Hospital Infection Control & Prevention
Once considered inevitable, then widely viewed as preventable, healthcare associated infections (HAIs) are now getting close to being flat-out illegal.
Recently we have seen enactment of various policies that fire workers that refuse flu vaccination, issue monetary fines if they do not wash their hands, and now there is a proposed law in New York that would essentially criminalize infection transmission due to negligence.
In the wake of possible hepatitis outbreaks at two New York medical facilities , New State Assemblyman Ken Zebrowski of New York City recently introduced Bill A05576 to create "the crime of reckless infection of a patient with a communicable disease by a health care provider.”
In particular, the bill targets the reuse of a syringes and needles, but specifies that it is “not limited to” that breach in basic infection control. The aforementioned incidents involved improper sterile processing of surgical tools and the reuse of a blood sugar testing device on more than one patient. Zebrowski introduced similar legislation in 2007 after more than 600 patients were advised to be tested for bloodborne infections because a New York physician allegedly reused needles .
According to a statement on his website, the subject is personal for Zebrowski because his late father (former Assemblyman Kenneth Peter Zebrowski) contracted HCV from blood transfused during a brain operation.
The bill had not been put to a vote as of this post, but even if it doesn’t pass we can expect to see more of this kind of legislative reaction to flagrant disregard of basic infection control. For years, these incidents have been followed by a familiar wave of outrage that inevitably recedes to inaction and apathy. Not any more.
A recently reported dramatic national reduction in central line associated blood stream infections (CLABSIs) puts a harsh spotlight on hospitals that have not adopted a “checklist” protocol and other proven measures to fight infections that are both expensive and deadly.
CLABSIs – which have mortality rates in the 12% to 25% range – were decreased by 58% in intensive care unit patients from 2001 to 2009 in national surveillance data reported by the Centers for Disease Control and Prevention. The striking decrease translates to 27,000 lives spared and $1.8 billion saved in excess health care costs.
After the celebratory reactions, this is the new normal: Hospitals that have not adopted CLABSI prevention measures – particularly in ICUs -- risk being perceived in violation of a standard of care that has now been widely proven in clinical practice.
“The message from CDC and everybody in this field is that compliance with these best practices for catheter insertion should be 100%,” says Arjun Srinivasan, MD, a medical epidemiologist in the CDC's division of health care quality promotion. “Each and every time a catheter is put in it should be done in the best way. We know what that best way is and we want hospitals to do it that way.”
Srinivasan’s boss – CDC Director Tom Frieden, MD, MPH – was likewise unequivocal in a statement: “Preventing bloodstream infections is not only possible,” he says. “It should be expected.”
In findings that may resonate with lawmakers and regulators, survey results released yesterday found that 84% of Americans polled believe reducing healthcare associated infections (HAIs) should be a top priority for hospital staff and resources.
The survey by Partnership for Quality Care (PQC) found that more than 80% of respondents believe hospitals and providers can have a significant impact on reducing death from sepsis and hospital acquired infections.
At the PQC news conference at the National Press Club, the organization highlighted examples of successful protocols that decrease the occurrence of HAIs and sepsis. Justine Carr, MD, chief medical officer of the Steward Health Care System, in Boston, Mass., described her hospital’s infection prevention program, which has reduced the prevalence of HAIs by more than 50%. When members of the public were asked in the survey about the value of these types of programs, respondents indicated a high degree of confidence that the initiatives could be replicated at their local hospitals.
PQC -- a national coalition whose members work to advance reliable and affordable access to health care for all Americans -- conducted the national survey in January 2011, to measure attitudes on American health care and hospital safety. The Benenson Strategy Group measured the opinions of 1,000 people chosen at random via a telephone survey (both landlines and cell phones were called). The margin of error for the entire data set is
± 3.10% at the 95% confidence level.
In the continuing hue and cry over mandatory flu shots for health care workers, questions have arisen about the regulatory position of the U.S. Occupational Safety and Health Administration (OSHA).
Can hospitals mandate that health care works be immunized without running afoul of OSHA? The answer is “yes,” with a key caveat, according to an OSHA position established in 2009.
In a “letter of interpretation” in response to a question about the increasingly popular but controversial policy, OSHA ruled that employers may mandate the vaccination as long as they don’t retaliate against employees who have “a reasonable belief” that they would have a serious medical reaction to the vaccine. There’s no mention of philosophical or religious beliefs, but if the worker claims to be at risk, for example, of “a serious reaction” to the flu vaccine, OSHA says they may be protected under “whistleblower” statutes.
The position was established during emergence of the H1N1 influenza A pandemic strain. The agency states:
“OSHA does expect facilities providing healthcare services to perform a risk assessment of their workplace and encourages healthcare employers to offer both the seasonal and H1N1 vaccines. It is important to note that employees need to be properly informed of the benefits of the vaccinations. However, although OSHA does not specifically require employees to take the vaccines, an employer may do so. In that case, an employee who refuses vaccination because of a reasonable belief that he or she has a medical condition that creates a real danger of serious illness or death (such as serious reaction to the vaccine) may be protected under Section 11(c) of the Occupational Safety and Health Act of 1970 pertaining to whistle blower rights.”
UPDATE: In what would be a major blow for infection prevention in health care reform, GOP moves to oust CMS chief Don Berwick http://bit.ly/hwNlaa
Surmising a recent national report of dramatic decreases in central line associated blood stream infections (CLABSIs), one of the most powerful players in health care reform sees much to like about infection prevention.
Donald Berwick, MD,is practically emboldened – as if he needed to be. A quality crusader turned administrator -- of the Centers for Medicare and Medicaid Services (CMS) no less – sees the opening of a new era in infection prevention.
“We can’t afford the human and financial costs of [HAIs],” he said March 2 at a forum on HAIs held by the National Journal. Thus – finally -- prevention speaks directly to costs, closing a loop that has snarled infection preventionists for decades as they tried to “justify” their programs. On the other unwashed hand, infections deemed preventable may be subject to reduced CMS reimbursement. This is the new paradigm that Berwick is looking over like a chess board.
“Our will is increasing -- we have better ideas, better science,” he said.
Indeed, the Centers for Disease Control and Prevention report of a 58% reduction in CLABSIs – with prevention methods including a now famous “checklist” approach for catheter insertion – is the latest triumph of science over a culture of blame.
“We understand the causes of these problems, and I think we are moving away, happily – from a culture of blame – where we just keep pointing fingers at everybody when things go wrong – into a culture of science,” he said.
As health care reform unfolds patient safety will be among the leading issues, in part because it is “charismatic,” he said. And you thought there was nothing glamorous about a UTI. On the contrary, HAIs are all the more compelling because it is becoming increasingly clear how to prevent them.
“[HAIs] are deeply connected to the overall agenda of improving quality in American health care,” Berwick said.
Likewise, the old model of the infection preventionist crunching data in a silo -- a stranger to the floors, an unwelcome sight when seen – is over.
"We are all in this together – everybody on the team doing what the patient needs. That’s the way out,” Berwick said. “People get infections that they could avoid because we drop the ball among these [health care system] fragments, these handoffs. We can learn our way out it – we know that. This amazing CDC report of a reduction in central line bloodstream infections for ICU patients in just a few years is a remarkable achievement. And it came through teamwork."
It seems only appropriate to begin HICprevent – Hospital Infection Control & Prevention’s new blog site – with a message near and dear to our hearts and hands. This Aug. 13th will mark 146 years since Ignaz Semmelweis – the Hungarian physician who was widely discredited by the medical community for rather tenaciously observing that hand washing prevents infections – died in an insane asylum in Vienna. This was after psychiatric “treatments” that reportedly included repeated cold water dousing and laxatives. And we think we’ve had rough career paths! Semmelweis was later vindicated, of course, but infection preventionists attempting to reaffirm his hand hygiene message have been flirting with madness ever since. Historically speaking, the odds of a health care worker having washed their hands before touching a patient have been roughly equivalent to a coin flip. Heads the patient wins, tails they could be joining the 100,000 souls lost every year to healthcare-associated infections (HAIs).
Today there is much talk of revolutionary checklists, public transparency, patient empowerment and various and sundry other things in a new era of infection prevention. But let me ask you this: If that is your child – grandmother, loved one – in the hospital bed the night-shift nurse is approaching, how comfortable are you that those hands touching the IV line were washed? Of course, knowing some patient on the same ward likely has MRSA or that C. diff eats alcohol hand rubs for breakfast doesn’t exactly ease the head toward the pillow. No, if you are like me, you’re going to want to be there – hectoring all who dare enter to wash hands or be gone. This is the problem; it has always been the problem. When I began covering this field – with its recurrent outbreaks and cautionary tales – Ronald Reagan was president and a dedicated cadre of infection control “practitioners” were trying to get health care workers to wash their hands. The band, has indeed, played on. Is the glass half full or half empty? Will poor compliance always be the Achilles hand of infection prevention? Heads or tails? Call it in the air.
Hospital Infection Control & Prevention has been the leading source for news and comment on health care epidemiology for 38 years. With the HICprevent blog site we extend our coverage and commentary on this dynamic field, opening a new dialogue with infection preventionists, health care epidemiologists and others seeking solutions to one of the most vexing problems in patient safety: health care associated infections. HICprevent welcomes your comments, questions, tips and strategies for infection prevention.