A good third of Americans say they either have had a healthcare associated infection (HAI) themselves or know someone who has, according to a survey by a sterilization product manufacturer.
Now hold that thought about bias, I also take such data sources with a box of Morton’s. But this finding sounds about right. Inevitably, when I tell people what I write about they recall someone they know who was infected with something while hospitalized. Indeed, given that some 2 million people aquire an HAI every year and the vast majority survive, you could argue that the results should have been higher. In any case, there was a time – and it was not so long ago – when you had to tell people that infections even occurred in healthcare settings. It was the biggest open secret in medicine. Not anymore, and that’s a good thing.
The survey results released today reveal that 34% of Americans polled have -- or know someone who has -- acquired an HAI. In addition, the survey found that 64% of Americans do not think they would be better protected from germs in the hospital than in their daily lives.
Good for them, it’s best to go into a hospital with an awareness of HAIs, motivated to take an active role in your own infection prevention. It takes a village to prevent these things, so welcome aboard.
The survey was conducted online within the United States by Harris Interactive on behalf of Advanced Sterilization Products from April 8-12, 2011 among 2,483 U.S. adults ages 18 and older. Respondents for the survey were selected from among those who have agreed to participate in Harris Interactive surveys. The online survey was not based on a probability sample and therefore no estimate of theoretical sampling error can be calculated. For complete survey methodology, including weighting variables, contact Katie Sweet at firstname.lastname@example.org.
Health care workers who want to “do the right thing” must be supported by a culture change that recognizes infection prevention as a system problem that warrants a system solution, said Elaine Larson, PhD, professor of pharmaceutical and therapeutic Research at the Columbia University School of Nursing in New York City.
“We need to move from a perspective where your `client’ is the individual physician or nurse. Your client is the system,” Larson said recently in Baltimore at the annual meeting of the Association for Professionals in Infection Control & Epidemiolgy. “We are we now called upon much more to be leaders. We are at the table and we need a skill set [for that mission]. You have to own it.”
A leading researcher on hand hygiene -- infection prevention’s cardinal principle and enduring challenge – Larson shared a personal anecdote at a packed session at the APIC conference.
“I remember when I was a nursing student working night shifts as a nursing assistant,” she said. “After my first few weeks, one of the other nursing assistants said to me, “When are taking your sick day?’ I said, ‘Well, I’m not sick. She said you have to take your sick day every month because we all do, and if you don’t it’s really going to [make us mad]. It was a huge dilemma and I think I only stayed there three months. But if I had stayed on that unit – these were professional nursing assistants that had been there a long time – that’s a huge amount of pressure. It’s really hard -- even if you want to do the right thing. So we have to see the unit as our client, not individuals. It’s too hard for people to fight, kick against [the prevailing culture.]”
For more on this story see the August 2011 issue of Hospital Infection Control & Prevention.
In language clear enough to any plaintiff’s attorney, the Centers for Disease Control and Prevention has released a new guidance document for outpatient settings emphasizing that clinic administrators “must ensure that sufficient fiscal and human resources are available to develop and maintain infection prevention and occupational health programs.”
That includes the availability of sufficient and appropriate equipment and supplies necessary for the consistent observation of Standard Precautions, including hand hygiene products, injection equipment, and personal protective equipment (e.g., gloves, gowns, face and eye protection), the CDC notes.
“Ongoing education and training of health care personnel are critical for ensuring that infection prevention policies and procedures are understood and followed,” the CDC stated.
The message couldn’t be much clearer, particularly for settings that have tried to cut costs by skimping on infection control or outright ignoring it. While voluntary, the CDC guidelines establish a clear standard of care for outpatient settings, which have been hit with a series of national hepatitis outbreaks fueled by reckless disregard of basic infection control. Moreover, the Centers for Medicare and Medicaid Services has stepped up inspection oversight of ambulatory settings and will certainly look to these new guidelines in enforcing infection prevention. Tens of thousands of outpatients have been advised to be tested for HIV, hepatitis B and hepatitis C in a series of shocking outbreaks over the last decade that culminated in a Las Vegas endoscopy clinic in 2008.
The guidelines are drawn from the evidence-based guidelines created by the CDC’s Healthcare Infection Control Practices Advisory Committee. Most of the outbreaks involved inappropriate use of sharps and vials, so accordingly, the document includes a section underscoring the single use of syringes and extreme caution with multidose vials.
In addition to emphasizing standard precautions, the CDC guidelines also outline the rudiments of infection surveillance systems in outpatient care, basic environmental cleaning, and disinfection and sterilization practices. The guideline should be considered as the minimum protocol followed in ambulatory care, where more and more patients are now receiving invasive medical care.“Vulnerable patient populations rely on frequent and intensive use of ambulatory care to maintain or improve their health,” the CDC concluded. “For example, each year more than one million cancer patients receive outpatient chemotherapy, radiation therapy, or both. It is critical that all of this care be provided under conditions that minimize or eliminate risks of healthcare-associated infections.”
[caption id="attachment_297" align="alignnone" width="85" caption="Madeline "Maddy" Renee Reimer "][/caption]
We are honored to announce that Hospital Infection Control & Prevention has been awarded First Place in the Newsletter Journalism Award category by the National Press Club in Washington, DC, for a special report on patients infected with MRSA. This one’s for you Maddy.
“MRSA Patient Stories,” a two-part series in the Nov-Dec 2010 issues of HIC, claimed top prize in the category of Best Analytical Reporting in Newsletter Journalism. While putting some pressure on the Centers for Disease Control and Prevention to adopt more aggressive measures against the pathogen, the report lent a human face to the annual toll of Methicillin-resistant Staphylococcus aureus (MRSA).
Infection preventionists, epidemiologists throughout the nation's hospitals, hold the discussion for an instant about how transmission occurred and whether the MRSA strains arose in the community or in the hospital. At the human level, it doesn't matter. Health care epidemiologists can point out the obvious caveats and logistical problems to some of the things MRSA activists presume and propose, but there is no medical calculus for the rended heart. These stories will be heard.
These powerful narratives may do more to change the culture and practice of infection prevention in the nation's hospitals than a thousand clinical reports to Congressional committees. Change is coming in infection prevention because from the patient's perspective a 300-page CDC guideline with a phone book of references is a doorstop indictment of an approach that has failed. A child is dead and her mother draws her breath in pain to tell her story.
"When they removed her from life support they warned us that she would only live for a few minutes," Beth Reimer told us, recalling her six-week old daughter Madeline "Maddy" Renee Reimer. "My daughter actually lived for 13 minutes and I was able to hold her as she took her last breath."
MRSA is now killing more Americans annually than HIV/AIDS. This is in part a story of intersecting epidemics, one declining to a chronic condition while the other gains new footing in the community. Still, the vast majority of these bacterial infections are acquired in the nation’s hospitals by patients seeking treatment for some other malady. They literally never see it coming. The individual stories of these patient’s – some 20,000 of them lost every year -- often die with them.
Infection preventionists and health care epidemiologists have been fighting the scourge of MRSA for decades, giving ground grudgingly as they hector health care workers to wash hands, don gloves and gowns, and practice other measures to keep MRSA from spreading from patient to patient within the hospital. Many times this works; too often it doesn’t. Patients who have acquired MRSA can confirm that in hellish detail.
In part two of our report we revealed that data from the Veterans Affairs (VA) hospital system – at that time still unpublished – found that as much as 76% of the 100,000 invasive MRSA infections occurring annually could be prevented. Going beyond current CDC guidelines, the VA has adopted a bundle approach that features aggressive MRSA testing and patient isolation in all of its 153 hospitals.
The CDC is aware of the findings, but balks at urging widespread implementation of the VA policy. “Our job here at CDC is to make sure that all health care is safe — not to tackle a specific organism at the exclusion of others,” Michael Bell, MD, deputy director of the CDC division of Healthcare Quality Promotion, says in our report.
You might fairly ask, “This, from the nation that eliminated polio and led the world in eradicating smallpox?” However, there is another side to the story and we reflect it in our analysis. We interviewed clinicians who similarly cautioned against tailoring infection control efforts against a single pathogen, arguing instead for a standard precautions approach that includes flexibility to go to more enhanced measures.
Indeed, as bad a bug as MRSA has been, there are troubling signs of emerging pan-resistance in other pathogens, including a broad array of gram negatives. For example, New Delhi metallo-beta-lactamase (NDM-1) — a virtually untreatable gram negative bacterial enzyme that originally emerged in hospitals in India — continues to spread globally.
“If I come into a hospital — whether I have MRSA, VRE or multidrug resistant acinetobacter — it doesn’t matter how you label me,” said Patti Grant, RN, infection preventionist, HIC board member, and reliable source of uncommon sense. “This [screening approach] is taking us all back to relying on an isolation sign or a patient label to practice basic good infection prevention and control. We need to put our resources where we can actually start preventing infections at the bedside. I don’t think labeling people with MDROs is going to be the answer.
Publisher’s note: This is Gary Evans fifth award from the National Press Club since 1996, including three 1sts and two honorable mentions (2nd). He also has won several journalism awards from newsletter and specialized publishing associations, including a Best Investigative Award in 1992 from the Newsletter Publishers Foundation for a report on the mysterious Florida HIV dental outbreak that led to the death of Kimberly Bergalis.
When a single imported case of measles led to a small outbreak in Tucson, AZ, two hospitals were forced to spend about $800,000 to contain it, with much of the cost tied to ensuring the immunity of health care workers. The 2008 incident and ensuing investigation serves as a cautionary tale as the United States struggles with its largest number of measles cases since 1996.
In the first 19 weeks of 2011, 118 measles cases were reported. Most (89%) were related to importation of measles from other countries. Nine outbreaks accounted for almost half (49%) of the cases. And the consequences were serious. Forty percent of the patients with measles required hospitalization, according to a report by the Centers for Disease Control and Prevention.
“Measles is quite severe,” says Jane Seward, MD, MPH, deputy director of the Division of Viral Diseases at the CDC and an author of an analysis of the Tucson outbreak. Hospitals need to consider a diagnosis of measles if a patient presents with a cough, fever and rash, she says. “Unvaccinated travelers coming into the United States continue to pose a risk,” she says.
Indeed, the Tucson case began with a 37-year-old traveler from Switzerland who was unvaccinated. She went to a hospital emergency room in Tucson on Feb. 12, 2008 and again the next day, when was admitted with fever and rash. Yet measles wasn’t initially suspected and she wasn’t isolated until two days later.
Meanwhile, a 50-year-old woman who was exposed to the Swiss traveler in the emergency department waiting room developed a fever and respiratory illness. At first, she was diagnosed with asthma exacerbation, then pneumonia and allergic drug reaction. Finally, on March 2, she was diagnosed with measles.
Measles spread from that second patient to several other people. A health care worker, who had just received her MMR vaccine the day she cared for Patient 2, developed fever on March 5 and fever, cough and rash by March 9. An unvaccinated 11-month-old boy who was in an emergency department room across the hall from Patient 2 developed measles, as did two unvaccinated children, ages 3 and 5, who walked past the patient’s room while visiting their mother in the hospital.
In all, there were seven cases that were confirmed as health care-associated – linked to the index case. Another five developed community-acquired cases and one person who developed measles was exposed to a patient in his home. Of 11 patients who sought medical care at a hospital or physician’s office for fever, cough and rash, only one was masked and isolated.
That delay in suspecting measles is a consequence of the success in controlling measles in this country, but measles is raging elsewhere in the world. France and India were responsible for the greatest number of imported cases in the United States this year.
The outbreak investigation involved 4,793 hospital or clinic patients and 2,868 health care workers. Only 75% of the health care workers at the two hospitals that received patients with measles had evidence of immunity. None of the Tucson hospitals had electronic records that enabled them to quickly determine if their employees were vaccinated or otherwise immune.
Of 1,583 health care workers who had serologic testing, 11% were found to be seronegative. Meanwhile, health care workers without evidence of immunity were vaccinated and furloughed for five to 21 days after their last exposure.
The furloughs alone cost the two hospitals about $444,000, according to the analysis of the outbreak.
“Hospitals can be prepared by just having the evidence [of vaccination or immunity] on file,” says Seward. For health care workers born before 1957, “they can choose to vaccinate them, routinely or they can have it on file that they need to be vaccinated in the event of an outbreak,” she says.
Michele MarrillSpecial update from our sister publication, Hospital Employee Health
UTIs have been termed the Rodney Dangerfield of infections, out of a skewed perception that they are easy to treat and have relatively little clinical consequence.
The conventional wisdom is that UTIs rarely lead to serious or fatal infections, but the Michigan Health & Hospital Association’s Keystone Center for Patient Safety & Quality estimates that 5% of all deaths caused by health care-associated (HAI) infections are from catheter-associated urinary tract infections (CAUTIs). That’s 5,000 fatal infections if one uses the typical ballpark figure of 100,000 HAI deaths annually.
The most common infectious complication of care, urinary tract infections are well worth preventing. It can be done, even in non-acute facilities that must adapt the guidelines created for other settings. Exhibit A is a 300-bed Nebraska rehabilitation hospital, where nurses, occupational and physical therapists, case managers and education staff collaborated with patients and their family members to dramatically reduce CAUTIs.
The interdisciplinary team at Madonna Rehabilitation Hospital in Lincoln, one of the largest free-standing rehabilitation hospitals in the country, reduced catheter associated urinary tract infections (CAUTIs) by 89% over a 14-month period, Kristina Felix, BA, RN, CRRN, CIC, an infection preventionist at the facility, reported recently in Baltimore at the annual educational conference of the Association for Professionals in Infection Control and Epidemiology.
Primarily, the team worked to decrease the use of catheters — a known risk factor for UTIs — discontinuing their use unless medically necessary. In cases where urinary catheters were required, the team educated nursing, therapy staff, family members and patients on proper care to reduce the chance of infection. When the project was initiated in February 2010 the CAUTI prevalence rate was 36.6%, but dropped to a stunning 6.6% three months later. The original pilot concluded in April 2011.
Felix’s team identified underlying reasons for catheter use when medical necessity was in question. Contributing factors included patients admitted to rehabilitation settings from acute care facilities with catheters in place, and patients whose families viewed catheters as a more convenient way to manage incontinence.
Education regarding proper care of catheters and tubing was reinforced to staff and patients. Felix estimated that their program prevented up to 30 UTIs per month and saved the facility about $1,000 per infection avoided. There were little additional costs associated with implementing these interventions. However, there was the rather difficult task of changing the perception of UTIs and catheters among staff and even patients.
“It was quite an issue,” she said. “At the beginning we asked a lot of questions of our therapists and nurses to see why we were using [catheters]. What was the thought process? People did think it was convenient, but we found that if the catheter was out — and it was a learning process — the patients were able to move about freer without the bag and tube — the patients actually felt better without it.”
An aspect of patient “dignity” was restored.
“Overall, we have seen such a change in the thought process,” she said. “We really don’t like to use them and we are focused on getting them out when we can. If the patient does need the catheter, the focus is how we can prevent the infection. Everybody’s mindset has changed. “
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.