In 2012, Jerolyn Ireland had a benign brain tumor removed. “The operation was a breeze,” she says, but back at home, the surgical site became red and irritated. As she waited to get in to see her doctor, the infection worsened. Finally, she found out it was caused by the dreaded MRSA bacterium, a form of staphylococcus resistant to many antibiotics that Ireland, a registered nurse, believes she contracted during her hospital stay. Now 76 and living in Houlton, Maine, Ireland has needed multiple surgeries to repair the damage to her head. “I still have pain because of nerve damage,” she says. And even with health coverage, her out-of-pocket costs have been crippling, especially since she had to stop working. “When I get a phone call, I think it’s a collection agency,” she says.
Recent statistics from the Centers for Disease Control and Prevention confirm what Ireland suspects that she illustrates: Medicine still has quite a long way to go to eliminate infections acquired via contact with the very health care system that is supposed to make people better. This type of infection affected about 722,000 people in acute care hospitals in 2011, more than 10 percent of whom died. Significant progress has been made on some fronts; central line infections, for example, are way down. But there’s been a smaller decline — just 17 percent — in surgical site infections and little movement at all in problems associated with urinary catheters.
Meantime, concern has been growing about the frightening prevalence of bacteria that are resistant to many antibiotics, thus rendering them potentially untreatable. The CDC says that in 2014, the chance that a health care-associated infection was caused by any of six key resistant bacteria, including MRSA and vancomycin-resistant Enterococcus, was 1 in 7 in short-term acute care hospitals and 1 in 4 in long-term acute care facilities. These are figures CDC director Dr. Thomas Frieden called “deeply concerning” and “chilling” respectively.
[See: 11 Items to Pack in Your Hospital Bag.]
As for the scope of sepsis, the life-threatening organ dysfunction that can occur with any type of infection, hospital-acquired or otherwise, the CDC’s data suggest that all told nearly 2.5 million people died at least in part due to sepsis from 1999 to 2014.
So what has been working and what further can be done? “The crown jewel” of prevention efforts to date is the one aimed at bloodstream infections associated with central lines, says Dr. Arjun Srinivasan, the associate director for healthcare-associated infection prevention programs at the CDC. At short-term acute care hospitals, the numbers were down by 50 percent in 2014 from 2008.
That’s the result of a big push to implement such steps as a simple checklist reminding clinicians to wash their hands, replace soiled dressings, and properly clean the patient’s skin. Dr. Peter Pronovost, who directs the Armstrong Institute for Patient Safety and Quality at Johns Hopkins School of Medicine and who developed the checklist, says success also has depended on a culture of high expectations emanating from the C-suite. “If the goal was ‘zero,’ even if they didn’t achieve it, institutions did better,” he says. Successful leaders have made reporting of infections transparent and established some kind of feedback loop so staffers can see how they’re doing, he says.
The same enthusiasm could be deployed in other trouble spots, such as that of catheter-associated urinary tract infections, called CAUTIs, where the numbers haven’t budged. Those infections extend hospital stays, require antibiotics, and cause an estimated 13,000 deaths per year. They call for more extensive efforts, since urinary catheters are widely used and are placed by a larger group of people, Srinivasan says.
But it can be done. “The recipe is very clear,” says Dr. Marvin Moe Bell, a family medicine physician at HonorHealth Scottsdale in Arizona. “Basically it’s to use urinary catheters less or to use them for shorter periods of time.” In 2012, the intensive care unit at his hospital, the Scottsdale Osborn Medical Center, had a high CAUTI rate, with 54 infections — about 60 percent higher than the expected number. Bell and his team implemented a system that educates clinicians about when catheters are and aren’t indicated, asks for justification in the patient’s electronic medical record if a catheter is ordered, and presents a daily reminder in the health record to consider whether it’s time to discontinue the catheter. As catheter use decreased, so did infections. In the ICU, rates dropped by 25 percent in 2014 and by 88 percent in 2015. (A change in the definition of CAUTI was responsible for about a quarter of the latter year’s decline).
[See: 10 Lessons From Empowered Patients.]
While commonsense basics such as hand hygiene and keeping surfaces clean have long been recognized as powerful and important tools, many facilities are still falling far short. According to the CDC, health care providers follow proper hand-cleaning procedures less than half of the time. And only about half of surfaces in hospitals are properly cleaned, says Dr. John Boyce, an infection control consultant who recently served as head of infection control at Yale-New Haven Hospital.
Internal audits at Sentara HealthCare, based in Norfolk, Virginia, have shown a much more impressive record on meeting hand hygiene guidelines, with 94 to 95 percent compliance at the end of 2014. Still, “it wasn’t at 100 percent,” says Jennifer Kreiser, vice president and nurse executive at Sentara Leigh Hospital. “We needed to set up a mechanism so we didn’t allow anyone to do the wrong thing.” The system changed its approach from individual to team accountability with a program called All Hands on Deck that encourages personnel to use that phrase if they see someone fail to wash. Those who don’t speak up are held accountable for the lapse.
The goal, says Dr. Scott Miller, an infectious disease physician who is vice president of medical affairs at Sentara Leigh, is to mimic the atmosphere of the operating room at the patient’s bedside. “If I walked into the OR and hadn’t scrubbed in, there would be people all over me pushing me out the door, asking why not.” At the end of 2015, audits showed the compliance rate had risen to 99 percent, with some units consistently hitting 100 percent, Kreiser says. Better hand hygiene along with other efforts have brought infection rates at Sentara lower.
As with hand-washing, proper surface cleaning is straightforward in theory, but not in practice. Some harmful bugs, like MRSA and the diarrhea-causing C. difficile, when shed from one patient, can survive long enough to infect the next patient who occupies the room. Regular disinfectant, properly applied, can kill the bacteria, but “properly applied” means covering every surface and keeping it wet for at least a few minutes to do the job. Such procedures have to be followed all the time, since even patients who show no symptoms can leave harmful bacteria on surfaces around them.
Boyce says change requires involving the housekeeping staff in quality improvement campaigns and giving them ongoing feedback about how well they’re doing. Hospitals are also looking to new technologies to help with improvement. Spraying hydrogen peroxide vapor into a room after a patient carrying antibiotic-resistant bacteria had moved out, for example, reduced the chances that the next occupant would acquire the bug by 64 percent, according to a 2013 study conducted at Johns Hopkins. The downside: The room has to be unoccupied for up to three hours.
Another promising method uses ultraviolet light on top of the normal cleaning process to irradiate any remaining bacteria. Last year, researchers at Duke Medicine found that adding the light reduced by one-third the chance that patients staying overnight in a room previously occupied by a carrier of antibiotic-resistant bacteria would get sick. A third approach uses copper’s antimicrobial properties. Researchers at Sentara are investigating whether copper-coated surfaces and copper-infused bed linens will reduce infections.
[See: What Your Doctors Wish You Knew.]
Health care organizations are also working to fight antibiotic-resistant bacteria by curbing the use of the drugs in the first place. Whenever antibiotics are called upon, some strains of bacteria don’t die off, and those resistant strains can survive and multiply. The more antibiotics are used without sufficient caution, the more resistance becomes a problem. Besides working to prevent infections that would trigger a prescription, the government and health systems aim to manage antibiotics better, using microbial cultures to pinpoint which drug should be prescribed and to reassess the need as time goes on, and by keeping a course of treatment as short as possible. Any patient who is prescribed an antibiotic should ask what’s being treated and whether the drug will actually benefit that condition, advises Dr. Trevor Van Schooneveld, an infectious disease physician at the University of Nebraska Medical Center and medical director of the hospital’s antimicrobial stewardship program.
And that’s not all patients can do to protect themselves. Kathy Day, a registered nurse in Bangor, Maine, who became a patient advocate after her father died from hospital-acquired MRSA pneumonia, says she recommends a MRSA screening test ahead of any but the most minor surgery. If you’re a carrier, you can be decolonized with some easy measures, helping to prevent infections in yourself or other patients. Some hospitals already perform this type of testing, but there’s an ongoing debate over which patient groups should be screened.
Day also recommends that family members keep bleach-based wipes next to the bedside and use them to keep “anything that’s touched by patient or caregiver” clean. Encourage any visitors to use hand sanitizer, too.
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Keeping Bad Bugs at Bay in the Hospital originally appeared on usnews.com
