The healthcare industrys continued failure to prevent hospital-acquired infections appears to have no end in sight, despite a steady stream of calls for improvement and the threat of regulation at the state level picking up steam.
The latest indication of how bad infection control is came by way of a report released last week by the employer-backed Leapfrog Group.
The report showed that roughly 87% of hospitals are not following all recommended guidelines in five categories to prevent avoidable infections. Leapfrog surveyed 1,256 hospitals for infection-control practices in its annual quality and safety rating system.
That means only 13% of hospitals are following all the guidelinesand that is inexcusable, said Sharon Kiely, medical director, quality and patient safety at 468-bed Allegheny General Hospital in Pittsburgh.
People know what theyre supposed to do. We cannot maintain the status quo, said Kiely, whose hospital ranked 52nd in the Leapfrog report. The hospitals coronary-care unit in May reached a benchmark of 15 straight months with no central-line-associated blood stream infection cases, and continues to be a leader in infection control practices.
The Leapfrog report stated hospitals are trailing in five areas: aspiration and ventilator associated pneumonia; central venous catheter related bloodstream infections; surgical site infection; vaccinating staff against flu; and hand hygiene. The practices measured in the survey are taken directly from the National Quality Forum list of safe practices.
Estimates show that 2 million people a year contract hospital-acquired infections, and 90,000 of those die from them. Some $15,000 can be tacked onto a patients bill if they acquire an infection and need to be treated for it while in the hospital as well. To find such a low level of safe practice compliance is alarming, the quality group said.
Its very scary, looking at these numbers, to be a patient entering the hospital, said Suzanne Delbanco, Leapfrogs chief executive officer. Leapfrog will release the full survey results of all four leap initiatives Sept. 18 along with its list of top hospitals based on those full scores.
Even after years of initiatives, legislation and policy guidelines, hospitals remain far behind the curve when it comes to infection control, according to the data. But its the variations in those initiatives and guidelines that are part of the problem of achieving improved infection rates, hospital representatives said.
The practices touted by Leapfrog are only one organizations recommendations of what to follow, officials say. Several organizations offer quality policies and guidelines, and there isnt a single, leading consensus on what to follow. Hospitals feel challenged to meet all these expectations, said Nancy Foster, vice president of quality and patient-safety policy at the American Hospital Association. Its a complicated issue to pursue if youre looking at infections as a whole.
One way the CMS hopes to inspire hospitals to take action is through their pocketbooks. The CMS issued a final rule this summer on hospital payments under the inpatient prospective payment system for fiscal 2008 that will deny hospitals payment under Medicare for the additional costs of treating patients who acquire a conditionincluding an infectionduring a hospital stay. The move has led hospitals to beef up their procedures (Aug. 20, p. 10).
Part of the problem is the tenacity of the infections. We dont have a magic bullet, like a vaccine, to eradicate infections globally, said Don Goldmann, senior vice president of the Institute for Healthcare Improvement.
But evidence shows that hospitals can achieve a goal of zero infection cases, and thats what they should strive for, he said, adding that all the organizations that push quality initiativessuch as Leapfrog, NQF and IHIdo collaborate to ensure efforts are aligned with research from organizations such as the Centers for Disease Control and Prevention. The institute championed the 100,000 Lives Campaign to reduce the number of deaths caused by hospital-acquired infections and other ways, and is now pursuing its 5 Million Lives Campaign to reduce the incidents of medical harm caused during care.
Emory HealthCare, Atlanta, has been fighting its infection rates for about 17 years, said Betsy Hackman, director of infection control. Its never been OK that we had them.
Emory follows IHI compliance measurements for various infections and has made enormous strides in reducing overall rates in its hospital, from 40% in the 1990s to 5% now, Hackman said. However, the various quality policies from different organizations are more often distracting than helpful because they provide only pieces of the pie, she added.
They tell hospitals what should be changed, but they dont tell you how to do it, she said. Hospitals are on their own in developing prevention strategies, she said.
Hospitals accredited through the Joint Commission follow relevant scientific guidelines set through the CDC, the Healthcare Infection Control Practices Advisory Committee and the NQF in developing infection-prevention goals to meet accrediting requirements, said Louise Kuhny, associate director, standards interpretation at the commission.
We do find organizations are not in compliance with our standards at times, and the commission takes corrective action immediately, she said.
The commission also recognizes organizations that perform successfully. Evanston (Ill.) Northwestern Healthcare system recently was named a winner of a quality award given jointly by the commission and the NQF for cutting infection rate of methicillin-resistant Staphylococcus aureus, or MRSA, by 60% in the first year of its program.
Changing infection-control practices requires not only evidence-based processes, but also a major cultural shift, something that has begun to happen only recentlyand slowly, healthcare professionals said.
Surgical infections emanate from poor operating compliance with established sterile technique, said Arthur Palamara, a private-practice surgeon in Hollywood, Fla., who has worked on patient-safety issues with the Florida Medical Association.
Staff will go from a contaminated case to a clean case without changing. Central supply is staffed by individuals with minimal education, and frequently instruments are improperly cleaned and incompletely sterilized, Palamara said. He added that he recently observed a nurse managing a patient with Clostridium difficile, a bacteria found in the intestines. After touching the patient, the nurse picked up a phone while in her gown and gloves and then handled the patients chart. To solve this problem, there will have to be wholesale re-education of practitioners, he said.
There is a long-standing belief in healthcare that infections were simply a part of medicine, said Gregg Meyer, senior vice president for quality and safety at 902-bed Massachusetts General Hospital in Boston. Its only been in the past decade that practitioners have begun to understand infections are preventable, he said.
Even that awareness is not enoughpractitioners need to see results to know their cultural shift has meaning before they will change their behavior, he said.
That probably has been some of the delay that we saw. You have to make it real to people, said Meyer, who helps develop standards on the NQFs safe-practices committee.
States also have been looking at those numbers and are beginning to more forcibly encourage public reporting. Illinois recently passed legislation mandating that all patients entering intensive-care units be screened for MRSA, and will require hospitals to report infection rates to the health department. New Jersey and Pennsylvania have similar laws.
State laws are well-intended, but hospitals are cautious about one standard of reporting for all. Trying to force a one-size-fits-all approach at the individual hospital level can have unintended consequences, said Debby Rogers, vice president of quality and emergency services for the California Hospital Association.
Theres not just one solution for such a multifaceted issue, she said.