Shining a Light on Hospital Infections
After the shock of a colon cancer diagnosis, anxious weeks spent waiting for surgery, and six days recovery in the hospital, Dr. Nelson Gunter was looking forward to the comforts of home.
“The surgery to remove the mass was successful,” the Columbia neurologist said of his 2006 health crisis. “Luckily, the cancer had not spread. I had started eating and moving around and was due to be released from the hospital that Sunday.”
But when Sunday came, it was clear that Gunter had developed an infection, possibly from a sterilization error during a bandage change.
To help the infection heal, Gunter’s doctor ended up removing the staples that sealed the 8-inch long, 1-inch deep incision.
“He did it right there in the hospital room,” Gunter said. “He had to lay it open.”
When Gunter finally made it home days later, he took with him an open, draining wound that had to be cleaned and packed with saline-soaked gauze three times a day for six weeks.
Like 1.7 million Americans each year, he had entered the hospital to fix one health problem only to be confronted with a brand new one.
Now employed by a healthcare risk management firm, Gunter is grateful that the cancer has not returned. And he knows that no one meant him any harm. But he is certain that the added trauma of a menacing infection could and should have been prevented.
Ironically, at the time of his diagnosis, Gunter had just joined a committee that was helping the S.C. Department of Health and Environmental Control find a fair and accurate way to monitor and compare hospital-acquired infection (HAI) rates in South Carolina.
According to the federal Centers for Disease Control and Prevention (CDC), more than 250 Americans a day — up to 99,000 per year — die from infections they got as hospital patients.
“We know that the vast majority of these infections are preventable,” said Dr. Jerry Gibson, the state epidemiologist and DHEC’s director of disease control.
Now, a new state law, the S.C. Hospital-Infection Disclosure Act or HIDA, requires South Carolina hospitals to use a standard method to report HAI rates for four common medical procedures to DHEC twice a year.
DHEC published its first annual report on South Carolina HAIs in February.
“We’ve tried hard to make this information understandable so that our residents can use it to make good decisions,” Gibson said, adding that additional medical procedures will be phased into the reports over time.
South Carolina’s HIDA was one of the first laws of its kind in the nation. Greenville Senator Ralph Anderson explained why he sponsored it.
“I heard from a lady who had had some very bad experiences,” Anderson said “She knew a number of people who had gone to the hospital, expecting to stay two or three days, and ended up dying or crippled for life because of infections. Then an old fraternity brother of mine went into the hospital for an operation, and ended up staying there six months because of an infection. He’s still in a wheelchair. It totally changed his quality of life.”
More than half of all other states have since passed similar laws.
Paying the Price
The cost to treat HAIs is staggering. U.S. taxpayers spend around $20 billion annually to treat HAIs among patients insured by Medicare and Medicaid, according to a 2005 study.*
That’s not surprising when you consider that patients who get HAIs spend nearly four times as long in the hospital as patients who do not get infections.
“The cost of infections often tends to get buried or lumped in with overall care,” said advisory committee member Dr. J.B. Sobel, chief medical officer for Blue Choice Health Plan, a subsidiary of Blue Cross and Blue Shield of S.C.
In fact, says HIDA advisory committee member John Ruoff, research director of the statewide consumer advocacy group Fair Share, “a big part of the problem is letting consumers see just how big the problem really is.”
Billions of dollars in HAI costs are passed on to consumers in the form of higher health insurance premiums and out-of-pocket co-pays.
HAIs cause Americans to suffer lost wages, lower productivity, and sometimes disability and death. Common HAIs include surgical wound, urinary tract, respiratory and bloodstream infections.
“There couldn’t be a more serious problem,” said Columbia resident Helen Haskell, a HIDA advisory committee member who lost her only son Lewis to medical error when he was 15. “People should not go into a hospital expecting to be healed and end up with one of these possibly disfiguring — or worse — infections.”
Committee member and Aiken resident Dianne Parker said her late husband, Willie, suffered a severe HAI that may have contributed to his death.
“He got a staph infection after a knee replacement surgery,” Parker said. “They ended up having to place him in a medically induced coma for two weeks.”
To encourage hospitals to place greater emphasis on infection prevention and rein in escalating healthcare costs, in October, 2008, Medicare stopped paying for 11 types of preventable HAIs and medical errors. It's expected that Medicaid and some, if not all, private insurers will eventually do the same. Hospitals will have to absorb these costs.
Obviously, there are strong incentives on all side to improve quality and reduce infection rates. So DHEC’s HIDA advisory committee purposely included consumer advocates, infection control experts, physicians, and representatives of South Carolina hospitals and insurance companies.
“The process has been a really good example of public-private collaboration,” said committee member Dr. Rick Foster, the S.C. Hospital Association’s senior vice president for quality and patient safety. ”It’s an excellent model for how we can solve some of the big problems we face in healthcare.”
The committee’s challenge was to find and agree on a reporting method that would ease their many concerns:
- Consumers worried that hospitals might underreport or manipulate infection rates.
- Hospital representatives worried that the public would misinterpret the data.
- Foster said hospitals feared a reporting system “so burdensome that it would collapse under its own weight.”
- Consumers wondered if the HIDA effort could backfire, if hospitals would begin turning away the sickest patients or giving patients unneeded antibiotics in an effort to improve their infection numbers.
- Infection control experts worried that the effort would raise unrealistic expectations. “I might believe that we should strive for a zero infection rate, to eliminate HAIs altogether,” said committee member Connie Steed, the infection prevention director for Greenville Hospital System University Medical Center. “But I also know that even if you’re as good as you can be, some high risk patients — those with weak immune systems, for instance — may still get infections.”
- Hospitals said complying with the requirements would divert staff from infection prevention to infection reporting.
- Large critical care hospitals pointed out that they treat much sicker patients who are more prone to infection, than small hospitals. They said this would put them at a comparative disadvantage.
- Hospitals also noted that small facilities may not do enough procedures in a given category to offer a fair comparison. Using the raw data alone would mean that one infection more or less could cause a big (and misleading) change in the rate.
Ultimately, DHEC and the advisory committee selected a CDC-managed reporting system that adjusted the raw numbers to factor out at least some of the risks beyond the control of a hospital. The system will track how standardized HAI rates change over time, so that infection control experts can measure the effectiveness of various prevention tactics used in S.C. hospitals.
The HIDA HAI Individual Hospital Report includes a summary for each hospital.
The system also compares S.C. hospital rates with national norms. The HIDA HAI Comparison Report features tables organized by surgical procedure and hospital location or unit. Each hospital earns what is called a Standardized Infection Ratio for each procedure. This number is compared with a “standard population rate” based on data from hundreds of other U.S. hospitals that use the same CDC reporting system.
Because healthcare resources are finite and many infection prevention methods are expensive, hospitals need to know what works.
“In the ‘70s we focused on the basics — hand washing, isolation and sterile technique,” said Steed, who has been working in the infection control field for 30 years. “Through the years we expanded the focus as invasive devices such as central lines came into use. We set up guidelines for how these devices were to be inserted and cared for.”
In recent decades, though, the use of invasive techniques — those which pierce the skin or go inside the body — and the number and variety of surgical procedures, have exploded, Steed said. While saving many lives, these advances have also multiplied opportunities for germs to enter patients’ bodies.
Hospitals have monitored their own infection rates for years, she said. But HIDA will allow them to compare their performance and methods with those of competitors for the first time. The result should be a win for all, she said.
Throughout the country, some of the infection reduction measures that are proving most effective are fairly simple. Tactics include:
- frequent, careful hand washing by hospital staff, visitors and patients;
- extraordinary attention to detail when cleaning and sanitizing all surfaces and items in hospitals;
- disinfecting of stethoscopes and blood pressure cuffs before and after they are used for each patient;
- review of simple checklists. The World Health Organization says that if surgical teams adopt three lists** to be reviewed before anesthesia, before the incision is made, and before the patient leaves the operating room, they will decrease risks for the three biggest causes of death in surgery — infections, excessive blood loss and anesthesia complications — by as much as 50 percent.
- testing patients upon admission to see if they have been colonized by dangerous bacteria.
Steed said that Greenville Memorial Hospital has tested its high risk patients upon admission for years to see if patients are carrying MRSA, a highly contagious form of staph bacteria that doesn’t respond to normal antibiotics.
Sometimes, even though a person may have the MRSA germ, it’s not causing an infection. If healthcare workers are aware of this, they can take extra precautions to keep from spreading the bacteria to others.
Steed said the hospital has just switched to a more advanced test that can identify MRSA faster, and they hope to expand the admission tests to the wider patient population in years to come.
But the MRSA test illustrates the economic complexities of the American healthcare system. Right now, Greenville Memorial absorbs the $40 cost of each MRSA test. Each test might prevent an infection, or multiple infections, that would end up costing tens of thousands of dollars to treat, so it’s definitely cost-effective.
However, Medicare, Medicaid and private insurers consider such voluntary testing a ‘cost of doing business’, sort of like cleaning supplies. They will not pay for the tests or allow the hospital to bill patients, so the hospital must absorb the cost. In reality, this means that the costs are eventually passed along in some form to private pay consumers and businesses.
Parker, whose husband suffered so terribly from a MRSA infection, can’t understand why every hospital doesn’t use the tests to reduce infections, or, for that matter, why an insurance company would refuse to pay for them.
“If a $40 test would prevent a death or a life changing experience with an infection, why would any institution not test all patients entering their hospital?” Parker said. “I certainly would have paid many times that amount, gladly, in exchange for my husband’s life.”
Starting a Conversation
Reducing HAI rates is not up to hospitals alone. Consumers can also take steps to reduce their risks:
- Consumer groups urge patients to be assertive in asking doctors and nurses to take precautions such as washing their hands upon entering a hospital room. Ruoff said that while many people will find this uncomfortable at first, “it’s more important to be a little embarrassed than have an infection with hideous results.”
- Steed said obesity, smoking and other lifestyle-associated conditions can put people at greater risk. She said the state’s infection reduction strategy needs to focus in part on getting people to take better care of their health.
- Haskell said her non-profit group, Mothers Against Medical Error, advises people to take their own bleach wipes to the hospital to make sure every surface is disinfected.
- Ruoff also said patients should discuss the HIDA numbers for their local hospitals with their personal physician. “Use it as a way to start a conversation about infection control,” he said.
On a broader scale, South Carolina’s public conversation about HAIs is just beginning.
“Infection prevention in hospitals must be a priority,” said DHEC’s Dixie Roberts, who coordinates the HIDA project. “Among other challenges, South Carolina needs to address the shortage of trained infection prevention professionals and the limited infection prevention training opportunities.”
Anderson believes HIDA is a good start, at least.
“I believe that we’re not only going to save lives and improve healthcare quality, but also save a lot of money,” he said. “I know this because I’m getting calls from people who work in hospitals around the state; they are telling me that big changes are already underway.”
*2004 Study by the Pennsylvania Health Care Cost Containment Council
Article written by Karen Addy