Patient Safety Focus

Protecting Healthcare Workers from H1N1 While They Work

Just before the Labor Day weekend, the Institute of Medicine (IOM) issued recommendations for how health care workers can protect themselves from H1N1 in the work place.  Commissioned by the Centers for Disease Control and Prevention (CDC) and the Occupational Health and Safety Administration, the report has fewer evidence-based recommendations for healthcare workers than it has suggestions for needed research.

For healthcare workers who encounter patients with unidentified febrile respiratory illness or in close contact with those known or suspected to have H1N1, the IOM report suggests they wear "fit-tested" N95 respirators or others equally or more effective.  This recommendation builds on CDC and World Health Organization guidelines, which also point to the importance of vigilant hand hygiene practices in all situations involving H1N1, and to isolation precautions (gloves, gowns, eye protection, masks).

But because the evidence is very limited for what protections to use when, the IOM recommends future research on influenza transmission and respiratory protection, particularly in the clinical setting.

Can Health Reform Work if Focused Only on Coverage? -- by Suzanne F. Delbanco, Ph.D.

In today's New York Times, Paul O'Neill, former Secretary of the Treasury, points out one of the big holes in the health reform debates in Washington, D.C.  While all of the talk about covering the uninsured and creating cost savings from enhancing competition among health insurance companies is very important, what about reducing the financial and human costs from preventable medical mistakes, including hospital-acquired infections?

If we are to aim to reduce current trends in health care costs and simultaneously find new resources to help provide care to a broader population, we best look at all our options.  According to a report by the Centers for Disease Control and Prevention (CDC), the costs of healthcare-associated infections in the U.S. each year range from $28.4 to $45 billion.  On the other hand, the savings from infection control measures could be as great as $5.7 to $31.5 billion.  We literally cannot afford to ignore this financial opportunity.

O'Neill lists a few examples of health care providers that have reduced infection rates drastically.  This means it can be done, and one can extend that fact to argue that there is no excuse for not doing it.  Arrowsight's approach to helping hospitals get it right - such as washing or sanitizing hands every time - is one example of the tools available to hospitals today. 

O'Neill challenges President Obama to add an important audacious goal to his list:  "ask medical providers to eliminate all hospital-acquired infections within two years."  On top of providing health insurance to everyone, that would be real health care reform.

Suzanne Delbanco is President, Health Care Division, Arrowsight, Inc.

Hospitals Wise to Cut Spending on Infection Control? -- by Suzanne Delbanco, Ph.D.

Does it make sense to cut spending on infection control when certain hospital-associated infections are on the rise and pressure is mounting to curb such infections?  Logical or not, a new study released today by the Association for Professionals in Infection Control suggests that hospitals are cutting staff, resources and educational efforts.

Almost 2,000 infection preventionists responded to the 2009 APIC Economic Survey.  Of those, 41 percent said that their budgets had been cut in the last year and half, due primarily to the economic downturn.  Among those who experienced cuts, three-quarters lost training money, and half had cuts for infection prevention resources like technology, staff, and equipment.  One in three of the survey respondents say that cuts in resources and staffing have restricted their capacity to focus on infection prevention.  On a related note, one quarter say they have cut back on surveillance activities to detect, track and manage hospital-associated infections. 

While infection prevention is not a source of revenue, APIC points out it can help reduce costs significantly.  The U.S. Agency for Healthcare Research and Quality estimates based on its Health Cost and Utilization Project (HCUP) data that acquiring an infection with methicillin-resistant Staphylococcus aureus (MRSA) during a hospital stay can double a patient's length of stay and almost double the cost of the stay (from $7,600 to $14,000).  Perhaps hospitals will get a chance to see the return on investment for infection prevention more clearly when they reduce the investment and need to live with the financial consequences.

Suzanne Delbanco is President, Health Care Division, Arrowsight, Inc.

New Monograph on Hand Hygiene May Push Us Forward -- by Suzanne Delbanco, Ph.D.

The Joint Commission, along with several partners, has just released a new framework for determining "when, why and how to measure compliance with hand hygiene."  The monograph, entitled Measuring Hand Hygiene Adherence: Overcoming the Challenges, is the result of a two-year collaboration among the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC), the Centers for Disease Control and Prevention (CDC), the Society for Healthcare Epidemiology of America (SHEA), the World Health Organization (WHO) World Alliance for Patient Safety, the Institute for Healthcare Improvement (IHI) and the National Foundation for Infectious Diseases (NFID).

What's the big deal?  There has yet to be agreement about how to measure compliance with hand hygiene protocols. Without some standardization, it is very difficult to measure the comparative effectiveness of different interventions to improve and sustain hand hygiene practices.  And depending on the measurement method, hospitals may produce for themselves a false sense of security that their hand hygiene practices are sufficient when they are not.  My suspicion is that the more rigorously we measure hand hygiene practices, the more disappointed we will be with performance - that is, until we also implement successful interventions to drive and maintain improvement.

The monograph does not create a single international standard for measurement of hand hygiene practices, though it draws from examples from several countries.  It moves us closer, however.  So let's cross fingers and get to the hard work ahead.

At Arrowsight, we offer a powerful methodology for implementing many of the features and elements of measurement the monograph outlines.  Arrowsight's deep experience in video monitoring and feedback in other industries allowed us to jump start our efforts in health care.  Our work is too new to have been cited in the monograph, though we have recently briefed many of its authors.  With 24/7 video monitoring, a very large and continuous sampling process, rigorous quality assurance and near-real-time feedback to front-line staff, we are excited for our Hospital Video Auditing approach to be part of the solution going forward. 

As a side note, it may not be a surprise to readers that the project was underwritten by GOJO Industries, the makers of Purell hand sanitizer.

Patient Sharing Among Hospitals Could Impact Spread of Infectious Diseases

Twenty-two percent of people who are discharged from acute-care hospitals are readmitted at different hospitals within one year, according to a study released today by the University of California, Irvine School of Medicine.  This has big implications for the spread of infectious diseases, as hospitals typically only track direct transfers of patients from one hospital to another.  Patients can carry organisms like MRSA for long periods of time, even if they aren't actively experiencing symptoms of infection.  As a result, they can bring these organisms with them from one facility to another, even with gaps between admissions.

The study was conducted by Susan S. Huang, MD, MPH, assistant professor and hospital epidemiologist and colleagues, and funded by both UC Irvine and the National Institutes of Health's Models of Infectious Disease Agent Study (MIDAS).  The study analyzed nearly 240,000 patient admissions at 31 acute care hospitals in Orange County, CA using a retrospective evaluation of 2005 California Hospital Discharge Data.

Does Public Reporting Prompt Hospitals to Reduce Infections? -- by Suzanne Delbanco, Ph.D.

In the U.S., exactly half of the 50 states now require public reporting of hospital-specific rates of hospital-acquired infections.  There are multiple purposes behind public reporting, including making hospitals accountable to the communities they serve, and providing information to help patients make informed decisions about where to seek care.  But does public reporting prompt hospitals to reduce the incidence of hospital-acquired infections?

In Pennsylvania, where the Pennsylvania Health Care Cost Containment Council has been reporting hospital outcomes publicly for many years, the evidence is mounting that public reporting is associated with improved outcomes over time.  The Council released a report on January 22 that analyzes data from 2007 and compares it to data from 2006.  The data submitted by hospitals was the same for both years, allowing a first year-over-year comparison.  From 2006 to 2007, the Council found an 8% decrease in the number of infections contracted by patients in Pennsylvania hospitals.

Pennsylvania hospitals must have implemented variety of measures to reduce the spread of infections between 2006 and 2007.  The spotlight shined on the problem by the Pennsylvania Health Care Cost Containment Council no doubt added to their vigilance.

Curious about a new approach to assuring infection control practices are implemented?  Learn about Hospital Video Auditing (HVA) by clicking here.

Suzanne Delbanco is President, Health Care Division, Arrowsight, Inc.

Even Patient's Bath Basins Can Harbor Infections

In a study released January 1, 2009 in the American Journal of Critical Care, researchers found that patient's bath basins are a reservoir for bacteria and could be a source of transmission of hospital-acquired infections.

Three hospitals participated in the study:  Presbyterian Hospital in Albuquerque, New Mexico; Wishard Health Services in Indianapolis, Indiana; and Westerly Hospital in Westerly, Rhode Island.  Across the three facilities, researchers analyzed 92 bath basins from three intensive care units and a rehabilitation unit.  They swabbed the basins after they had been used to bathe patients and had been given a chance to air dry, and sent the samples to a microbiological testing laboratory.

Some form of bacteria grew in 98% of the samples, including enterococci, staphylococcus aureus, vancomycin-resistant enterococci and methicillin-resistant S aureus.  These findings suggest a need to develop and implement bathing protocols that protect the patient from exposure to pathogens.  The researchers site prepackaged bathing supplies as a helpful component.

Clostridium Difficile on the Rise Among Hospitalized Patients

The fight against hospital-acquired infections is even more challenging than experts previously thought.  Yesterday, the Association for Professionals in Infection Control and Epidemiology (APIC) released the results of a new survey showing that Clostridium difficile is more prevalent among hospital patients than experts had estimated. 

 

The National Prevalence Study of Clostridium Difficile in U.S. Healthcare Facilities, conducted by APIC members who gathered sample data from the 648 hospitals in which they work, found that more than 1% of (13 out of 1,000) hospital patients are either infected or colonized with C. difficile.  This incidence is between 6.5 and 20 times higher than earlier assessments.  C. difficile is spread by hand contact with items contaminated by feces.

 

Based on the 1% incidence, 7,000 hospital patients in the U.S. have C. difficile on any given day.  Of those infected, 94% exhibited symptoms including diarrhea, fever, loss of appetite, nausea and abdominal pain.  Of the 7,000, about 300 will die from the infection.  According to APIC, the costs to care for the infection range from $17.6 to $51.5 million annually.

Important preventive measures for C. diff include:  adherence to the Center for Disease Control’s hand hygiene guidelines, use of contact precautions, identification of high-risk areas within the institution, surveillance programs, environmental and equipment cleaning and decontamination, and antimicrobial stewardship.

APIC has published a guide to help the health care industry reduce the incidence of C. difficile. APIC summarizes the issues with C. difficile and APIC's recommendations on its web site.

GAO Report on HAIs Provides New Resource and Identifies Opportunities for Hospital Video Auditing -- by Suzanne Delbanco, Ph.D.

On October 2, the U.S. Government Accounting Office (GAO) released a report entitled Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections. 

The report outlines which states are currently or soon planning to publicly report hospital-specific performance on specific hospital-acquired infections.  The emphasis in the 23 states with activity in this arena is largely on reporting incidence of particular infections, though a small number are also reporting adherence to protocols designed to reduce certain hospital-acquired infections.

In addition, through surveys and onsite visits, the GAO reports on the activities of fourteen hospitals known to have programs designed to reduce the spread of Methicillin-resistant staphylococcus aureus (MRSA).  These programs focus on routine testing, hand hygiene, contact precautions, and antibiotic stewardship.

All fourteen changed their hand hygiene programs in various ways with almost all increasing the number of hand hygiene compliance audits they conduct through observation and and most enhancing staff training and public education programs. A smaller number also increased the number of dispensers of alcohol-based hand sanitizer or measured the consumption of hand hygiene products.

Imagine if these hospitals had more rigorously collected data on hand hygiene compliance and ongoing feedback to staff about their hand hygiene performance, along with positive reinforcement.  To improve, staff need to know where they stand at the start.  Short term observations conducted periodically cannot produce the richness of data Arrowsight Medical gathers from hospital video audits of hand hygiene compliance 24/7/365, which can identify issues by room, by hour of day, by shift, by day of week and by type of care giver. 

While the GAO report does not touch on the rates of hand hygiene compliance calculated by the onsite observers in the hospitals that are the focus of its report, it is unlikely those hospitals were able to achieve the kind of results that Arrowsight achieved at its first pilot at an outpatient surgery center - from a baseline of 38 to 90 percent within three months, and above 90 percent for twelve months running.  Arrowsight sends automated intra-shift emails to nurse managers and attending physicians that rank current shift performance room by room.  Additionally, Arrowsight automates the delivery of aggregate team metrics to LED boards at the work site, which are updated every ten minutes for all staff to see.  Arrowsight is excited to help hospitals already committed to serious programs of infection prevention take this obvious next step.

Suzanne Delbanco is President, Health Care Division, Arrowsight, Inc.

New Compendium of Strategies to Prevent Healthcare-Associated Infections

Today, the Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals was released in Infection Control and Hospital Epidemiology.  The Compendium contains practical strategies for preventing the six most significant hospital-acquired infections in acute-care hospitals.  The strategies include recommendations for first- and second-tier infection control practices – ones which should be adopted by all acute-care hospitals in all cases, such as hand hygiene, and others that might need to be employed in the event of certain outbreaks.  The six hospital-acquired infections that are the focus on the Compendium are:

 

• Methicillin-resistant staphylococcus aureus (MRSA)
• Clostridium difficile infections (C-diff)
• Central-line associated bloodstream infections
• Ventilator-associated pneumonia
• Catheter-associated urinary tract infections
• Surgical-site infections

The report was sponsored by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).  Partners in the work were the Association for Professionals in Infection Control (APIC), the Joint Commission, and the American Hospital Association.  The Joint Commission also announced that it would be considering adoption of the strategies into its accreditation standards and patient safety goals.