Keeping Patients Safe
What hospitals are doing to prevent infections from within
The last thing health care should do is make you sicker. But patients being treated for an injury or illness can all too often end up with a healthcare-associated infection (HAI)—an infection from microorganisms associated with their treatment.
These infections are no small problem. Researchers cited by the Centers for Disease Control and Prevention estimate that 1.7 million HAIs and 99,000 associated deaths occurred in the United States in 2002 alone. Some 200,000 such infections occur in Texas each year, with 60 percent thought to have been preventable. Also called nosocomial infections, HAIs affect about one in every 20 hospitalized patients. Some may just extend the patient’s hospital stay, while others are much more serious. Taken together, HAIs add up to a heavy burden for patients and families, as well as costing hospitals tens of billions of dollars annually. Worried about this trend, health care leaders affiliated with the U.S. Department of Health and Human Services created in 2009 a National Action Plan to Prevent Healthcare-Associated Infections. All 50 states have created individual HAI prevention plans, with Texas receiving some $1.2 million from the 2009 federal stimulus bill to tackle the problem.
Risks with modern medicine
We all know we can get an infection from a sneeze, a dirty surface, a handshake. This happens in hospitals just as they do in other public places. Health care carries an extra risk, because modern medical techniques themselves can put patients at risk for an HAI. Ventilators or breathing machines, for example, are a crucial tool for effective critical care. But people on ventilators are liable to inhale bacteria they can’t cough out, raising the risk of ventilator-associated pneumonia. Similarly, even though a Foley catheter lets urine leave the body, it can also usher in bacteria, leading to a catheter-associated urinary-tract infection. Life-saving antibiotics can reduce healthy bacteria in the gut, allowing bad bacteria like Clostridium difficile to multiply and cause illness like diarrhea. Other common HAIs include surgical site infections, central line-associated bloodstream infections and infections from drug-resistant bacteria.
“You have the perfect combination of bad things happening in a hospital,” says Luis Ostrosky-Zeichner, MD, professor of internal medicine and epidemiology at The University of Texas Health Science Center at Houston (UTHealth) Medical School. “You have populations that are susceptible to infection. You have people with active infections within the hospital, which are usually complicated, multi-drug-resistant organisms. You have people undergoing a lot of life-saving procedures. And then you add human behavior to the mix. All these elements together can create the perfect storm to transmit infection within a confined space.”
Taking preventive steps
The good news is that medical professionals nowadays have a much better understanding of HAIs than they once did. In 1847, a doctor in Vienna named Ignaz Semmelweis noticed that new mothers in the wards staffed by doctors and medical students were dying of postpartum infections at a much higher rate than those staffed by midwives. Suspecting that this had something to do with the fact that doctors went directly from autopsies to deliveries, he established a stringent handwashing policy. The result was a drastic (10-fold) drop in postpartum infections. Unfortunately, handwashing took decades to catch on, in part because Semmelweis was working long before anyone knew that infections were caused by microorganisms. By the late 19th century, scientists had firmly established the germ theory of disease, and they began to devise ways to control infection.
That’s easier said than done. Some microorganisms can survive alcohol hand gels and standard cleaning techniques, while others can dodge antibiotics. Some produce toxins. Some provoke the immune system to attack with a scorched-earth ferocity that winds up hurting the patient. Keeping ahead of these enemies calls for a wide range of strategies, and the learning process begun more than 100 years ago continues today.
“The field of infection prevention or hospital epidemiology has dramatically changed in the past 10 years,” says Ostrosky-Zeichner. Before then, he says, hospitals mainly encouraged handwashing and monitored the rate of HAIs. But today, infection control leaders are tightly focused on prevention, and they’re taking the battle to the bedside like never before. “We now take active steps to prevent these things,” says Ostrosky-Zeichner, “and don’t leave it to chance or goodwill.” In particular, he says, hospitals are using checklists called “infection prevention bundles.” Each bundle lists evidence-based practices for doctors and nurses to follow during patient care. Combined with oversight to ensure these checks are followed through, the bundles provide a powerful way to reduce HAI rates.
For instance, here is the checklist for placing a large IV into a central vein: Providers are reminded to wash their hands; wear sterile gown and gloves; put on cap and mask; drape the patient head to toe; choose the optimal antiseptic and the site of the body with the lowest possible infection rate. And once the line’s in, the clock is ticking. “We’re also using a tool where physicians are prompted to evaluate lines every day on their patients to decide if the line is needed or not,” says Ostrosky-Zeichner.
Similarly, the risk of pneumonia for patients on breathing machines can be reduced by measures like placing the head of the bed at an angle and by suctioning secretions from the patient’s mouth. And the checklist for preventing surgical site infections includes dosing the patient with the correct antibiotic within an hour before the incision is made, carefully maintaining the patient’s normal body temperature, and maintaining optimal blood-sugar levels, even in non-diabetic patients.
None of this is left to memory or good intention. Hospitals actively check to make sure these guidelines are followed, and many make themselves publicly accountable. Both Medicare and large insurance companies can use such information to penalize or reward hospitals. Since 2008, many hospitals have reported results of their self-monitoring on a monthly basis to the CDC’s National Healthcare Safety Network, where the public can review the results on HospitalCompare.hhs.gov. (Health care facilities in Texas are also required by law to report selected HAIs to the Texas Department of State Health Services.)
Another tool hospitals can use to control HAIs is the antibiotic stewardship program. Antibiotics are powerful weapons against harmful bacteria, but if they’re not used with utmost care, bacteria can evolve to resist them. So hospitals have taken to overseeing practitioners’ decisions about antibiotics. Pharmacists and infectious-disease specialists study how bacteria in that hospital are reacting to antibiotics—a pattern that varies from place to place and from year to year—and then create guidelines for the optimal use of antibiotics. The stewardship team also reviews practitioners’ antibiotic orders to make sure they are optimal. They may suggest a better drug or even stop a course of antibiotics when they are no longer needed.
Similar to airport security checkpoints, hospitals can look for dangerous bacteria hiding on people entering the hospital. Many people are carriers of Methicillin-resistant Staphylococcus Aureus (MRSA), a drug-resistant form of the common skin bacterium Staphylococcus aureus, which can live quietly in some people’s bodies without necessarily flaring up into infection. Those people, called carriers, can pass MRSA on to patients with weakened immune systems, placing those patients at risk for serious MRSA infections. One research team, of which Ostrosky-Zeichner was a part, screened incoming patients for the bug, then placed carriers in isolation rooms during their hospital stays. “We can see dramatic drops in the rates of in-house transmission of MRSA by doing that,” he says.
There are even new ways to clean hospital rooms. After it has housed a patient with a hazardous bug, a room must be cleaned even more thoroughly than usual. To check for that degree of clean, infection-control specialists can dust the room with an invisible fluorescent powder. After the housekeeper has cleaned the room, any areas that were not effectively cleaned will show up under a black light. Another method: sealing off a room and releasing hydrogen peroxide vapors by remote control. That sterilizes every surface. “The way you clean in hospitals really makes a big difference,” says Ostrosky-Zeichner.
Early detection is crucial
When infections do develop, jumping on them early is key. Again, easier said than done. For one thing, not all infections are obvious. When doctors suspect infection, they have traditionally found the culprit bug by culturing it, or encouraging it to grow in the laboratory until it can be identified. But that can take days or weeks, so practitioners typically rely on guidelines to make a good guess about which bug is at fault and which treatment is best. Though largely reliable, that strategy can cause problems—especially in cases where the treatment itself is risky. Ostrosky-Zeichner is among a group of specialists that is developing state-of-the-art blood tests, or markers, to pick up some types of infections sooner. That way doctors can treat them early and with greater confidence. “We've been developing all sorts of strategies that allow you to identify very high-risk patients that may benefit from what we call empirical or preemptive treatment,” he says. “The moment you have a positive signal [rather than waiting for culture results] you start treating them.”
The cornerstone of infection control is still the same thing that Semmelweis ordered: handwashing. Hospitals expend a great deal of effort urging people to clean their hands, and strategically placed alcohol gels make it easier to remember (as a bonus, they don’t dry out the skin). A little surveillance comes in handy: “Secret shoppers” who assess handwashing are now common in most hospitals.
Strategies like these work. The Centers for Disease Control and Prevention recently reported a dramatic drop in central line-associated bloodstream infections in ICU patients—from 43,000 in 2001 to only 18,000 in 2009, a decrease of 58 percent. That’s due in part to strict adherence to guidelines like the ones described above, as well as a culture of patient safety that is gathering momentum in the health care industry.
Thanks to all this vigilance, there is reason to hope that HAIs will continue to dwindle in American hospitals. “Being in a hospital today is much safer than being in a hospital 10 years ago,” Ostrosky-Zeichner says. “It's definitely a top priority for every hospital to do this right and to do it well.”