Redness, pain, and drainage from the skin around a catheter. Bloody, cloudy, or pungent urine and mental confusion. Severe diarrhea and a dilated colon: The potential symptoms of some of the most common hospital-acquired infections in the United States aren’t particularly pleasant.
The numbers don’t paint a pretty picture, either.
One widely cited study estimates that the nation’s hospitals report 1.7 million healthcare-associated infections (HAIs) every year, along with nearly 100,000 associated deaths.1 All told, the additional healthcare costs could tally $30 billion or more annually, according to a 2009 Centers for Disease Control and Prevention (CDC) analysis. Though some bright spots have emerged, healthcare advocates, including Kevin Kavanagh, MD, MS, FACS, director of Kentucky-based patient advocacy group Health Watch USA, contend that the overall size of the problem is likely underestimated. And unless brought under control, he says, emerging pathogens could make a bad situation worse.
The incredible variety of healthcare settings precludes any across-the-board solutions for hospitalists and other care providers. A recent survey of more than 1,200 healthcare professionals from 33 hospitals, however, revealed some common themes. According to the study authors, the data show that “hand hygiene is consistently identified as the greatest barrier to reducing HAIs, and that sustaining the necessary behavioral change to overcome this barrier is difficult.”2 In fact, the study highlighted a widespread belief that medical staff, and doctors in particular, are not fully engaged or in compliance with HAI reduction efforts. “The data suggest that physicians often do not adhere to protocols and guidelines; moreover, some respondents questioned whether many physicians are open to change,” the authors wrote.
So what can hospitalists do to help their colleagues embrace a culture of positive change and turn back a worsening healthcare epidemic? If simple answers are in short supply, studies aimed at central-line-associated bloodstream infections, catheter-associated urinary tract infections, and Clostridium difficile infections have at least highlighted some keys to a successful intervention.
In Focus: Central Lines
Central-line-associated bloodstream infections (CLABSIs) arguably have received the most attention of any HAI. Not coincidentally, most researchers point to the anti-CLABSI effort as the high point in the struggle to reduce infection rates.
In a landmark 2006 study led by hospitalist Peter Pronovost, MD, more than 100 ICUs in Michigan nearly eliminated CLABSIs over an 18-month period.3 The “remarkably successful” intervention, according to its authors, focused on changing provider behavior through education and collaboration with infection-control specialists. Nationwide, a recent CDC study estimated that absolute CLABSI numbers in ICUs dropped to 18,000 in 2009 from 43,000 in 2001, a 58% decline.4
Sheri Chernetsky Tejedor, MD, SFHM, assistant professor in the division of hospital medicine at Emory University School of Medicine in Atlanta, points out a major caveat in CLABSI prevention efforts, however: To date, she says, most have targeted insertion practices and ICU patients, which do little for the more than half of CLABSIs that occur on hospital wards. These wards thus represent “a ripe opportunity for intervention, especially the low-hanging, ‘low tech’ interventions of removing unnecessary devices,” she says.
Among a small random sample of patients with temporary central venous lines (CVCs), including peripherally inserted central catheters (PICCs), a study led by Dr. Chernetsky Tejedor found that 25% of all CVC days were “idle.”5 In other words, in 1 out of every 4 CVC days, the catheter was retained despite failing to meet standard justification criteria. In particular, the study suggested that PICCs were associated with longer catheter use and more idle days, fueling her group’s suspicion that increased PICC availability has changed CVC use patterns.