A Winnable Battle


Research shows infection prevention warnings often are ignored. The best defenses: sterile gowns, gloves, hands washed with soap and water, and cleaning with bleach.

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.

The study suggested that PICCs were associated with longer catheter use and more idle days, fueling Dr. Chernetsky Tejedor’s group’s suspicion that increased PICC availability has changed CVC use patterns.

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.

Among her group’s interventions, a patient safety checklist has been built, with questions about catheter use entered into a daily electronic progress note used by all services on the inpatient wards. One particularly successful strategy empowered nurses to determine whether continued catheter use seems justified and to ask physicians whether an “idle” CVC could be removed.

With a decline in CLABSI rates in ICUs and a shift in focus to the medical wards, Dr. Chernetsky Tejedor says, hospitalists are in a prime position to help reduce the inappropriate use of catheters and other invasive devices. More broadly, hospitalists may be well-suited to help change the culture of medicine toward a wider acceptance of proven interventions, such as central-line checklists.

Dr. Kavanagh argues that the slow and arduous process to move past what he calls “a huge resistance to checklists” and win universal adoption of such protocols “is not a good chapter in medicine.” He isn’t laying the blame at the feet of doctors alone, however. “In some institutions,” he says, “there needs to be a change from a profit-driven to a patient-centered culture.”

Greg Maynard, MD, MSc, SFHM, director of the University of California at San Diego Center for Innovation and Improvement Science and senior vice president of SHM’s Center for Hospital Innovation and Improvement, acknowledges the integral role of checklists in improvement efforts. He cautions, however, that they should be viewed as only one part of a multipronged approach.

As with hand hygiene, Dr. Maynard concedes that some facilities are still facing resistance from medical staff in integrating checklists into their routines, though he argues that an ingrained anti-checklist medical culture may not be solely at fault. “If you insert a checklist in such a way that it’s very inconvenient, that stops the flow of work,” he says, “you’re not going to have as much success as if you’ve thoughtfully designed it so that the checklist is called into play when it makes sense to bring it into play and made it easy to do, as opposed to difficult and awkward to do.”

In Focus: Catheter-Associated UTIs

Catheter-associated urinary tract infections (CAUTIs) account for roughly 1 in 3 healthcare-associated infections, according to the CDC. And yet many researchers say the “Rodney Dangerfield of HAIs” has long been overlooked.

A frequently cited study led by Sanjay Saint, MD, MPH, FHM, professor of internal medicine at the University of Michigan and the Ann Arbor VA Medical Center, found that nearly 40% of attending physicians were unaware that their patients even had an indwelling urinary catheter.6

Dr. Saint has dubbed the phenomenon “immaculate catheterization” to highlight the glaring discrepancy. “Because we also found, in a significant number of patients, there was no documentation anywhere in the medical record that the catheter existed,” he says. “It’s not in the physician’s notes, it’s not in the nursing notes, but we knew it was there because we could see it coming out of the patient.” Catheters that were inappropriately placed, he found, were more often “forgotten” than appropriate ones.

Perhaps more than anything else, the startling observation underscores the intense need for basic awareness of the two biggest UTI risk factors: whether a catheter is used, and how long it’s left in place. “You can get marked reductions by just taking care of those two factors,” Health Watch USA’s Dr. Kavanagh says.

At the Ann Arbor VA Hospital, one unit’s presence of a “Patient Safety Professional” to help ensure better oversight virtually brought the inappropriate use of indwelling catheters to a standstill. Dr. Saint and his colleagues are now gathering data to determine whether that decrease has translated to a drop in infections.

If you insert a checklist in such a way that it’s very inconvenient, that stops the flow of work, you’re not going to have as much success as if you’ve thoughtfully designed it so that the checklist is called into play when it makes sense to bring it into play and made it easy to do, as opposed to difficult and awkward to do.

—Greg Maynard, MD, MSc, SFHM, director, University of California at San Diego Center for Innovation and Improvement Science, senior vice president, SHM Center for Hospital Innovation and Improvement

One fundamental key, he says, is paying close attention to whether a catheter is really in the patient’s best interests. “If we ask that question—‘If this was my family member, what would I want?’—we usually do the right thing,” Dr. Saint explains. Another key is leveraging the hospitalist’s core skill in communicating often and well with nurses to ensure that they are in sync during the “team sport” of CAUTI prevention.

With pockets of success in reducing inappropriate catheterization, the larger question now is how to scale up the individual interventions to achieve nationwide reductions. “How do you take what will work in one hospital, given its culture and microculture, and then apply it to hospitals across the state, or even across the country?” Dr. Saint asks.

Karen Clarke, MD, MS, MPH, a hospitalist and assistant professor of medicine at Emory University Hospital in Atlanta, is in the midst of tackling such issues. Using a bundled approach that included four interventions, she and colleagues reduced CAUTI rates by 70% at 276-bed West Georgia Medical Center in La Grange, Ga.7

The interventions were straightforward and inexpensive, Dr. Clarke says, meaning that they could be widely applied. “The only thing is that there has to be a champion overseeing the interventions to make sure that the steps are followed through on,” she says. Even at cash-strapped facilities, then, a similar approach could prove effective as long as someone assumes responsibility—and hospitalists would be a natural choice.

Based on her study’s promising results, Dr. Clarke hopes to begin implementing the intervention in at least one other hospital starting Jan. 1. If the success can be replicated, she says, the CAUTI-reduction protocol will branch out to include more regional hospitals.

In Focus: C. Diff-Associated Disease

Even as many hospitals are improving their CLABSI and CAUTI rates, hospital-acquired Clostridium difficile infections appear to be getting worse, particularly among older patients. In some facilities, the potentially fatal, diarrhea-causing microbe is now the top pathogen (see “Gut Reaction,” December 2011).

With a timely intervention, however, Kaiser Permanente Medical Center in Santa Clara, Calif., cut its own infection rates by one-third.8 In brainstorming how to improve the medical center’s rates, Susanne Mierendorf, MD, MS, FHM, a hospitalist and associate residency program director for internal medicine, joined colleagues in thinking through the barriers for healthcare providers. “It wasn’t ‘Why don’t they follow the infection-control guidelines?’ It was, ‘Why can’t they?’” Dr. Mierendorf says.

The thought exercise led to some eye-opening observations, including the realization that disposable gowns, gloves, and other personal protective equipment weren’t in the room and were hard to find. To help establish habits, Dr. Mierendorf’s team picked a consistent drawer in each patient’s room to stow the equipment and instructed that a wall-mounted holder be filled with gloves at all times.

The researchers also realized that the rooms of patients with suspected or confirmed C. diff infections had warning signs that were too simplistic at first, then overly wordy. Both were being ignored. The solution was simple signage with yellow color-coding and easily recognizable symbols that readily conveyed the infection-control message to staff: sterile gowns, gloves, hands with soap and water, bleach. Those messages were reinforced through a brief, simple, and mandatory educational module for all hospital workers who might come into contact with the patients.

National Implications

On a national scale, hospitalists have helped compile other educational packets and toolkits to address the spectrum of HAIs, from ventilator-associated pneumonia to methicillin-resistant Staphylococcus aureus (MRSA).

More help may be forthcoming through the American Hospital Association’s Health Research and Education Trust. The broad-based effort, funded by the federal Agency for Healthcare Research and Quality (AHRQ), is partnering with SHM and other professional societies to implement small HAI-reduction successes on ever-wider scales. The University of Michigan’s Dr. Saint, for example, is a key partner in the trust’s national initiative to reduce CAUTI rates and improve patient safety.

How do you take what will work in one hospital, given its culture and microculture, and then apply it to hospitals across the state, or even across the country?.

—Sanjay Saint, MD, MPH, FHM, professor of internal medicine, University of Michigan, Ann Arbor

Medicare has rolled out its own collection of carrots and sticks to address the problem. The largest carrot, the public-private Partnership for Patients, has joined with SHM, other professional societies, and roughly 3,000 hospitals, so far, and set the ambitious goal of reducing hospital-acquired conditions by 40% by the end of 2013, compared with 2010 tallies. Although applauding the program’s overall goals, physicians, including Dr. Maynard, are taking a wait-and-see attitude, pointing out that many of the details have yet to be ironed out.

Among the sticks, Medicare has begun withholding reimbursement payments for such HAIs as CLABSIs and CAUTIs. Due to intricacies in how hospitals bill under the current DRG system, Dr. Kavanagh says Medicare’s nonpayment policy has recouped relatively little money from its first full year: about $18.8 million in all.

“The policies that cover public reporting, however, do have much more of an impact,” he says. “It’s more of a perceptual sting. Believe me, it is more concerning to have data of bad results that are available to the public than to be penalized by the current financial incentives.”

Other financial policies could carry considerably more weight. The threat of nonpayment for hospital readmissions, Dr. Maynard says, “totally changed the game” by intensifying efforts to reduce those rates, addressing contributing factors such as HAIs in the process. In combination, he says, public accountability through mandated reporting plus financial penalties could prove more powerful than either tactic alone.

Regardless of how federal policy plays out, experts say a new era of accountability and transparency is on its way. As the champions of positive change, hospitalists have a distinct opportunity to help lead the way and bring about a culture that consistently embraces effective interventions—before things get really ugly.

Bryn Nelson is a freelance medical writer based in Seattle.


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