How can hospitals prevent infections?
Protecting patients from getting an infection while hospitalized isn’t just about sanitizing surfaces and washing hands. It’s also about making wise choices when it comes to antibiotics.
Clostridium difficile infections — causing a sometimes-deadly diarrhea — are closely tied to antibiotic use. These infections have the opportunity to attack a patient when antibiotics kill off the good germs in a patient’s gut that would normally combat C. difficile.
Hospitals across Georgia now have “antibiotic stewardship” programs designed to reduce C. difficile infections. These programs also combat the threat of “super bugs” — the growing number of infections that do not respond to antibiotics.
Up to half of the antibiotics prescribed are either unnecessary or aren’t prescribed correctly. The stewardship programs are designed to push doctors to handle antibiotics more wisely. Reducing the use of high-risk antibiotics by 30 percent can lower deadly diarrhea infections by 26 percent, the CDC says.
In 2012, state public health official created a statewide program focused on antibiotic stewardship.
Health officials want to make sure that every hospital has the best possible approach to antibiotic use. Part of those programs require educating patients, who often push doctors to give them an antibiotic even when it’s not the right choice.
“Patients should be good about listening to clinicians when they are explaining that you probably don’t need an antibiotic,” said Dr. Michael Bell, of the CDC. “Clinicians need to take the time to explain why something is not necessary and what the alternative is.”
Digging deep
Today’s report on healthcare-associated infections is the latest in a series of Atlanta Journal-Constitution scorecards on hospital performance. The AJC has explored ER wait times, quality statistics for joint replacement and hospital CEO salaries and bonus programs for metro Atlanta hospitals in recent months. Over the past two years, the AJC has also regularly explored infection control records for area hospitals. In today’s report, the AJC is sharing some brand new performance measures related to Clostridium difficile infections and drug-resistant staph infections. This report also includes the latest scores on other types of infections that the AJC has explored. The Atlanta Journal-Constitution is committed to holding hospitals accountable when it comes to quality of care. These reports push our hospitals to improve and help our readers make informed choices as healthcare consumers.
The toll of healthcare-associated infections
- Deaths and illnesses: There were 722,000 healthcare-associated infections in U.S. hospitals in 2011, according to CDC estimates. About 75,000 patients with infections that were picked up while receiving care died during their hospitalization.
- The money: The treatment of healthcare-associated infections costs between $28.4 and $33.8 billion annually. Treating Clostridium difficile infections alone costs at least $1 billion a year, according to the CDC.
Have you or a family member acquired an infection while at the hospital? We'd love to hear about it. Email our reporter, Carrie Teegardin, and tell us what happened: cteegardin@ajc.com.
Eighteen hospitals across Georgia — including some of the state’s most highly regarded healthcare facilities — rank among the worst in the nation for rates of life-threatening bloodstream infections, surgical site infections, a dangerous diarrhea or other serious conditions that patients can pick up while hospitalized for something else.
Atlanta’s Piedmont Hospital stood out for high rates in two types of healthcare-associated infections, according to an Atlanta Journal-Constitution study of federal data. One was for Clostridium difficile, a bacterial infection included in the federal reports for the first time amid growing concerns about its threat to patient safety.
Georgia Regents Medical Center in Augusta also stood out for relatively high rates in two categories.
Five other metro Atlanta hospitals — including WellStar Kennestone and Emory University Hospital — posted relatively high rates in one category: urinary tract infections associated with catheters.
Some of the same hospitals called out for a poor performance on some types of infections were also lauded for low rates in other categories. In fact, Emory University Hospital stood out for some of the best rates nationally in two of the six categories that are tracked in the public reports. [See infection scores for metro Atlanta hospitals.]
Hospitals across Georgia are heavily focused on infection control and closely study their own data to track how they’re doing. Yet while most support public reporting, some say that using the public rates for hospital-to-hospital comparisons should be done with caution.
“It’s like when you go to a restaurant, and they have the little score on the wall. That’s a relatively small snapshot that may not tell the whole story,” said Dr. Leigh Hamby, Piedmont Healthcare’s chief quality officer. “If you’re going to have surgery at our place, or any place, talk to the surgeon about infection concerns they may have or what things they see that are being implemented. Bring the data and say, ‘What do you think about this?’”
Grim diagnosis
Patients place their trust in doctors and hospital staff to treat their cancer, keep their hearts pumping, repair their broken bones or remove a raging appendix before it has a chance to burst. But on a typical day, 1 in every 25 hospital patients is battling an infection caused by the care they hoped would make them better — not worse.
One in nine of the patients who gets an infection dies during their hospitalization, according to the Centers for Disease Control and Prevention.
Even patients who survive a serious infection they pick up in the hospital sometimes deal for the rest of their lives with the consequences of a nurse’s unwashed hands, a hospital’s unsanitized floor or a doctor’s inappropriate antibiotic prescription.
Take Dave Bartel. He rushed to the emergency room in 2012 with lung problems. He left weeks later — without his colon.
Bartel had lung surgery at DeKalb Medical, but he was having difficulty recovering while in the ICU. His doctors figured out why: He had picked up a Clostridium difficile infection. Bartel needed another surgery to stop the infection, and doctors said removing his colon was the only option.
“It was very grim,” said Ardys Bartel, Dave’s mother.
When they got the diagnosis, the Bartels were like most Americans. They’d never heard of C. difficile. But this germ was very much on the radar of infectious disease specialists and the CDC. It has become the most common germ causing health care-associated infections, slightly eclipsing even the more widely-know Staphylococcus aureas — or staph infections.
Across the nation, C. difficile infected 107,000 hospitalized patients in 2011, according to the CDC. “That is a huge number,” said Dr. Michael Bell, an expert in infection prevention and patient safety at the CDC.
Almost every C. difficile infection is linked to getting health care. Although many cases result only in a few days of diarrhea, the infections can escalate, as they did in Bartel’s case.
The CDC estimates that at least 14,000 deaths a year are tied to the infection.
Dave’s parents asked for a hospital chaplain to help them deal with his dire prognosis. One quickly arrived and helped the family get focused. “She said ‘Let’s take one day at a time. Right now, we just need to pray for Dave and his recovery,’” Ardys remembered.
That’s what they did, and day by day after the colon surgery, Dave got better. Dave said he spent about six weeks in the hospital and then went home, 50 pounds lighter and without much strength, to recover. He learned to adjust to his altered digestive system. About six months later, he had another surgery at DeKalb that allowed him to get rid of an external bag that had been put in place to handle the waste from his intestines.
Bartel’s parents spent weeks by his bedside getting to know his doctors. They were impressed by them and don’t blame the hospital for what happened. The AJC’s study of federal reports found that DeKalb Medical’s C. difficile rate is in line with the state average and below national benchmarks.
But Dave, whose life will never be the same, can’t help but wonder: Could this have been prevented?
“I feel lucky to be alive,” Bartel said. “I guess that means God is not done with me yet. But I’m disappointed that this has to happen to people.”
A success story
Federal health officials have placed hospitals on notice that they must change the way they do business and sharply reduce the number of infections that patients contract while in the hospital.
To measure progress and to apply pressure for improvement, federal health officials in 2011 required hospitals to start reporting infection rates for one type of infection in hospital ICUs.
The Centers for Medicare & Medicaid Services started publishing the infection rates a year after the reports started rolling in.
Now hospitals must report six infection measures.
“When we have data, we are able to drive change,” said Bell, of the CDC. “When facilities, the public and payers all have access to this information, we find there is good attention that is brought to the issue and all three groups can work together to improve the situation. We want to share the data so that action can be taken.”
The biggest success story in infection prevention has been in bloodstream infections associated with a tube that doctors place in a patient’s large vein for treatment. These often deadly central line infections decreased 44 percent from 2008 to 2012, the CDC reported.
In Georgia, these infections decreased by 33 percent, state public health officials said.
Battling other problems has been more difficult, with little progress being shown in cases of hospital-onset C. difficile and MRSA.
Gail Deckard, a retired nurse from Cartersville, discovered how an infection acquired as a result of surgery can change a patient’s life.
Deckard underwent surgery to repair her shoulder, which had a torn rotator cuff. Within days, she noticed post-op pain that did not seem normal.
“They decided to take a look at it,” she said. “Puss was just oozing out of the incision.”
It was MRSA, which causes infections that often do not respond to antibiotics. She underwent two additional surgeries and two courses of IV antibiotics lasting four to six weeks before the infection was finally stopped.
After all that, she was worse off than when she started, with the rotator cuff repair undone and with frequent pain and the inability to reach anything high, including the microwave above her stove.
“It’s a pretty horrible thing,” she said. “I wish I had left it alone.”
Conflicting treatments
One of the challenges for hospitals is that for every type of infection, there’s a different plan of attack, and some can even conflict with one another.
For example, surgical site infections can be limited by using antibiotics. But antibiotic use can also leave patients vulnerable to C. difficile. Using catheters helps patients avoid getting out of bed to go to the bathroom, but the longer the tubes stay in place the higher the risk of infection.
There’s a different set of protocols associated with each plan of attack and constantly-changing hospital staff has to do the right thing every time to keep infection rates low.
That’s why it’s not unusual to see hospitals make significant strides combating some types of infections while still struggling with others.
Emory University Hospital, for example, is posting strong results for controlling bloodstream infections associated with central lines in ICU patients. It also stands out nationally for lower rates of surgical site infections related to colon surgery. But like many large hospitals in Georgia and across the nation, its results for catheter-associated urinary tract infections were lagging, the data show.
Georgia Regents Medical Center, the teaching hospital associated with the Medical College of Georgia in Augusta, has one of the best records in the state for controlling bloodstream infections associated with central lines. But the hospital stands out for high rates when it comes to catheter-associated urinary tract infections and surgical site infections for abdominal hysterectomies.
Need to improve
Hospitals always quibble about publicly reported infection rates. Some with higher rates say the “risk-adjustment” models do not adequately compensate for the number of complex cases in their patient mix.
Piedmont Hospital said a recent outside study found that it had some of the sickest patients in its hospital of any similar-size non-academic medical center in the nation. The adjustments that the CDC gives to academic medical centers to account for complex patients wouldn’t apply at Piedmont.
In addition to relatively high rates reported for C. difficile and catheter-associated urinary tract infections, Piedmont’s rate for bloodstream infections associated with central lines is about twice the Georgia average, according to the most recent public data. Hamby said new processes allowed Piedmont Healthcare to cut its central line infection rate in half over the past year.
The first six months of data for MRSA bloodstream infections show a relatively high rate at Emory Saint Joseph’s. That rate was driven by five cases, but the hospital said two of those were improperly reported and have been corrected.
Although hospitals want consumers to take the public infection reports with a grain of salt, most readily acknowledge that they need to do better. “We absolutely have opportunities,” said Hamby, of Piedmont Healthcare.
For some people, a health care-associated infection is just an unpleasant memory of a few extra days in the hospital. For others, it’s the event that led to the death of a mother, a grandfather or even a child.
Deckard, who got the MRSA infection after surgery, was told by her doctor that they would never know exactly how she got her infection. But she wants doctors and nurses to do more, so that fewer patients find out what she did: A hospital can actually make your health worse than it was when you walked in the door.
While she doesn’t know what the hospital’s infection rate is, she said she knows what it should be: “Zero.”
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