AAMC Reporter: November 2007

Teaching Hospitals Battle Hospital-acquired Infections

By Barbara A. Gabriel, special to the Reporter

At a time when surveys and reporting agencies are indicating that the majority of hospitals are failing to prevent hospital-acquired infections, many teaching hospitals have been working hard to reduce them.

A recent survey of 1,256 hospitals conducted by the Leapfrog Group found that only 35.4 percent followed recognized guidelines for reducing venous catheterrelated bloodstream infections (CRBIs), which, as their name suggests, occur when hospitals use contaminated catheters, creating an infection that can lead to potentially serious complications and costly additional treatments. However, hospitals like Beth Israel Medical Center in New York have used a series of very simple measures to virtually eliminate their cases of CRBIs.

Brian Koll, M.D., chief of infection control at Beth Israel, explains that his team of certified infection control practitioners began their efforts to eliminate CRBIs in 2004, when the hospital experienced 9.1 infections per 1,000 line days.

"We were chugging along in terms of reducing the infection rate, but things were not going as quickly as we would have liked," said Koll.

Published studies showed that when five simple precautions were taken—practicing proper hand hygiene, maximizing barrier precautions during insertion, prepping the patient's skin properly, placing the line in the chest rather than the groin, and removing the line as soon as it was no longer necessary—infection rates plummeted.

Such steps sound simple, but Koll's team knew that consistently practicing these precautions would take an interdisciplinary effort involving everyone from house staff to nurses to physicians. And so they identified nursing and physician "champions" of the protocols, trained nurses to become the "police force" for enforcing the measures, regularly evaluated compliance, and provided feedback and a sense of "ownership" in departments over their numbers of infection-free days. Telethon-style thermometer posters measured the number of days a unit remained infection-free, and milestones were rewarded with gold stars and coffee shop coupons.

Under the new procedures, hand hygiene compliance reached 100 percent within two weeks. To maximize barrier precautions when inserting lines, "insertion bundles" (essentially, a series of precautionary steps and related materials bundled together) were created along with a 12-step checklist to be followed in succession, so that all the materials that physicians and nurses needed were immediately at hand.

In 2005, CRBI infections at Beth Israel per 1,000 line days dropped to 2.8. In 2006, the number was 1.1, and in 2007, it stands at 0.4. An original cost outlay of $37,500 to create the bundles and implement the training has translated into a cost savings of $1.3 million and an estimated 12 lives saved.

Like Beth Israel, the 10-hospital North Shore-Long Island Jewish Health System has implemented the five precautions defined by Koll and the bundle approach to reduce its CRBI rates. By consistently applying these protocols, its bloodstream infection rate has dropped from 3.15 (per 1,000 line days) in 2005, to 1.97 in 2006, to 1.68 through June 2007. Joseph Conte, senior vice president of quality management at North Shore, said his team acts as an "auditing force," continually monitoring compliance with its checklist of tasks that composes the "bundle" approach. Each time a line is inserted, the checklist is used and then placed in the patient's record.

Members of Conte's team make unannounced visits to ensure that all items are checked off and sometimes to directly observe line insertions. He said the perception that CRBIs are an inevitable by-product of inserting central lines has changed.

When there are occasional spikes in infection rates in one of North Shore's hospitals, Conte said his auditing team typically sees a variance within the bundle protocol. Trish Perl, M.D., the senior hospital epidemiologist at the Johns Hopkins Hospital and an associate professor of medicine and pathology at Johns Hopkins Hospital University, said her institution likewise usually sees deviations from such protocols when an infection is detected.

"When we dissect what happened in the rare infection events that we now have," said Perl, "I can't tell you how many times the checklist wasn't filled out."

Noting that the new approach to eradicating such infections entailed "old hat stuff that had just not been emphasized as important," Perl, like Conte, said that positive reinforcement through transparent data and the designation of initiative leaders for individual units contributed to the hospital's success.

Each of the above hospitals is also busy combating a more insidious type of infection—so-called "superbugs," antibiotic-resistant bacteria that are finding their way into hospitals across the country. One of the best known of these "bugs," Methicillin-resistant Staphylococcus aureus, or MRSA, is a potentially deadly, community-acquired antibiotic-resistant staph infection. The University of Pittsburgh Medical Center (UPMC's) Presbyterian Hospital launched a "huge effort" to reduce MRSA infections in its ICUs in 2002, says Carlene Muto, M.D., director of hospital epidemiology and infection control.

Muto said the hospital's initiative to battle the infection began in the medical ICU with the highest MRSA infection rate. Her office helped the hospital create an infrastructure that included implementing the fastest possible identification of bacteria carriers and training staff to intervene in real time to take the most effective barrier precautions to prevent spreading. The rate of MRSA infections in that ICU dropped from 3.8 cases per 1,000 patient days in 2001, to 2.7 in 2002, to 0.5 in 2003. In 2006, the rate of infection dropped to 0.4, and Muto said they have been able to sustain that rate.

Modeling the success of their most susceptible ICU and applying it to UPMC Presbyterian's seven additional ICUs, and then to all UPMC hospitals, Muto said the system-wide rate in fiscal year 2007 stood at 0.6.

"We have 160 ICU beds at Presbyterian," Muto said, "so we know if we can do it, anyone can."

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