Squashing the super bug
A year before a new reporting law takes effect, Virginia hospitals are beefing up defenses against hospital-acquired infections

by Marjolijn Bijlefeld and Robert Burke
for Virginia Business
May 2007

When it comes to germs, methicillin-resistant Staphylococcus aureus is the “big bad one.” It spreads easily, and can kill, even in a hospital setting. A typical attack begins when bacteria enter a patient’s body through a central line or catheter. Then the deadly invader may trigger an infection in the bloodstream or a surgical wound, or a nasty bout of pneumonia.

Each year about 1.7 million patients get a hospital-acquired infection in the U.S. and 99,000 people die, according to the Centers for Disease Control and Prevention. In Virginia in 2005, 957 hospital patients were identified as having infections related to medical care, and nearly 6 percent of them died in the hospital, according to Virginia Health Information. (The data doesn’t distinguish between infections acquired during a hospital stay and those present upon admission.)

Besides the danger, the financial cost is high. On average, the drug-resistant bacterial infection (usually referred to by the acronym MRSA) adds $30,000 to the cost of patient care, says Dr. Mark Werner, executive vice president and chief medical officer for Carilion Clinic, a Roanoke-based physicians’ group that operates eight hospitals in Southwest Virginia.

Patients who develop staph infections require intensive treatment. It’s not unusual for some patients to need additional hospital stays and surgeries, which drives up health- care costs even more — costs born in part by employers.

For the past several years, health-care providers in Virginia and around the country have been trying to crank up their vigilance in preventing hospital-acquired infections. In fact, there’s a growing movement among the states to require the reporting of these infections. Fourteen states are already recording this data, and Virginia will join their ranks in 2008.

Another change late that year is sure to be an incentive for hospitals to beef up defenses: The federal centers for Medicare and Medicaid Services plan to pay hospitals no more for the care of patients who develop a hospital-acquired infection than for patients who don’t develop one.

Carilion is not waiting until then to take action. In April, the health-care system started a new protocol: skin swab tests for patients at risk of carrying staph germs. Until fairly recently, the conventional wisdom was that MRSA mostly lived inside hospitals or nursing homes. But researchers have found that many people carry colonies of the bacteria on their skin even though they have no infection. What that means is that anyone who walks in the door might be carrying the bacteria and could spread it easily, essentially infecting them and others during a hospital procedure.

That’s why Carilion wants to detect the bacteria early. It is checking high-risk patients — anyone admitted to intensive care, or transfers from other hospitals or nursing homes, for example — for the bacteria with a simple skin-swab test that detects MRSA antigens. In about three hours, hospital staff will know if the patient carries the bacteria. If so, “we begin proper isolation procedures, meaning we use gown and glove precautions in that patient’s room, thereby preventing the spread to others in the hospital,” says Werner.

The new tests will cost about $200,000 a year, but it’s worth it, he says. “We think if we can prevent 25 percent of the MRSA-related infections, our savings will exceed $1 million a year.”

What’s happening in Roanoke is a compelling example of a nationwide trend as hospitals move from quality assurance to quality improvement. “When the focus was on quality assurance, hospitals were monitoring to see whether they were below a threshold, but those thresholds were not always particularly aggressive,” notes Werner. “They were often based on national averages for similar kinds of hospitals. Starting about three years ago, we began to say, ‘Wherever we are now, we need to be better.’”

When reducing infection rates, there are two strategies, according to Dr. Richard P. Wenzel, professor and chair in the Department of Internal Medicine in the VCU School of Medicine and president of the International Society for Infectious Diseases. The first involves technology; the second requires a change in behavior on the part of caretakers.

A central line catheter — an IV for long-term use — with antibiotics chemically bonded on it represents a technology-assisted improvement. “In clinical trials, these catheters resulted in a 70 percent to 90 percent reduction in infections,” says Wenzel.

With central line catheters, the national average rate of infection is 5 per 1,000 catheter days, resulting in nearly 50,000 patients developing dangerous bloodstream infections per year, Wenzel wrote in an editorial in the Dec. 28, 2006, issue of The New England Journal of Medicine.
At VCU Medical Center, these catheters are used for patients in the critical-care unit. Hospital procedures also call for other changes, such as putting the catheter in under the collarbone instead of in the groin area — where there are more bacteria.

To foster behavioral changes, Wenzel says hospital administrators can implement a zero-tolerance policy for skirting infection-control procedures, such as hand-washing, sterilizing equipment, and using gloves and masks with infected patients. “Ten years ago, even critical-care units reported hand-washing compliance of about 45 percent to 50 percent. People couldn’t see the outcome from a break in technique,” he says. In other words, not every instance of unwashed hands resulted in an infection. “Now, there should be zero tolerance. It’s unacceptable behavior not to wash hands,” he says.

That slow evolution shows that change does not happen quickly in medicine.

It can take years before processes shown to work in clinical trials become standard practice in hospitals. But the pace seems to be picking up as hospital data and processes become more transparent and as more people are involved in assuring that safety practices are met.

In his editorial, Wenzel discusses a team-based approach to infection control. Under that model, any member of the care-giving team is empowered to point out a lapse in infection control. “You don’t assign blame. You just start over. It used to be that someone might notice something, but think it’s too minor to worry about,” he says. Now, any member of the team can point out the lapse, and the process starts over, with sterile surgical kits and fresh gowns and gloves.

Wenzel even encourages his patients to take an assertive approach. “Before anyone touches you or your catheter, you have the right to say, ‘Wenzel said to wash your hands.’” Some patients are too shy, but others appreciate being able to play some part in their safety.

By next year, patients will have another way to look out for their own safety. A Virginia law that takes effect in July 2008 will require most hospitals to begin recording and reporting infection rates. Under the proposed regulation now working its way through the review process, the law would apply to acute-care hospitals with adult intensive-care units. Instances of bloodstream infections associated with the use of a central-line infusion device would be reported to the CDC’s National Healthcare Safety Network, which would tabulate the data and give it to the Virginia Department of Health. The department would then make that data available to the public upon request.
Reporting only central-line bloodstream infections sounds like a relatively narrow category, since infections can be caused by other kinds of contact as well. But targeting infections associated with central lines makes sense.

hey’re widely used, are relatively simple to track, and the associated infections are dangerous and warrant the attention, says Janis Ober, infection control practitioner at VCU Medical Center. It is “where you can make the most improvement,” she says.

Some state laws go further than Virginia’s in terms of gathering and publicizing data. Pennsylvania, for example, passed legislation in 2003 requiring data collection on 14 categories of infections.

In a report last November — the first of its kind in the country — Pennsylvania reported that 19,154 patients contracted hospital-acquired infections at 168 hospitals, or a rate of 12.2 per 1,000 cases. The figures covered the 2005 calendar year.

Other key findings: The mortality rate for Pennsylvania patients with a hospital-acquired infection was 12.9 percent versus 2.3 percent for patients without an infection. The average length of stay was 20.6 days compared to 4.5 days. The difference in the average hospital charge was substantial as well: $185,260 compared to $31,389. In terms of private-sector insurance reimbursements, the average payment for a case with a hospital-acquired infection was $53,915, while the average payment for a patient without such an infection was $8,311.

In a statement released with the report, Marc Volavka, executive director of the Pennsylvania Health Care Cost Containment Council, said, “It’s time that hospitals, patients and those who pay the bills know how many patients develop hospital-acquired infections, the type of infections they develop, and the quality and cost implications.”

While proposed regulations for Virginia aren’t as broad as the ones in Pennsylvania, if done right, says Ober, they will provide more reliable data than what consumers have access to now. Plus, they will be useful for consumers trying to gauge the safety record of a particular hospital. Others point out that insurance companies will use the data, and hospitals will be able to see how they fare against similar facilities.

However, the value of the information to the public might be limited, because it doesn’t necessarily tell someone how well a hospital does at preventing infections. “Our concern is that there is a lot of variety between hospitals because of the kind of patients they see and the kind of medical services that they provide that would lead to differences in rates,” says Diane Woolard, director of the division of surveillance and investigation with the Virginia Department of Health. Additionally, she adds, less than a third of infections are actually preventable. “A lot of them are not … People think it boils down to hand washing. It’s more complicated than that.”

Carilion hospitals have been among the few, if not the only, hospitals in Virginia to publicly report their infection rates in advance of the new reporting requirements. “We see no reason to not be open and transparent. We’re happy for patients to know that we acknowledge there is room to improve,” says Werner. The rates vary at six Carilion hospitals, from a low of 0.26 percent per 100 patients to a high of 3.4 percent per 100 patients.

For medical consumers, however, it may not be as simple as comparing numbers. The information hospitals are required to report to various agencies is often filled with jargon and nuance. Even so, Werner says “consumers… gain because of the increased attention to improving patient safety and quality.” Doctors like him are hoping that, in this case, they’re starting something that will be contagious.