USC's Unlikely Victory Over a Killer Bacteria

By Janet Cromley, Los Angeles Times Staff Writer

These days, USC's football players might seem more like fussy disciples of the TV detective Monk than scrappy athletes. They use paper towels on the practice field and at games, and they shower before setting foot in the training room. Their laundry is washed at a constant 140-degree temperature, which is regularly monitored. Portable cold therapy tubs are drained and cleaned after each use, and the team brings its own soap to away games.

That's because while racking up wins in the 2003 and 2004 seasons, the players and trainers were also facing down a different type of adversary -- a potential killer known as MRSA, methicillin-resistant staphylococcus aureus.

S. aureus is a common strain of bacterium, often found on the skin and in nasal passages, that can cause infection if it enters the body through a cut or scrape. Although it can be easily treated with antibiotics, methicillin-resistant strains don't respond as readily to common antibiotics and thus can be difficult to eradicate once infection takes hold.

The strain of MRSA that infected the USC athletes was a community-acquired strain, as opposed to a hospital-acquired strain, which means that it occurred in otherwise healthy people who hadn't been hospitalized. The bacterium, which can lead to disfiguring skin infections, is generally passed along through skin-to-skin contact but can linger in showers, on towels and on exercise equipment.

The Trojans' MRSA battle -- two hospitalizations in 2002, followed by 11 confirmed cases as well as six suspected cases in 2003 -- was highly publicized at the time. By 2004, though, MRSA at USC was a nonstory.

Why? Because as USC nears the midpoint of the 2007 season as one of the top 10 winningest Division 1 schools in history, it is also winning the MRSA battle. In the 2004 season through this year, the football team has logged only two cases in total.

USC's response to the MRSA outbreak has been quite extraordinary, says David Klossner, NCAA director of education services. "Their staff recognized the situation, took steps to eradicate spreading of the infection and added monitoring measures on a scale that was not commonly found in the athletics setting."

The story of what USC did to fight MRSA is a valuable lesson and a cautionary tale not only for those who play team sports but also for anyone who has swapped sweat on a community exercise machine.

Caught off guard in 2002The year 2002 was a bad one for CA-MRSA infections. "In 2002, we investigated four outbreaks of community MRSA, which included USC," says Elizabeth Bancroft, medical epidemiologist with the L.A. County Department of Public Health.

"We also investigated an outbreak in a newborn nursery, among men who have sex with men and at the L.A. County Jail, which is still the largest facility outbreak reported in the nation," she says.

Caught off guard by the outbreaks, the Health Department scrambled to get the word out, issuing fact sheets to consumers and medical professionals on how to prevent the spread of the bacterium, documenting the outbreaks in medical newsletters and journals and initiating surveillance programs at county hospitals. The National Collegiate Athletic Assn. also stepped up to the plate, developing educational outreach programs for coaches and trainers involved in team sports. "We took a look at the problem and knew it wasn't going away," Klossner says.

Following the outbreaks at USC, which occurred at about the same time as outbreaks at a fencing club in Colorado and among high school wrestlers in Indiana, the NCAA launched a series of initiatives. It created a MRSA website to educate players and coaches, updated its sports medicine guidebook, which is available online, and sent prevention posters to its member institutions.

The state of fitness centersFitness centers, on the other hand, have not exactly rallied to the cause.

If health clubs are doing anything extra to curb MRSA transmissions, they're not talking about it. Officials at Bally Total Fitness, the Sports Club/LA, Gold's Gym and Crunch Fitness either didn't return repeated calls or declined to comment. But in fairness, no one really knows what danger fitness clubs may pose in the transmission of the bacterium.

Although health officials assume that some cases are transmitted through communal use of equipment and towels, it's nearly impossible to prove that because of the long incubation period of the bug. "People will call us at the Health Department, and say, 'I know I got this skin infection because I went to this gym,' but it's almost impossible to know for certain," says Bancroft. "It could be that they were exposed through their child at school." Cedric Bryant, chief science officer for the American Council on Exercise, acknowledges that there's a reasonable danger of contracting something in a gym. "A set of dumbbells can be a hotbed for common bacteria as well as the handrails on the aerobic equipment, bikes and stair climbers." Nevertheless, he says, "you don't want to be a germaphobe, but following basic hygenic principles should minimize the risk."

Reducing risk of contracting MRSA at the gym and elsewhere is a simple matter of adopting common sense hygiene routines that can be found on the county's public-health website, says Bancroft. "None of these guidelines are rocket science," she says. "Wash your hands. Keep things clean. Follow directions. They're things you learned from your grandmother or in kindergarten."

The problem in generalIt's impossible to know just how many people contract MRSA each year because physicians and medical facilities aren't legally required to report it, but according to Bancroft, the numbers are soaring.

"Countywide, MRSA is the new normal for causing skin and soft-tissue infections," she says. "In fact, it's becoming one of the most prevalent causes of skin soft-tissue infection in emergency rooms." Bancroft believes that about 50% to 60% of people who come to the county emergency rooms with a skin infection have CA-MRSA, based on reports from local county hospitals. These figures vary 15% to 75% across the nation.

In addition, CA-MRSA -- which previously has been confined to the homeless, men who have sex with men, and prison inmates -- has effectively moved out of those risk areas, and now essentially anyone is at risk, says Dr. Paul D. Holtom, hospital epidemiologist for LAC+USC Medical Center and associate professor of medicine and orthopedics at USC Keck School of Medicine.

Holtom, who was consulted extensively on USC's MRSA outbreak, has seen CA-MRSA in basketball and volleyball players, but not to the extent that he's seen it in football players. "Why football players are vulnerable is not well explained," he says. "They have more scrapes on the field, but basketball players, for example, have a lot of physical contact too."

What USC didTo combat MRSA, USC developed and implemented an aggressive plan of attack based on Health Department guidelines that included eliminating towel sharing; using alcohol-based hand sanitizers; using 3% hexachlorophene (Phisohex) or 4% chlorhexidine, intermittently, in the shower soap dispenser; eliminating multiuse lotions and gels with pump dispensers; spraying equipment with disinfectant throughout the day; boosting water temperature in the laundry facility and increasing drying temperature of towels to 180-190 degrees; examining all suspicious lesions; and administering antibiotics to players who are colonized with CA-MRSA. This final move is somewhat controversial, as some public health officials fear the use of antibiotics in this context could increase resistance in the CA-MRSA bug.

Football players and other athletes who engage in vigorous exercise for 90 minutes or more, such as cyclists and swimmers in hard training, appear to be at greater risk for contracting CA-MRSA because of the exercise, says David C. Nieman, an exercise immunologist at Appalachian State University in Boone, N.C.

"The immune system of a marathon athlete after a race is very similar to what you'd see in an elderly person. But it's transient; it lasts about a day."

Nieman, who led a study of 2,300 L.A. marathoners in 1990 that showed a steep increase in upper respiratory tract infections among the athletes one week after the marathon, doesn't believe that fitness facilities are doing enough to educate staff and customers about the dangers of MRSA.

"All it's going to take is some fitness facility having an outbreak, and the whole fitness facility community is going to have to respond to that with improved prevention practices to keep it down."

Despite the precautions that USC took to control its MRSA outbreak, it's hard to say which changes were most responsible for the improvement.

Nevertheless, "it's a safe assumption that the measures USC took caused the decrease," says Holtom.

USC's head athletic trainer, Russ Romano, who spearheaded USC's effort to control MRSA, believes that all of the infection control measures USC undertook were important.

Certainly USC has set the bar higher for everyone else. After a recent talk on MRSA at a conference for athletic trainers, Romano was besieged with questions from coaches, trainers and educators.

"We still have to be very vigilant," he writes in an e-mail. "The problem is very prevalent in our community as well as all over the country. The battle is not over."

For When a Doctor and a Nurse Just Aren't Enough

By Judy Foreman

The most valuable asset for coping with today's medical system may be an adult family member - preferably one who is well educated, tactful, feisty, and unemployed.

It's helpful to have someone at your bedside in the hospital to make sure overworked nurses notice if your vital signs are going downhill or to ensure that the right medications are given at the right time. It's good to have someone who can get on the Web and research your disease. And it's important to have someone to take notes during doctor visits and ask the questions you forget. But since many of us don't have the perfect family member handy, so-called patient advocates are eagerly leaping into the breach.

Some advocates have minimal medical training; others are nurses and doctors. Some charge nothing; others thousands of dollars. Some advocates might help save your life; others may complicate patient-doctor communication.

It's so early in the life of this new profession that it's not entirely clear what an advocate is or how to judge whether you've found a good one. There is no regulatory body that oversees or licenses patient advocates, just some people, companies, and, now, colleges that see a need.

So far, the only school that offers a master's degree in patient advocacy is Sarah Lawrence College in Bronxville, N.Y. At the University of Wisconsin Law School, criminal defense lawyer Meg Gaines, a former ovarian cancer patient, has started the Center for Patient Partnerships to train doctors, nurses, lawyers, and others to help patients research their diseases, find doctors for second opinions, and get insurance coverage. And at the University of North Carolina at Chapel Hill, Jo Anne Earp is creating a set of courses to teach patient advocacy as a career.

The very idea that patients would need an outsider to lobby for them inside a hospital is anathema to many doctors and nurses, who feel passionately that they are already advocates for patients, doing their best to get patients the care they need.

Moreover, many hospitals actually have staff members hired specifically to be patient advocates -- folks who try to straighten out miscommunications between families and doctors and field complaints about bad food, parking, and the like. Massachusetts General Hospital, for instance, has three such advocates.

Still, in some situations, there is a need for yet another layer of patient advocacy.

If you're in the hospital, for instance, and want more-constant monitoring than staff nurses can readily provide, you might consider hiring a private-duty nurse, said Diana Mason, editor-in-chief of the American Journal of Nursing. She hired one recently for the first 24 hours after her sister-in-law had surgery.

The nurse acted as a ''surveillance system," Mason said, frequently checking blood pressure, watching for bleeding, and generally making sure that the sister-in-law did not become a case of ''failure to rescue" - someone who deteriorated or even died because early signs of problems were not addressed.

Hospitals often have registries of private-duty nurses to choose from, and some staff nurses are grateful for an extra pair of eyes and ears, Mason said. Insurers won't pay, but if you can afford it, the cost - $250 a day in Mason's case - may be worth the peace of mind and a chance for family members to get some sleep. If a fully trained nurse is more than you need, you can also hire a ''sitter" to keep an eye on a patient, who might be in danger of pulling out tubes or falling out of bed.

In other situations, what you may need is a doctor willing to dig into the research your regular doctor may not know about. There aren't many of these folks around - yet - but one of the pioneers is Dr. Gwendolyn Stritter, who runs a telephone -based advocacy practice in the San Francisco Bay area.

Stritter, an anesthesiologist, got fed up with the fast-paced practice she had been in and branched out five years ago into clinical advocacy. She charges $300 for an initial two-hour appointment, then a sliding scale after that. Most of her clients are cancer patients. She reviews their medical records, combs six to eight online physician databases to find the latest research, then talks to the researchers who've done the studies. She also attends major cancer conferences with her patients in mind.

Carolyn Greenspon, 37, a Newton social worker and mother of two, was also happy to have used a patient advocate when her 4-year old son became sick last summer. ''I am a pretty good advocate myself," Greenspon said. But her son had awakened hysterical after a colonoscopy under general anesthesia. (Agitation is common in children when anesthesia wears off.) When he needed a second one, Greenspon begged the doctors and nurses to sedate him better after anesthesia. She felt her efforts failed when her son became hysterical again.

She then turned to PinnacleCare, a service based in Baltimore that charges as much as $15,000 for an initiation fee plus a $10,000 annual fee for a range of services for a family. Pinnacle's advocate, Teresa Lepore, said she got the chief of pediatric anesthesiology to make sure ''everyone at the hospital knew this was important."

From Greenspon's point of view, it worked -- the nurses carefully managed her son's medication and he did not become hysterical after the third colonoscopy.

But the boy's physician, Dr. Jeffrey Biller, a pediatric gastroenterologist at Massachusetts General Hospital, was less thrilled. The multiple calls from PinnacleCare personnel put an extra burden on his office staff, he said. ''Putting a third party in who is not directly involved in patient care actually complicated the situation and made it more difficult."

Bottom line? If you've got a Wonder Woman, or Wonder Man, to help you get what you need from the medical system, count your blessings. If not, consider hiring a private patient advocate. There's a chance that adding yet another person to the mix may complicate your communication with nurses and doctors. But it could also help get you the care you need.

We Pay for Medical Errors

Healthcare acquired infections fall under the category of medical error. Here's an interesting article by Richard Lord and Dr. Marylou Buyse published on September 12, 2007 ...

What your mechanic forgot to replace the lug nuts after changing one of your tires and you got into a serious accident when the wheel came off? You wouldn't expect your mechanic to send you a bill for the repairs, would you?

Unfortunately, that's what happens in healthcare and we pay a high price for mistakes. Eight years have passed since the Institute of Medicine's landmark study, "To Err is Human," which found that as many as 98,000 patients die each year in America's hospitals as a result of medication overdoses, postsurgical infections, and other medical errors. These are preventable deaths, yet medical mistakes cause more deaths than car accidents, breast cancer, or AIDS.

Even when mistakes are not fatal, they can still have devastating results. They can lead to injury, disability, extended hospital stays, or lengthy recoveries. And we often pay twice when errors occur - once for the mistake and again to correct it. Nationally, the cost of preventable medical errors, lost income, and lost productivity is estimated at $17 billion to $29 billion a year.

Employers bear a large part of that expense. In Massachusetts, more than four out of every five insured individuals under the age of 65 receive coverage through an employer. So when preventable errors occur, it is businesses that pay.

Take, for example, routine bypass surgery, which can cost more than $50,000. When a sponge or a surgical instrument is left inside the patient, correcting the mistake can add tens of thousands of dollars to the cost of caring for that individual. These errors should never happen, but are far too frequent and, ultimately, employers are left paying the bill through higher health and disability premiums.

Medical care in Massachusetts is the most expensive in the country - $7,075 per resident is spent every year, compared with the national average of $5,313. Healthcare costs are increasing three times faster than the annual rate of inflation, and the quality of care can vary between and among healthcare facilities.

On many measures, Massachusetts healthcare providers and medical institutions are the envy of the world, but we can do more to improve the quality of care in the state. We can start by raising the bar higher, through public reporting of medical errors and by removing the financial benefit when serious mistakes occur.

Legislation to require public reporting of medical errors that will be heard by the Legislature's Public Health Committee today is a good place to start, and many in the healthcare system have been working to make that information available. Still, we can go farther. The legislation should be revised so that providers are not allowed to bill for the extra costs of treating preventable errors, injuries, and infections that occur in hospitals.

Healthcare entities should not be rewarded financially when such preventable errors occur. Hospital-acquired infections offer one example. An August 2007 report by the state's Betsy Lehman Center for Patient Safety and Medical Error Reduction found that infections contracted during a hospital stay could be causing up to $473 million in medical costs annually in Massachusetts. Meanwhile, there are hospitals around the nation that have driven their infection rates down to zero.

Prohibiting billing for so-called "never events" is another example. These are rare but serious medical errors that should never happen to a patient, such as conducting surgery on the wrong body part, leaving a foreign object in a patient after surgery, or patient death or serious injury resulting from a medication error.

While healthcare facilities currently are required to report major medical incidents to the state, these reports are not readily available or useful to the public. In 2005, the state's Board of Registration in Medicine issued a report that found that healthcare facilities reported 24 never events the prior year, but did not identify the institutions, leaving both patients and the healthcare system unaware where these mistakes occur. We need stronger measures in place to prevent these errors from continuing to happen.

No other industry generates revenue from mistakes. Preventable errors should not be part of the usual cost of healthcare.

Richard Lord is president and CEO of Associated Industries of Massachusetts. Dr. Marylou Buyse is a practicing primary care physician and president of the Massachusetts Association of Health Plans.

© Copyright 2007 Globe Newspaper Company.

Majority of Hospitals Unprepared Survey Says

WASHINGTON, D.C. -  Eighty-seven percent of U.S. hospitals surveyed by the Leapfrog Group do not have all of the recommended policies in place to prevent many of the most common hospital-acquired infections (HAIs), according to findings issued today. The results are from an analysis of 1,256 hospitals that participate in the Leapfrog Hospital Quality and Safety Survey, an annual rating system that provides an up-to-the-minute assessment of a hospital’s quality and safety practices.

Each year as many as 2 million people – one out of every 20 who obtain care at an American hospital – contract an infection during their care; 90,000 of them die. On average, HAIs add more than $15,000 to a patient’s hospital bill, amounting to more than $30 billion a year wasted on avoidable costs.

The Centers for Medicare and Medicaid Services (CMS) announced on Aug. 18 that the Medicare program will no longer provide reimbursement for the additional costs incurred when beneficiaries experience certain hospital-acquired conditions, such as certain infections. 

The Leapfrog Survey asks hospitals about their practices related to the prevention of four common infections: aspiration and ventilator associated pneumonia; central venous catheter related bloodstream infection; surgical site infection; and influenza (staff vaccination against the flu). The survey also asks about handwashing, which can impact the rates of several different kinds of HAIs. For each of these areas, the survey inquires about a hospital’s efforts on infection surveillance (tracking the frequency and severity of the infection in question), whether management is held accountable for preventing the infection, the hospital’s level of investment in improving its ability to reduce the preventable infection, and whether it is taking further action to detect and prevent the infection.

The Leapfrog Group, representing major corporations and public agencies that buy health benefits, finds an alarmingly low level of full compliance with any of its recommended standards for preventing certain avoidable infections.

The following is the percentage of hospitals with full compliance with preventive practice according to infection type:

-- Aspiration and Ventilator Associated Pneumonia: 38.5 percent

-- Central Venous Catheter Related Bloodstream Infection: 35.4 percent

-- Surgical Site Infection: 32.3 percent

-- Influenza: 30.7 percent

Of note, just 35.6 percent of hospitals have full compliance with hand hygiene practices.                                                                                       

Herb Kuhn, deputy administrator at CMS, stated, “A continued focus on hospital acquired infections provides critical information as both public and private purchasers implement payment policies to provide incentives for improvement in this area.”

Jill Berger, chair of The Leapfrog Group and vice president of health and welfare for Marriott International, Inc., stated, “There are protocols that every hospital should have in place to prevent infections. Unfortunately, many hospitals are missing the mark and that spells trouble for everyone: the patient, the hospital and the healthcare system.”

“Leapfrog’s hospital survey helps identify significant shortcomings in hospitals’ practices to reduce preventable infections. The healthcare system needs now to agree to standardized measures to assess the frequency and impact of preventable infections. Without such measures, it will be difficult to identify the best ways to put an end to hospital-acquired infections,” stated Suzanne Delbanco, CEO of The Leapfrog Group.

A full analysis of the data gathered from this year’s Leapfrog Hospital Quality and Safety Survey will be released on Sept. 18.

Source: The Leapfrog Group  


New Medicare Regulations Adopted to Reduce HAIs and Medical Errors

WASHINGTON, D.C. SEPTEMBER 2007 - Under new Medicare regulations, hospitals will no longer receive higher payments for the additional costs associated with treating patients for certain hospital-acquired infections (HAIs) and medical errors. The new rules will give hospitals a powerful new incentive to improve patient care, according to Consumers Union, the nonprofit publisher of Consumer Reports.

“Every year, millions of Americans suffer needlessly from preventable hospital infections and medical errors,” says Lisa McGiffert, director of Consumers Union’s Stop Hospital Infections campaign. “These new rules are a good beginning for Medicare to use its clout to mobilize hospitals to improve care and keep patients safe.”

Under the rules adopted by the Centers for Medicare and Medicaid Services (CMS), payments will be withheld from hospitals for care associated with treating certain catheter-associated urinary tract infections (UTIs), vascular catheter-associated infections, mediastinitis after coronary artery bypass graft (CABG) surgery and five other medical errors unrelated to infections (bed sores, objects left in patients’ bodies, blood incompatibility, air embolism and falls). The new rules will go into effect in October 2008.

To comply with a 2005 law passed by Congress, CMS evaluated a number of serious, preventable healthcare-acquired conditions and identified these eight for the first round of non-payment due to the high volume of patients affected, the high cost of treating patients and the existence of prevention guidelines. The agency intends to consider other HAIs and medical errors for non-payment in future years.

The new Medicare regulations include protections to prevent hospitals from billing patients when payments are withheld and to minimize avoidance of patients perceived to be at risk for infections.

“We are pleased that the rules clearly state that hospitals cannot bill patients for the amount that Medicare refuses to pay,” McGiffert adds. “CMS will need to make sure these protections are enforced so patients are treated fairly. And the agency should be on the lookout for hospitals that try to game the system by falsifying codes to avoid nonpayment.”

Catheter-associated urinary tract infections are the most common infection developed by patients in hospitals. The Centers for Disease Control and Prevention (CDC) has reported that there are 561,667 catheter-associated UTIs per year. According to a study in the American Journal of Medicine, the annual cost of UTIs in hospitals is as much as $451 million.

Bloodstream infections are high in volume and cost and are preventable. The CDC has reported that there are 248,678 cases of central line associated bloodstream infections every year. The Institute for Healthcare Improvement (IHI) estimates that approximately 14,000 people die every year from central line-related bloodstream infections.

According to Consumers Union, CMS failed to address the incidence of infections caused by methicillin-resistant Staphylococcus aureus (MRSA). According to CMS, more than 95,000 Medicare patients had MRSA infections in 2005, running up hospital charges of almost $3 billion. MRSA was not selected for nonpayment because of coding issues and because CMS does “not believe there is a consensus among public health experts that MRSA [infection] is preventable.”

“CMS needs to take strong action to curb the spread of this powerful superbug,” McGiffert emphasizes. “Many hospitals do not share the attitude that MRSA infections cannot be prevented and CMS should be on the front lines with them fighting this deadly and costly problem.”

HAIs are a leading cause of death in the United States. CDC estimates that 2 million patients suffer from hospital infections every year and nearly 100,000 of them die. Research shows that hospitals could prevent many infections through stricter adherence to proven infection control practices. The financial costs associated with hospital infections are equally staggering.

John A. Jernigan, MD, chief of interventions and evaluations at the CDC, has said that HAIs result in up to $27.5 billion in additional healthcare expenses annually. Medicare foots the bill for a big portion of infectionrelated healthcare costs. A 2005 report by the Pennsylvania Health Care Cost Containment Council found that Medicare was billed for 67 percent of the total number of patient infections reported by the state’s hospitals.

“Taxpayers spend billions of dollars every year covering the cost of patient infections,” McGiffert says. “Restricting Medicare payments for medical errors like patient infections will help ensure that the healthcare taxpayers pay for is safe and effective.”

Source: Consumers Union