Sharp Rise In Skin Infections In U.S.

ScienceDaily (July 29, 2008)

A national analysis of physician office and emergency department records shows that the types of skin infections caused by community-acquired MRSA doubled in the eight-year study period, with the highest rates seen among children and in urban emergency rooms.

The study, conducted at the University of California, San Francisco, examined annual data from the National Center for Health Statistics of patient visits for skin and soft-tissue infections from 1997 to 2005. The results appear in the July 28, 2008 issue of the Archives of Internal Medicine. During that time period, office and emergency room visits for all skin infections rose from 8.6 million nationwide to 14.2 million, according to Adam Hersh, MD, PhD, lead author on the paper and a fellow in the divisions of general pediatrics and of pediatric infectious diseases at UCSF.

The vast majority of that increase was attributable to visits for abscesses or cellulitis, which Hersh called the hallmark signs of infections from the variety of staph bacteria known as MRSA, or methicillin-resistant Staphylococcus aureus. Those infections rose from 4.6 million to 9.6 million during the study period. “This shows that community-acquired MRSA infections are occurring nationwide and affect all subsets of the population,” Hersh said. “But there clearly are some subsets that are disproportionately affected, such as children.“

The increase was predominantly seen among children and among patients who visit emergency rooms in urban areas at so-called safety net hospitals. Those are hospitals in which at least half of the patients receive Medicaid or are uninsured. From 1997 to 2005, the number of visits for abscesses or cellulitis nearly quadrupled in safety-net emergency departments, from 1.3 people per 1,000 total population to 4.9. Among children, the incidence nearly tripled from 10.1 patients per 1,000 children to 27.6. By contrast, incident rates among patients older than 45 rose less than 50 percent, from 27.9 to 41.3 patients per 1,000 adults in that age group.

By comparison, the number of patients who sought medical care for any skin infection rose from a rate of 32.1 to 48.1 visits per 1,000 people during the same period. Previous studies at UCSF and other urban medical centers have indicated that MRSA had begun to spread outside hospital settings in the late 1990s, but until now, no one had been able to verify those suspicions with hard data or to indicate the extent of MRSA nationwide, Hersh said. There also was no way of assessing whether the rise was due to population shifts or to people visiting emergency rooms instead of family physicians.

“This validates what San Francisco physicians have been suspecting for several years,” says Henry Chambers, MD, a co-author of the study and UCSF professor of medicine at San Francisco General Hospital. “This is the first national report to look at the impact of MRSA on public health nationwide.” Chambers is lead scientist of a large multi-centered clinical trial recently funded by the National Institutes of Health to study treatment of community-acquired MRSA infections.

While the rate of this rise is dramatic, public health researchers say these infections can be limited with simple behavioral changes in hygiene. “This is certainly a cause for increased awareness among clinicians and the public nationwide, but it is not cause for alarm,” said Erica Pan, MD, MPH, a UCSF assistant professor of pediatric infectious diseases and a medical epidemiologist at the San Francisco Department of Public Health. Pan was not involved in this study, but works frequently with the UCSF team on MRSA research.

“A simple way to avoid these and many other infections is to practice good hygiene habits, such as routine hand-washing with soap and water, as well as by covering open cuts and wounds when participating in sports or other activities involving skin-to-skin contact with other people,” she said. “If you notice that you or your child has a skin infection that does not seem to get better on its own after a few days, consult a medical provider.”

The study also found a shift in prescribing practices among physicians seeing these patients. The number of prescriptions written for medications effective against MRSA infections more than tripled over the study period. At the start of the study, less than 8 percent of antibiotics prescribed nationwide for skin infections were those effective for MRSA infections. By 2005, 28 percent were in that category.

“We had anticipated seeing a rise in office visits for abscesses due to the emergence of community-acquired MRSA, but we were somewhat surprised by the rapid changes in antibiotic prescribing,” Hersh said. “It is evidence of growing awareness of community-acquired MRSA nationwide among physicians.”

Hersh acknowledged that the data, which is the most recent available, is too old to show what is happening right now, or even last month, but does confirm that the emergence of community-acquired MRSA in the 1990s led to a rapid increase in the number of patients with skin and soft tissue infections nationwide. It also raises opportunities for further research, including determining the risk factors for developing an abscess and how best to care for patients with recurrent infections, he said.
Ralph Gonzales, MD, MSPH, a professor in the UCSF departments of medicine and of epidemiology and biostatistics, is the senior author on the paper. It was co-authored by Judith H. Maselli, MSPH, also with UCSF.

The research was supported by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Positive Deviance Reducing MRSA

The Positive Deviance Initiative (PDI) and Plexus Institute collaborate to reduced MRSA infection in hospitals.

Hospital Acquired Infections (HAI) kill an estimated 90,000 people in US hospitals every year. These individuals enter the hospital to address specific health problems, and die from an infection that directly results from their stay in the hospital.

Methicillin-resistant Staphylococcus aureus (MRSA) is one on the most lethal of the HAIs.

In August 2005 the PDI began collaborating with the Pittsburgh VA hospital (VAPHS) to utilize PD to address the problem of MRSA. The PD approach enabled the hospital to reduce MRSA infection by an estimated 50%.

To learn the steps they took to accomplish the reduction in infections, go to:

She Expected Routine Surgery - But Not Flesh-Eating Bacteria

Two years later, Alicia Cole says she's still recovering from her experience at Providence Saint Joseph. The hospital says it ranks 'above average' in the state for surgical infection prevention.

By Rong-Gong Lin II, Los Angeles Times Staff Writer

On Aug. 15, 2006, Alicia Cole entered Providence Saint Joseph Medical Center for a routine surgery -- removing noncancerous growths from her uterus. Several days after the procedure, it was clear something was wrong.

The actress' abdominal area was red and swollen. She had a temperature of 103 degrees. At one point, the inflamed incision site oozed a brown fluid. A hospital record dated Aug. 21, 2006, said Cole had a postoperative wound infection, according to a state report.

But it would take four more days before doctors made a presumptive diagnosis that she had necrotizing fasciitis, better known as flesh-eating disease, according to the state report. On Aug. 25, she underwent the first of five surgeries to remove dying flesh and infected tissue.

"All this area was on fire," Cole said, pointing at her abdomen. "I was being eaten alive." The diagnosis of flesh-eating bacteria -- an infection that destroys muscles, skin and underlying tissue -- was confirmed on Aug. 31.

"They took me back and strategically cut apart my abdomen and left butt cheek to the point where I basically looked like a shark attack victim," said Cole, now 46. "I had a big cavernous hole where the center of my body was."

A friend of Cole's filed a complaint with the California Department of Public Health regarding the hospital's infection control practices. Cole later followed up, and state health officials visited the medical center Oct. 10, 2007, to examine hospital records involving her case.

The state later cited the hospital for failing to report the case to the Public Health Department, which requires that any "unusual occurrence" that threatens the health of patients be reported to public health officials.

State inspectors also wrote that the hospital failed to follow its policy on monitoring and controlling hospital-acquired infections. They said a review of the minutes from the hospital's infection control meeting held on Aug. 22, 2006, showed no discussion of Cole's postoperative infection.

In a written response to the state, hospital officials said they would report such cases to public health authorities in the future. They also said staff discussions on Cole's illness were held at her bedside.

Hospital officials declined to talk specifically about Cole's case, but said no other patients contracted necrotizing fasciitis when she was in the hospital. They said they sympathize with patients who acquire infections while at the hospital, adding that the facility ranks as "above average" in the state for "surgical infection prevention."

Nonetheless, hospital officials said they are beefing up oversight of infection control issues.

In the meantime, Cole, who has had roles in movies and television shows, is still recovering from her wounds and suing the hospital.

Ideally, she said, hospitals should be required to report infection rates to the public. She supports such efforts in the state Legislature; similar efforts died last year along with the proposed comprehensive overhaul of California's healthcare system.

"If you go to a restaurant, you can decide where you want to eat by looking at the letter grade in the window," Cole said. "I would like to see that for hospitals."

Hospital's Blood Stream Infections Down to Zero

By Anne Federwisch

Ever since her article on achieving zero catheter-related blood stream infections (CRBSIs) appeared in the Journal of the Association for Vascular Access (JAVA) in December 2007, Sophie Harnage, RN, BSN, has become very popular.

“I get calls and e-mails daily from everywhere throughout the country,” says the clinical manager of infusion therapy services at Sutter Roseville Medical Center (SRMC) in Roseville, Calif. “People asking me specific questions about the team, how many members, how long you’re there, what catheter do you use — many different types of questions.”

Her popularity is not surprising, due to the magnitude of the problem in terms of patient outcomes and financial costs, as well as the nationwide focus on hospital-acquired infections. The Centers for Disease Control and Prevention (CDC) estimates there are at least 250,000 cases of CRBSI annually, with an associated attributable mortality rate of 12% to 25%, and a cost of $25,000 to $56,000 per infection. Reducing CRBSIs was a target of the Institute for Healthcare Improvement’s (IHI) 100,000 Lives Campaign, which was underway when Harnage started building her bundle, and has been folded into the IHI’s updated 5 Million Lives Campaign.

Harnage’s bundle builds on best practice models from around the country, CDC and IHI recommendations, an extensive literature review, and new product technology. In her JAVA article, she cites the specific rationale for each particular practice in her bundle, which varies for each of the seven steps.

Other practitioners’ intense interest also stems from the facility’s impressive results. Before SRMC developed the bundled practices, the hospital recorded 11 CRBSIs in 2005. However, in the two years since implementation, there have been no infections on any of the more than 4,000 PICC lines that have been inserted using the sequence of seven practices (see sidebar).

Notably, during the 15-month period of time chronicled by Harnage’s article, PICC insertions increased by 103%, while interventional radiology referrals decreased to less than 2%. Patients are sent to interventional radiology if an anatomical blockage prevents the nurse from threading the catheter completely through, because a radiologist can bypass the blockage. “I don’t know what the industry standard is, but I wouldn’t be surprised if it’s 30% in other areas,” says Deborah Dix, RN, MS, director of cancer services at SRMC.

What’s the secret?

And their success can be replicated, Harnage notes. “It’s not rocket science,” she says frequently.

The key to success is the use of a specially trained team of nurses to insert PICCs, instead of other non-tunneled central venous catheters, using the bundle and following up on the patients throughout their stay. Team members must complete a course on ultrasound-guided PICC insertion; demonstrate competencies in understanding the anatomy of the veins and chest; commit to using ultrasound-guided technique in all insertions, rather than falling back on a previously learned technique; and religiously follow the bundle. “It’s self-fulfilling,” Harnage says. “The team [members have] generated a tremendous level of confidence in their [own] abilities. Thereby, they insert a tremendous number of PICCs, which results in consistent, repeated, reliable results, which increases the confidence in their skills.”

The first step is locating the basilic vein in the upper arm using ultrasound. Evidence has shown that the bacteria counts are much less on the upper arm versus subclavian, jugular, or femoral insertion points, she notes.

Nurses use full-barrier precautions during the procedure. “The insertion process is something like you would see in an OR,” Dix says. “The patient is covered. The nurse is covered. The skin is prepped just like it would be before an incision. They don’t let people wander in and out while they’re doing it. When we use the term ‘maximum barrier precautions,’ that’s the level of scrutiny that’s being applied.”

Next in the sequence is the central line dressing kit, which was revised to include a two-step cleansing and disinfecting process, a chlorhexidine gluconate impregnated foam disk, and a stabilization device.

The facility decided to change its connector system for the subsequent step in the process. “We chose a neutral system needle-less connector because you don’t have to worry about clamping,” Harnage says. While it’s not magic, its ease of use helps prevent problems “if you correctly flush your line and take care of your line,” she says.

The smooth septum of this new connector also facilitates the next practice — IV connector septum disinfection. “You’re not dealing with crevices in the grooves,” she says. The protocol calls for a vigorous, back-and-forth scrubbing of the connector with an alcohol pad for 5 to 10 seconds.

The flushing protocol comes next. The nurses flush implanted ports and dialysis catheters with heparin, but all other central lines are flushed with normal saline. The team members conduct an inservice for the rest of the nursing staff on proper technique. “We are really on top of the educational piece to maintain these lines,” Harnage says.

The final — and essential — practice involves diligent monitoring of the lines by the team.

“I think the big message is, you can’t just be a PICC-stick-and-run team,” Harnage emphasizes. “You can’t just insert the line and never see it again. I think that’s where you lose the consistency and the reliability.”

Blue Cross Won’t Cover Costs Tied to Hospital Errors

By Marion Davis
Contributing Writer Providence Business News

Blue Cross & Blue Shield of Rhode Island has issued a “statement of principle” saying it will not pay health care providers – specifically, hospitals – for costs associated with 28 “serious reportable events” such as wrong-site surgery, severe bedsores, or patient death or disability resulting from a fall or from the use of contaminated drugs or devices.

The policy, which Health Insurance Commissioner Christopher F. Koller called “an example” for others within the health care system, is based on a list of so-called “never events” developed by the National Quality Forum, a nonprofit coalition of physicians, hospitals, businesses and policymakers, that are considered generally preventable and of serious concern.

For costs associated with such events, Blue Cross said, it expects hospitals to cover not only the insurer’s share of the costs, but also not bill patients for their share.

“BCBSRI considers patient safety to be one of the most pressing issues facing the health care system today,” said Dr. Harold Picken, associate chief medical officer for the insurer, which covers 680,000 lives, in a news release. “As the state’s largest nonprofit health insurer, we would like to continue to collaborate with the rest of Rhode Island’s health care community to strengthen the systems and procedures necessary to ensure these events never happen.”

Last month’s announcement came just a week after the Commonwealth of Massachusetts said it was adopting the same policy for four state agencies that collectively insure or cover health care costs for more than 1.6 million people, becoming the first in the nation to implement a uniform non-payment policy across state government.

That same day, Blue Cross Blue Shield of Massachusetts, which hailed the new policy, said it would also stop reimbursing hospitals for costs related to the 28 “never events.” And the Massachusetts Hospital Association expressed support for the policy as well, noting that Bay State hospitals were already leading the way by adopting a voluntary practice of not charging for certain serious reportable events.

Locally, the Hospital Association of Rhode Island wasn’t quite as effusive in embracing the BCBSRI’s new policy, but President Edward J. Quinlan did say in a statement that the group and its members “fully support and share the commitment of BCBSRI to reduce medical errors and improve patient safety.”

“Hospitals in Rhode Island have a national reputation for quality health care,” he said. “This status is the result of collaborative efforts that continue to provide measurable gains and a culture that values safe, responsible and cost-effective care.”

But while no one disputes the importance of safety and quality, the merits of this particular approach are not, in fact, universally accepted. For starters, as Quinlan noted in an interview, these are matters normally covered in contract negotiations between payers and hospitals. Moreover, he and a senior official at Lifespan said, many of these situations are not really cut-and-dried.

In refusing payments for all 28 “never events,” Massachusetts and the Blues are going beyond what the federal government is preparing to do effective Oct. 1. After a painstaking review process, and with a year’s notice to hospitals, the Centers for Medicare and Medicaid Services (CMS) is going to stop paying for costs associated with three so-called “never events” – objects left in the body during surgery, air embolisms and blood incompatibility. In addition, it will no longer pay for other avoidable events, such as patient falls, urinary-tract infections related to improper use of catheters, pressure ulcers, catheter-related vascular infections and mediastinitis, an infection that can develop after heart surgery.

In April, the federal agency said it wanted to add nine more problems to the list, at a potential savings of $50 million per year if adopted. It was unclear last week how much the agency projects to save from the changes already approved.

Neither Massachusetts nor the Blues have said how much they expect to save, and BCBSRI’s Picken said he doesn’t believe a great deal of money is at stake.

But asked whether the Lifespan hospitals now charge Blue Cross or other payers for costs associated with those 28 “never events,” Dr. Mary Cooper, the health care system’s chief quality officer, said it’s hard to tell, and people within the organization are trying to figure that out now – and determine what kind of impact the new policies are going to make.

Some of the 28 “never events” involve crimes: sexual assault, battery, murder, kidnapping. But also included are actions by others that hospitals are expected to prevent: patient suicides and attempted suicides or elopements resulting in serious disability; care provided by someone impersonating a licensed health care worker. In addition, burns “from any source” incurred while being cared for in a health care facility are covered by the policy.

Then there are straight-out errors: inseminating a patient with the wrong donor sperm or egg; discharging an infant to the wrong mother; operating on the wrong body part or on the wrong patient; leaving a foreign object inside a patient.

Yet several of the “never events,” while serious, may not always be the result of poor or unsafe care, Cooper noted. For example, patients with certain heart arrhythmias might show no sign of those problems before they go into surgery, and be deemed a low risk, but then die on the operating table because of the arrhythmia.

Even pressure ulcers, Cooper said, can be affected by factors beyond a hospital’s control, such as the person’s nutrition, heavy smoking, circulatory problems and mobility – and the research on those factors continues to yield new information.

Both Cooper and Quinlan at HARI noted that the implementation of the new CMS policy would provide an opportunity for the entire country to see how well that approach works in promoting quality and safety and how to ensure there are no unintended consequences. And they pointed out that even without non-payment policies, Rhode Island’s hospitals are working aggressively to prevent errors, most notably through the ICU Collaborative, which includes all the adult intensive-care units in the state.