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: www.positivedeviance.org

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."

ron.lin@latimes.com

Hospital's Blood Stream Infections Down to Zero

For Nurse.com
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.

The Answer to Infection Prevention and How We Must Proceed

by Victoria Nahum, co-founder of safecarecampaign.org

This morning I woke up slowly and not without some anxiety amidst many deep thoughts having to do with my family. I wondered which memories my husband, Armando would concentrate on today, Father’s Day 2008 - the warm, happy ones associated with his own father and our children - or the sad ones of loss and loneliness and how he sorely missed our son Josh a year and a half after he’d died from a health care acquired infection. This day would be even more difficult since we just found out 3 days ago that his own father has been diagnosed with chronic leukemia.

I laid there thinking about all the issues surrounding infection prevention like compulsive hand hygiene and the 2 very different camps regarding the “zero infection rate” controversy. I considered issues like the additional costs associated with prevention and hospital budgets and what the providers will pay for and blah, blah, blah. Suddenly, I knew the answer we were looking for all along. Surprisingly, the answer itself came from another question.

It asks -
What if it is YOUR (fill in the blank: young son, beautiful daughter, loving mother, terrific father, dear sister, favorite brother, best friend, etc.) who is or might become sick or infected or die from a health care acquired infection? Would YOU INSIST on:
the test,
the cure,
the pill,
the procedure,
the herb,
the balm,
the remedy,
the hand hygiene,
the elixir,
the thingamajig,
the antidote,
the potion,
the treatment,
the therapy,
the vaccine,
the preventative,
the ointment …
no matter WHAT the price or inconvenience to make sure your loved one would be well and would not die?”

In a moment - all of the unnecessary discord and clamor associated with infection prevention: the inconvenience of compulsive hand hygiene, the costliness of the extra ounce of prevention, nursing staff issues and the question of active surveillance culturing – disappeared once and for all.

And as far as infection prevention initiatives and next steps go – I am confident and assured that we all know the right way to proceed.

Germs in Surprising Places

by Jon Barron

You go to the bathroom at the bookstore, wash your hands, then lift your purse off the shelf where you had it resting and continue into the store where you purchase a book. Do you think you're safe from germs because you washed your hands with soap? Think again, because according to studies, the toilet seat has fewer bacteria than the bottom of the purse you just handled, and it's cleaner than the money you receive as change from the store clerk.

Although most of us are conscientious about hand washing after using public restrooms (let us hope), we ignore some of the most insidious sources of bacteria. A recent study by Nelson Laboratories in Salt Lake City investigated the cleanliness of women's purses. Study director and microbiologist Amy Karen found the results shocking, noting that the handbags in the sample tested positive not only for the presence of bacteria, but for bacteria of the worst kind--including pseudomonas, which can cause eye infections; staphylococcus aurous which can cause serious skin infections; and e coli, which causes food poisoning.

In one test, four out of five handbags tested positive for salmonella. Perhaps worse, a similar study out of the University of Arizona found that one-third of the hand-bags in the sample had fecal bacteria present. In fact, some of the purses were 100 times dirtier than the average toilet seat. While a bacteria level of 200 is considered safe, most of the purses weighed in at tens of thousands, and a few had bacteria counts in the millions.

Of course, this makes sense if you think about it. Women stash their purses on car floors, on the baby-changing table in the restroom, on the floor at the café or the bar, on the unmade bed at the friend's house, on the counter at the bank -- places they wouldn't think of eating off of because of the germ factor. And those places are repositories of bacteria, bacteria that attach themselves to the purse and then to the hand that grabs the purse. Plus, after letting the purse scrape the floor, the typical person sets it down on the kitchen table or on the counter, where the germs happily jump off onto the food. Geronimo!!! And the issue is the same for briefcases, backpacks, and lunchboxes.

But the germs we ignore hardly limit themselves to our purses and briefcases. At the office, we share telephones, copiers, fax machines, and computer keyboards with our colleagues, and so we also share the germs that they leave on these surfaces. Dr. Chuck Gerba, the same guy who studied handbags at the University of Arizona, measured germ count in a variety of office environments and found that keyboards contain 400 times more germs than bathroom surfaces.

The telephones tested contained 25,127 microbes per square inch, contrasted with toilet seats, which had only 49. Dr. Gerba points out that virus germs can survive up to 72 hours, so the sneezing coworker who used the copier yesterday might give you the flu today without even coming into the office.

Another repository for germs is "filthy lucre," which really is filthy. A recent study found that cashiers and bank tellers are at greater risk for the flu than people who don't handle money constantly. Think about it. A man with the flu sneezes into his hand, then reaches into his wallet and hands a dollar bill to the cashier, and then you come along and receive that same bill just two minutes later.

A 2001 study of paper money at Wright-Patterson Air Force Base Medical Centre, near Dayton, Ohio, found that 86 percent of the bills tested contained germs, and seven percent carried truly harmful bacteria, like Staphylococcus aureus and Klebsiella pneumoniae. Although few extensive tests of germ counts on money have been completed, a study just this month at City University in Dublin, Ireland, found that 100 per cent of the banknotes tested carried trace amounts of cocaine. Similar research in the US has yielded comparable results, indicating not only that we have a rampant drug problem, but also, that money does indeed carry contamination.

There are other equally ugly sources of contamination -- fruits that people squeeze in supermarkets, shopping cart handles, the doorknob at the doctor's office, and so on. When you think about it, you can get pretty paranoid. A friend of mine carries a can of Lysol with her at all times to fend off germs, and that level of fear isn't healthy. (Nor do I recommend eating off the toilet seat -- a thought that might occur to you since it seems to be so much cleaner than every other surface we deal with.)

Nevertheless, here are a few things you can do to protect yourself:

Wash those handbags, briefcases, and lunchboxes periodically. Watch where you put your bags, and especially avoid the bathroom floor and eating surfaces.

Keep your work surface clean and stash a supply of cleaning pads at work for wiping down the telephone and other equipment.

Wash your hands a lot-- several times a day, and keep your hands away from your face.

Champions for Success Cover Bases With Infection Control Bundles

From HEALTHCARE PURCHASING NEWS
by Jeannie Akridge

All eyes are on infection control as hospitals anxiously await regulations soon to be enacted by the Centers for Medicare and Medicaid Services (CMS) in which they will no longer be reimbursed for certain hospital acquired conditions (HACs). Infection control practitioners and clinicians are stepping up to the plate and being applauded for their efforts to reduce rates of healthcare acquired infections (HAIs) and other preventable errors. They’re helping to prove that reaching the elusive "zero infections" target is in fact attainable for extended periods of time, if not sustainable forever.

Leading infection control expert William Jarvis, M.D., who worked with the Centers for Disease Control and Prevention for 23 years, told Healthcare Purchasing News, "Depending on the patient population, getting to zero may be more challenging, but I think it really needs to be the goal for everyone. We have a number of studies now – out of Johns Hopkins; Michigan, where virtually all the ICUs in Michigan participated in the Keystone Project; as well as a number of hospitals that have participated in the Institute for Healthcare Improvement (IHI) collaborative – where they have been able to get their rate of central venous catheter related bloodstream infections in their ICUs down to zero."

He added, "CMS has identified nine different conditions that they’re not going to pay for as of October 1, unless they’re present on admission. And one of them is vascular catheter related infections, so I think it is going to put a lot of pressure on hospital personnel to reduce these infections and reduce them not just in the ICU but in the hospital in general."

Mark E. Rupp, M.D., medical director of the department of healthcare epidemiology-infection control at the University of Nebraska Medical Center (Omaha) foresees that the CMS quality improvement measures will ultimately benefit ICPs. "I feel that the CMS reimbursement rules are helping to focus scrutiny on these infections. Many catheter-associated infections can be prevented and I think the CMS rule change is going to have a positive effect by reinforcing the preventive efforts that we’re trying to spearhead."

David Parks, general manager, global business management, Kimberly-Clark Health Care noted, "With the ever increasing state-level legislation and focus on mandatory reporting of healthcare-associated infections and the trends in pay-for-performance, I believe the role and objectives of the materials manager will change significantly over the next year or two. There will be a greater focus on investing in prevention solutions to reduce the costs associated with adverse events such as VAP and SSI."

Experts agree that in order to survive in this new pay-for-performance environment, it will no longer be enough for hospitals to simply meet the status quo when it comes to quality and safety standards.

Kathleen A. McHugh, R.N., BSN, chief executive officer of the Association for Vascular Access, noted, "I think that the expectation that you go into a hospital and get an infection is based on the fact that we don’t have high expectations. I’m not sure that zero is sustainable forever. People need to be constantly reminded to be hypervigilant," she added, "It’s this lack of attention. Two hundred years ago we were told that washing hands would reduce 90 percent of all complications. And here we are in the year 2008 and all of a sudden hand washing is not being done on a regular basis."

David Shulkin, M.D., president and chief executive officer for Beth Israel Medical Center (New York City), credits early pioneers for efforts to help facilities move beyond accepted boundaries. "I think that there has been a mindset that frankly the University of Pittsburgh as one of the leaders helped break through. The way that clinicians had looked at things is that you look at the average and you try to be better than the average. Very few people had thought about the goal should be zero, not being below average. And I think that the University of Pittsburgh in not accepting the average scores but really shooting for zero, helped the industry have a mind shift in terms of, the goal should be zero."

"We’re a top performing hospital nationally," noted Steve Lawler, president, Pitt County Memorial Hospital, Greenville, NC. "We’re well within the 90th percentile, but that last 10 percent is the hardest. You try to reinforce that every patient is important to us so therefore we need to work extra hard to get to that Zero. I think that’s what you shoot for. And even though it may be tough and it may be long in coming, that you’re not satisfied until you get there and then once you get there you look for the next big thing."

HPN talked with several trend-setters who demonstrated what it takes to break the Zero barrier.

Sophie A. Harnage, BSN, R.N., has led her nursing team at Sutter Roseville Medical Center (SRMC), Roseville, CA, on a two-year winning streak of zero catheter-related blood stream infections (CRBSIs) with every patient who is managed by an innovative central line bundle. Her work, including details of the seven-practice bundle, was featured in the December 2007 issue of the Journal of the Association for Vascular Access (JAVA)1.

Under the leadership of Brian Koll, M.D., infection control chief, Beth Israel Medical Center has also had success with implementing a bundle to eliminate central line-associated BSIs, reducing rates by 95 percent institution-wide, and maintaining zero CLABs in several units for greater than a year. While costs to implement the program were $32,000, the hospital avoided $1.4 million in charges to treat patients with CLABs.

Community Health Network in Indianapolis, IN, was part of an initial team from VHA Inc. and IHI that developed a ventilator-associated pneumonia (VAP) prevention bundle which is now in place throughout their five-hospital system. As a result, two of the system’s adult ICUs have had zero incidence of VAP in four years and the five-hospital system has achieved zero incidence of VAP for one year.

Pitt County Memorial Hospital (PCMH) significantly reduced the rate of VAP due to methicillin-resistant Staphylococcus aureus (MRSA) in the Surgical Intensive Care Unit (SICU) with the implementation of an active surveillance program for MRSA. The facility previously practiced high-risk screening, but according to Lawler, "we believed it was important that we screen all patients coming in to create the safest environment."

With the goal of rapidly identifying, isolating and treating patients with MRSA to prevent transmission to other patients, in February 2007, PCMH – led by Keith Ramsey, M.D., medical director for infection control – began a hospital-wide (universal) active surveillance for MRSA using the BD GeneOhm MRSA real-time polymerase chain reaction (PCR) diagnostic test. With laboratory results back in three to four hours versus two days, PCMH is able to test about 150 patients a day. Subsequently the MRSA VAP rate in the SICU decreased 68 percent during the initial 12-month intervention period, from 1.74 to 0.54 per 1,000 ventilator days, and there have not been any VAPs since June 2007 in the PCMH SICU.

Peggy Thompson, R.N., BSN, CIC, director of epidemiology at Tampa General Hospital (FL) said that after they adopted bundled products usage, "We started really making changes in our (VAP) percentages at the end of 2005, that’s when we really focused on the VAP bundle and implemented a mouth care kit from SAGE Products." The mouthcare kit has a toothbrush with suction, antiplaque solution, suction catheter, perox-a-mint solution, alcohol free mouthwash, oral suction adapter, toothettes with and without suction, and mouth moisturizer, designed to provide mouthcare every 2 hours.

With this change, Thompson said, "We reduced our VAP rate by 42 percent, which was a statistically significant reduction.

Thompson continued, "In August 2007, we added the usage of Kimberly-Clark’s MICROCUFF Endotracheal Tube along with the mouth care kits and other VAP bundle practices. At the end of 2007 we found that when we compared VAP rates in 2006 to 2007 we had achieved a 54 percent reduction. We then went back and compared January through July 2007 rates, to August through April 2008 to determine what if any effect the implementation of the new ET tube had made. We discovered that we had achieved a 39 percent reduction in VAP, largely attributed to the new ET tube." Since August 2007, Tampa General has had three months with zero VAP rates. Thompson said this was a significant accomplishment because they were averaging the use of 75 ventilators a day during those zero rate months.

At the heart of nearly every successful HAI reduction program is a bundle, the kind endorsed by the IHI and others.

Deborah Dix, R.N., Sutter Roseville Cancer Services director, described a bundle as a "combination of products and procedures that consistently and reliably give you an outcome."

The Association for Vascular Access (AVA) is working with the Association for Professionals in Infection Control & Epidemiology (APIC) to develop a model central line bundle. "The whole notion of CRBSIs has been a problem for many years, said McHugh, "even making decisions on which vascular access device to use has been rooted in the incidence of CRBSI, based on whether it’s a non-tunneled central line, which is the highest risk, to an implanted port, which is the lowest risk."

Baxter Healthcare sponsored a symposium at the 2008 Society for Healthcare Epidemiology of America (SHEA) Annual Scientific Meeting titled, "Battling Catheter-Related Bloodstream Infections: What has worked; What is now needed?" Panel moderator Robert Weinstein, M.D., chair, infectious diseases, Stroger (Cook County) Hospital, Chicago, described the measures that should be part of any program to help prevent CRBSIs:

• Performance measures from HICPAC 2002 BSI Prevention Guidelines

• Educate personnel

• Remove unused catheters

• Use chlorhexidine for site prep and care

• Use maximal barrier precautions for CVC insertion

• Use a check list to insure that the performance measures are followed

• Empower nurses to stop CVC insertion if guidelines are not being followed.

Dr. Weinstein noted that the above measures "prevent the early onset of skin/insertion site related BSIs (the ‘extraluminal’ pathway of infection) and prevent two-thirds or more of BSIs, up to 100 percent."

The central line bundle implemented at Sutter Roseville included: Optimal site selection using ultrasound guided insertion; full barrier precautions; a central line dressing kit that includes ChloraPrep (Cardinal Health), BioPatch disk with CHG (Johnson & Johnson), optional Statlock, and 3M Tegaderm Transparent Dressing (3M Health Care); replacement of positive pressure connectors with InVision-Plus Neutral IV Connector System (RyMed Technologies Inc.); a clear and defined technique of cleansing the septum connector; clearly defined flushing protocols; and daily monitoring of PICCS.

"It’s not like we made just one change and it worked," explained Dix. "We developed an entirely new process that works together as a complete package. We don’t know which [element] makes the greater difference. We just know the package resulted in a successful outcome."

Agreed McHugh: "No one thing as a standalone probably would have worked, but everything together works in synergy, because [they’re] covering all the bases."

Hands-on intensive training was integral to the Sutter Roseville bundle with PICC nurses rounding to the bedside daily. Dix believes that meticulous daily monitoring and site checks are key to their success. "We can identify problems early. And we create a relationship with the nursing staff [and physicians] so that they feel very comfortable coming to us with questions and problem solving."

According to Dan Kidwell, network director of neuro sciences and pulmonary outcomes, Community Health Network, components of the vent bundle, developed in conjunction with VHA and the IHI as part of the Idealized Design of the ICU collaborative, includes keeping the head of the bed elevated to
30°, appropriate sedation, oral care, assessment for the ability to extubate the patient, DVT and PUD prophylaxis. Community Health Network also utilizes other innovative and cost-saving measures throughout their system in what Kidwell calls their "recipe for prevention of VAP". With laser like focus, Kidwell and the Community team set out to eradicate VAP from their health system by looking at processes, protocols and equipment, challenging the status quo and implementing ground-breaking ideas along the way.

"I would tell every institution that reads this, that they need to follow the vent bundle because it is a good base," said Kidwell. "There’s evidence to support it. I would also tell them that it’s a very comprehensive view that they’ve got to take because it is now understood that VAP is avoidable. They’ve got to look at the culture of their organization, instill the belief that they can not only get to zero, but perhaps can eradicate VAP through the empowerment of staff and leaders to look at their environment and make change. By integrating education, cultural transformation, staff empowerment, and even instituting technology adaptation, those things can completely change how you work."

At Beth Israel Medical Center, compliance with bundle practices is enforced with kits that that contain the necessary components for safe central line insertions. Dr. Shulkin explained, "We make this easier for the clinicians by putting everything together into one centralized kit, which includes maximal barrier precautions plus an applicator and protective disk with chlorhexidine gluconate."

Sources related the importance of a checklist in ensuring consistency. "The primary thrust of any bundle is a ‘checklist’, borrowing from the airline industry," said McHugh. "If everybody does everything they’re supposed to do there will be no errors."

Added Dr. Jarvis, "If that checklist is used at the time of catheter insertion, then if a bloodstream infection occurs, you can go back
and look and see if those processes were all done correctly. And if they were, then perhaps it was a CRBSI that was inevitable."

McHugh emphasized the need for basic hygiene and aseptic technique in preventing CRBSIs. "While there’s a lot of technology out there and there are a lot of good products – there are hundreds of good products – washing hands and using antisepsis when accessing a central line, that’s the most important thing."

Dr. Jarvis discussed the need to ‘scrub the hub’ in order to maintain sterile technique. "Often times you see clinicians when they manipulate a catheter, they’ll take the needleless connector at the end and then they’ll swab it with alcohol for about one second and then disconnect it. Well, that’s insufficient," he explained. "There was a study by Dr. Dennis Maki that showed that if you did that for literally five seconds to ten seconds, that almost 70 percent of them were still contaminated. So you need to have probably at least a 15 second scrub with either alcohol or chlorhexidine whenever you manipulate that needleless connector."

Dr. Rupp of the University of Nebraska recently led one of two studies presented at the 2008 SHEA Annual Scientific Meeting that evaluated 3M’s new Tegaderm CHG IV Securement Dressing. Dr. Rupp’s study2 compared the 3M Tegaderm product to the facility’s standard transparent dressing and concluded that "the Tegaderm CHG dressing containing a chlorhexidine gel pad is an innovative means to potentially minimize CA-BSI", and also that "the Tegaderm CHG dressing is well-tolerated and judged to be superior to the comparator dressing with regard to catheter securement and overall satisfaction." Dr. Rupp commented that while additional studies are still needed to determine if the 3M Tegaderm dressing does indeed reduce BSIs, "all of these preliminary studies are very optimistic. They’re very reassuring that the dressing performs well and does have some good microbiologic effects."

Leading change management

Support from the top is essential for any successful infection prevention program, said Dr. Ramsey. "First of all you have to have administrative support. Secondly, you have to have buy-in from your staff, physicians and nurses."

A successful HAI reduction program also needs a champion for that change as well as empowerment of staff and clinicians. Said Dr. Shulkin, "We have really empowered our staff – every nurse, nursing assistant, housekeeper, physician – any member of the team who sees anybody who is not using an appropriate kit for insertion, or violating one of the infection control practices can declare Red Rule, and that can stop the insertion process in its tracks so that every healthcare team member has the power if they see something that puts a patient at risk to stop the process. And they know that they will be supported in this."

Dr. Weinstein advised, "Create high expectations from staff, create a culture of safety, educate and hold staff responsible for their actions and patient outcomes, treat HAIs as internal sentinel events that trigger an analysis of what happened and what was preventable. Don’t settle for less."

See the 2008 Infection Control Buyer's Guide:

These Things Happen

Excerpted from Paul Levy's BLOG "Running a Hospital"

I was reminded of this by our Chief of Medicine. In the movie, It's a Mad, Mad, Mad, Mad World, Ethel Merman, playing Mrs. Marcus, says:

Now what kind of an attitude is that, 'these things happen?' They only happen because this whole country is just full of people who, when these things happen, they just say 'these things happen,' and that's why they happen! We gotta have control of what happens to us."

I am struck by the relevance of this to running a hospital.

Several years ago, we had that attitude in our hospital with regard to certain types of medical outcomes. For example, we were content with our level of central line infections because we were below the national average. After all, these things happen. Then our chiefs of medicine and surgery said, "No, they don't have to happen. When they happen, people die. We are going to insist that we achieve zero central line infections." And then they got to work. As I have noted below, it is not an easy problem to solve, but it is worth the effort, and you can improve.

One way to encourage organizational improvement is to publicize the results of your program. I have done that below for our hospital, and I have made the suggestion that others in the city could do the same. As I noted, I did not make the suggestion for competitive purposes -- after all, I don't know if our numbers are better or worse than those of other hospitals -- but because public exposure of all our efforts will drive all of us to do better. Also, it will build, rather than erode, public confidence in the academic medical centers in our city.

The response, as you have seen from the press reports, ranges from simple recalcitrance to technically sophistic arguments about comparability of data. Please, does anyone argue that the goal should not be zero? If it is zero, it does not matter whether the data is measured in cases per thousand patient-days, cases per thousand catheter-days, or just the raw number of cases.

We all keep track of these numbers in some form or another. We could easily post them in real time voluntarily on a website maintained by the state or an insurance company, along with our own explanations of how and what we measure. (And perhaps, over time, we will agree on what single metric is most useful.)

People can and will understand this. They already spend hours on the Internet reading medical websites. Why do we give them so little credit? It will demonstrate to the public that we care about this problem, and will show our individual progress towards our ultimate goal.

Finally, it will enhance the reputation and credibility of all of the academic medical centers, two aspects of our character that will be more and more under siege because of the broader problems of the health care system.

POSTED BY PAUL LEVY AT 3/08/2007 09:22:00 PM

Your Purse is Contaminated

A purse. It’s something just about every woman, teenager or girl carries with them. We throw it over our shoulder or we carry it in our hand but we also put our purses in places with lots of germs.

WSB-TV, Channel 2 in Atlanta, GA. saw women setting their purses on a public sidewalk, on the floor at their office, on the floor in public bathrooms and on table tops and counters in restaurants and bars.

“I only have two hands and if it comes between putting the baby down on the floor or putting the purse down on the floor then I will put the purse down,” said Kerry Ludlum. “I usually sit it on the floor in my van, underneath my desk on the floor at work,” said Veronica Daniels. “You put your purse everywhere. At work I put it on the floor. Of course at home, I put it on the kitchen counter, that is not a good thing to do, but I don't think people give it any thought,” said Anna Hovind. “I go to the gym a lot and I am always putting it on the floor in the gym,” said Gloria Pritchett.

These ladies aren't the only ones who put their purses in germ-laden places. Channel 2’s Jovita Moore said she puts hers on the floor all the time and then sits it on her desk at work and even on her kitchen counter. So, she swabbed it to see what kind of germs were on it.

Channel 2 also took germ samples from 37 other purses. We swabbed the bottom and handles of purses and then put those samples in sterile vials and sent them to Nelson Laboratories in Salt Lake City for analysis. After incubation and intense testing what we found was pretty disgusting.

“We had several of them that came back with fecal contamination,” said Beau Rollins, a microbiologist with Nelson Labs. You read that correctly. Fecal matter was found on a lot of the purses we tested, including Jovita Moore’s. Needless to say, the women who let us test their purses were shocked to hear that.

“I am shocked. I am embarrassed. I am…my heart is palpitating. I'm thinking fecal matter? I have a 3-year-old. Where did that come from,” asked Daniels. “That’s disgusting. That is really, really gross,” said Kelly Gallagher.

The lab technician that analyzed our samples said when he sees ladies putting their purses on restaurant tables, he cringes.

“I don't think they ever realize what they are transferring onto the plate. That is basically like wiping feces on your plate and eating it,” said Rollins.

Our testing also found the bacteria Staphylococcus Aureus. If you ingest it, it can cause serious food illness and sickness.

“My mom always said to never bring your purse home and put it on the kitchen counter or kitchen table. That was the rule always,” said Elaine Warren. Some other good rules to follow when it comes to your purse include hanging it on the hook in public bathrooms. Don’t set it on the floor. Also, clean your purse from time to time.

“I plan on cleaning that purse and all the other purses I have or getting rid of them,” said Daniels. If you have a cloth purse, throw it in your washing machine at least once a week. If you have a leather or vinyl bag, using disinfecting wipes at least once a week to keep it clean will help.