Pronovost on HAIs

Photo: Johns Hopkins Medicine

There's an interview with Peter Pronovost on reducing healthcare associated infections in tomorrow's Wall Street Journal. You can view it here.

Aspirational goals

There's a paper in the February issue of Infection Control and Hospital Epidemiology by a group of investigators at the University of Pennsylvania. They set out to perform a systematic review of the literature to determine the proportion of healthcare associated infections that are reasonably preventable. Their determination was that 65-70% of central line associated bloodstream infections and catheter-associated urinary tract infections were reasonably preventable, and that 55% of ventilator-associated pneumonia cases and surgical site infections were reasonably preventable. Quick, someone call APIC--they're still targeting zero! I know, I know: zero is an aspirational goal. And I'm still aspiring to be a professional football player.

Addendum, 1/23, 9:55 AM:  I just ran across this article published yesterday in a California newspaper. Now here's a piece that's apropos, and one that tries to tell the other side of the story.

Learning to count...

There's an old joke about asking an accountant "what's 2+2?" and the accountant responds "what do you want it to be?"

Unfortunately, CDC has some creative math rules of its own. So for hospital epidemiologists, 1 + x = 1 when it comes to counting central line days. That is, for patients who have more than one central line, only one line can be counted per day for the denominator in calculation of central line associated bloodstream infection (CLABSI) rates. It's as if only one of the three central lines in the acutely ill ICU patient poses a risk to the patient. Magically, the other two are immune.

In the February issue of Infection Control and Hospital Epidemiology, there is a study by the Hopkins group that examined the effect of the one-catheter-per-day rule and found that counting only one catheter falsely overestimated their CLABSI rate by 36% in 3 surgical ICUs.

Two years ago, our group presented a very similar study at SHEA done in our medical and surgical trauma ICUs. We found that the CDC rule falsely overestimated our CLABSI rate by 20%.

In the era of mandatory public reporting of HAIs, it's imperative that everything be done to produce the most valid data for consumers. I'm baffled that CDC has been so slow to respond to these issues. The focus seems to be on validating surveillance using the methodology as is, rather than modifying the methodology to make it more valid.

Bug-mobiles?

There's a new study in the American Journal of Emergency Medicine that caught my eye this morning. It asks the interesting question: are patients who present to the hospital via advanced life support (paramedic) transport more likely to develop HAIs than those who do not.

The design was a retrospective cohort which evaluated over 150,000 hospital admissions over a 5-year period at a hospital with a level 1 trauma center. The study found no difference in community-acquired infections between the two groups. However, patients arriving by ambulance were 1.4 times more likely to develop an HAI.

Since observational studies can be plagued with bias and confounding, we can't determine whether the ambulance transport led to the higher rates of HAIs. Nonetheless, as infection rates fall in hospitals, the identification of new groups at potential risk is important, since this can lead to the implementation of new interventions. As I begin to put together our annual report on HAIs, it's evident that we've picked the low-hanging fruit, and although rates of infections continue to fall, the slope of the curve is flattening. Thus, we need to return to the drawing board to develop new strategies.

Madame Necker lives on

Madame Suzanne Necker
Source: Wikimedia Commons

You are probably asking: Who is Madame Suzanne Necker? And what does she have to do with infection prevention? Well, she was the wife of a French finance minister who started a campaign in the late 1700s to limit the number of patients per hospital bed to 1. At that time, up to 8 patients shared a bed in French hospitals.

So the one patient-one bed standard came to be and has lived on. In 2006, over 200 years later, the American Institute of Architects Guidelines for Design and Construction of Health Care Facilities called for a new standard of one patient-one room. A 2008 commentary in JAMA outlined many reasons for the private room standard, including reduced potential for HAIs, reduction of patient transfers, enhanced patient throughput, and greater privacy for patients and families.

A new study in the Archives of Internal Medicine, looks at the acquisition of pathogens before and after the move from an ICU with multiple patients per room to a new ICU with all private rooms. Another hospital in the same city with the same infection control service and multi-bed rooms throughout the study period served as a comparator. The authors report that the acquisition of MRSA, VRE and C. difficile fell 54% after the move to the all private-room ICU. I think the study has a number of problems, which I won't belabor here, but will point out one curious finding that somewhat undermines the authors' conclusions--although the rate of MRSA acquisition fell after the move, the rate of MSSA acquisition did not.

Two years ago, all the ICUs at my hospital except one moved to a new tower with all private rooms, including our NICU. Clearly, it's easier to practice good infection prevention with patients separated nicely, though one downside that we noticed immediately was that it became much more difficult for our hand hygiene observers to collect as many hand hygiene observations from any single point of observation.

Bottom line: I think that private rooms probably do have an impact on reducing infections, though I don't think we have proven that yet. And whatever gains can be made by better design can probably be undone by poor compliance with hand hygiene.

Needed: CLABSI tune-up

We have blogged before about problems with NHSN HAI case definitions. For central line associated bloodstream infections (CLABSI), a major problem is the lack of specicity of the definition, which many believe leads to an overestimation of the rate of these infections. In this month's Infection Control and Hospital Epidemiology there is a commentary on the CLABSI definition by Dan Sexton that is well worth reading. He proposes some simple changes to the definition that would make a big difference in improving specificity.

Headline: "Hospital Accused of Putting Patients at Risk to Cut Costs"

The Milwaukee News reports that 5 patients at a local hospital are suing the hospital after acquiring infections following surgery. Lawsuits involving nosocomial infections aren't unique, but the argument at play in these cases appears to be, and should be of great interest to hospital administrators and the infection prevention community. The plaintiffs claim that the hospital cut positions in its infection control unit as part of a cost savings plan while building a $400 million new facility. This begs the question: what is the appropriate level of resources hospitals should provide for infection prevention? There is no current national standard to answer this question. But I wonder if the public would be better served if legislative activity focusing on HAIs mandated resources (e.g., IPs/100 beds) rather than particular strategies, such as active surveillance for MRSA.

Holy Superlatives, Batman! Hospital-acquired infections have significant economic costs!

1935 Dollar


There is a well done study out in Medical Care by Rebecca Roberts et al. from Stroger/Cook County that assesses the attributable costs of HAIs in a cohort of patients from 2000.  What sets this paper apart is the careful attention they paid to design and analysis methodology.  Just to paste from the abstract, they used "ordinary least squares linear regression and median quantile regression, Winsorizing, propensity score case matching, attributable LOS multiplied by mean daily cost, semi-log transformation, and generalized linear modeling. Three-state proportional hazards modeling was also used for LOS estimation. Attributable mortality was estimated using logistic regression."  They did all the right things and it's a bit like that Snicker's commercial from years ago - "No matter how you slice it, it comes up peanuts."  Costs ranged from $9300 to $21,000 depending on the method used - hey methods matter!  Attributable variable costs, which are more likely to be recoverable in the short term, ranged from $1500 to $6800. Excess Length of Stay (LOS) ranged from 5.9 to 9.6 days.  Of note, the sample was selected from a higher-risk pool, so their estimates might over estimate the "true" costs.

When their data was extrapolated to estimate national impact of HAIs, they predicted that there are ~350,000 HAIs annually in the US with an impact of $3.2 to $7.3 billion.  Not chump change, but far lower than other published estimates.  They suggested that 1/3 of infections might be preventable (Mike - What do you think about that?) so that in 2009 dollars, preventing these infections could save $8.4 billion in medical AND societal costs. They also offer a nice comparison amount, since most of us have no idea what a billion dollars represents, when they state that estimated 2008 medical malpractice claims were about $3.6 billion. No word on how many of those claims were for HAIs!

Overall, a great study with great methods.  Health economics can be pretty ugly at times, these investigators should be congratulated.

Link: Roberts RR et al. abstract Medical Care November 2010

Why I took the job? Low HAIs and high flu vaccine compliance!

Dr. Churchwell

Delaware's only children's hospital, Alfred I. duPont Hospital for Children, just announced that Dr. Kevin Churchwell will become chief executive officer in December.  I'm not sure even why I read the article, but what caught my eye was why he said he took the job:

Churchwell said the new (renovation) project was one issue that factored into accepting the job. He also was impressed with the quality of care delivered at duPont, which has low hospital-infection rates compared with other local and national hospitals. It also has high vaccination rates for the flu among its health care workers.

"They have a great safety infrastructure," Churchwell said. "A.I. is a leader in that, and they need to step out and teach other hospitals how it's done. That will make a big difference."

Something is up. Not only is it great that a CEO has HAIs as a major priority, which is hopefully becoming more common, but also that he selected the job based on the quality and safety of the hospital.  Perhaps it's because he's a pediatric critical care doc. Either way, it's pretty cool.


Delaware online announcement

The bean counters are missing some beans

There is a recently released report from the Society of Actuaries entitled the Economic Measurement of Medical Errors. It's nearly 300 pages long and includes data on catheter-associated UTI, central line associated bloodstream infection, and surgical site infections. It is based entirely on administrative claims data, which are notoriously inaccurate for healthcare-associated infections. See Kurt Stevenson's paper on this topic here.

As I looked through the report, I noted that the numbers looked quite odd based on my familiarity with the literature. So I compared the SOA report data to CDC's estimates on the burden of HAIs in the US (Klevens et al) and Eli's review of the literature on attributable cost in the table below.

	Estimated annual number of cases		Attributable cost/case
	SOA Report	CDC	SOA Report	Perencevich
CA-UTI	9,080	561,667	$32,820	$1,257
CLABSI	3,679	248,678	$110,462	$18,462

Now there a number of caveats to point out:

• The SOA reports the estimated number of cases due to error; to convert from number of cases to cases due to error they multiplied the number of cases by 0.95. Therefore, I divided the "error" cases by 0.95 to convert back to number of cases (Does anyone believe that 95% of CA-UTI cases are due to error, that is, preventable???)
• Eli used 2005 dollars for cost data, and SOA used 2008
• SOA used 2008 claims data, and CDC (Klevens et al) used 1990-2002 NNIS data and National Hospital Discharge Survey 2002 data
• CDC data appear to included non-device associated infections, though we know that the vast majority of UTIs and BSIs are device related

However, despite the differences I note, the SOA data seem hugely flawed. They appear to vastly underestimate the frequency of HAIs, while substantially overestimating the attributable costs. I suspect the SOA report will be widely quoted, so take a look at it and be prepared!

Avoiding SSIs

It's not often that a major newspaper prints an editorial on healthcare associated infections, but here's one from this morning's Boston Globe.

What in the world?

Could the UK come up with any more crazy infection control rules? They've banned Christmas decorations, aquariums, fresh flowers, and sitting on the hospital bed. Now a major hospital in Scotland is limiting visiting hours to three and a half hours daily to reduce infections. That's a half hour less than the old rule, but apparently the old rule wasn't enforced. I won't even try to guess what's next....

No MRSA here (part 2)

I'm in Charlottesville to participate in a debate at UVA with Dennis Maki on whether impregnated central venous catheters should be used in the critical care setting. I was assigned to argue the "no" side of the debate. Now I must have been temporarily insane when I accepted that invitation since no one in the world knows more about this topic than Dennis Maki. But I think it should be fun.

Now to the topic of this post. I've blogged before about the progress we have made at our hospital on reducing MRSA infections in our ICUs. We recently were able to sustain a period of no MRSA infections for over 6 months, and in the last 9 months we have had only 1 device-related MRSA infection (a VAP) in our 8 ICUs. Critics have argued (and rightly so) that just because our ICUs are doing well, it may not be so in the rest of the hospital. Our hospital leadership supported us in recruiting a new infection preventionist to take on the task of doing surveillance for device associated infections outside of our ICUs. And this morning before I traveled to Charlottesville, I finished an analysis of the first quarter data. Drum roll please!!!...For the first three months of 2010, we had zero nosocomial MRSA bloodstream infections associated with either peripheral IV lines or central lines across the hospital (ICU and wards, 820 beds). What's the significance of this? It's yet another finding that dispels the widely propagated myth that the only way to control MRSA in the hospital is by active detection and isolation. The only unit in our entire hospital where we obtain surveillance cultures for MRSA is our NICU (a unit that accounts for only 5% of our beds). And it validates our horizontal strategic approach to infection prevention--a focus on interventions that prevent all infections (e.g., hand hygiene, chlorhexidine bathing in ICU patients, the central line bundle, and lots of feedback to frontline providers).

Now I better get back to sharpening my arguments for the debate!

How many chickens for a 7-day linezolid course?

Like many, I’m intrigued by the health care reform proposal recently put forward by a Nevada Senate candidate. The proposal calls for a return to the barter system for health care delivery. There are only a few problems. One recent analysis concluded that basing such a system solely on chickens would be impossible, given the sheer number of chickens required.

Another shortcoming--what to do about adverse events and nosocomial infections? Shouldn’t a patient also receive goods or services if he or she is harmed during the delivery of health care? I can see it now…returning home after a hospital stay complicated by a nosocomial infection, you discover that the hospital has sent someone over to paint your house…

Tracheotomy, VAP, p-values and death

There is a new RCT just published in JAMA by a large group in Italy looking at the benefits of early (day 6-8) vs late (day 13-15) tracheotomy completed in 12 ICUs. The primary endpoint was VAP. There is also a very nice accompanying editorial. There are several interesting findings. First, patients randomized to early tracheotomy were less likely to develop VAP by day 28, 14% vs 21%, but the p-value was 0.07. Since the p value was greater than 0.05, the authors were forced to say that there was no benefit from early tracheotomy.

Interestingly the also found significantly greater vent-free days, ICU-free days, successful weaning and ICU discharges in the early tracheotomy group. There was even a trend towards higher survival in the early vs late group, HR=0.80, 95% CI 0.56-1.15. The authors and editorial do a nice job of pointing out that 31% or early and 43% of the late group didn't even receive a tracheotomy due to impending extubation or death. The editorial even makes the point that selecting an early tracheotomy is really a strategy of more trachs. The study did not assess patient comfort, which may be associated with early tracheotomy.

What is always troubling to me is that scientists, editorialists, journals and clinicians are stuck in this p-value trap. Here we have a study, a very good randomized trial, which shows likely clinically significant reductions in VAP and potentially lower mortality, but since the study was underpowered we are forced to say "no difference." I wonder if you calculated how many patients are intubated each year in the US (or Italy) and reduced VAP rates by 33%, how many VAPs would be prevented and how many deaths would be prevented? I know this study should be repeated, but will it? You have a negative JAMA study, what's the incentive? I describe this phenomenon as "Death by p-value."

iPad as a metaphor for the future of infection prevention

I've been doing a lot of thinking lately. This is perhaps because I'm between jobs and have some occasional downtime but it's more likely the result of not actually owning a computer these past two weeks, unless you count my phone. What I've been thinking about is why I ended up in hospital epidemiology in the first place. I mean, who, in their right mind, would choose to go into a profession that is under appreciated, under funded and lacks the proper scientific data to make rational clinical decisions. I could go on, and I'd be happy to if you meet me at the local pub...

What keeps sticking in my head is how little we've advanced since Semmelweis described the benefits of hand disinfection. For one, we're still doing quasi-experimental studies, although Semmelweis's design was at least controlled (midwives). It also seems that most of our contentious debates, including those around active detection and isolation, would be unnecessary if we'd followed his advice and had 100% hand hygiene. As for recent advances, the CLABSI checklist popularized by Peter Pronovost is probably the most important. Why was this advance made by someone who wasn't an ID physician or hospital epidemiologist? I think it's because as a profession we're stuck. Perhaps more clinical trials will advance things, but I have this suspicion we'll just end up proving what we already know - where will the advancement come from?

So, what does this have to do with the iPad? I just came across this article by Daniel Eran Dilger on how Steve Jobs utilizes creative destruction to change the world. The article is a little tech heavy and perhaps Apple biased, but I don't think that detracts from it's main points which I believe have relevance for a potential 'new' future for infection prevention. Dilger's main points are: (1) "Jobs understands death as a creative force better than most people. For society, culture, and technology to progress, old thinking has to die off to make way for fresh new ideas. People who don’t die are dragged kicking and screaming in the future..." and more importantly (2) "When something works, you don’t need to kill it. But in some cases you should."

So what does this mean for infection prevention and what should be "killed off"? I don't know. It's only been two weeks! However, I think we need to discuss what old ideas we are unnecessarily holding on to and we shouldn't back away from killing off things that work. Yes this is easier said than done and is perhaps a useless exercise. I'm just one guy, I don't even own a computer and I'm not even sure I know what a metaphor is.

2009 AHRQ National Healthcare Quality Report: Getting Worse(r)

AHRQ just published the "2009 National Healthcare Quality Report and National Healthcare Disparities Report" and things don't look too good. Full reports available here. Post-op sepsis or BSI---increased 8%. Post-op catheter-associated UTI---increased 3.6%. And for CLABSI - drum roll----no change. Ouch! Post-op pneumonia down 12%. The New York Times seemed upbeat, calling the problem of these infections "largely solvable."

I'm not sure where these data leave us and perhaps Mike, Dan and Connie will have some comments on this report too. However, I think what these data are telling us is that when you don't fund enough proper studies (and multiple studies) on methods to prevent HAIs - the 6th leading cause of death and when you are mostly left to resort to "absence of evidence-based medicine" tricks like kitchen-sink bundles...well, this is where you end up.

To suggest, as Katherine Sebelius did, that the new health care law would “help turn these numbers around” since hospitals with high rates of infections will be penalized starting in the 2015, is a bit hopeful. I think we haven't invested in HAI prevention studies like we have in cardiology and other areas, and I don't think we're going to get these rates down with sticks alone. You can't see in the dark if you don't know how to make a flashlight or even light a fire.

Move over, MRSA!

This morning's New York Times has a piece by Andrew Pollack on healthcare associated infections. That in itself is not a surprise anymore since the general public is quite interested in the topic. What is surprising is that the article isn't about MRSA--it's about Acinetobacter and the lack of effective drugs to treat multidrug resistant gram-negative organisms. Could this be a harbinger that the fixation on MRSA is starting to wane? Pollack remains, to my knowledge, the only journalist that has linked the frenzy to culture inpatients for MRSA with big profits by the companies who manufacture the MRSA testing kits.