Use patient safety furor as opportunity to educate public on infection control
Only one-third of infections are preventable
Fueled by a recent Institute of Medicine report on medical errors, the nation’s burgeoning patient safety movement should look to infection control as an epidemiologically proven model that can be applied to tracking and preventing medical errors and non-infectious adverse outcomes, ICPs emphasize. While presenting possible opportunities for ICPs, the highly publicized IOM report also raises concerns that nosocomial infections may be increasingly viewed as "preventable errors" despite spiraling inpatient acuity and the ubiquitous use of invasive devices.
"There is an unspoken assumption [in the IOM report] that these hazards ought to eliminated," says William Schaffner, MD, chairman of the department of preventive medicine at Vanderbilt University in Nashville, TN. "That is an untutored, unrealistic concept. There are clearly some hospital-acquired infections that are going to occur. The realistic charge is to keep the occurrence of nosocomial infections to the smallest rate that can be reasonably achieved within the resources allotted."
Projecting that between 44,000 to 98,000 patient deaths may occur annually due to medical errors, the report by the Washington, DC-based IOM calls for Congress to establish a national patient safety center and require reporting of adverse events by states.1 (See report recommendations, p. 19.) Whether such reporting systems would include nosocomial infections remains to be seen, particularly because the primary focus and subsequent discussion of the report have dealt with medication errors. However, the IOM report cited "hospital-acquired or other treatment-related infections" by way of example along with transfusion errors and adverse drug events; wrong-site surgery and surgical injuries; preventable suicides; restraint-related injuries or deaths; and falls, burns, pressure ulcers, and mistaken patient identity.
President Clinton directed a health quality task force to assess ways to implement the recommendations and report back to Vice President Gore in mid-February. Given the resources, ICPs have the expertise to help in fulfilling many of the IOM recommendations throughout the health care system, including tracking and preventing such non-infectious adverse outcomes as medication errors.
"Whatever group they set up at the national level would be extremely well-advised to go to the infection control community for expertise in epidemiology, surveillance, analytical techniques, definitions of problems, crafting of solutions, and long experience within the system to improve quality," Schaffner says. "But locally, much depends on how resources are allocated. I would not wish infection control programs to be given more responsibility without commensurate resources."
Still, by drawing national media attention and a presidential press conference, the IOM report may well put patient safety issues on the "front burner," adds Fran Slater, RN, MBA, CIC, CPHQ, manager of infection prevention at Methodist Hospital in Houston. That could present opportunities to underscore the importance of infection control as well as opening avenues for ICPs to become involved in other patient safety issues, she says. "Granted, the whole emphasis of this particular report had to do with errors," she says. "How ever, if you look at patient safety in a much broader context, then certainly it applies to infection prevention and control programs. I see some possibilities for infection control to hop on this bandwagon. There are opportunities here for our profession. ICPs should be part of whatever team the hospital puts into place to improve patient safety."
While emphasizing that it is important not to dilute the primary clinical mission of infection control programs, an epidemiologist with the Centers for Disease Control and Prevention adds that ICP expertise is certainly applicable to non-infectious outcomes like medication errors. Applicable infection control approaches include establishing surveillance, defining populations, and using rates to benchmark and trigger interventions, says Robert Gaynes, MD, chief of nosocomial infection surveillance activity in the CDC hospital infections program. Multidisciplinary interventions across a broad range of practices are typically required to reduce infection rates, because only about 10% of nosocomial infections occur in clustered outbreaks, he says.
"ICPs could actively participate in developing a multidisciplinary, targeted approach for other adverse events in hospitals using the model that has been developed in the field over the last 10 years or so," he says. "We have found that when there have been significant [infection] rate reductions, it has been through using multidisciplinary teams. When there is an outbreak, often one thing has gone wrong, and when you correct the situation it returns to baseline. Whereas in [ongoing] surveillance, if you find by benchmarking that a rate is high, very often you cannot target a single intervention. You have to look at multiple interventions with multiple people."
Indeed, ICPs have to move from "outbreak thinking" to address broader patient safety issues, says Donald Berwick, MD, one of the IOM committee members who wrote the report, and president of the Institute for Healthcare Improvement in Boston. "I think it is a great thing for them to get invested in," he says. "[But] we are not talking about some background rate that is acceptable and we are watching for outbreaks of either infections or medication errors. The idea behind the report is that the prevailing rates — the background rates —- are unacceptably high, and therefore the agenda is not simply control of spikes. It is a continuous reduction in prevailing rates."
Hand-washing failures preventable
While the report focused primarily on medication errors and other non-infectious adverse outcomes, the IOM also noted that some nosocomial infections result from preventable errors of execution (i.e., failure to wash hands.) "For example, if a patient has surgery and dies from pneumonia he or she got postoperatively, it is an adverse event," the IOM report states. "If analysis of the case reveals that the patient got pneumonia because of poor hand washing or instrument cleaning techniques by staff, the adverse event was preventable (attributable to an error of execution)."
The IOM report cites that "2 million cases of nosocomial infection occur each year. . . . Epide mi o logical studies have estimated that one-third of nosocomial infections can be prevented by well-organized infection control programs, yet only 6% to 9% are actually prevented." While the bulk of the IOM report did not focus on nosocomial infections, future reports may deal in more detail with the issue, Berwick adds. "With a hospital-acquired infection, to regard any of them as inevitable is not modern thinking," he says. "So the whole idea is to take the currently non-preventable [infections] and make them preventable by understanding them more. That is not in the current IOM report, but it is in the domain of quality. This is only the first in a series of reports by the IOM. I’m sure we’ll be speaking to issues like that [in upcoming reports]."
Yet while historic problems with hand-washing compliance are a continual source of frustration for ICPs, many nosocomial infections today are a trade-off for keeping very sick patients alive with invasive devices, Gaynes says. "That is where nosocomial infections or other health-care related infections may diverge a bit from medication errors," he says. "From all evidence that I have seen, nosocomial infections have a degree of preventability, but they are not always preventable — particularly when they revolve, as most do, around invasive devices. They may be the price we pay for inserting these life-saving invasive devices. You are bypassing host defense mechanisms when you put a patient on a ventilator or a central venous catheter."
Indeed, Schaffner argues that infection control was not given sufficient credit in the IOM report for preventing infections in the face of adverse conditions such as increasing severity of inpatient illness and nursing staff reductions under managed care. "One of the first things that gets cut by a busy health care worker attending to sick patients is the mundane, repetitive aspects of infection control such as hand washing," Schaffner says. "And even if 95% of the activities at the bedside are done according to infection control standards, if at 2 o’clock Saturday morning infection control is not attended to, the organism can completely move from patient A to patient B. It’s not a dose-related phenomenon. You can get complete cross-transmission through one breach. Yet patients under surveillance have become substantially sicker, treatments more aggressive and hazardous, and diagnostic procedures more invasive. The fact that nosocomial infection rates haven’t doubled or tripled is absolutely astounding."
In CDC sentinel hospitals, infection rates rose 36% from 1975 to 1995, due in part to such aforementioned factors as an increase in intensive care patients and rapid discharge of less severely ill patients. (See Hospital Infection Control, August 1998, pp. 121-122.) While a 1985 CDC study on the efficacy of nosocomial infection control estimated that about one-third of nosocomial infections are preventable, Gaynes says it is getting more difficult to determine preventability.2 "It’s hard enough to determine if [patients] have an infection by reviewing a record, but it is almost impossible on an individual case-by-case basis to determine whether the infection was preventable," he says.
The CDC’s most recent estimates project that 1.8 million infections occur annually, a rate of five per 100 hospital admissions, and the resulting infections contribute to 88,000 deaths annually. (See HIC, May 1998, pp. 72-73.) Comparing the CDC and the IOM estimates is difficult because the IOM cited several studies in assessing the toll of medical errors, but nosocomial infections are not clearly defined and included in all of them.3-6
Regardless, any such extrapolations should be viewed with caution because mortality due to nosocomial infection is often difficult to assess, adds veteran epidemiologist William Scheckler, MD, one of the original founders of the Society for Healthcare Epidemiology of America. "It’s kind of hard to say sometimes what is the cause of death," says Scheckler, hospital epidemiologist at St. Marys Medical Center in Madison, WI. "If you have a patient with multiple-organ system failure who then gets septic, the best you may be able to say is that septicemia is a contributing factor. If you have someone with acute leukemia and they get blasted with chemotherapy, their white count is less than 500, and they get septic, is that an adverse event’ from the medications they received? No, it is a side effect of the medications that they received, assuming they received the appropriate dosage."
In that regard, Scheckler reminds that the IOM’s recommendations for a national center and state reporting of adverse events raise critical questions about patient risk adjustments and using common definitions for the events being reported. "Requir ing everybody to report in the same way is a huge challenge," he says. "Just having the Congress pass a law to set up an agency won’t do it."
Berwick concedes that "the definitional issues" are difficult, and the mortality projections used in the IOM report do not represent attributable mortality by epidemiological standards. "These numbers are estimates," he says. "I continue to feel if we are off by 50% and we are only killing 20,000 people, that is still pretty important. I think we have enough precision in these estimates to know that we have a problem here."
Still, Schaffner questioned whether the IOM report would ultimately only lead to another ineffectual bureaucracy unless funding to fulfill any recommendations includes bolstering nursing staff and upgrading health care worker training on safety and infection issues. "You can’t empower something unless the Health Care Financing Administration, Medicare, and the third-party payers are willing to pay more for health care," he says. "How is it that we can add more personnel and train people better if we are losing money in health care? These are paradoxes that are not coherently addressed [in the IOM report]."
On the contrary, an investment in patient safety issues should reap benefits for hospitals, and resources should be forthcoming to support such programs, Berwick says. "Clearly, the public energy behind this issue has gone up, so I suspect that there will be some resources that will move to this," he says. "[But] if the position of a hospital leader is to say, OK, I will work on safety if you’ll pay me to do it,’ that is wrong. To increase patient safety is an obligation of leaders under current circumstances — including current financing."
(Editor’s note: The IOM report is on the Internet at http://books.nap.edu/html/to_err_is_human/.)
References
1. Institute of Medicine Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
2. Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in U.S. hospitals. Am J Epidemiol 1985; 121:159-167.
3. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard medical practice study I. N Engl J Med 1991; 324:370-376.
4. Leape LL, Brennan TA, Laird NM, et al. The nature of adverse events in hospitalized patients: Results of the Harvard medical practice study II. N Engl J Med 1991; 324:377-384.
5. Thomas EJ, Studdert DM, Newhouse JP, et al. Costs of medical injuries in Utah and Colorado. Inquiry 1999; 36:255-264.
6. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care (forthcoming Spring 2000).
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