Increased nosocomial infections may be downside of downsizing
CDC beginning to link infection rates with economic trends
Ongoing economic changes in health care -- including downsizing staff and delivering an increasing array of services beyond the hospital setting -- may carry the price of increased infection rates, researchers are warning.
Discussions and research presented recently in Washington, DC, at the annual conference of the Society for Heathcare Epidemiology of America (SHEA) linked an increase in bloodstream infections to staff reductions and raised a red flag about the use of "pool" nurses in intensive care units. The studies were conducted by the Centers for Disease Control and Prevention in Atlanta, which is beginning to routinely include such assessments in its epidemiologic investigations, says William Jarvis, MD, chief of the investigations and preventions branch of the CDC's hospital infections program.
"There is no doubt that as managed care, health care reform, and cost containment come into play, one of the major methods of dealing with that is cutting the number of nursing staff," he tells Hospital Infection Control. "I'm hearing this repeatedly. There are certain things that nurses do on ICUs that require a set amount of time. As you reduce the number of nurses, the amount of time they have to do those things decreases, and it leads to breaks in technique and failure to wash hands. Lapses in infection control are almost inevitable when you reduce staffing."
Time will draw a clearer picture
Those initial reports are likely only the beginning, as Jarvis says the CDC hospital infections program continues to receive anecdotal accounts of staff changes tied to infection rate increases. While infection control professionals may be left with few options in hospitals that are already downsizing staff in an increasing shift to a managed care environment, Jarvis says the CDC hopes the findings will give them some data to cite to administrators considering such cuts.
"The hard part is getting CEOs and administrators to pay attention," he says. "We are hoping as we get these data out, it will start giving [ICPs] some ammunition."
Addressing the shift to outpatient care, other SHEA discussions included a report of surgical site infections in an ambulatory clinic and the unexpected recurrence of hepatitis B virus outbreaks in freestanding dialysis clinics. (See related story, p. 72.)
"I believe these [HBV] circumstances may be a harbinger of things to come," said William Schaffner, MD, SHEA keynote speaker and chairman of the department of preventive medicine at Vanderbilt University in Nashville, TN. "Because as we all know, an ever-growing feature of the medical scene in the United States is doing more complicated and invasive things in the ambulatory care environment. The more they are done in the ambulatory care environment -- some in the context of hospitals, but some more remotely -- the more danger there is of infection control misadventure."
Staff cuts linked to outbreak
In one study presented at SHEA, CDC researchers assessed the influence of the nurse- to-patient ratio on an outbreak of bloodstream infections (BSIs) related to central venous catheters used to administer total parenteral nutrition (TPN) at a surgical intensive care unit (SICU). They conducted retrospective case-control and cohort studies of SICU patients during a protracted BSI outbreak at the Tucson (AZ) VA Medical Center. Case-patients -- who were hospitalized at least 48 hours in the SICU and developed nosocomial infections -- were compared to randomly selected SICU controls. Compared with SICU patients in the pre-outbreak period, SICU patients in the outbreak period received more TPN -- a known risk factor for infection. In addition, however, investigators found a subtle but ultimately significant decrease in the nurse-to-patient ratio during the outbreak period.
The nurse-to-patient ratio dropped from 5.1 nurses for every six patients to 4.3 nurses for every six patients during the epidemic period, said principal CDC investigator Scott Fridkin, MD, now an infectious disease fellow at Cook County Hospital in Chicago. The nurse-patient ratio remained a risk factor for infection even when investigators controlled for TPN and ventilator use in a logistic regression model.
"We hypothesize that a lower nurse-to-patient ratio in the SICU in the presence of an increased use of an infection-prone treatment such as TPN, may lead to increased infections," he reported at SHEA. "Decreased staffing may lead to inadequate catheter care by decreasing attention to infection control practices that take a fixed amount of time, such as catheter dressing changes."
The staff reductions in SICU nurses at the hospital were part of "planned cuts" under a hospital nursing policy, Fridkin told SHEA attendees, adding that the outbreak subsided after TPN use was reduced rather than due to augmented staffing.
Asked about the findings, the hospital public relations department issued a statement that cited the primary intervention as "increased education of physicians, students, residents and nurses in the placement and care of the central venous catheters. Since implementation of this . . . there has not been a central line infection problem at the Tucson VA Medical Center. This corrective action has resolved this problem without increasing the number of nursing hours in the surgical intensive care unit."
Suzanne Pear, RN, MS, CIC, an infection control practitioner at the medical center and co-author with Fridkin, Jarvis, and colleagues of the recently published version of the study, noted that the CDC findings provided some measure of relief to health care workers.1
"One of the things that was rewarding -- when the CDC came in and the staff were told about the findings -- they kind of felt relieved," she said. "It was [a feeling of] 'It's not our fault. We couldn't help it. There's just not enough people to do quality care, and this is the outcome.'"
Though the changes in the nurse-patient ratio were not dramatic on the surface, Pear says the study shows that even modest staff reductions can affect the "delicate balance" of care being delivered to high-risk patients.
"Care in the critical care unit is care under a lot of stress," she notes. "The patients are quite labile, often their situations change, almost by the minute sometimes. When you are short-staffed, that means that patient is no longer the sole focus of the SICU nurse. You have to prioritize, and if time is of the essence, you do cut corners. That's human nature."
Though specific infection control breaches were not identified, Pear says time constraints likely translated to minor lapses in catheter care.
"Maybe you don't clean off that catheter junction as well as you should before you access it," she says. "If the dressing is loose over the catheter insertion site, you might wait a while because you have something else to do before you come back and put a new dressing on -- even though you know it should be done right now. Those are decisions, and they're almost not even consciously made."
In the published account of the investigation, the authors concluded that "during health care reform, as hospitals downsize their staff in efforts to contain rising health-care costs, reduced staffing should be considered a potential risk factor for nosocomial infections."
They also noted the irony that hospitals attempting to cut costs by reducing staff may actually incur cost increases due to higher rates of nosocomial infections. Although a direct relationship between understaffing and the occurrence of bloodstream infections has not been described previously for adult ICU patients, they cited another report in a neonatal special care unit.2
Not an easy measure
Nonetheless, though the findings seemed to strike a universal and receptive chord with SHEA attendees, Fridkin advised caution in broadly extrapolating the conclusion to other medical settings and situations.
"The nurse-to-patient ratio is not an easy measure -- this was, I think, very superficial," he said. "There are different quality of nurses -- ICU-trained, non-ICU trained, years of experience, pooled nurses from an agency. These are all issues we need to think about if we are going to start looking at this."
Indeed, some indication of how fine a line may have to be drawn in such assessments was evidenced in another study presented at SHEA. In that study, CDC investigators tried to assess the influence of nursing staff changes on the bloodstream infection rate of an SICU at Grady Memorial Hospital in Atlanta. The hospital was not experiencing an outbreak, but the CDC investigators expected to link staff reductions to increased risk of BSIs, said Jerome Robert, MD, MPH, a medical epidemiologist with the CDC who presented the findings at SHEA.
"We were thinking that we would see a little downward trend in nurse-to-patient ratio and an upward trend in patient infections -- and we were very surprised not to find this," he told Hospital Infection Control.
A closer look at staffing patterns brought some detail to the picture. Data on regular ICU staff, RN pool staff nurses from other units, patient admissions, and other risk factors were collected prospectively. The study was divided into two periods: one of decreased regular staff-to-patient ratio, and an increased pool staff-to-patient ratio. BSIs were significantly more likely to occur during the second period (2.8 vs. 7.6 BSIs per 1000 patient days), the research revealed.
"When [the hospital] started cutting their full-time RN and ICU staff, they started pulling more and more from the pooled staff," Jarvis says. "So when looking at the total nurse-to-patient ratio -- as we did out in Arizona -- we didn't really find any significant increase in infection rates. But looking down below that at the full-time RNs vs. the pooled RNs, we found that there was, in fact, an increased infection rate associated with the full-time RN decrease and the pooled RN increase."
The study raises the issue of the level of nursing experience and familiarity with a given unit's patient population, suggesting that shifting to nurses that are not regularly assigned to a setting may contribute to a rise in infection rates.
Still, in a multivariate analysis, only the duration of SICU stay was associated with BSI infection, and the data are too preliminary to definitively conclude that the staffing changes heightened infection risks, says Henry Blumberg, MD, who participated in the study as hospital epidemiologist at Grady and assistant professor of medicine in the division of infectious disease at Emory University School of Medicine. Even the pool nurses were RNs, not licensed practical nurses (LPNs) with less nursing training, he emphasized.
"If there was a problem, we would go to the administration, but I think it is too early to say what the final conclusion is because the data are still being analyzed," Blumberg tells Hospital Infection Control. "RNs at some institutions are being replaced with LPNs because it is cheaper, and with managed care, these hospitals are trying to save money. I think that is a legitimate concern -- are we putting people who are not as trained in these positions, and could that influence infection rates at different hospitals? But in our hospital, we only use RNs."
References
1. Fridkin SK, Pear SM, Williamson TH, et al. The role of understaffing in central venous catheter-associated bloodstream infections. Infect Control Hosp Epidemiol 1996; 17:150-158.
2. Haley RP, Bregman DA. The role of understaffing and over-crowding in recurrent outbreaks of staphylococcal infection in a neonatal special-care unit. J Infect Dis 1982; 145:875-885. *
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