ICPs question accuracy of widely read series
A recent nationally publicized newspaper report on the "hidden epidemic" of hospital-acquired infections gives a sensationalized and oversimplified view of an increasingly complex challenge, veteran infection control professionals and epidemiologists tell Hospital Infection Control. The series — which ran in the Chicago Tribune in July 2002 and was distributed by other major media outlets — found that in 2000, nearly three-quarters of hospital-acquired infections were preventable because they were "the result of unsanitary facilities, germ-laden instruments, unwashed hands, and other lapses."1
In a series titled "Unhealthy Hospitals," the report largely dismisses the long-held rationale that nosocomial "infections are random and inevitable by-products of lifesaving care." To account for preventable deaths linked to hospital infections, the Tribune analyzed millions of computerized patient records from the nation’s hospitals, and compiled thousands of state and federal surveys and investigative reports.2 The story opens with the ominous sentence, "A hidden epidemic of life-threatening infections is contaminating America’s hospitals, needlessly killing tens of thousands of patients each year."
While hoping the publicity may at least result in more support for the nation’s hospital infection control programs, ICPs and epidemiologists interviewed by HIC found some aspects of the Tribune report highly suspect. For starters, they expressed exasperation at finding they had dedicated their professional lives to fighting a "hidden" epidemic. Indeed, the Washington, DC-based Association for Professionals in Infection Control and Epidemiology (APIC) — which has chapters in just about every U.S. state — has been fighting hospital-acquired infections since Richard Nixon was president.
"It is not hidden," says Patti Grant, RN, BSN, MS, CIC, director of infection control at RHD Memorial Medical Center in Dallas. "APIC has some 10,000 members who do this job. It is not a secret society."
Hidden in plain sight
For decades, nosocomial infections have been the subject of national and international meetings, professional associations, and several peer-reviewed and journalist-written publications. The Centers for Disease Control and Prevention (CDC) in Atlanta has held international decennial conferences on hospital-acquired infections since 1970, with the last occurring in 2000. The CDC has an advisory committee, the Healthcare Infection Control Practices Advisory Committee (HICPAC), that holds open meetings twice yearly to discuss guidelines and other infection issues.
Yet the Tribune states that "the health care industry’s penchant for secrecy and lack of meaningful government oversight cloak the problem." Some have been in the field long enough to see this kind of exposé recur intermittently over the years. "I have been in infection control for 25 years; and every once and in a while, the lay press or a newspaper discovers’ [nosocomial infections] and they think they have struck the latest American scandal," says Patrick Joseph, MD, chief of epidemiology, at San Ramon (CA) Regional Medical Center.
"The reader [of the Tribune report] is left with the image that there is a secret epidemic that we don’t want anybody to know about because we are lazy, uncaring, and because we have reckless disregard for patients. Nothing is further from the truth."
There is no argument that nosocomial infections are a major medical problem. In data distributed to the press attending the CDC’s 1998 Emerging Infections conference on hospital-acquired infections, the agency estimated that the infections cost the U.S. health care system about $4.5 billion annually. The CDC estimates that annually nearly 2 million patients acquire an infection while being treated for another illness or injury, and nearly 90,000 die as a direct or indirect cause of their infection. The Tribune went through an apparently exhaustive investigation to reveal numbers well within the same range, though its death count was higher at 103,000. Regardless of the numbers, infection control clearly is facing the greatest set of challenges in the history of the profession, Joseph emphasizes.
"Maybe it wouldn’t have sold as many papers, but I think it would have been more appropriate to discuss where we are in infection control in the current millennium," he says. "We have an increased number of invasive procedures; we have an increased invasiveness of the ongoing procedures; we have a growing number of immune-compromised patients who are living longer than ever; and we have a new era of [highly vulnerable] transplant recipients. In the midst of these growing demands, our charge is to continue to provide a safe environment."
Most infections do not occur in outbreaks
While the Tribune report focused largely on deadly outbreaks and clusters of infections, the problem is much subtler than that, reminds William Scheckler, MD, a member of the CDC HICPAC committee and hospital epidemiologist at St. Mary’s Medical Center in Madison, WI.
"It’s not hidden, and it’s not an epidemic," he says. "The reality is that clusters, outbreaks, or epidemics of infection — based on CDC’s data and our analysis at our own hospital — [account for] less than 5% of nosocomial infections. Most of them are endemic and very difficult to prevent, and many of them are related principally to the organisms that the patients are already carrying when they enter the hospital. So using all these cluster and epidemic stories as [representative] of the way things really happen is really quite inaccurate. That is worrisome to me. Not that they are not important, but they don’t really tell the story."
Grant also questioned the implication of this sentence in the Tribune report: "All hospitals are required to adopt general infection-control standards to qualify for the federal Medicaid program, but each facility is allowed to draft its own rules on everything from potency of drugs to eradicating germs."
Grant says the reason for that flexibility is based on the radical idea that infection control programs should not be one size fits all. "The desensationlized interpretation of that is that every infection control program is individualized and customized based on the epidemiology of that hospital — the historical data, the patient demographics, and the services provided."
She also expressed concern about the Tribune’s contention that deaths were considered preventable if patients’ infections were spread as a result of deficiencies documented by state, federal, or health care investigators. Linking some checked-off deficiency to a nosocomial infection is a stretch, she says, noting that the deficiency could include such items as a discrepancy in a refrigerator temperature log.
Preventable or not?
The Tribune’s claim that nearly 75% of infections are preventable is likely the most controversial aspect of the report to epidemiologists. "There is no basis in fact that I know of for that high of an estimate," Scheckler says.
The Tribune states, "though CDC officials now say they believe most hospital infections are preventable, the agency has not arrived at a precise number." Given that, Scheckler asks, "If the outfit that has been studying infections for 34 years — that has some of the best scientists and epidemiologists around — can’t make an estimate of how many are preventable, what makes an investigative reporter think he can do that? That’s chutzpah of the first rank."
The whole issue of preventability and medical errors has surfaced in recent years with the patient safety movement, and the CDC is reluctant to be drawn into a debate that could have political fallout. While the Institute of Medicine (IOM) patient safety report primarily focused on medication errors and other noninfectious adverse outcomes, the IOM also noted that some nosocomial infections result from preventable errors of execution (i.e., failure to wash hands.)3
Yet while woeful hand-washing compliance is well-documented, there still is the prevailing argument among many in the field that a large portion of nosocomial infections are a trade-off for keeping very sick patients alive with invasive devices. The only definitive study on the subject — the landmark CDC Study on the Efficacy of Nosocomial Infection Control (SENIC) — estimated in 1985 that a well-run program could prevent one-third of nosocomial infections.4
"The SENIC study was done many, many years ago," says Denise Cardo, MD, chief of the prevention and evaluation branch at the CDC’s division of healthcare quality promotion (DHQP). "We believe that probably now we may be able to prevent more infections than at that time. But we don’t know exactly what percent of the infections we are detecting are preventable. We are trying to have the approach to prevent as many as we can. We cannot get to zero, but hopefully, we can do a better job."
NNIS data undercut increase claim
The Tribune report also cites "a disturbing trend buried within government and private health care records: Infection rates are soaring nationally, exacerbated by hospital cutbacks and carelessness by doctors and nurses. . . . Hospital infection rates have quietly pushed higher each year, registering a 36% increase in the last 20 years, according to CDC records."
To set the record straight, the CDC previously has reported that infection rates rose 36% from 1975 to 1995 in its sentinel system for National Nosocomial Infections Surveillance (NNIS). However, in a separate data set reported in 2000, the CDC revealed that NNIS hospitals reported dramatic overall decreases in infection rates during the period of 1990-1999.5
In addition to declines in respiratory and urinary tract infections, the CDC reported a 44% decline in NNIS hospitals’ bloodstream infection rates in medical intensive care units. The data were used to underscore that infection control programs can provide an "evidence-based" model for the patient safety movement. Thus, the more recent trend is one of reduction not increase, and the only place the data are buried is on the CDC web site in its publication Morbidity and Mortality Weekly Report (www.cdc.gov/mmwr).
"We know that health care-associated infections are still a major problem, but with the data we have, we did see reductions in the [NNIS hospitals] that were doing very active work in trying to detect and prevent infections," Cardo says. "But we don’t have any data in terms of [overall] trends in the United States. With the NNIS hospitals, we have data that we can monitor and show that if you are doing very active work in trying to prevent infections, you can really succeed."
The CDC issued its own response to the Tribune series, and Cardo was reluctant to get roped into a point-counterpoint about the issues of its accuracy.
"Although there may be some problems with the estimates and some of the information they provided, people are paying attention to this," she says. "I think it can be a really good way to promote prevention of infections. They are drawing attention to a problem that we and our partners in public health and health care have been addressing vigorously for the last 20 to 30 years. Instead of getting into discussions about whether the numbers they provide are accurate or not, I think we need to see that they may be helping us show that this is important."
Scheckler adds, "I think there are a number of things that are useful in the article, one is that it highlights the fact that nosocomial infections are important and can cause morbidity and mortality. We need to have the best prevention efforts available to all of our hospitals."
The series also emphasized that the nursing shortage and cutting staffing levels can be dangerous because it becomes even more difficult for the medical staff to follow through on infection control practices.
Indeed, Grant notes the Tribune did a good job of covering the hand-washing issue, which has been the bane of ICPs for years. Many are hopeful that the CDC’s new emphasis on waterless hand-washing products may improve the dismal record of compliance, which the Tribune accurately reported was observed no more than half the time by harried health care workers. The Tribune’s observation that hospital housekeeping departments are understaffed and overwhelmed rings true as well, Grant says.
But the article gave short shrift to the longstanding efforts of thousands of ICPs and epidemiologists to improve the situation and protect patients, she adds. "I was glad they did include the sentence, And many hospitals battle infections with diligence and the latest technology,’ she says ironically. "I read every single word [in the lead article], and I think that is the only sentence that even hints at all the work that has been done the last 30 years."
References
1. Berens MJ. Infection epidemic carves deadly path: Poor hygiene, overwhelmed workers contribute to thousands of deaths. Chicago Tribune, July 21, 2002.
2. How the Tribune analyzed infection cases. Chicago Tribune, July 21, 2002.
3. 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.
4. 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.
5. Centers for Disease Control and Prevention. Monitoring hospital-acquired infections to promote patient safety — United States, 1990-1999. MMWR 2000; 49:149-153.
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