I'll be curious to hear about the weapons that will be rolled out tomorrow at a press conference on combating healthcare-acquired infections. It has been billed as a first-ever event, with five leading healthcare organizations linking hands to announce a unified approach to reduce, ideally wipe out, infections in healthcare facilities. The five groups—the American Hospital Association, Association for Professionals in Infection Control and Epidemiology, Infectious Diseases Society of America, Joint Commission, and Society for Healthcare Epidemiology of America—have undeniable clout.
But how much of an answer can institutional muscle provide, really? Many of the tactics that will defeat HAIs are well known and at least in theory not difficult to put into practice. Everyone who walks into a patient room—that includes family and friends as well as caregivers—can and should faithfully sanitize his hands. Insertion and maintenance of central venous line catheters can and should follow established procedures, called a central line bundle, that minimize the chance of infection. Antibiotics can and should be administered before and after surgery based on timing that both reduces the possibility the surgical wound will become infected and minimizes the growth of antibiotic-resistant bacteria. I could go on.
I certainly don't have the answers, and this is a war that must be won. Bacterial, viral, and fungal infections are killing some 90,000 Americans in healthcare settings, mainly hospitals and nursing homes, every year. It's not news that some of the bugs, such as methicillin-resistant Staph aureus (MRSA) and vancomycin-resistant Enterococcus (VRE), are shrugging off even potent germ-killers. Moreover, hospital inpatients and residents of acute-care nursing homes are increasingly sicker and weaker than in years past. Children are especially susceptible to outbreaks of respiratory syncytial virus; the elderly to flu viruses. Diarrhea caused by C. difficile can quickly dehydrate infected patients.
No question, attention is being paid. Tomorrow's session was preceded by a press conference last Friday, during which infection experts who had gathered for a two-day summit on lowering the incidence of central line infections announced various tactics they had agreed upon. Some of the actions that particular hospitals are taking sounded fresh and inventive, such as weekly "bug rounds" in which different disciplines—doctors, nurses, pharmacists—consider individual cases of infected patients and ask, "Where did that infection come from? How did our prevention standards fail?" Self-examination, without blame and finger-pointing, can be tremendously successful, if the result is a change in a flawed culture or system. It removes the onus from individual caregivers, so there is less inclination for them to go into a defensive crouch when a mistake is made on their watch.
But the bullet points that came out of the summit were the same ones that have been made for years: Standardize "best practices" measurement and implementation; develop a culture of patient safety from the top; create incentives for hospitals to comply with known infection-control measures and make their data public (as opposed to punishing them for infections considered preventable); get patients more involved in their own care. "No national group has called for patient involvement," noted David Nash, the summit's moderator and professor of health policy at Thomas Jefferson University in Philadelphia. "Patients need to ask caregivers: 'Did you wash your hands?' 'Did you follow the standardized procedure for inserting my central line?' For that matter: 'Do I need a central line?' "
I wanted to know how many patients, especially those in the beeping, intimidating medical environment of an intensive-care unit, could be expected to speak up. "This may not be for everybody," Nash readily conceded.
Nor will it be simple to impose standardized protocols on hospitals. "It's no secret that the [infection-minimizing] central line bundle is not used in every hospital in the U.S.," said Nash, and a significant reason is that different doctors often have their own ways of doing things.
I'll come back to the infection conundrum regularly. Not only is it a high-stakes medical problem, but it also encapsulates much of the dilemma that confronts major improvements in safety and quality. We know what works: How do we encourage/order/force the healthcare system to make use of the armamentarium?