How Hospitals Can Better Prevent and Cope With Infections

One in 20 people hospitalized each year develop a health care-associated infection. How can hospitals reduce that number?

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Reduction of infectious diseases was a primary driver of longevity in the 20th century, a public-health historian of sorts, New York Times "Doctor's World" columnist Dr. Lawrence K. Altman, said Wednesday morning during a breakout session at the US News Hospital of Tomorrow conference in Washington.

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A century ago, noted Altman, former chief of the U.S. Public Health Service's division of epidemiology and immunization, there was no U.S. Centers for Disease Control and Prevention or World Health Organization. Infectious disease did not exist as a medical specialty. Most people who went into hospitals went there to die, he said. Heart attacks could only be diagnosed after death.

Altman said Dr. Ernest A. Codman was forced to quit Massachusetts General Hospital in 1915 and open his own hospital when leadership there disapproved of his rudimentary outcomes research. "None of those hospitals resemble those of today, nor of tomorrow," he said. Still, nearly 100 years later, there is much more to be done.

Citing a 2007 study in the journal Public Health Reports, Dr. Jonathan Perlin, chief medical officer of Nashville, Tenn.-based Hospital Corp. of America (HCA), said that one in 20 patients hospitalized in the U.S. each year, or 1.9 million people, will develop a health care-associated infection, running up $10 billion to $20 billion in avoidable costs. He said 80,000 people die annually due to these mostly preventable infections.

At Main Line Health, an integrated delivery network in suburban Philadelphia, hospital-acquired infections was the top problem for the organization, according to Vice President for Quality and Patient Safety Denise Murphy. Murphy, a registered nurse, said infection control simply was not part of the culture. She told attendees that creating a culture of safety and reliability meant doing three things and doing them well:

Set clear expectations about safety behaviors. "Everyone had to understand they were accountable for patient safety, and their roles were a little bit different," Murphy said.

Provide staff with education, skills and tools to address each type of error. This should include methods to build and sustain reliability, including redundancy, visual cues and team training.

Hold everyone accountable for safety.

Hospital executives need to address the common issue of people being afraid to speak up for safety, Murphy said. Reduce the "power gradient," which is what subordinates perceive as the distance between them and their superiors, so front-line practitioners and workers feel comfortable raising their voices, she added.

Well-known safety guru Dr. Peter Pronovost, senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore, said that a patient in a typical intensive care unit is at the risk of a dozen harms. ICU clinicians would have to do 150 things every day without a roadmap. Clinicians want to know what to do and when, so Hopkins created a schedule of checklists as a way of changing institutional culture.

"Too many hospitals refuse to divulge their findings" about nosocomial infections, or infections that originate in a hospital, Altman said.

"[Typically in the U.S.] we ensure safety by heroism instead of safe design," Pronovost added. There also seems to be a lack of empowerment.

"You've got to have some really courageous senior leaders" who can stand up to the legal teams and encourage clinicians to report errors, Murphy suggested. There also needs to be some standardization of what is being reported and how that information is interpreted, she added, saying that there are too many measurement groups with too few standards.

Pronovost told the story of a central line infection killing 18-month-old Josie King at Johns Hopkins in 2001. "At the time, our rate of infections at Johns Hopkins was sky high," he said. Such a record might cause the hospital to get shut down today, said Pronovost, a 2008 recipient of a John D. and Catherine T. MacArthur Foundation "genius grant."

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