Hospitals need to do more than “make us better”
At a cost to the industry of more than $5 billion annually, hospital-acquired infections are responsible for at least 90,000 deaths each year
By Bruce Flickinger
Improving patient health and well-being is obviously the prime directive for any healthcare organization, but the dramatic rise in the rate of hospital-acquired infections means that hospitals often do the patient more harm than good. Handwashing and hygienically designed facilities are the keys to combating this problem.
In July 2005, Pennsylvania became the first state-indirectly, and perhaps unwittingly-to officially contribute to the emerging trend toward more consumer-empowered healthcare. Through an organization called the Pennsylvania Health Care Cost Containment Council (PHC4), the state began mandating the reporting of hospital-acquired infection numbers from all hospitals and healthcare facilities in the state, and made this information available to the public. While PHC4’s mission primarily concerns escalating health costs, quality of healthcare, and improving access to care, the public posting of infection rate numbers has already begun to change the way patients make decisions about their healthcare providers.
Five additional states have since enacted mandatory laws for reporting hospital infection rates and another 32 are ready to enact similar legislation. “The writing is on the wall,” says Maryanne McGuckin, Dr. ScEd., senior research investigator and adjunct associate professor at the University of Pennsylvania, Philadelphia. “People used to come to a doctor or hospital and just want to ‘get better.’ But there’s more empowerment now, and patients are not shying away from asking questions.”
To this point she adds, “If you ask your surgeon about what his facility’s infection rate is, and he doesn’t know or says ‘don’t worry about it,’ it’s time to find another surgeon.”
McGuckin’s group at the University of Pennsylvania, through a program called Partners in Your CareSM, has many years’ experience and thousands of data points regarding hand hygiene, hospital-acquired infections (HAIs), and the impact that patients themselves can have on the healthcare dynamic. Most recently, it released results of a survey, co-sponsored by Steris Corp., that found that consumers cite infection rates and cleanliness as two of the three most important criteria when choosing a hospital, outranking other factors such as reputation and proximity.
“We asked people what is important to them when picking a doctor or a hospital, and we thought the top responses would be insurance or geographic location,” McGuckin says. “But the top-ranking factors were cleanliness and infection rates. And these were the main reasons for leaving or discontinuing treatment, as well.”
In addition to public reporting of infection rates, increased media coverage of antibiotic-resistant organisms has brought the issue of HAIs to the fore, and the numbers are disconcerting: HAIs, or “nosocomial” infections, are generally reported to occur in 5 to 10 percent of patients, and are responsible for at least 90,000 deaths each year at a cost of more than $5 billion annually. That’s more people dead each year from HAIs than from AIDS, breast cancer, or car accidents. It’s therefore fair to say that many patients leave the hospital in worse shape than when they arrived.
The University of Pennsylvania survey also confirmed another unfortunate statistic: that handwashing by healthcare workers typically occurs only about 50 percent of the time between patient contacts. This is a major contributor to the rise in HAIs; a second cause is the growing antibiotic resistance among virulent organisms, notably Staphylococcus aureus and enterococci species. Controlling the situation is enough of a challenge, but the healthcare community now clearly has to contend with the fact that consumers are more aware that data about infection rates are available to them, so they are more cognizant of the risk of infection in the healthcare setting.
Best practices are unevenly applied
What does this new paradigm mean for hospitals and healthcare facilities? Firstly, the focus has concentrated on two critical areas: proper hand hygiene, and facility design and engineering that promote good patient health and mitigate the spread of disease. Secondly, there are a number of guidelines and industry standards that mandate procedures for better infection control. Most notable among these are the 2005 standards proffered by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), the nation’s most prominent healthcare accrediting body. The new set of standards specifically calls for procedures and processes to have a measurable impact on infection rates and outcomes.
A number of industry groups have developed guidelines and best practices documents. One, for example, is the Society for Healthcare Epidemiology of America (SHEA; Alexandria, VA), which recently published guidelines for the prevention of transmission of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) within healthcare settings. Chief among the recommendations is an emphasis on adherence to hand-hygiene guidelines. Other measures SHEA points to as preventing the nosocomial transmission of MRSA include improved antibiotic stewardship, staff cohorting, maintenance of appropriate staffing ratios, reductions in length of hospital stays, contact isolation, active microbiologic surveillance and better staff education.
Researchers analyzing the effectiveness of these guidelines published a report in the American Journal of Medicine (June 2006), writing that “currently, the efficacy of many of these individual infection control interventions remain in doubt,” adding that “many studies reporting improvement in infection control outcomes involve simultaneous institution of several of these measures, making it impossible to tease out the effects of any of the individual components.”
There is other evidence that, despite the existence of industry best practices, infection control (IC) efforts are a mixed bag throughout the healthcare community. A study published in Infection Control and Hospital Epidemiology (March 2006) assessed IC staffing resources, organizational structures and clinical processes, and how they were related to reducing the incidence of HAIs in 31 community healthcare facilities. Although the researchers found positive ratios between the number of patients and the number of IC staffers in the facilities studied, they reported inconsistent IC practices and wide variation in IC department structure and processes. Their conclusion: there is a need for more-effective implementation of current evidence-based recommendations for preventing HAIs and reducing the risk of harm to patients.
Officer in charge?
Most hospitals employ one or more IC practitioners (ICP) to coordinate infection monitoring and control efforts. McGuckin paints a picture of the typical hospital IC unit as overworked, understaffed, and with “a lot of responsibility but not much authority or funding.” Ideally, there should be one IC practitioner for every 200 beds, she says, but in reality this one person, although they might have some administrative help, is the only IC staffer at a typical 300-bed community hospital.
The ICP and hospital epidemiologist officer head up the IC committee, which typically meets monthly to discuss infection rates and hygiene procedures, policies, and product evaluations, and which usually includes representatives from varied departments, such as housekeeping, the lab, surgery, administration, and dietary services. “The problem is, if a facility’s infection rates are under control, then people ask, what exactly is our ICP officer doing?” McGuckin says.
Loretta Litz Fauerbach is director of infection control at Shands Hospital at the University of Florida, in Gainesville, a private, not-for-profit hospital that specializes in tertiary care for critically ill patients. Fauerbach makes the important distinction between sterile procedures and a clean facility. “Instruments and body sites like the heart can be sterile or microorganism-free, but a hospital can only be clean,” she says. “It’s impossible to establish a sterile environment in a facility where people come and go and patients are seen. It would be cost-prohibitive [and] not very conducive to patient-staff interactions.”
Fauerbach and others emphasize that HAIs are most commonly associated with procedures and activities performed on the patient. The patient’s own normal flora can play a role, along with the hands-on contact from healthcare staff. “Thus the most important function of a facility is to minimize the potential for cross-contamination between patients and/or staff by providing easy access to handwashing or alcohol-based waterless hand rubs,” says Fauerbach, who is a member of the Association for Professionals in Infection Control and Epidemiology (APIC).
“The concept of interventional patient hygiene is becoming very important,” McGuckin adds. “It involves looking at overall patient bioburden [because] so many other things come into play besides handwashing. You need to look at catheter care, oral care, pressure ulcers, surgical site infection, the use of prepackaged bathing towels instead of washbowls. When you’ve reduced the bioburden of both the patient and the worker, then you’ve got a good handle on infection control.”
Hygiene by design
Observers point to two key facility design strategies for reducing bioburden and preventing cross-contamination among patients and workers: single-occupancy rooms and the strategic and prolific placement of handwashing and alcohol wipe stations.
Fauerbach says single-occupancy rooms are key to assuring that “cross-contamination between patients is minimized and that staff have the appropriate opportunities to perform hand hygiene and/or remove any protective garb before going to the next room and the next patient. The physical separation of the patient makes compliance easier.” She adds that new room designs should have designated areas for easy access to gowns, gloves, and other personal protective equipment to make it easier to use those items during patient care.
“There is overwhelming evidence that the risk of infection is less in single rooms versus double rooms,” says Anjali Joseph, PhD, director of research with the Center for Health Design (CHD; Concord, CA), an organization that works to promote research, education, advocacy, and technical assistance to improve the quality of healthcare through evidence-based building design. “Single rooms are easier to disinfect after a patient is discharged, and the viral load is less as there are fewer visitors and staff in the room. Also, the risk of infection through contact transmission of pathogens is reduced.”
Joseph adds, “The highest concentration of visitors and people are in the public areas of the facility, such as the lobby or cafeteria, and most immunocompromised patients are not exposed to these sources of pathogens. But they are at increased risk if the patient shares his or her room with another person because this increases the traffic within the room.”
Unfortunately, many hospitals currently in operation were built prior to the patient safety initiative of private rooms, so healthcare providers must be alert to the potential for cross-contamination in a multi-bed room. Fauerbach says facility design can encourage good hand hygiene and removal of any protective garb when going from one patient to the next by having alcohol hand rubs readily available at the bedside and in the room. Also, the availability of sinks and personal protective equipment helps to facilitate compliance. She again emphasizes that “it’s important to provide space for gloves, gowns, and other equipment within the room so the healthcare provider doesn’t have to search for these items when they’re providing care.”
“It’s important to provide well located, accessible and visible sinks, and multiple handwashing-liquid dispensers and alcohol rubs inside and outside of patient rooms,” concurs Joseph. “This helps improve poor handwashing compliance, which is the key problem in addressing nosocomial infections from the staffing perspective.”
An additional vehicle for reminding and encouraging good hygiene practices among workers is the patients themselves. “Patients do observe what the workers are doing,” McGuckin says. “We asked them [in the survey], if encouraged to do so, would they remind a healthcare worker to wash their hands, and most indicated they would. This is the essence of our program: involving and empowering the patient as part of the healthcare team.”
McGuckin’s database of information involving hundreds of healthcare centers shows that “if you involve the patient, you can increase the level of hand hygiene by 60 percent within five months. So having patients remind healthcare workers to wash their hands is critical. The patient is always there, so there’s an ongoing vigilance.”
Look before you build
Another key feature for a hospital is its ability to be readily cleaned and maintained. Although surfaces generally are not linked to the direct transmission of infection, they should be nonporous, easy to clean, and able to withstand rigorous cleaning regimens.
This, along with a number of other facility design criteria, is explored in a 16-page paper recently released by CHD, authored by Joseph and titled “The Impact of the Environment on Infections in Healthcare Facilities.” In it, she distinguishes between frequent hand-contact surfaces, such as medical equipment, door knobs, bed rails, light switches, patient toilet areas and privacy curtains, and minimal hand-contact surfaces, such as walls and floors. The former obviously need to be cleaned and disinfected more frequently than the latter.
Joseph also addresses the issue of carpet versus vinyl flooring, noting that while there is scant evidence linking carpet contamination with nosocomial infections, carpet can support the growth of fungi and bacteria, and studies have shown that the air over carpeted areas tends to have higher pathogen levels compared with hard flooring. “While carpeting contributes to noise reduction, a possible reduction in falls and resultant injuries, and to a less institutional ambience, it should be avoided in areas where spills are likely to occur and in high-risk patient care,” she says.
Though noting that such considerations are important, McGuckin echoes the opinion of many observers in noting that “it’s hard to find direct correlation between infection rates and environmental conditions. Most disease transmission is via the hands, not dirty walls and floors.”
While facility-design issues are not as much of a headache for newly constructed facilities, they can be a major budgetary and logistical concern for older facilities, which often need to be rebuilt or refit-construction projects that create their own infection-containment concerns. Hospitals are generally in a near-continual state of expansion and rebuilding, so containment of these projects is a major issue with regard to the spread of infection.
“There are many instances of the spread of infection during periods of construction and renovation,” Joseph says. She lists a number of measures in her paper that can be implemented to prevent the spread of airborne pathogens from construction sites to the rest of the hospital. These include using portable HEPA filters; installing barriers between the patient-care and construction areas; using negative air pressure in construction
enovation areas relative to patient-care spaces; and sealing patient windows.
APIC has had a guideline for preventing infections associated with construction for many years, and CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC) also offers guidance on environmental infection control and the management of construction risks. “Today, the industry standard is to perform an infection control risk assessment (ICRA) on each and every construction project to assure the safety of patients, staff, and visitors,” Fauerbach says. “The project is also to be monitored along the way to ensure compliance with recommendations made in the ICRA and to identify any new issues that need to be addressed.”
The ICRA, Fauerbach says, should be done in cooperation with the facility construction staff, infection control, and the nursing and medical staff of the affected area. With appropriate planning and intervention, risks of construction-related infections (both airborne and waterborne) can be minimized. “JCAHO is also interested in seeing documentation of this process when they survey a hospital,” she says.
JCAHO stipulates that the ICRA delineate infection control issues that impact air and water quality, in particular, during any healthcare construction project. It should include ongoing monitoring requirements to ensure the health and safety of patients and staff while buildings are being constructed-and that new buildings or renovations will be constructed to facilitate ongoing cleanliness and mitigate related infection-control problems after construction.
People as a source of problems
Air quality is a primary concern in the healthcare setting, whether or not construction is under way. Evidence from many studies leaves no doubt that air ventilation and filtration play decisive roles in affecting air concentrations of pathogens such as Aspergillus and, as such, have major effects on infection rates. Considerations include type of air filter, direction of airflow and air pressure, air changes per hour in the room, humidity, and ventilation system cleaning and maintenance.
The overarching goal is to reduce the amount of particulate matter in the air through proper, well-maintained ventilation systems. Peak efficiency for removing particles from the air typically occurs between 12 and 15 air changes per hour, Joseph notes. Particles bearing potentially pathogenic organisms are introduced into the environment in three main ways: by activities involving the respiratory tract, such as coughing or sneezing; by movements that shed bacteria from the skin; and by the disturbance of dust. So, again, people have the biggest impact on an environment’s cleanliness, and while this can be controlled in a finite cleanroom environment, a hospital is a larger and much more variable situation.
“The standards for filtration vary depending on the unit and its function,” Fauerbach says. “The operating room, for example, has a different set of standards than does a general patient-care area. One level of HEPA filtration can be used in the overall hospital ventilation system, with a higher efficiency being reserved for the protective environment for the immumosuppressed patient.”
CHD and others advocate laminar airflow rooms with HEPA filters for operating-room suites and areas with ultraclean room requirements, such as those housing immunocompromised patient populations. However, “laminar flows are relatively expensive and difficult to achieve because furnishings, vents and other features can create turbulence,” Joseph notes.
Joseph and others point to convincing evidence that immuno-compromised and other high-acuity patient groups have lower incidence of infection when housed in HEPA-filtered isolation rooms. She cites one study in which bone-marrow transplant recipients assigned beds outside of a HEPA-filtered environment were found to have a tenfold greater incidence of nosocomial Aspergillus infection compared to other immunocompromised patient populations.
“HEPA filters are strongly recommended by the CDC for spaces housing immunocompromised patients,” Joseph says. “Most hospitals have a filtration system that is 90 percent effective in filtering out harmful pathogens. Once the frames for the filters are in place, it is possible to increase the efficiency of the filters by adding HEPA filters for special-care areas of the hospital, such as surgical areas, burn ICU units and protective environments for immunocompromised patients.”
Whether via people, the air or physical surfaces, infectious agents can and do prosper in even the best-maintained healthcare settings. Their prevalence can be attributed to a number of factors, but their transmission among patients and workers can clearly be reduced by proper facility design and engineering, and staff compliance to good hygiene principles.
Perhaps more importantly: “It is critical to have infection-control information available to the public in a way that they can interpret and use it,” McGuckin says. “Hospitals are businesses, and patients are their customers. Hospitals have to be accountable to them. That’s the way it is in every other industry, and it should be in healthcare, too.”
1. Association for Professionals in Infection Control and Epidemiology (APIC), http://www.apic.org.
2. Center for Health Design (CHD), http://www.healthdesign.org. Visit this Web site to access the report “The Impact of the Environment on Infections in Healthcare Facilities.”
3. Partners in Your Care Program, http://www.med.upenn.edu/mcguckin/handwashing. For more information about the program, contact Dr. McGuckin at firstname.lastname@example.org. Visit http://www.steris.com/aic/partners.cfm to access a copy of the University of Pennsylvania Caravan® Survey report.
4. Society for Healthcare Epidemiology of America (SHEA), http://www.shea-online.org.
5. CDC Guideline for Environmental Infection Control in Healthcare Facilities (2003), http://www.cdc.gov/ncidod/dhqp/gl_environinfection.html.
6. CDC Guideline for Hand Hygiene in Healthcare Settings (2003), http://www.cdc.gov/ncidod/dhqp/gl_handhygiene.html.