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March 14, 2006

BehindTheMedspeak: Why are hospitals so dangerous?

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"Each year, studies show, about two million patients — or one in 20 — contract an infection after they are admitted to a hospital. This accounts for half of all major complications and 90,000 deaths annually." — Laura Landro, writing in the March 8 Wall Street Journal.

Can this really be true?

90,000 deaths annually?

Wait a minute.

That means that 90,000 out of the two million patients — about 1 in 20 — who contract an infection die.

Can that be?

Translated into easier to understand terms, that means that you have a 5% chance of getting infected if you're admitted to a hospital, and once you get infected your chance of dying is 5%.

With odds like that why would anyone go to a hospital unless they were mortally ill?

Even if the numbers are wrong — and no one really knows what the true numbers are, they're like the Federal budget, a collective fantasy tempered with educated guesswork — the problem of hospital–acquired infections is a very real one, for the simple reason that hospital–centric bacteria are fiercely resistant to commonly–used antibiotics.

Why?

Because these drugs kill all the susceptible bacteria, allowing resistant strains to emerge and become the dominant in–house flora.

Here's Landro's excellent article.

    Hospitals Take Stronger Steps Against Bacteria

    New State Laws, 'Killer Gloves' Help Combat Dangerous Infections; Ninety Thousand Deaths a Year

    Hospitals are unleashing some new weapons in the war against drug-resistant bacteria.

    For patients, the growing risk of life-threatening infections from a surgical catheter, health-care worker or contaminated bed rail may seem frightening enough to avoid entering the hospital in the first place.

    Each year, studies show, about two million patients -- or one in 20 -- contract an infection after they are admitted to a hospital.

    This accounts for half of all major complications and 90,000 deaths annually.

    But with growing pressure to fix the problem, hospitals are beefing up infection-control departments and investing in high-tech surveillance systems that provide early warnings about bacteria "hot spots" and can trace outbreaks to a ward, a playroom for sick kids, or a surgeon's hands.

    At the annual conference of the Society for Healthcare Epidemiology of America in Chicago later this month, experts will share strategies ranging from new disinfection methods to more rapid testing and screening of patients at high risk for infection.

    Medical-supply companies, meanwhile, are offering new products and services to fight bacteria, such as surgical catheters coated with antibiotics, "killer gloves" that release powerful disinfectants, new diagnostic tests to more quickly identify bacteria, and microbe-resistant bed sheets and lab coats.

    Five states have passed laws requiring reporting of hospital infections, and several other states are considering such laws.

    The Centers for Disease Control and Prevention has a voluntary infection-reporting system, but only 300 hospitals participate and report only certain types of infections in certain units, such as bloodstream-infection rates in intensive-care units.

    The CDC plans to launch a new Web-based reporting tool to broaden the program later this year, but has had some technical snafus.

    One major force behind the drive to control infections is the growing recognition by hospital administrators that infections are eating into profits.

    MedMined Inc., a Birmingham, Ala., company that mines hospital data to spot nascent problems with bacteria before they spread, estimates that private and public insurers paid $11.5 billion in reimbursement to hospitals because of complications from infections last year.

    But hospitals still lost nearly $9 billion from the costs of longer hospital stays and extra treatment.

    The key to stemming the tide of hospital infections is still reducing unnecessary use of antibiotics, which lead to resistance and the creation of "superbugs."

    Bacteria that cause the most vexing hospital infections, such as the virulent MRSA strain, have become increasingly resistant to the broad-spectrum antibiotics long used to treat them.

    But studies show bacteria's resistance to disinfectants is nowhere near as common as antibiotic resistance, because disinfectants work differently, killing bacteria outright, while antibiotics go after the bacteria and either break down the cell walls or interfere with reproduction -- and bacteria can learn to resist the mechanisms of antibiotics.

    If microbes escape after a disinfectant is used, it may be because the disinfectant wasn't used correctly.

    For example, hospital studies have shown that drenching surfaces or "active damp scrubbing" more reliably removes bacteria than quickly wiping with a damp cloth sprayed with the same disinfectant.

    The single most important way to stop the spread of bacteria is for health-care workers to clean their hands.

    But hospitals are also focusing on reducing the amount of bacteria present on the patient's skin prior to surgical procedures, using faster-acting antiseptics like chlorhexidine, instead of less-effective iodine products.

    They are also using catheters coated with microbe-fighting compounds and taking more sterile precautions when inserting catheters and intravenous tubes, where bacteria often enter the bloodstream, notes Rabih Darouiche, professor and director of the Center for Prostheses Infection at Houston's Baylor College of Medicine.

    In Pennsylvania, for example, a group of hospitals reduced bloodstream-infection rates for central-line catheters by 67% between 2001 and 2005 by adhering to guidelines including using chlorhexidine for skin disinfection before inserting catheters, and prompt removal of catheters when they were no longer necessary.

    And 14 hospitals working with the nonprofit Institute for Healthcare Improvement eliminated cases of a type of pneumonia for one year, following six relatively simple steps such as raising the head of patients on mechanical ventilators so bacteria don't get into the lungs.

    At Rush University Medical Center in Chicago, bedridden patients in the intensive-care unit are no longer bathed by hand with soap and water from a basin.

    Instead, nurses wipe them down with a "bath in a box" -- disposable cloths saturated with chlorhexidine combined with moisturizer.

    The change was made after a study found that switching to the cloths reduced by 60% the contamination of patients' skin with one of the most powerful strains of antibiotic-resistant bacteria, known as VRE.

    Robert Weinstein, the professor who led the study, published last month in the Archives of Internal Medicine, says there is increasing recognition that hospitals aren't doing a good enough job of simple cleaning and disinfecting.

    Intensive-care doctors "should insist that the performance of the ICU cleaning staff is reviewed routinely," says Dr. Weinstein, also director of infectious disease services for Cook County.

    Hospital infection-control professionals say that just buying new products to fight infection won't do the trick.

    "An organization could go broke buying every product out there they think is going to reduce infections," says Mary McNally, director of infection control at Memorial Health University Medical Center in Savannah, Ga.

    Ms. McNally says the key is for hospitals to identify bacteria problems unique to their facility, and intervene.

    Her hospital was alerted by MedMined to a "mini–outbreak" of the bacteria acinetobacter in the intensive-care unit, enabling the hospital to take immediate steps to halt its spread.

    The system culls information from hospital databases that is already being collected, such as patient admissions and results of tests, and analyzes it for trends.

    Before the hospital began using MedMined, Ms. McNally says, staffers had to gather data and analyze them manually: "It would take hours per day just to do routine surveillance, and two or three weeks to detect the outbreak and then it's out of control."

    G.T. LaBorde, chief operating officer of MedMined, says the company's data-mining system is used in 167 hospitals in 26 states.

    Hospitals that use the system, which costs about $150,000 a year, are able to reduce infections acquired in the hospital by 13% to 20% and cut losses by about $5.35 for every dollar they spend, he says.

    Mark Vaaler, vice president of medical affairs at the nine-hospital Baycare Health System in Tampa, which uses the MedMined system, warns that no matter how clean hospitals are, "there are still going to be bacteria."

    But by investing in new surveillance tools and adhering to guidelines for prevention, Dr. Vaaler says, "we can reach the goal of minimizing infections."

    Shannon Oriola, the chief infection-prevention and control officer at Sharp Metropolitan Medical Campus in San Diego and chairwoman of the public-policy committee of the Association of Professionals in Infection Control and Epidemiology, says patients can play a role in avoiding infections.

    "There's no reason you can't point out that you are one-day post-op, and ask, do I really need this urinary-tract catheter?" says Ms. Oriola.

********************

May I make a suggestion, one that may seem really stupid?

Why don't hospitals open their windows?

Some of the most dangerous air on the planet lurks within the hermetically sealed walls and heating, ventilation and cooling ductwork of our hospitals.

So why allow lethal bacteria to enjoy the favorable conditions enabled by tight buildings and constantly recirculated air?

Makes zero sense to me.

Flush 'em out into the great world and let them contend with the great unwashed, I say.

But hey, what do I know?

I'm just a blogging anesthesiologist.

March 14, 2006 at 12:01 PM | Permalink


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Comments

Yeah, that might clear some of the mold out. There have been some articles lately about male doctors going patient to patient, yet rarely dry cleaning their ties, carrying germs from patient to patient, not unlike the old bloody frock coats.

Posted by: Riannan | Mar 15, 2006 7:25:19 PM

While I was taking infectious processes, one of the most interesting and influential classes I ever took anywhere, I remember this same situation about 200 years ago at any hospital or dr. office. Currently I agree, open the windows, and doors, and closets, most assuridly closets...

Posted by: matt | Mar 14, 2006 8:31:25 PM

I complained of the same thing about office buildings in general the other day. I have never worked anywhere I could open the windows - even though they have all had big windows.

Posted by: Shawn Lea | Mar 14, 2006 3:04:41 PM

I am fortunate enough to work in a hospital that does open its windows (in the hallways, and in many patient rooms, at least), but in our department, everything is sealed up tight so we can stay negative-pressure. :(

Showering with chlorhexidine soap sounds awful.

Posted by: d | Mar 14, 2006 2:29:16 PM

They tell us that the windows are kept closed so people don't jump. People CRAVE fresh and/or moving air, but portable fans are few and will just stir up the resident cruft in the environment.

I have a problem with the "Staying Clean" list. Since when does wiping something with an alcohol swab kill "germs"? Scrubbing with alcohol has an effect ie.. scrubbing a person's skin before an injection, but mere wiping is just about useless.

Posted by: mick | Mar 14, 2006 1:51:15 PM

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