Germ Paper Task Force Targets Hospital Infections

Ignaz Semmelweis — a man Kurt Vonnegut once called his “hero” — was, to many in the medical community, a man ahead of his time.

Semmelweis was a doctor in Vienna who, during the 1860s, was concerned at the rate of disease and death among maternity patients at his hospital. Many of the new mothers were being treated by student physicians who worked on cadavers in an anatomy class before beginning their maternity rounds.

And they didn’t wash their hands.

Semmelweis oversaw a ward staffed by midwives and insisted they wash their hands before treating any patient. Deaths on his ward, compared to that staffed by the students, fell dramatically following the order. So Semmelweis published a study of his findings. If he expected to be lauded for what now seems like common sense, he was mistaken.

“He was laughed at,” said Kevin Sullivan, coordinator of Infection Control at Mercy Medical Center. “He stated that handwashing was the issue, but that was sacrilegious at the time, so when he published his results, they were roundly laughed at.”

More than 150 years later, in hospitals equipped with technology that 19th-century physicians couldn’t have dreamed about, “hand hygiene is still the most basic infection control measure,” Sullivan said.

That makes it the main weapon in the battle against hospital-contracted infections, an issue that has roared to the forefront of Massachusetts’ medical community in the form of a statewide task force charged with studying the issue and presenting remedies.

The group’s recently released findings are significant: potentially lethal infections that are contracted during hospital stays could be responsible for up to $473 million in medical costs annually in the Bay State. As for the human toll, national studies indicate that perhaps 90,000 patients die every year from infections contracted in the hospital, with germs entering their bodies through incisions, catheters, ventilators, or simply contact with — that’s right — unwashed hands.

Sure, health professionals are no longer running from dead bodies to new mothers with dirty hands, but the report demonstrates — with the help of 135 recommendations — that providers still have a long way to go to eliminate hospital-contracted infections completely. Here in Western Mass., hospital officials are listening.

Zero Tolerance

Donna Truesdell, director of Quality Improvement at Cooley Dickinson Hospital, recently attended the National Health Care Quality Conference in Boston and came back with a good feel for where the bar is being set.
“My focus was on the idea of 100{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} compliance with best practices: zero accidents, infections, pressure ulcers, and falls,” she told The Healthcare News. “There were about 200 people in the room, and when I asked how many of them had set a goal for their organization of 100{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} compliance, zero infections, etc., maybe 25 or 30 hands went up. That’s one of the big differences with us — we’ve set the bar as high as it can go.”

That means that, when the hospital’s first incidence of ventilator-associated pneumonia in 534 days occurred in June, the hospital immediately began to analyze what went wrong and where it could make further improvements.
Two Cooley employees, infection prevention nurse Linda Riley and respiratory therapist Daniel Barrieau, served on the state task force and shared some of the hospital’s progress. For example, to work toward its goal of zero infections, CDH has issued to its staff a lengthy list of procedures to follow to prevent such incidents — dozens of recommendations involving hand hygiene, equipment cleanliness, patient education, respiratory care, surgical site cleanliness, and communicating with staff.

There’s a whole section of the document devoted to preventing the spread of methicillin-resistant staphylococcus aureus, or MRSA. Cooley is one of only two hospitals in the Pioneer Valley, it claims, to screen all critical-care admissions for MRSA so those patients can be isolated. In a recent three-month period, Truesdell said, 15 patients were diagnosed with the infection, only one of which displayed the kinds of symptoms that traditionally trigger a culture.

“That’s 14 potential opportunities to spread MRSA from one patient to another that we wouldn’t have discovered otherwise,” she said.

Mercy has specifically targeted MRSA as well, not only isolating patients with the infection but requiring gowns, gloves, and sometimes masks for employees or visitors who come into contact with them, as well as enacting strict policies for cleaning surfaces, where the bacteria are known to live a long time.

To stress its zero-tolerance policy, CDH’s Infection Control department changed its name about 18 months ago to Infection Prevention. “That represents a significant shift in the focus,” Truesdell said. “We believe that infection prevention can really happen, rather than just controlling it. And not everything you do to prevent infection has to cost a lot of money. It’s just as important for us to focus on the small things as it is the high-tech kinds of things.”

The smallest, yet the most important, remains hand hygiene, both with soap and water and antibacterial rubs, and hospitals are taking the issue more seriously than ever before. Both Mercy and Baystate Medical Center actively monitor how much of the alcohol-based hand rub employees are using. In addition, Baystate employees are observed to ascertain their hygiene habits, said Mary Ellen Scales, manager of the Infection Control program at Baystate Medical Center and vice chair of the state task force.

“We want to know how many times a health care worker has washed their hands, how much product they’re using, and their technique – are they doing a good job, washing well?” she said. “When people are watched, they do better, and our people don’t know when they’re being watched.”

“Handwashing is the core of any infection control program. Hand hygiene is absolutely the most important thing,” Sullivan said, noting that other key factors include proper aseptic technique when doing a dressing or handling an IV, isolation procedures, vaccinating patients against influenza and pneumonia, and even having patients use antiseptic mouthwash to prevent the spread of germs.
Patient education is also key, Scales said.

“The handrubs are available at the local drugstore or grocery store, so patients are aware of it, and when they see it here, it’s a reinforcement for their private lives,” she said. “Patients have a responsibility in relation to infection prevention, to make sure they don’t pass infection to visitors. So when they see us cleaning our hands, it’s a helpful reinforcement.”

Need to Know

The devil’s in the details, the axiom goes, and Sullivan wants to know the details of every infection at Mercy.

“I get a copy of every bacterial culture done in the hospital on a daily basis, and that gives me a window on the community,” he said. “I take these cultures and see the patients’ charts to ascertain the severity of the infection. Are any of them hospital-acquired, and if so, how and why did this happen? I do have to say that Mercy has an excellent infection rate.”

However, as the state task force grapples with how to share infection data with the public, Sullivan said, it has to face the fact that every hospital reports its infection rates in a different way, using different criteria. Still, communicating with patients remains one of the committee’s top priorities, said Scales.

“It’s one thing to reduce infections and another to be able to publicly report it,” she said. “There are various methods, and we’re working out the details. Most of us only report to our internal institutions or the Department of Public Health, and some things are not disclosed to the public at all. When we complete our work, we want to get it out there in a way that people want.”

Dr. Lisa Hirschhorn of JSI Research and Training Inc., the private research firm hired by the state to prepare the task force report, told the Boston Globe that, while dollar figures may be bandied about, little literature is available on the personal cost of hospital-contracted infections. “That’s the unknown and unspoken cost.”

“What does the public know about infections?” Scales asked. “Everyone has a story of a loved one or neighbor or someone they work with who has developed an infection or something they didn’t expect after medical care — but did they really understand the whole process? When we look at infection reporting, we want to make sure they’re getting the information they need in a way that’s user-friendly and comprehensive.”

It’s data that hospitals are not expected to take lightly, particularly since Medicare, beginning in October 2008, will no longer pay them for care resulting from eight complications, including falls, objects left inside patients during surgery, pressure ulcers, and three types of hospital-acquired infections.

Massachusetts insurers said they are also reviewing the issue. Meanwhile, state Sen. Richard Moore, D-Uxbridge, has filed legislation that would prohibit hospitals from charging for such ‘never events,’ as they’re called.

When it comes to infections, never may be a difficult goal, but one hospital officials say is within reach. Reaching for the soap — or the hand rub — is a good place to start.