New procedures, attitudes cut cases
By Liz Kowalczyk, Globe Staff | November 22, 2009
Massachusetts’ largest hospitals say they have significantly cut the number of patients who acquire painful, costly, and sometimes deadly infections in their operating suites and intensive care units, suggesting that pressure from government regulators and patient groups, as well as a shift in doctors’ attitudes, is starting to make medical care safer.
Several academic medical centers in Boston said the number of ICU patients contracting bloodstream infections had dropped by at least half in the past several years because of new procedures to keep intravenous lines and other tubes cleaner.
Hospitals also said they have reduced the number of patients on respirators who develop pneumonia – Beth Israel Deaconess Medical Center said so few patients now get this type of infection that the hospital was able to cancel plans to expand its ICU.
At New England Baptist Hospital, a leading knee, hip, and spine surgery center, the number of orthopedic surgery patients with infected incisions has stead ily declined to 0.3 percent. There were 28 cases in the fiscal year that ended Sept. 30, down from 63 patients seven years ago.
“Absolutely, our hospital is safer than it was,’’ said Maureen Spencer, infection control manager at Baptist, which now treats some high-risk patients with germ-fighting baths before they are admitted.
National studies estimate 90,000 patients a year die from infections they contract while in hospitals or other medical facilities, and thousands of others require follow-up operations or treatment with intravenous antibiotics for weeks – which can cost the health care system $50,000 to $100,000 per case. Physicians long saw such infections as unavoidable, but in part because of rising public anger and tougher government oversight, they now recognize most cases are the result of preventable medical errors.
State public health officials, consumer groups, and patient safety organizations said they were cautiously optimistic about hospitals’ reports that infection rates are falling, but noted that they have not verified most of the data, and that it’s hard to sustain such improvements.
Not all types of infections have shown declines – hospitals are just beginning to work on reducing urinary tract infections, for example – nor have all hospitals adopted stringent infection-control measures. And even hospitals making concerted efforts to reduce infections still experience outbreaks: Beth Israel Deaconess had a rash of serious staph infections in its obstetrics unit last spring, and state health officials uncovered problems with its infection-control methods. The hospital said it has addressed those issues.
But given the “intense focus’’ doctors and hospital executives have placed on reducing infections, a drop in infection rates is “quite plausible,’’ said Elizabeth Daake, a policy director at the Massachusetts Department of Public Health. Hospitals across the country are reporting similar improvements.
“All the data has to be validated for us to really know that it’s accurate. But, in general, we’ve been seeing this kind of result when hospitals really buckle down and do the kinds of infection control that they haven’t done in the past and when they measure it,’’ said Lisa McGiffert, campaign manager of the safe patient project for Consumers Union, a nonprofit organization that is lobbying state legislatures to require public reporting of hospital infection rates.
The Massachusetts health department plans to begin publicly releasing certain hospital infection rates in March, Daake said. The initial data, for a yearlong period that ended in July, will provide a baseline to measure future improvements. Spencer, of the Baptist, said the threat of public reporting has helped push hospitals to attack the problem.
Medicare, the federal health insurance program for seniors, last year stopped paying hospitals for treating patients with three types of hospital-acquired infections, adding a financial incentive for institutions to solve the problem.
The gradual shift in physicians’ attitudes about the inevitability of infections also helped, and was accelerated in 2007 when a group of Michigan hospitals reported cutting bloodstream infections in half among ICU patients – with ordinary measures such as thorough hand washing, cleaning patients’ skin with an antibacterial agent before inserting intravenous lines, and using checklists to make sure patients were properly covered or “draped’’ before surgery.
“The excuses vanished,’’ said Dr. Donald Goldmann, a senior vice president at the Institute for Healthcare Improvement, a Cambridge group that helps hospitals improve care.
Consumers Union has publicized patient stories, adding to the outcry. One patient who wrote to the organization was Katie Quilitzsch, 38, of West Bridgewater, who had abdominal surgery for diverticulitis at Good Samaritan Medical Center in 2007. More than a week after her surgery, an inflamed area around her incision worsened into a serious infection and she was rushed back to the Brockton hospital. The wound tested positive for methicillin-resistant Staphylococcus aureus, or MRSA, an aggressive form of staph resistant to certain antibiotics.
Quilitzsch was in the hospital for five days, on intravenous antibiotics, needed care from a visiting nurse at home for six weeks, and was out of work for three months. She also required follow-up surgery. “It knocked me down,’’ she said. “I couldn’t believe how physically exhausted I was.’’
Hospital spokeswoman Teresa Prego said Good Samaritan launched an infection prevention program in 2008, which included mandatory education for staff, and has reduced its infection rates, including an 80 percent drop in MRSA infections.
Some of the greatest gains appear to have been made against bloodstream infections, which can be fatal and occur when bacteria spread down tubes, also called central lines or catheters, that are placed in patients’ veins to deliver medicine. Most ICU patients have central lines.
The hospitals in Michigan, as well as some in Pennsylvania, developed techniques to reduce central line infections, and they have been adopted by many hospitals in the Boston area. Beth Israel Deaconess, Boston Medical Center, Brigham and Women’s Hospital, St. Elizabeth’s Medical Center, and Massachusetts General Hospital said that the rate of intensive care patients with bloodstream infections has fallen between 50 percent and 80 percent in the past several years.
Hospitals say their goal is to eliminate these infections entirely, but some patients, such as those who have suffered multiple injuries, have such damaged immune systems that doctors don’t completely understand how to ward off infections, said Dr. William Barron, vice president for quality and patient safety at Boston Medical Center.
Hospitals also said surgical site infections are dropping, and the state health department will publicly release data on four types of surgery: hip, knee, hysterectomy, and coronary artery bypass graft. Many surgical infections blossom after the patient has left the hospital, however, so hospitals that have poor tracking methods may show lower infection rates.
A bigger concern is whether hospitals can maintain the focus needed to continue reducing hospital-acquired infections – and to keep them from bouncing back.
“I have seen a lot of hospitals make initial improvement and then take their eye off the ball,’’ Goldmann said. “I do worry that unless the attention stays on these issues and the systems become much more reliable, that we will slip.’’
Liz Kowalczyk can be reached at kowalczyk@globe.com.
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