Hospitals Struggle To Beat Back Serious Infections

Oct 21, 2014
Originally published on October 30, 2017 10:12 am

While Ebola stokes public anxiety, more than 1 in 6 hospitals — including some top medical centers — are having trouble stamping out less exotic but sometimes deadly infections, federal records show.

Nationally, about 1 in 25 hospitalized patients gets an infection. Some 75,000 people die each year from them — more than from car crashes and gunshots combined. A Kaiser Health News analysis found 695 hospitals with higher than expected rates for at least one of the six types of infections tracked by the federal Centers for Disease Control and Prevention. In 13 states and the District of Columbia, a quarter or more of hospitals that the government evaluated were rated worse than national benchmarks the CDC set for at least one infection category, the Kaiser analysis found.

The missteps Texas Health Presbyterian Hospital made this month in handling an Ebola patient echo mistakes hospitals across the nation have made in dealing with homegrown infections. Dr. Kevin Kavanagh, a patient safety specialist from Kentucky, said hospitals often fail to strictly follow protocols to deal with infectious diseases, and the government's standard responses aren't specific enough. "Right now there are too many recommendations on how to handle infectious diseases, too much leeway," he said.

A 2011 study in the New England Journal of Medicine underscored the problem. While hospitals have reduced the frequency of many infections over the last decade, they could do better if staff complied fully with recommendations. Those include diligent attention to hand-washing and using stringent barrier protection when tubes are being inserted, such as covering patients from head to toe with a sterile drape and wearing sterile caps, masks gowns and gloves.

"The percentage of time that health care providers do all of the things they are supposed to do when caring for a patient with a contagious disease can be pretty low," said one of the authors, Dr. Don Goldmann, chief medical and science officer at the Institute for Healthcare Improvement, a nonprofit in Cambridge, Mass. "There's a lot of room for improvement."

Goldmann said that hospitals tend to become more focused on following procedures when facing novel, highly publicized outbreaks such as Ebola. "When [an infection risk has] been around for a long time, it kind of becomes part of the background," he said.

Since 2012 the federal government has been analyzing and publishing the CDC rates for specific hospitals on Medicare's Hospital Compare website. Starting this fall, Medicare is considering infection rates when deciding how much to pay hospitals.

The CDC reports six categories of infections: those from flexible tubes inserted into veins to deliver medicines or nutrients; infections from catheters that drain bladders; two antibiotic resistant germs, Clostridium difficile and Methicillin-resistant Staphylococcus aureus; and two surgical site infections after hysterectomies and colon operations.

States with more than a quarter of hospitals having at least one high infection rate in the CDC data were Arizona, California, Colorado, Connecticut, Florida, Massachusetts, Montana, Nevada, New Jersey, New York, Rhode Island, South Carolina and Utah, according to the Kaiser analysis of the most current CDC records.

Three highly regarded institutions — New York-Presbyterian Hospital in Manhattan, Geisinger Medical Center in Danville, Pa., and the University of Michigan Health System in Ann Arbor — were among seven hospitals the CDC rated as having worse rates for four of the six infections, Kaiser found.

The CDC data, based on reports hospitals submit, are considered the most reliable assessments that exist. Still, many hospitals the CDC judged as having worse rates disputed those verdicts. They said that they look bad because they are more vigilant in identifying and reporting infections, or because they handle very sick patients who are more prone to catching a bug.

For instance, Dr. Darrell Campbell Jr., chief medical officer at the University of Michigan Health System, said hysterectomies are performed on cancer patients at four times the rate than at other Michigan hospitals that compare information with each other. Because cancer surgeries take longer than regular hysterectomies, often involving removal of pelvic lymph nodes, the chances of infection are greater, he said.

"When you adjusted for the cancer, we don't look different from any of the hospitals," he said. Campbell said none of Michigan's infection rates deserved being rated poorly. "Eventually, we'll get where we are more comfortable with this data, but we're not there now," he said.

New York-Presbyterian said in a statement it has made "significant improvements." Geisinger said in a statement that its infection rates have dropped since 2012 and that its MRSA rate appeared high because the hospital made a "data entry error" when it reported cases to the government. Geisinger also noted that many patients who test positive for C. diff never develop any symptoms, but hospitals still must report it as an infection.

Some major teaching hospitals, like Denver Health Medical Center, Duke University Hospital in Durham, N.C., and Mayo Clinic's hospitals in Rochester, Minn., have been able to maintain low infection rates, the KHN analysis shows.

Others are succeeding in controlling some infection types but not others, according to the CDC data. Yale-New Haven Hospital had lower rates of bloodstream infections caused by central lines, but higher rates of infections from catheters inserted into the bladder to remove urine. Since one of the main ways to avoid such infections is to remove the catheter as soon as it isn't essential, the hospital now allows nurses to take them out without a physician's order under certain conditions, said Dr. John Boyce, the hospital's director of epidemiology and infection control. "Busy physicians sometimes forget their patient has a catheter in, but the nurses know," he said.

Nationally, surgical site infections dropped by a fifth and central-line infections decreased by 44 percent between 2008 and 2012. MRSA decreased by a third during that period.

Battling C. diff is very different than fighting Ebola and in some ways harder, because it requires hospitals to restrain use of the antibiotics necessary for so many patients. When those drugs eliminate weaker bacteria from the intestines, C. diff is able to prosper. Patients can get massive diarrhea and, while C. diff can be treated, the worse cases may require surgery to remove the infected part of the intestines.

Other infections for which the CDC tracks but doesn't yet publish hospital-specific rates, known as gram negative, are impervious to nearly all antibiotics.

Reducing the frequency of C. diff and these kinds of infections requires hospitals to become more judicious in deploying antibiotics. But only about half of hospitals have established stewardship programs that help doctors use the appropriate antibiotics in the most effective doses without overdoing it, researchers say.

"We have increasing amounts of data that 30-50 percent of the antibiotics we are prescribing are inappropriate," said Dr. Kavita Trivedi, a consultant and former infection control official for California. "It sounds crazy to people who are not in medicine: Why would a patient be prescribed an antibiotic they don't need? But it happens frequently because we don't know what they need."

Copyright 2018 Kaiser Health News. To see more, visit Kaiser Health News.

AUDIE CORNISH, HOST:

While the Ebola epidemic may be a new challenge for American hospitals, infections contracted inside the hospital are not. In the United States about 1 in every 25 patients gets an infection during a hospital stay. The government collects information about six common infections in hospitals and makes this information available to the public - something it didn't do up until a few years ago. And it names names - which hospitals are doing a good job or bad job at stamping out infections.

Starting this fall, the federal government will begin penalizing hospitals with high infection rates. Jordan Rau of Kaiser Health News has been crunching the numbers, and he says there's a lot at stake.

JORDAN RAU: About 75,000 people die every year from infections that they got in a hospital. That's more than in car crashes or from breast cancer. And researchers have found that a lot of times if you post the infection rates - if you make that public, that brings a lot of self-induced pressure on hospitals to pay more attention to that...

CORNISH: A kind of name-and-shame policy?

RAU: Yes. And even if people outside of the hospital don't pay attention, the hospital executive boards are very aware of it. So about five years ago, the government set standards for how much they wanted to see particular infections drop. And then the Affordable Care Act tied infection rates to money in that hospitals would get less money if they didn't report the Rates, and also they would - starting this year, they will get less money if they do very poorly.

CORNISH: So what infections does the government report information on?

RAU: They report on two types of infections that come through catheters or flexible tubes. They also report on two very nasty bugs that are resistant to many antibiotics. One is called C. Diff and one is called MRSA. And finally, they are reporting on two types of infections that you get during surgery - one from hysterectomies and one during colon operations.

CORNISH: So let's get to the data here. Which hospitals are doing poorly when it comes to preventing infections?

RAU: About 695 hospitals did worse than average in at least one infections, and some of them are really big names - New York Presbyterian, Geisinger Medical Center, Tulane Medical Center, University of Michigan Health Systems - all did badly on several areas. And then they're just scattered. They're in pretty much every state except for one or two.

CORNISH: What sorts of penalties might these hospitals face if they continue to get low scores?

RAU: Well, coming this fall - so really any day now - we're expecting hospitals - about a quarter of them are going to lose one percent of their Medicare payments because their infection rates are too high. It's not just infections, but it's also other mishaps in hospitals like cuts and tears and falls and bed sores. And that's a significant amount of money, and this is the first time that will happen.

CORNISH: We call this a kind of name-and-shame policy. Do you get the sense or is there the sense in the hospital industry that this is, in effect, changing their approach - helping push the culture towards improvement?

RAU: There's no question that it's put more pressure on the hospitals. And some have reacted in a defensive manner and said well, you know, you're not measuring me right or my infection rate is really high because I'm really diligent in reporting every single infection and some people aren't looking for them. But everyone is paying some attention to it and trying to get their numbers better.

CORNISH: I want to end on a good note here. Can you name some hospitals that are doing well?

RAU: Yeah, there are several hospitals that handle really sick patients and complicated cases and have done excellently better than average - Duke University Hospital, Denver Health. Both of Mayo Clinic's hospitals in Rochester do terrifically, and that really shows that there is the ability to get your infection rates down for a hospital.

CORNISH: Jordan, thanks so much for speaking with us.

RAU: Thank you.

CORNISH: That's Jordan Rau. He's a reporter with our partner Kaiser Health News. And if you want to see hospital infection rates in your state, please head over to NPR's "Shots" blog. Transcript provided by NPR, Copyright NPR.