The Big Screen

7 October 2009 (Last Updated October 7th, 2009 18:30)

The frequency of infections such as MRSA has prompted further efforts by the healthcare community on control. Patricia W Stone, associate professor of nursing at Columbia University and director of its Center for Health Policy, explains to Nic Paton the advantages and disadvantages of screening as a method for controlling healthcare-associated infections.

The Big Screen

It's a shocking statistic, but healthcare-associated infections (HAIs) claim the lives of nearly 100,000 patients in the US every year, according to the US Department of Health and Human Services (HHS), in the process costing hospitals some $6.5bn a year. Despite advances in infection control, a tougher regulatory and compliance environment and much better education of healthcare workers, patients and families, the number of cases remains stubbornly high.

Yet there are some success stories. For example, in July, HHS secretary Kathleen Sebelius cited the Michigan Keystone ICU Project as a possible model for the future. The project, a joint partnership between the Michigan Health & Hospital Association and the Johns Hopkins University, has dramatically reduced the number of HAIs in the state, saving more than 1,500 lives and $200m. The project targeted catheter-related bloodstream infections, with clinicians being encouraged to follow a simple checklist when inserting catheters into ICU patients.

The Obama administration has begun work on a new American Recovery and Reinvestment Act to make available $50m in grants for states to help fight HAIs, with Sebelius calling for ICUs to commit to using the same sort of checklist Michigan uses for central line associated bloodstream infections, in an effort to reduce such infections by three-quarters over the next three years.

Then there is the University of Maryland Medical Center, which screened over 33,000 patients in the past year, dramatically cutting its levels of infection in the process. The centre has long been at the cutting edge of much work around HAIs and their implications for the US healthcare system, including recently examining how infection control departments should be making better business cases for infection control.

"The Michigan Keystone ICU project has dramatically reduced the number of HAIs in the state, saving more than 1,500 lives and $200m."

While attention still needs to be paid to proper sanitation and disinfecting of wards and equipment, the first line of defence for many hospitals and infection control units when it comes to the battle against HAIs is increasingly this screening of patients, says Patricia Stone, associate professor of nursing at Columbia University and director of its Center for Health Policy. A recent poll of some 250 hospitals and 415 ICUs carried out by the university found that 59% regularly screened for MRSA, another 22% for Vancomycin-resistant enterococci (VRE), 11% for Clostridium difficile and 12% for other types of multi-type infection.

"It is something that people have increasingly been aware of," she says. "Screening is more likely to happen in large teaching hospitals, as you would expect. And the main difference between the US and Europe is that when you are screening there are presumptive isolation precautions in 31% of ICUs."

Screening consequences

There is a growing recognition among clinicians and healthcare workers that, while screening can be effective in tackling HAIs, when it comes to wider patient care best practice, there can be other patient consequences from a screening programme that must be addressed.

"Although isolation is recommended with someone who has MRSA, it does have some unintended consequences," suggests Stone. "There tends to be less healthcare worker contact and you can see increased symptoms of things such as depression and non-infection related adverse events. If you have two minutes and you are walking by a patient's room you may stop in and say 'hi', but if you are going to have to put on a gown you may think twice. If you have to gown-up and put gloves on every time you want to go in and see them then it is probably inevitable that doctors and nurses are not going to go in so much."

There are also concerns that too narrow a focus on screening can end up being self-limiting.

"Many people don't think screening is the right way to go, but it is something that is now happening more" says Stone. "It focuses on just the organism and, in some respects, it is a blunt instrument, especially if you are not putting them in isolation. If they are just colonised and have not got the infection, there is an argument that the hospital should be treating them just to eradicate the organism. But really it also has to come back to proper hand-washing and infection control. Hospitals should be concentrating on having that happen as well, rather than concentrating on whether they have a culture for this or that organism."

Business case for infection control

The 2007 study, Raising Standards While Watching the Bottom Line, by Eli N Perencevich, medical director for infection control at the hospital of the University of Maryland Medical School#s Department of Epidemiology and Preventative Medicine, set out with the intention of looking at the business case for infection control.

While it had long been recognised that HAIs were costly and associated with significant excess mortality and extra length of stay, few studies had actually examined the cost-effectiveness of infection control interventions, including automated surveillance technologies.

When business cases were made for infection control they often failed to deliver, mostly because they didn't account for the difference between fixed costs (such as buildings, equipment, salaried labour, heating and water) and variable costs (such as healthcare worker supplies, patient care supplies, diagnostic and therapeutic supplies and medications). Yet some 85% of hospital costs tended to be fixed, meaning only 15% of infection costs could be saved in the near term, making the business case much harder to argue.

"Making reporting mandatory can also constrain an infection control department's room for manoeuvre."

The study used three surveillance strategies: passive (where a patient with a history of MRSA colonisation or infection is isolated), active (with isolation only happening when cultures return positive in an average of 48 hours) and active with a rapid PCR-based (polymerase chain reaction) test with an eight-hour turnaround.

The study also used admission surveillance cultures for MRSA on all patients admitted to the medical ICU, with a compliance rate among nurses since 2001 of more than 90%.

The rapid-screening programme was found to prevent ten additional MRSA acquisitions a year compared with the standard screening. Both active surveillance strategies were estimated to cost less than $1,500 per MRSA acquisition prevented, with the rapid test programme costing $15,000 more. The study concluded that both business case and cost-effectiveness analyses were needed in order to optimise infection control practice.

It recommended clinicians focused on the length of stay issue, which hospital infections extended, and the fact that interventions could help prevent infections with a length of stay of four days or more. They could then determine revenue added by filling bed-days with new admissions, so increasing volume, and compare that with the cost of their intervention.

It also recommended a number of strategies that could be worthwhile implementing more widely, including:

  • the use of printed or computer-based reminders with automatic stop orders to reduce unnecessary urethral catheterisation
  • printed or computer-based reminders to improve surgical antibiotic prophylaxis
  • active educational interventions with the use of checklists to improve adherence to central line insertion practices
  • active educational interventions such as tutorials to improve adherence to preventative interventions to ventilator-associated pneumonia.

Mandatory reporting

The other big talking point for infection control specialists is the regulatory and compliance environment, particularly the spread of mandatory state-by-state reporting of infection, with much more reporting on healthcare-associated multi-drug resistant organisms the next likely step.

"When it started in 2004, there were just three states that did it, now it is around 36," says Stone. "With mandatory reporting, infection control departments now have much more voice in the strategic planning of the hospital."

At one level this can be seen as a good thing, giving infection control departments and professionals more clout, the potential for greater resources and disseminating the message of HAI prevention more widely and higher up the management chain. But making reporting mandatory can also constrain an infection control department's room for manoeuvre.

"With limited resources, infection control departments are no longer able to target exactly what they want to do," Stone concludes. "They have to do much more meeting of targets and surveillance when they are reporting. So there is an issue of spending your resources and whether there is a better way to spend money than through screening. There is an underlying assumption that anyone has the potential to become infected, so we should always be doing proper hygiene and good infection control."