Sunday, May 10, 2015

Infection Control in a Small US Hospital

Today’s blog is related to something quite different than the discovery and development of antibiotics – sorry.

It may also sound like a familiar plaint to anyone involved in infection control.  I expect to hear a lot of “suck it up, buddy” out there.

According to CDC data, almost 80% of US hospitals have less than 200 beds and over 50% have less than 100 beds, like the hospital where I volunteer.  I am helping their infection control committee on a consultant basis since they do not have an ID physician on their committee. My hospital is on the border of two states and has recently been acquired by a larger hospital in the neighboring state. The morass of state and federal regulations imposed on this hospital is a nightmare in terms of trying to provide the services that patients and physicians need to prevent and control infections and at the same time fulfilling various agency bureaucratic requirements.

The state where the hospital is located is mandated to supply hospitals with influenza vaccine.  But for the last several years, they have either been unable to fill orders on time or have substituted inferior vaccines (trivalent instead of tetravalent) without notice or warning.  Also, our state will not pay for vaccine administered to out of state patients.  But because we're close to the border, we have a lot of those.  We have to track who is from out of state to make sure we do not charge the state for their vaccine. The hospital, wisely, finally decided to buy their vaccine on the market this year rather than rely on the state and they were able to obtain the vaccine they ordered on time and in adequate supply.

Recently, with my help, the infection control committee instituted an antimicrobial stewardship program.  The goals were to decrease antibiotic resistant infections and healthcare-associated infection with Clostridium difficile. A major stumbling block to implementing the program as envisioned by the committee has been the inability of pharmacy personnel to track antibiotic usage using daily defined doses – the standard required for best practice. There has been no budget for software nor has there been budget available for additional pharmacy staff help to analyze usage manually.

This year, the state conducted practice drills and carried out inspections of our hospital to assure that we could handle Ebola patients should they show up on our doorstep. While this might have been necessary – at least as far as assuring the safety of hospital and emergency personnel is concerned – it was a major distraction to those involved in the routine of everyday infection control in the hospital.

Then there is the requirement of reporting to the National Health Safety Network (NHSN) of the CDC. We report certain surgical site infections, all intravenous catheter infections and all urinary catheter infections.  We also now report something called “ventilator associated events.”  We used to report ventilator-associated pneumonia – something I thought I understood.  Now we’re reporting the changes in pressures on the ventilators used to support patients in our small ICU as well as changes in patients’ ability to oxygenate their blood and other parameters. But I don’t know what we as a hospital are supposed to do with this information nor do I understand exactly why it falls within the purview of the infection control committee.  I do understand what we are supposed to do about ventilator-associated pneumonia and I also understand why that would fall within the role of infection control.  But now, the CDC requires that a patient have a bronchoscopy for the diagnosis of this infection – something that almost never happens at my hospital.  As such – we virtually never see ventilator-associated pneumonia anymore.  Pretty good progress – huh?

What happens with all these data?  We can get a summary of the CDC analysis of our data – but our numbers are so small that in the new CDC paradigm of accounting for various risk factors and then comparing to other hospitals in their database – the resulting data becomes meaningless.  We never achieve anything resembling  statistical significance.  And our numbers can vary wildly with the addition of a single case of say IV catheter infection in a year. 

To make things worse, CMS (Centers for Medicare and Medicaid) now punishes hospitals for having infection rates higher than the CDC-defined “norm.”  In 2013, we had a single case of IV catheter infection in our ICU for the entire year. But because our numbers of days where patients had catheters on our ICU was so low – our risk-adjusted rate based on this single case was higher than the CDC norm.  The hospital was asked to refund 1% of its Medicare payments from that year - something we could ill afford.  Of course, our goal is to have no IV catheter infections – but does this policy make sense to anyone out there at least insofar as small hospitals are concerned?  We are trapped by the tyranny of small numbers and a Federal Government who couldn’t care less.  

All this reporting to the CDC requires that someone spend hours on the CDC website filling out virtual forms. And who is that someone?  Our infection control nurse, of course. Her time might be better spent working on enforcing our hand hygiene policy – that is making sure health care providers wash their hands between patients. She could also be more useful spending her time assuring that best practices are always followed when intravenous lines are inserted and making sure that the urinary catheter the nurses want to insert in a patient is actually needed for something other than the nurses’ convenience.

OK - I’m done for now . . .we’ll just “suck it up” . .. . .

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