David's New Book

Saturday, December 19, 2015

Infection Control in a Small Hospital

Today I want to continue talking about what its like to work in infection control in a small hospital.  About 70% of all hospitals in the US are under 200 beds and 55% are under 100 beds. I carry out infection control work on a volunteer basis for a hospital near my home with an average census of around 40-50 patients. Since I began working there about four years ago, the hospital has undergone receivership, was purchased by a larger hospital in the area, and our system is now about to merge with another huge health care system in our region. This constant series of administrative earthquakes has challenged our infection control efforts.

We have made enormous progress on a number of fronts. Our hand hygiene program has had huge success with compliance rates now approaching 100%. We have revamped our microbiology procedures to better diagnose patients with pneumonia and to better identify resistant bacteria. Our antibiotic resistance rates among key pathogens remain low. We are revamping our surgical wound infection prevention program in a way that I believe will further reduce our already low rates of infection. And we have made great strides in assuring that patients requiring isolation remain isolated during all their sojourns around the hospital for diagnostic testing and procedures.

Our hospital is one of the highest rated medical centers in our area based a number of criteria including patient safety and infection control.  We do very well on all our external audits including those by the Joint Commission on Accreditation of Hospitals. And I agree that the hospital provides high quality care. I just know that we could do even better.

We do have a number of challenges that I think are directly related to our small size.  Our digital medical records system is badly in need of overhaul. It cannot perform any of the key infection control functions such as microbiology lab surveillance, diagnostic code surveillance for hospital-acquired infection nor can it provide reporting to the National Healthcare Safety Network of CDC.  All of this must be done by hand by our infection control nurse.  Our nurse also carries out daily rounds on all the hospital inpatient units, screens the OR schedule and peruses the emergency room patient and diagnosis list in pursuit of infections that might have been acquired at the hospital and of patients in need of some sort of isolation for colonization or infection by multiply-resistant organisms. She struggles to get all this done without computer support.

Our computer systems also are unable to support our antimicrobial stewardship efforts.  We are unable to determine antibiotic dosing in standard format such as defined daily doses. This makes it almost impossible to follow antibiotic usage trends. The pharmacy staff has been cut continually since I joined such that it is difficult for them to keep up with basic stewardship functions such as assuring that patients are getting the correct doses of the antibiotics that the physician has ordered.  Other functions, like trying to get patients off of unnecessary antibiotics, have fallen by the wayside.

Every time we attempt to bring on new functionality to our system or bring in a new computer system for infection control, we are about to merge and are told that we have to wait for the merger to occur.

My hospital has a small intensive care unit.  It exists to back up our surgeons who refuse to operate (understandably) in a hospital without such a unit.  In fact, our ICU maintains a census of 3-5 patients and there is almost always at least one or two on a ventilator. The problem is that we have only one intensivist.  Obviously, he cannot be there 24/7.  Although this may work well, the reliance on trained physicians assistants, ICU nurses and frequent telephone contact makes me nervous. I would prefer to have enough intensivist coverage such that some trained physician was easily available on a 24/7 basis. To resolve this would require systematic changes that might be forthcoming with the latest merger – but in the meantime, we are still on hold. 

Some might say that we should close the hospital altogether.  But those people do not live in this community.  To the community, the hospital is very important and extremely well liked and, as I noted in the beginning, we provide high quality care for our patients.  



Having worked in a very large hospital system (I was at a university-affiliated VA for 16 years), I now understand the issues confronting both types of systems, large and small. Small hospitals have unique problems that are not appreciated by insurers and key payers like Medicare and Medicaid.  Yet small hospitals comprise the bulk of hospital-based healthcare in the US. We need to start paying more attention to them.