Hospitals taking more steps to prevent infections

The patient in Sentara Bayside Hospital's critical care unit suffered from septic shock and needed a catheter near her heart.

Knowing that such central lines can cause serious bloodstream infections, Dr. Nadeem Inayet proceeded with caution. He confirmed the patient's name and announced the planned procedure. He noted that consent had been given and sterile equipment was available.

Inayet washed his hands, donned a mask, gloves, gown and hat and draped the patient from head to toe with a sterile covering. He washed the insertion area with a special antiseptic.

He administered a local anesthetic and was about to begin when a nurse suddenly said, "Stop."

The cover had moved, exposing the patient's bare left foot. They discarded the open equipment tray and started over. From the very beginning.

"It was fantastic," Inayet later said.

That kind of methodical - but effective - culture of infection prevention is spreading among hospitals in Hampton Roads and nationwide. It's driven by patient safety concerns, money, state reporting laws and a conviction that a near-perfect record is attainable.

In the early 2000s, researchers showed that by using a checklist, health care professionals could dramatically reduce costly and potentially deadly infections that patients could acquire in a hospital.

That conclusion spurred changes on at least two fronts.

Starting in 2008, Medicare stopped paying treatment costs for certain hospital-acquired conditions and started requiring that hospitals foot the bills.

Virginia's Medicaid program followed suit in January, and private insurance companies are moving in the same direction.

Additionally, 30 states, including Virginia, instituted laws requiring hospitals to report statistics about patient infections originating in their facilities.

The Virginia Department of Health began posting numbers on its Web site last year and plans to add more.

"The increased emphasis on patient safety makes it a priority," said Linda Greene, a board member of the Association for Professionals in Infection Control and Epidemiology.

So far, reporting efforts have focused on central line-associated bloodstream infections. These infections are relatively common, potentially fatal and largely preventable.

A central line is a flexible tube inserted near the heart or into a large vein or artery to distribute fluids, measure the amount of fluid in the body or dispense medications, according to the Virginia health department.

Creating an entrance into the bloodstream can lead to infections when micro-organisms from sources such as a patient's skin make their way into the blood, said Greene, who is the director of infection prevention at Rochester General Health System in New York.

About 250,000 bloodstream infections occur each year in U.S. hospitals, according to the Centers for Disease Control and Prevention. The CDC estimates a large proportion of bloodstream infections are associated with central lines.

"Until a couple of years ago, people thought that a central line infection was the price of doing business," Greene said. "There are just so many ways we can prevent these infections."

The estimated cost of treating a central line infection ranges from $6,500 to $29,000, according to the CDC.

For Medicare, the decision to stop paying for certain hospital-acquired conditions, including bloodstream infections from central lines, would save $21 million in the 2009 fiscal year, according to projections from the federal Centers for Medicare and Medicaid Services.

No estimates for potential savings to Virginia's Medicaid program were available, but infection control is gaining steam with state health leaders.

The Virginia Department of Health now publishes the infection rates for adult intensive care units on a quarterly basis. Infection rates may vary by hospital size, the size of the intensive care unit, the volume of patients, their medical histories and the conditions treated in the unit.

The goal is to provide the public useful data to help them evaluate hospitals. Public reporting also can motivate health care providers to improve their numbers.

Hospitals report their own statistics, using a formula that measures the number of central line infections and the number of days ICU patients had central lines, then calculating a rate of infections per 1,000 days. State officials haven't yet settled on a way to verify the data.

Local hospital executives say they favor sharing the information but want the public to keep it in perspective.

"It's an indicator, but it's certainly not the only indicator, of what goes on in a hospital," said Victor Sonnino, vice president for medical affairs at Bon Secours DePaul Medical Center.

Both local hospitals in Bon Secours Hampton Roads Health System finished last year with infection rates higher than the state averages, which ranged from 1.13 to 1.49 infections per 1,000 central line days.

DePaul Medical Center took several steps to decrease the number of infections after a spike in the spring, said Lynne Zultanky, a Bon Secours spokeswoman.

The measures included changing the type of device used, ceasing to allow certain medications to be delivered through central lines and creating a specialized team to focus on patients' central lines.

The facility recorded two infections over the next six months, but it had three in December. Zultanky said staff members were less vigilant in their daily rounds that month. The infection count returned to zero in January after that practice was emphasized.

At Maryview Medical Center, the patient population was a factor, Sonnino said. There, a high number of patients suffer from infection-susceptible conditions, such as untreated diabetes or renal failure.

The infection rate at Chesapeake Regional Medical Center last year also was higher than state averages. Dr. Cynthia Romero, the center's chief medical officer, said the hospital put a focus on infection control about four years ago and has improved its rates.

Statistics from the center show its rate at 8.4 in 2006, compared with 2.16 last year.

Among South Hampton Roads hospitals in 2009, the Sentara Healthcare facilities reported the lowest rates, with numbers better than state averages. Intensive care units at Sentara Leigh and Bayside logged no central line-related infections last year.

In 2004, the Sentara system joined a nationwide initiative to reduce infections from central lines, said Dr. Gene H. Burke, Sentara's vice president and executive medical director of clinical effectiveness.

Between 2002 and 2009, the system's rate of central line-associated bloodstream infections fell from 3.68 to 0.42, he said.

Sentara annually sets goals to be in the nation's top 10 percent in some areas. Some infection control measures, such as hand hygiene, have been factors in employee bonuses.

"One of the things we believe here," Burke said, "if you don't measure something, you can't make it better."

At Bayside, the most recent central line-associated bloodstream infection occurred on April 8, 2008. The hospital's low rate was noted in the March issue of Consumer Reports magazine.

Inayet and others in the unit attribute the hospital's success to a variety of factors, including a new program assigning intensive care specialists to the unit; regular rounds by representatives from a number of disciplines, including a pharmacist and a patient care advocate; and a new ultrasound to help with central line insertion.

The unit also now encourages nurses to speak up more, including stopping a procedure if they see a violation of an infection control practice.

"It's about culture," Inayet said, "and it's about changing it."

Amy Jeter, (757) 446-2730, amy.jeter@pilotonline.com