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VOL. 125 | NO. 163 | Monday, August 23, 2010

Infection Offensive

Local hospitals increase efforts to battle the blood bugs that kill

By Tom Wilemon

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Tennessee has lifted a curtain of secrecy, exposing the successes and failures of Memphis hospitals in preventing bloodstream infections.

The likelihood of getting a central line-associated bloodstream infection at some area hospitals is double what it should be. Data compiled by the Tennessee Department of Health in a recent report show some hospitals have a standardized infection ratio (SIR) of 2.0 or more when the national guideline is 1.0.

The ratio is determined by dividing the number of observed infections by the number of predicted infections for a specific hospital. The predicted number is based on a formula that considers total central line use at the hospital and computes what is expected, according to a national standard.

Only three Memphis hospitals had standardized infection ratios better than the national guideline. But the good news is that a majority of hospitals improved their performance over a six-month period. These infections, which federal studies have proven are preventable, kill thousands of Americans each year and cost the health care system billions of dollars.

“We are moving in the right direction,” said Karen Smith, director of continuous quality improvement at Saint Francis Hospital-Bartlett, one of the hospitals that made progress.

Le Bonheur Children’s Hospital had the most dramatic reduction, cutting its SIR in half and achieving the best performance in the city. Its score of 0.6 was much better than the national standard.

Other Methodist Le Bonheur Healthcare hospitals remain challenged on this front, but the system is replicating the prevention measures from the children’s hospital at all its locations.

Bloodstream infections occur when the catheters for delivering medicine and other fluid solutions to patients become contaminated with bacteria, such as staphylococci, or, in a worst-case scenario, an antibiotic-resistant bug, such as MRSA. These infections, once considered a risk of being hospitalized, are now known to be preventable if five simple steps are followed. The steps on this checklist include an emphasis on hand-washing and the use of the skin disinfectant chlorhexidine gluconate.

Tennessee residents can track how their hospitals are doing in the prevention of bloodstream infections by accessing the reports on the state Health Department’s website. The state for the first time released infection rates on specific hospitals in December. The updated report allows progress to be measured. Although most hospitals lowered their SIR scores, Delta Medical Center and Baptist Memorial Collierville experienced an increase in infections and wound up with the worst numbers.

Advanced practice nurse Beth Baker of Methodist University Hospital cleans her hands before inserting a central line. Hand hygiene is performed before, during and after the procedure, and is one of the biggest steps for preventing infection, she said.

Photos: Lance Murphey

The Regional Medical Center at Memphis (The MED) and Methodist University Hospital continued to be tagged as “significantly higher” than the National Healthcare Safety Network standard, but both hospitals reduced their infection rates over the six-month period.

Delta Medical Center and the Baptist Memorial Collierville were spared the “significantly higher” designation because of their smaller size. One or two infections at a small hospital can skew the numbers and lower the confidence level of the SIR.

That caveat didn’t placate Delta Medical Center. In January, the hospital started using chlorhexidine disinfectant swabs and changed the design of the caps for its catheters, said Debra Braddock, the infection preventionist. Delta also set up covert observers to monitor hand-washing.

“When those numbers came out, that was our first opportunity to see what other hospitals were able to do,” Braddock said. “So I started doing some checking around and talking to colleagues. I found out there was some improved technology out there that they had had good success with.”

From the time Delta implemented the changes in January until July 31, the hospital has not had a single central line infection, she said.

Accountability failure

The U.S. Centers for Disease Control and Prevention is pushing for the public reporting on infections. Tennessee is the Mid-South leader in this regard. It is one of 21 states whose legislatures have mandated public reporting on bloodstream infections acquired at hospitals. Arkansas and Mississippi are not.

“Sunshine is a great disinfectant,” said CDC Director Dr. Thomas Frieden, referring to the laws that mandate open records.

Health-care-associated infections kill about 100,000 Americans and cost about $30 billion a year, Frieden said last month during a speech in Memphis. The CDC has set a national goal of reducing these infections by 40 percent during the next five years. Hospitals are the starting point in this campaign.

“Health-care-associated infections in the non-hospital setting are virtually unknown territory,” Frieden said. “Long-term care facilities, dialysis centers, ambulatory surgery centers in particular, as well as other sites, are undoubtedly having the same kind of lapses in infection control and spreading the infections that occur in hospitals. But we don’t have a sense of how widespread those are.”

The CDC has set guidelines for “bundles” when administering central lines that include protective gear and a five-point checklist. The checklist is the result of research by Dr. Peter Pronovost, a professor at the Johns Hopkins University School of Medicine.

“Where we fail is accountability,” Pronovost said during a July teleconference.

He was reacting to the results of a survey commissioned by the Association for Professionals in Infection Control and Epidemiology. Half of infection preventionists surveyed said their biggest challenges were inadequate enforcement policies and staff education. The culture at many hospitals is such that nurses feel intimidated to remind doctors, who may be treating multiple patients during short time frames, to wash their hands.

“If the nurses are still afraid to speak up in their ICUs, it is not going to solve the problem,” he said. “Or if the CEO never gets a report of the infections, he has no clue as what the magnitude of the problem is.”

The five-step checklist includes hand-washing, the use of chlorhexidine soap, avoiding the leg/groin area for catheters, wearing transmission barriers when the catheters are inserted and removing the catheters sooner instead of later.

Dr. Richard Drewry Jr., chief medical officer for Baptist Memorial Health Care, noted that although most hospitals are using the CDC “bundles” and following the prevention checklist, some seem to be performing better than others.

“There are some questions out there that we don’t know or haven’t totally answered,” he said.

The hospital system is constantly researching best practices and investigating whether some catheters and other medical devices work better than others at preventing infection.

“This is one of those things in the health care industry where we’re not ashamed to borrow from someone else,” Drewry said. “That’s the nice thing about being able to benchmark with facilities that we know have good results.”

Baptist Memorial Hospital in Memphis had a 1.2 SIR, which is near the national standard. The scores for its smaller hospitals ranged from a perfect SIR of 0 at Tipton to the SIR of 4.1 at Collierville. However, the reliability of these scores for comparison purposes is questionable because of the small size of the hospitals.

Statewide comparison

The data in the health department reports is old by the time it is issued. The most recent report covers July 1, 2008, to June 30, 2009.

Dr. Gail Thurmond, senior vice president of clinical effectiveness for Methodist Le Bonheur Healthcare, said the system is pleased with the 0.6 standard infection ratio achieved at its children’s hospital and is working to achieve similar ratios at its other facilities.

The Methodist system’s infection ratios varied hospital by hospital, with Germantown and University performing badly with SIR scores of 1.8 and 1.7, while Le Bonheur and Methodist South beat the national standard with SIR scores of 0.6 and 0.9. Instead of just using chlorhexidine when administering a central line or hooking up medicine to the catheter, the system is giving its ICU patients baths with a chlorhexidine mixture.

“We are hoping this is going to be a very big change for us and create a trend that’s closer to our goal of having zero central line infections,” Thurmond said.

How They Measure Up

Memphis hospitals are striving to score a ratio of less than 1.0, which indicates bloodstream infections are below the National Healthcare Safety Network standard. A standardized infection ratio (SIR) of 1.0 means the number of infections is equal to the expected number. The SIR scores are less reliable for smaller hospitals.


Hospital | Cases | Expected | SIR
Baptist Memorial Tipton | 0 | 0.2 | 0.0
Le Bonheur Children's Hospital | 6 | 11 | 0.6
St. Jude | 4 | 4.9 | 0.8
Methodist South | 2 | 2.3 | 0.9
Baptist Memorial Memphis | 34 | 28 | 1.2
Methodist North | 6 | 5.1 | 1.2
Saint Francis Hospital-Bartlett | 5 | 4.2 | 1.2
Saint Francis Hospital-Memphis | 12 | 8.7 | 1.4
Methodist University | 34 | 20 | 1.7
Methodist Germantown | 10 | 5.4 | 1.8
The MED | 17 | 7.1 | 2.4
Delta Medical Center | 4 | 1.1 | 3.7
Baptist Memorial Collierville | 2 | 0.5 | 4.1


Source: Tennessee’s Report on Healthcare Associated Infections: July 1, 2008 – June 30, 2009. The full report can be accessed at health.state.tn.us.

So far, the system is on track to have better SIR scores in the next report.

“Through June, at all of our hospitals, we were doing extremely well,” she said. “For our adult ICUs, the infection ratio is less than 1. We have several hospitals with a zero rate. Le Bonheur is still doing extraordinarily well, and I’m sure it’s leading the state among pediatric hospitals. Their infection rate in the pediatric ICU is still less than 1.”

West Tennessee hospitals fared worse overall than their counterparts in the middle and eastern sections of the state. The overall blood infection rate for intensive care units in West Tennessee was 30 percent higher than the national rate. The region faces at least one additional hurdle. Memphis has a high percentage of people with end-stage renal disease who require dialysis, putting them at higher risk for central line infections.

Kidney disease is often a complication from diabetes and hypertension.

The MED, which treats this population and has a burn unit and trauma unit, scored 2.4 on its SIR, an improvement from the prior SIR of 2.8. The hospital reduced the number of central line infections from 22 for the 2008 calendar year to 17 for the period from July 1, 2008, to June 30, 2009 (there is a six-month overlap in reporting periods.)

“Quality processes related to vascular placement and maintenance were developed and implemented in 2009, which led to a decrease in catheter-related infections at The MED,” said Dr. Mack L. Land, an epidemiologist at the hospital.

Although the state makes adjustments in the reporting system to keep data from burn and trauma units from skewing a hospital’s score, many of the patients from those units end up being part of the hospital’s other units.

“The MED is in a comparison group with major teaching hospitals in Tennessee,” Land said. “Unlike many in the comparison group, The MED is home to a Level 1 trauma center and a Level 3 neonatal intensive care unit. Approximately one-third of patients in the medical/surgical intensive care unit are trauma and neuro patients.”

Federal and state officials are releasing more data about hospitals as they push for transparency so health care consumers can make better choices. Patients and their families are also encouraged to not be bashful about asking questions that might seem rude. Key words to remember are “CDC-approved bundles” and “chlorhexidine gluconate” when a central line is to be administered in a hospital or other health care facility.

Saint Francis Hospital-Bartlett recently had a discussion with employees about how they would react if someone asked whether they had washed their hands, Smith noted.

“Patients need to ask questions and not be afraid,” she said. “We appreciate them doing so.”

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