Journalist and Author
I’ve been moving my RSS feeds over to a new reader and so am behind in reading things. That’s my lame excuse for not noticing an excellent story in the Washington Post Tuesday, a first-person account tracing the “conversion” of one skeptical physician to the cause of reducing hospital infections.
The story was highlighted at the New Health Dialogue, a must-read health-reform blog, by my friend and former fellow Kaiser fellow, Joanne Kenen.
Constant readers, for those of you who are following the back-and-forth over the economic stimulus bill, I wanted to let you know that the Association of Professionals in Infection Control (APIC) is saying that the compromise may cut money for state programs to reduce hospital-associated infections.
Here is APIC’s alert:
ACT NOW TO PRESERVE HAI AND PUBLIC HEALTH FUNDING IN STIMULUS BILL
Your urgent action is needed now to preserve public health funding related to HAIs in the stimulus bill pending in Congress.
The stimulus bill passed by the House of Representatives includes $3 billion in funding for overall public health, prevention and wellness programs. Part of this funding includes $150 million for carrying out activities to implement a national action plan to prevent healthcare-associated infections, $50 million of which would be provided to states to implement HAI reduction strategies.
Because of the fast-moving action on this legislation, and the fact that an agreement has been reached to remove prevention and wellness from the Senate stimulus bill, your Members of Congress need to hear from you today as the House and Senate prepare to confer over a final version of the bill. We need them to support the House-passed provisions for public health, prevention and wellness and the HAI language in the stimulus bill (the American Recovery and Reinvestment Act of 2009).
I apologize that, being deep in book production, I don’t know the details of the HAI-reduction programs they are talking about, whether it means support for new mandatory reporting programs or some other thing. (I’ll ask some of the HAI-focused organizations to weigh in back-channel if they can.)
But if you are concerned about the recent new initiatives in various states to report, track and control HAIs, this is probably worth looking at.
Happy holidays, constant readers. Whatever you celebrate, I hope your days are full of security, calm and joy.
For those of you reading over the break, here’s a pointer to a post that takes us on the other side of the curtain, into the world of hospital administrators. Those of us who are concerned about nosocomial infections are often confused about why HAIs are so intractable. I mean really, how hard could it be?
This post and especially its associated comments suggests why it’s so hard. It comes from the marvelous blog Running a Hospital, which is written by Paul Levy, president and CEO of the Beth Israel-Deaconess Medical Center in Boston. As a thought experiment, he proposes getting all the hospitals in Boston (which is a LOT of hospitals: Harvard-associated, Tufts-associated, Partners, community hospitals — a huge, dense concentration) to commit to eliminating three categories of infections: central-line infections, ventilator-associated pneumonias and surgical infections, three categories for which there are well-recognized, well-tested interventions. He says:
The medical community in Boston likes to boast about the medical care here, but we don’t do a very good job holding ourselves accountable. This would be a terrific way to prove that we are serious about reducing harm to patients and that we can cooperate across hospital lines for the greater good.
It’s a stirring and elegantly simple proposal — but as we all know, simple is seldom easy, and the commenters — whom I take to be health care workers and executives as well — light up how not-easy this might be. They say:
… and on.
The entire exchange, and Levy’s blog, is worth reading. It’s a consistently succinct, thoughtful, revealing look at the complexities of modern American health care, and at the unintended consequences — such as intractable infections — those complexities can provoke.
Constant readers, you’ll note that posting has slowed down a bit: I am deep into a chapter that is giving me some difficulty. (And I seem to be playing holiday host to an unexpected bout of bronchitis. I’m sure I didn’t need both lungs…)
But here’s something that crossed my monitor this morning, and it’s worth looking at. Sir Richard Branson, founder of Virgin Air and many other extremely successful entrepreneurial efforts. has accepted a post as vice-president of the Patients Association, a nationwide nonprofit that advocates for hospital patients in the UK. Speaking up in his new position, Branson gave an interview to the BBC in which he talked about hospitals’ failure to curb MRSA:
It feels like they have tinkered with the problem rather than really got to the heart of the problem. The hospitals are there to cure people. They are not there to kill people.
It’s a marvelous interview — read the whole thing, it’s not long — because it’s such a breath of fresh air. Branson is an outsider to health care, but he knows how to make businesses work. And as the head of an airline, he’s extremely familiar with what we in the US call “never events”:
Sir Richard says the health service could learn a lot from the airline and rail industries on how to avoid mistakes.”In the airline industry if we had that kind of track record we would have been grounded years ago,” he said.”In the airline industry if there is an adverse event that information is sent out to every airline in the world. And every airline makes absolutely certain that that adverse event doesn’t happen twice.”
So his advice is brutally practical: Health care workers carry MRSA? Screen and swab them. Workers are positive for MRSA? Treat them, and take them out of direct patient contact for two weeks. That costs money? Spend the money: It’s less costly in the end than killing your patients.
Via the BBC comes a report, from a conference hosted by the journal Lancet Infectious Diseases, that some healthcare-infection experts in the UK are publicly questioning efforts to reduce hospital-acquired MRSA.
The argument is that, by focusing so tightly on MRSA, hospitals neglect other drug-resistant HAIs to such an extent that the overall rate of illness in the hospital remains approximately the same. They argue instead for a broader focus on all resistant and nosocomial organisms:
“It’s not clear that overall things have got better,” … said [Dr Mark Millar, a medical microbiologist at St. Bartholomew’s Hospital and the London NHS Trust].
“Rates of E. coli are going up and it almost compensates for MRSA.
“All you’ve done is replaced one problem with another one,” he said. … “”There’s no evidence that overall we have fewer hospital infections or fewer people are dying.” (Byline: Emma Wilkinson)
This is a highly contentious debate in the US as well, with no resolution in sight. I’ve covered some aspects of it here, and there is a long point-counterpoint from Infection Control and Hospital Epidemiology here and here.
My friend and colleague Helen Branswell of the Canadian Press reports (via the Toronto Sun) on the cruel and accidental irony behind an outbreak of healthcare-associated infections at Toronto General Hospital between Dec. 2004 and Mar. 2006. Based on a new paper in Infection Control and Hospital Epidemiology, it’s a fascinating and bizarre tale of the unpredictable hurdles that a hospital can face in attempting to eradicate HAIs.
It seems the hospital, in an attempt to reduce HAIs, installed hand hygiene stations in each room in its medical-surgical intensive care unit, in between the patient’s bed and a countertop that held patient-care materials. This would seem like good design: The sink was right in the middle of the “zone of action” in the room, so health care workers would be reminded to use it (unlike, for instance, retrofitted rooms I have seen where the sink is away from the bed or out of the path between the bed and the door, and where health care workers have to consciously think about using it rather than having it be automatic). And the sinks were of a particular design meant to reduce accidental contamination of health care workers’ hands: When the water was turned on, it flowed from a high gooseneck faucet straight down into the sink drain, without washing around the sink’s side.
But it turns out that design and location both had unanticipated flaws. Water flowing straight into the drain was more likely to splash from the drain back out of the bowl; when investigators marked the sinks with fluorescent dye, they found splashes up to a yard away. Because the sinks were so close to the patient beds, the water was able to contaminate the patients, and the countertops on the other side as well. And because the water was falling directly into the sink drains, without the reduction in velocity caused by allowing it to wash around the sides of the sink, it was able to dislodge biofilm colonies of drug-resistant Pseudomonas aeruginosa, a moisture-loving organism that was growing in the sink pipes — which then splashed out of the sinks in the water bouncing back from the drain.
When the investigators found that, they had an explanation for why 36 transplant patients in that ICU had become colonized with MDR pseudomonas over 18 months. Twenty-four of the patients developed invasive infections, and 17 died; 12 of those deaths were either caused or closely related to pseudomonas infection.
The investigators tried multiple times to decontaminate the sink drains; in a few cases, they were successful, but the drains became recolonized and grew fresh biofilms. It was not practical to relocate the sinks. Nevertheless, they shut down the outbreak: They swapped out the faucets, decreased the water pressure, put a splash barrier on the sides of the sink, and moved patient care materials on the counter next to the sink elsewhere in the ICU rooms. Once those rearrangements were complete, the outbreak stopped.
This outbreak obviously was not MRSA, and in the strictest sense it is not relevant to MRSA, which is not an organism that lives in sink drains. But in a broader sense — as an illustration of the completely unpredictable hurdles that can stand in the way of excellent infection control — it is a useful and tragic cautionary tale.
The abstract is here. The cite is: Susy Hota, MD; Zahir Hirji, MHSc; Karen Stockton, MHSc; et al. Outbreak of Multidrug-Resistant Pseudomonas aeruginosa Colonization and Infection Secondary to Imperfect Intensive Care Unit Room Design. Infection Control and Hospital Epidemiology 2009 30:1, 25-3.
There’s been a running story for several weeks now about the Queen Elizabeth Hospital on Prince Edward Island (home to mussels and Anne of Green Gables). The hospital struggled earlier this year with an outbreak of MRSA and a second outbreak of VRE among adult patients. It got those under control, but since earlier this month has been dealing with a new outbreak of MRSA in its newborn nursery, according to the PEI Guardian:
Nine newborns and one mother have now tested positive for MRSA. Five of those nine cases can be connected to the same source. (Byline: Wayne Thibodeau)
The stories are detailed, for a small paper — they go into depth about the cleaning measures the hospital is taking — and yet they don’t answer the questions that we here want to know. Does “tested positive” mean colonized or infected? Does “connected to the same source” mean they all have the same strain, or does it mean there is an epidemiologic link?
In the latest news (Tuesday’s paper and online edition), the hospital reports that it is doing nasal swabs on more than 300 staff, with the intention to do a 7-day decolonization regimen on anyone who turns up positive. They won’t however, disclose the source when they find it — though, again, it’s not clear whether that means not identifying the staffer (appropriate) or not admitting that it is a nosocomial outbreak (inappropriate and at this stage lacking in credibility):
Rick Adams, CEO of the Queen Elizabeth Hospital, said about 290 staffers have already been screened.
“In terms of the test results, we’re not going to be making anything public,’’ Adams told The Guardian.
“We want to make sure the environment here is supportive of staff and create a climate where they can feel comfortable and open to come forward and be screened knowing that any results will be kept strictly confidential.’’
Adams said he realizes a solid argument can be made that the public should be informed if the source is found and that source is a staff member.
But he said the public should also realize the hospital is doing everything it can to prevent a further spread of the superbug.
“The staff are under enormous pressure. They feel like they are under a microscope.’’ (Byline: Wayne Thibodeau)
Some readers may know that it is outbreaks among newborns that have demonstrated that the designations “community-associated” and “hospital-acquired” are passing out of usefulness. There have been several MRSA outbreaks in newborns and their mothers in the US (in New York City, Houston, Chicago, Los Angeles and Houston again because Baylor College of Medicine has been particularly alert to this) that were clearly nosocomial, and yet when the microbiology was done, were found to be caused by community strains.
Why does this matter? Well, for the PEI hospital, it may not: They have an outbreak, it appears to be nosocomial in nature, and whether it is HA left over from their earlier outbreak, or CA that came in via a health care worker or a pregnant woman, mostly affects what drugs they give the children and mothers if those patients do in fact have infections. And for those of us who are primarily concerned with nosocomial infections, the distinction may also feel not-relevant: Failures of infection control are failures of infection control and should not happen period full stop.
But for those of us who are are also interested in the natural history of this perplexing bug, the answer to what is going on at the Queen Elizabeth will be an important piece of information, because it could underline that the distinction between HA and CA is becoming increasingly artificial. The epidemics are converging.
Via the Guardian comes news that British hospitals are failing miserably at hygiene and infection-control targets set by the Healthcare Commission, a government-funded but independent watchdog agency somewhat analogous to the United States’ Joint Commission (formerly called JCAHO).
While community-associated MRSA is still a somewhat new story in the the UK, hospital or nosocomial MRSA is a major epidemic, with resistant Clostridium difficile (“C.diff”) coming close behind. So there has been significant attention paid in the UK to improving infection control programs in hospitals, through the vehicle of benchmarks set for the National Health Service trusts (essentially, regional organizational groupings of hospitals).
And the results, according to unannounced spot-checks made by the UK commission, are appalling. Only 5 of 51 trusts ( 51 = 30% of all acute-care hospitals in the UK) that were checked hit the mark. For those slow at math, that means 3% of UK hospitals are doing what they should to protect patients from infections they cause. (UPDATE: To be fair, if we assume the “5 out of 51” holds true across the NHS, then 10% are doing what they should. That’s still appalling.)
“At nearly all trusts we have found gaps that need closing,” said Anna Walker, the commission’s chief executive. “It is important to be clear that at these trusts we are not talking about the most serious kind of breaches. But these are important warning signs to trust boards that there may be a weakness in their systems.” (Byline: Sarah Boseley)
How weak? This weak, according to the commission’s own report:
UK hospitals have until next April to learn to hit these benchmarks or be held accountable under a new Care Quality Commission.
For infection-control geeks, the full text of the “hygiene code” which the hospitals must abide by is here. Details of inspections at individual trusts are here.
The Seattle Times this morning launched an three-day investigative project on incidence of HA-MRSA in Washington State that is worth reading.
As readers here already know, MRSA is not a reportable disease, and there are no diagnosis codes that directly correspond to MSRA that make infection or death easily trackable through hospital records or death certificates. The Times’ team came up with some innovative data-drilling techniques and apparently did a massive amount of number-crunching to come up with the incidence estimates that underpin their reporting. They use those to challenge hospitals’ reluctance to undertake surveillance and treatment that would wipe out MRSA on colonized patients and thus reduce the likelihood of MRSA infecting those patients or spreading to others via healthcare workers who neglect infection control. (NB, Michael Berens, the series’ co-author, did a huge project on nosocomial infections when he was at the Chicago Tribune a number of years ago.)
I am puzzled by one thing I am seeing on the story’s web page — one of the items in the break-out box that sums the story up very quickly to attract eyeballs to it. It says: “About 85 percent of people infected with MRSA get the germ at a hospital or other health-care facility. ” That figure doesn’t make sense to me; it sounds as though it is a mis-translation of the CDC finding a year ago (in the Klevens JAMA paper) that approximately 85% of invasive cases of MRSA have hospital-associated risk factors. Constant readers will remember that estimate has been challenged by researchers on community MRSA, who believe that CA-MRSA accounts for a much larger proportion of the current epidemic than has been acknowledged, and think that the wide spread of the community strain is the actual driver of the overall epidemic. I can’t see where in the text the Times team has done the math to support that assertion, so if anyone else spots it, or knows the reference it comes from, please let me know.
The ICAAC-IDSA (48th Interscience Conference on Antimicrobial Agents and Chemotherapy and 46th annual meeting of the Infectious Diseases Society of America) meeting ended a week ago, and I’m still thrashing my way through the thousands of abstracts.
Here’s my final, highly unscientific selection of papers that caught my eye:
* Evidence that the community-strain clone USA300 is a formidable pathogen: It first appeared in the San Francisco jail in 2001. By last year, it had become the sole MRSA strain found in the jail — it crowded out all others. (P. Tattevin, abstract C2-225)
* Another paper from the same UCSF research group finds that the emergence of USA300 has caused a dramatic increase in bloodstream infections, most of which are diagnosed in the ER, not after patients are admitted to the hospital. (B. Diep, abstract C2-226)
* And the CDC finds that USA300 is picking up additional resistance factors, to clindamycin, tetracycline and mupirocin, the active ingredient in the decolonization ointment Bactroban. (L. McDougal, abstract C1-166)
* An example of the complexity of “search and destroy,” the active surveillance and testing program that seeks to identify colonized patients before they transmit the bug to others in a health care institution: Patients spread the bug within hours, often before test results judging them positive have been returned from the lab. (S. Chang, abstract K-3379b)
* In addition to the report from Spain I posted on during the meeting, there is a report of emerging linezolid resistance in France. (F. Doucet-Populaire, abstract C1-188)
* And in addition to the abundant new news about MRSA in pork, and “pork-MRSA” or ST 398, in humans, over the past few days, there were reports of MRSA in milk in Brazil (W. Gebreyes, abstract C2-1829) and Turkey (S. Turkyilmaz, abstract C2-1832), and beef and chicken in Korea (YJ Kim, abstract C2-1831), as well as ST 398 itself acquiring resistance to additional drugs. (Kehrenberg, abstract C1-171)
* Echoing many earlier findings that MRSA seems most common among the poor, the poorly housed and the incarcerated, BR Makos of the University of Texas found that children are more likely to be diagnosed with the bug if they are indigent, or from the South (which I imagine is a proxy for lower socio-economic status, since the South is a more rural, more poor region). (abstract G2-1314)
* And finally, to the long list of objects (ER curtains, stethoscopes) that harbor MRSA, here are more: The ultrasound probes in emergency rooms (B. Wessman, abstract K-3377). Also: Dentures. (Ick.) (D. Ready, abstract K-3354)
