Jennifer Manganello had beaten a staph infection. She won out over a nasty bug called Klebsiella, too, as she lay in the intensive-care unit, suffering from complications of a seven-year-old spine procedure and was breathing with a ventilator.
But the 22-year-old, who had been partly paralyzed since the spine operation when she was 15, was attacked by two more infections as the weeks passed at Hartford Hospital in Connecticut. She finally died, one of the 99,000 Americans killed by a hospital-acquired infection in 2005.
Jennifer’s mother, Susan Manganello, was horrified by the toll that hospital care took on her daughter’s body. “Whatever antibiotic they gave her burned the entire side of her arm. It was like a huge, huge burn,” Manganello, a former transplant nurse, said in a telephone interview. “They kept it wrapped. When they took it down in front of me one day, I actually gagged. And I am a nurse. It was very deep and very nasty. She died with that. It never got healed.”
Doctors used to shrug off cases like Jennifer’s. Infections, they argued, are an unfortunate but inevitable side effect of long-term hospital stays. Germs are everywhere, they are invisible, and they can cause infections in so many ways when patients have multiple tubes inserted in veins, arteries, and other parts of their bodies. People carrying all sorts of microbes go in and out of hospitals all the time, and nurses are busy. It’s impossible to control all the exposures.
Public-health groups disagree, and they have become increasingly vocal about hospital-acquired infections. The influential Institute of Medicine made headlines when it issued a report in 1999 estimating that as many as 98,000 Americans die annually from preventable medical errors, mostly infections, at a cost of up to $29 billion a year. But the report changed little. “Hospital stays for methicillin-resistant Staphylococcus aureus infection have more than tripled since 2000 and have increased nearly tenfold since 1995,” the Health and Human Services Department reported in 2009. “One decade later, we can’t say whether we are any better off today than when the IOM first sounded the alarm about medical errors in 1999,” Arthur Levin, director of the Center for Medical Consumers and a member of the IOM’s Committee on Quality of Health Care in America, said at the time. Health and Human Services estimated that 1.7 million people acquired infections in the hospital, and that 99,000 of them died, in 2002.
But bit by bit, a combination of patient outcry, government reports, state requirements to report infection rates, and—finally—federal government action, including the 2010 health care reform law, is starting to move the needle. A few projects by big hospital groups demonstrate that hospitals can begin, perhaps for the first time in human history, to become safe places for sick people.
“SHE KILLED MY DAUGHTER”
Germs are sneaky. They stick to stuff, and they generate spores that can hide and grow long after the parent microbes have been cleaned away. They evolve in the flash of an eye to resist antibiotics, coming up with tricks that allow them to pump out toxic drugs or grow thick membranes as defenses. No red light flashes when a nurse transfers a few dozen methicillin-resistant Staphylococcus aureus bacteria onto a bandage he is changing. But the tiny batch of MRSA microbes can quickly multiply and make their way into a patient’s bloodstream, causing an impossible-to-trace lethal infection.
“One simple little medical error can cause a calamity and kill somebody,” Manganello said. “And that nurse who did that doesn’t even know she killed my daughter.”
Experts do, in fact, know how to prevent infections. “Wash your hands, wash your hands, wash your hands,” Julie Gerberding, former director of the Centers for Disease Control and Prevention, has intoned for years. Plain, old-fashioned hygiene really does work—keeping surfaces clean, keeping fecal matter away from open wounds, putting clean dressings over punctures made by catheters, and following sterile procedures in the operating room. So why is it so hard to make people follow such simple precautions?
“Creating a culture of safety requires changes that physicians may perceive as threats to their autonomy and authority. Fear of malpractice liability, moreover, may create an unwillingness to discuss or even admit to errors,” wrote Lucian Leape of the Harvard School of Public Health and Donald Berwick, who just stepped down as head of the Centers for Medicare and Medicaid Services, in a 2005 review of the Institute of Medicine findings.
“We don’t want to throw a bunch of antibiotics at people who don’t need them.” —Pharmacist Kevin Roshak
So step No. 1 was to require hospitals to get a handle on how bad things were in their own institutions, and then publicly fess up. The Health and Human Services Department’s 2009 Action Plan to Prevent Healthcare-Associated Infections lays it out. “The first thing you do is surveillance and know what the rates of infection are in your particular institution,” says Don Wright, deputy assistant secretary for health care quality at HHS. “No hospital wants a bad report card.”
The plan is painstakingly detailed and targets only a few—the absolute worst—of the various infections that people can get in hospitals. It starts with acute-care units, such as intensive care or neonatal intensive care, setting goals for reducing incidents such as central-line infections, associated with the thin tubes inserted to deliver drugs; urinary-tract infections caused by improper catheter use; and ventilator-associated infections that occur when people are on breathing machines for too long and germs get into their lungs.
Washington needed a stick to enforce this. Starting in 2011, the Centers for Medicare and Medicaid Services required hospitals taking part in Medicare to report rates of central-line infections in adult intensive-care patients, or risk a 2 percent pay cut. The potential humiliation of public reporting offers a big carrot to hospitals and hospital systems. They can brag as their rates fall and use low infection rates to recruit patients.
Even so, a lot of work remains to be done. A report out just this month from HHS’s inspector general found that hospital employees failed to report 86 percent of errors, including infections, because they did not understand what they were supposed to report. Of 293 cases of harm studied in depth, only 40 were reported to hospital managers, 28 were investigated, and five led to a change in hospital policy.
“Hospitals are doing a poor job of tracking preventable infections and medical errors and making the changes necessary to keep patients safe,” said Lisa McGiffert, director of Consumers Union’s Safe Patient Project.
Vocal criticism like McGiffert’s is responsible for what success the progam has enjoyed, said the CDC’s Denise Cardo. “If it weren’t for Consumers Union pushing for legislation, public reporting, we would not be here now,” she said at a forum sponsored by National Journal and the Association of Professionals in Infection Control and Epidemiology in October. “We have many states with public-reporting legislation. That’s the reason I can come and tell you what is going on in the nation.”
But mere awareness isn’t enough, because it’s not just carelessness that causes infections. Even when hospitals are on their best behavior, disaster can strike.
T. Stewart Hamilton, retired president of Hartford Hospital in Connecticut, was still active at 91 and planning a cruise with his daughter, Jeanne Hamilton. He fell and hit his head on the dishwasher in July of 2002 and went to his old place of employment to get the two-inch gash stitched up.
“You can bet they rolled out the red carpet for him,” Jeanne Hamilton, a retired chef, said in a telephone interview from her home in Mystic, Conn. But even for such an august personage as the hospital’s former president, the wait was five hours, she said—five hours during which microbes could easily have drifted into his open cut. “They wanted to rule out stroke and hematoma, so they didn’t stitch him up right away,” she said. Blows to the head can cause both, and they can be deadly. “I think sitting around with an open cut in an emergency room is what started the infection,” Hamilton said. She said that a urine test showed he wasn’t infected when he arrived at the hospital.
After doctors stapled his scalp wound closed, they kept Dr. Hamilton for observation for four days. But he deteriorated quickly after discharge and was right back in the hospital 12 hours later, dehydrated and low on oxygen. “I had never heard the word ‘MRSA’ when they said to me he had an infection,” Hamilton said. “They said, ‘He has an infection that isn’t touched by all the antibiotics that we have been trying.’ ”
Six days later, Jeanne Hamilton surrendered and agreed to have her father’s breathing tube removed. He died within four hours, in the hospital he had managed for 22 years.
“We believed in hospitals, and we believed in the medical system, and we didn’t believe they had done something wrong,” Hamilton said. She later heard Jean Rexford of the Connecticut Center for Patient Safety speaking about the need to prevent hospital infections; Hamilton became president of the group in 2009. “I knew I couldn’t go back and sue my father’s hospital. It would have killed him,” she said. She has faith that, with the right incentives, hospitals can improve. “I don’t think it’s hopeless,” Hamilton insists. “I think there are a lot of things they can do.”
FREEWAY TO THE HEART
Hospitals have tried all sorts of technological advances, from faucets that turn on automatically to copper surfaces that repel germs. The hands-free faucets, it turned out, harbored germs. A Johns Hopkins University study published last April showed that the new faucets were more susceptible to contamination with common bacteria such as Legionella than old-fashioned, hot-and-cold-handled fixtures. Repellant surfaces such as copper and Corian help, but study after study shows that wiping existing surfaces down with bleach is far more effective.
“That wouldn’t have happened five years ago.” —Reston’s Charlene Pennington, describing the emphasis on preventing hospital infections
In 2001, Congress began allocating $50 million a year to HHS’s Agency for Healthcare Research and Quality to study patient safety. The research points to a winning formula. It’s not sexy, and it breaks no new ground. Success relies on tedious and comprehensive record keeping, writing and using checklists, following rigid routines, and emphasizing accountability—all approaches that fly in the face of the myth of medicine as an art and physicians as creative but uncontrollable creatures.
Here’s what the formula looks like.
Michael is lying under what looks like a large plastic tablecloth. It covers him from his chin to beyond his feet. His right arm is pulled to the side, and draped under blue sterile cloths so that only a small square of skin shows. Dr. Joe Ruiz covers the lens of an overhead fluoroscope, a type of X-ray, with what looks like a large plastic shower cap. Everyone entering the room wears a gown, paper booties, a cap, and a mask. This is a surgical sterile zone.
But Michael (we haven’t named him, for privacy reasons) is not going to have surgery. He’s at Reston Hospital Center in Northern Virginia to have a PICC line inserted through his arm. The wire-thin PICC, short for peripherally inserted central catheter, will carry regular doses of antibiotics for a month-long course of treatment, saving Michael from countless needle sticks. The flexible thin tube can carry drugs to the bloodstream. It’s also a potential freeway for bacteria to travel straight to his heart, which would then pump the germs around the body.
CDC estimates that 248,000 central line-associated bloodstream infections, or CLABSIs, occur in U.S. hospitals each year, many of them caused by PICC lines.
Putting a line in is a simple procedure, says Cindy Robinson, director of infection prevention and control and employee health at the hospital. “Everything we do here, we do as a surgical procedure,” says Ruiz, the interventional radiographer. The routine is part of a program enforced by the Hospital Corporation of America, Reston’s owner.
Next to the X-ray machine, a wheeled cart is covered with sterile cloth. Disposable syringes, scalpels, and other tools are arranged on top. An ultrasound machine is covered in plastic.
Ruiz cleans the visible patch of Michael’s arm with chlorhexidine, a disinfectant. His colleague, Dr. Srini Tummala, enters and gowns up. Nurse Christina Daniels helps him, using a paper tag to pull the last tie around his waist so no germs transfer from her to the gown. Daniels takes attendance in a ritual called time-out—everyone in the room is named, Michael is identified, and the procedure recorded. Everyone agrees that Michael will have the line inserted into his right arm. The fluoroscope will help Tummala see as he threads the line through a large vein in Michael’s arm to just outside his heart’s right ventricle—a large vein where the antibiotic can disperse into his blood without burning the delicate lining of his blood vessel.
All of this preparation has taken half an hour. The procedure itself—typically, five minutes. In the past, it would have been done in the patient’s room with few sterile precautions.
Blood drips as Tummala pierces Michael’s skin. He quickly and deftly threads the line into the vein. Above Michael’s chest, the fluoroscope screen shows his beating heart. An iodine contrast agent is injected, and the vein appears clearly. “There’s something there,” Tummala says. “A narrowing of the vein. You’ve probably had it all your life,” he tells Michael. But the PICC line won’t go past it.
“Let’s do it in the other arm,” Michael says. Ruiz gathers up the paper draping the bedside cart. “I am going to trash all this, just to make sure,” Ruiz says cheerfully. They will start all over again with the sterile procedure.
It may seem like a big waste of time, not to mention of paper, plastic, and other sterile materials. But Jason Hickok, a registered nurse who helps direct patient safety and infection prevention at the Hospital Corporation of America, says it works. “We are making sure that people understand that zero is our goal,” Hickok says in an interview. “It is a permanent culture change that zero is our target.”
NO ONE IS IMMUNE
One way to reach a zero infection rate, HCA says, is through standardization—of practice, goals, and equipment. So, every HCA hospital gets kits for inserting a central line to deliver antibiotics, chemotherapy, or other drugs. Each kit includes a full body drape, chlorhexidine wipes, and other equipment for inserting the line in a sterile manner. “We tried to make it foolproof,” Hickok said.
Tummala denies that standardization takes the art out of medicine. Diagnosis, he says, still relies strongly on expertise and intuition. “But standardization in terms of getting a patient ready, monitoring, and evaluating those protocols—that makes sense.”
Daniels says that having a structure makes things easier for nurses, too. “Back in the day when every doctor did it a little bit differently, things could be overlooked,” she said.
“There is no hesitation, no questions,” Tummala agrees. “It gives a lot of confidence to the patient.”
One thing the program has demonstrated: The traditional top-down power structure, with the physician considered the font of knowledge and the center of power, cannot work in a new world of infection control.
This approach empowers patients, nurses, and even visiting family members. No one is immune from the reminder to wash hands, put on a mask when necessary, and clean up. “We had a whole campaign around ‘Speak up,’ ” Hickok said. Anyone, from a physician to a nurse to a technician, who sees a colleague doing something incorrectly is encouraged to point it out right away—and the person being corrected is encouraged to be grateful rather than huffy. Physicians went through competency training on how to insert a central line, regardless of seniority.
The same goes for Inova Fairfax Hospital for Children in Falls Church, Va. “We have empowered the nurses, especially with outside consulting physicians coming in,” said Deirdre Griffith-Ball, a nurse in the pediatric intensive-care unit that is part on an infection-control program organized by the National Association of Children’s Hospitals and Related Institutions. Signs on the doors encourage patients and visitors to watch all staff, who are supposed to sanitize their hands as they enter a room and before they leave. Any doubt, and even the sternest doctor can and should be asked to resanitize.
A new infection is a big deal. On the unit’s bulletin board is a handwritten sign celebrating “32 Days!” without an infection. A frowny face accompanies another note about the incident 32 days before, the first infection in months. The unit had been using four or five different dressing types. They decided to ditch all but one and standardize its use. “We had to totally reeducate 61 nurses over three weeks,” says Carol Rosenberg, a spokeswoman for the hospital group.
But such strict procedures work. The association has documented a 75 percent reduction in infection rates in its pediatric intensive-care units since 2006. Reston Hospital Center has had no central-line blood infections for four consecutive quarters in its critical-care and newborn intensive-care units. The previous year, the hospital recorded just one such infection.
The numbers nationwide are less impressive, CDC’s Cardo says, but still moving quickly by public-health standards. The national goal is to reduce central-line infections by 50 percent from 2009 to 2013, and the latest national survey numbers show a 33 percent decrease. Nationally, surgical-site infections have dropped 10 percent from 2009.
No one can argue against the new rules because they are all evidence-based. Study after study has shown, for instance, that hospital workers can and do infect patients with influenza if they are not vaccinated. So Reston has a 100 percent flu-vaccination policy. Infection-control specialist Cindy Robinson says that 94 percent of the staff are vaccinated, compared with about 40 percent of hospital employees nationally. Hospital Communications Director Joanna Fazio flashes her name tag, which has a small silver holographic sticker in the corner. “That’s your get-out-of-jail card,” she laughs. The 6 percent of employees who opted not to have a flu shot, mainly because of egg allergies (flu vaccines are made in eggs), must wear masks during flu season.
Setting and reaching the goal required little more than focus, but health care has rarely before seen such attention to detail. “We looked at other industries such as aviation,” Hickok said. Airlines have a good safety record because they have consistent procedures—including the use of checklists. “We saw there were lots of things we weren’t doing yet that we should.”
Another must for controlling infections is getting everyone on board. “It’s not just the doctors, the nurses, but the dietary health [experts], the nursing assistants. Even the patients themselves have a role to play in reducing these infections,” Wright told participants at the infection-control event. At Inova Fairfax Children’s, where the tiniest newborns lie amid tangles of tubes and cables, parents are allowed to handle their babies when possible, but they are encouraged to first scrub, use hand sanitizer, and gown-up. “When we put it in terms of infection control,” Griffith-Ball says, “they understand we are not just being mean.”
“I think as the entire spectrum of the clinical-care team owns up to the responsibility of preventing infection, that is the key to success,” said CDC’s Scott Fridkin. “Having one person responsible is an outdated model.”
That means that pharmacists are now part of the team, all the time. “We have them at every unit,” says Reston’s Robinson. “We rely on them. They are the experts.” They help prevent the overuse and misuse of antibiotics—the main factor that has led to the rise of “superbugs” such as MRSA.
“We don’t want to throw a bunch of antibiotics at people who don’t need them,” says Reston pharmacist Kevin Roshak. Would physicians have listened so closely to a pharmacist five years ago? “I don’t think so,” he says. “Pharmacy is, more and more, getting the respect of physicians. We are getting more and more involved in patient care.” Reston Hospital Center President and CEO Tim McManus agrees. “In the old days,” he says, “a pharmacist would have been stuck in a room, dispensing drugs.”
Another new tool: fighting infections from the top. “One of the things I think is incredibly important is that reports of any infections come to me,” McManus says. “That really pushes all of us to have it front and center.”
The culture change may be the biggest breakthrough in fighting hospital infections—producing a bigger effect than any new technology or even new drugs could have. “That wouldn’t have happened five years ago,” says Charlene Pennington, quality coordinator at the hospital. Top management would have known what the general infection rate was from month to month, she says, but would not have been notified about individual infections.
Dr. Keith Dockery says that there is little reason that hospitals cannot begin putting the proven principles into effect immediately. It’s not like they need any high-tech equipment. Where he works, in the pediatric intensive-care unit at Inova Children’s, nurses keep a checklist in a loose-leaf notebook. It helps them keep track of regular chores, such as bathing each infant in chlorhexidine every day. “Otherwise, it would be easy to breeze on by,” Dockery says. The hospital is moving to an electronic format in a year, he says, but paper isn’t necessarily a bad thing. “This piece of paper here, it is easy, it is convenient,” he argues. “To do the same thing electronically, I am going to have to have 15 iPads.”
Another low-tech innovation at Children’s is a steel equipment cart loaded with the standardized kits needed to change peripheral lines and other tubes. Before, tubing was often hung near sinks or trash cans, where it could easily be splashed with germs. The steel is easy to wipe and undamaged by bleach. A generic approach like this can help target all the various germs out there, from MRSA to Clostridium difficile—a particularly nasty bug that makes spores that cannot be destroyed by alcohol-based hand sanitizer or disinfectants but must be tackled with bleach.
The Hospital Corporation of America and the National Association of Children’s Hospitals and Related Institutions are trying to spread the word about their successes. But, not surprisingly, simply telling hospitals and staff what they should do has been a miserable failure. CDC issued hand-hygiene guidelines in 2002, and infection rates stayed stubbornly high. MRSA hospitalizations more than doubled, from 127,000 in 1999 to nearly 280,000 in 2005, according to a study in the journal Emerging Infectious Diseases.
The Joint Commission on Accreditation of Healthcare Organizations issued requirements in 2003 aimed at preventing the dumbest hospital mistakes, such as getting a patient’s name wrong or amputating the wrong limb. But it wasn’t until the federal government weighed in with a stick that hospitals really started to get on board to prevent such errors. Starting in 2008, Medicare stopped paying hospitals for treating certain urinary-tract infections caused by catheters, some central-line infections, bed sores, objects left inside patients after surgery—everyone’s heard the horror stories about scissors and sponges—and falls.
Wright credits the 2010 health care law for setting the policy in stone. “In that particular piece of legislation, it was made clear that the department must tie quality outcomes to financial incentives,” he says.
Manganello sees the difference as she works in home hospice care, often treating patients who have been discharged from long-term care facilities. “Three years ago, everybody was coming out with pressure ulcers,” she said, using the technical name for bed sores. “I never see it now.”
As for Hamilton, she still takes her own precautions. “I stay out of hospitals, as best I can,” she said. “I did have to go in for a couple of days. I wiped everything down with antibacterial stuff. I made sure people washed their hands.”
This article appears in the Jan. 21, 2012, edition of National Journal.