Recent demands for disclosure of data on hospital infection rates have spurred efforts not only to measure and publicize the numbers but also to demonstrate progress in controlling infections. The pressure is on to improve performance, because many insurers, employers, state and federal regulatory agencies, and consumer groups view infection control as a proxy for quality and patient safety.
During the past year, 39 states introduced legislation and 6 states passed laws requiring hospitals to disclose nosocomial infections to the state, and—in many instances—also to the public (N. Engl. J. Med. 2005;353:225–7).
But most surveillance and measurement efforts have been made behind closed doors. For example, the Centers for Disease Control and Prevention lets hospitals compare infection rates with other hospitals through the National Healthcare Safety Network, but this information is not available to the public.
The Joint Commission on Accreditation of Healthcare Organizations says it does not maintain statistics on hospital infections, although it recently published a study tracking how well hospitals did in giving antibiotics to pneumonia patients, among other quality of care measures (N. Engl. J. Med. 2005;353:255–64).
And the Centers for Medicare and Medicaid Services (CMS) sponsored a pilot project in which hospitals that focused on improving infection control were able to decrease the overall infection rate by 27%.
Robert A. Weinstein, M.D., recently said that those efforts are “a reality” and could lead to improved performance (N. Engl. J. Med. 2005;353:225–7). But to allow for meaningful comparisons among facilities and to spur better quality care, the measures should include such assessments as timely administration of perioperative antibiotic prophylaxis, vascular catheter insertion practices, and hand hygiene, said Dr. Weinstein, chairman of infectious diseases at the John H. Stroger Hospital of Cook County (Ill.). Infection control report cards should also track rates of infection in the ICU that are associated with central vascular catheters; reoperation or rehospitalizations for surgical site infections; rates of nosocomial influenza; and infections caused by multidrug-resistant organisms, he added.
Focus Brings Improvement
Many of those suggested measures were used to track performance in a group of hospitals that participated in the National Surgical Infection Prevention Collaborative. The collaborative was sponsored by CMS and managed by Qualis Health, a Medicare Quality Improvement organization that monitors quality for Washington state, Idaho, and Alaska. Of the 56 hospitals that joined the 12-month project, 44 reported enough data to draw conclusions (Am. J. Surg. 2005;190:9–15).
At each hospital, a team identified a limited set of surgical procedures or surgeons and tracked them for at least 30 days post procedure to determine the proportion of patients getting prophylactic drugs within an hour before the incision, the proportion getting appropriate agents, and the proportion who had prophylaxis discontinued within 24 hours. After identifying the procedures or surgeons to be monitored and gauging a baseline rate for each process to be measured, interdisciplinary teams worked on instituting ways to improve processes.
Over the year, 35,543 patients were tracked. The infection rate was 2.28% in the first 3 months (215 infections among 9,435 cases during that time period); it fell to 1.65% by the last 3 reporting months, constituting a 28% reduction.
Lead author E. Patchen Dellinger, M.D., chief of the division of general surgery at the University of Washington's Eastside Specialty Center, said in an interview that the collaborative focused partly on getting hospitals to more closely identify and monitor infections such as having a nurse check on a patient a set number of times post procedure, or conducting telephone follow-up to ask about problems with wound healing.
The hospitals did not receive any financial assistance for participation; for most, it cost the equivalent of a full-time nurse for the year, Dr. Dellinger estimated.
Achieving initial progress is the easy part, he observed. “The hardest thing is spreading the gains beyond the pilot population and then holding the gains and not backsiding.”
Spreading and Holding the Gains
Evergreen Hospital is one facility that has managed to keep improving, said Stuart Schrader, R.N., director of surgical services for the 244-bed community facility in Kirkland, Wash. The hospital did not have a grasp on baseline infection rates, although they appeared to be low (about 0.25% in 1999), Mr. Schrader said in an interview.
But the rate climbed each year, hitting 0.7% in 2001. After joining the project and learning some new surveillance techniques, the hospital found that its rate was closer to 1.1%.
Since then, the hospital has adopted quality improvement measures, such as using a convective warming blanket on patients preoperatively and requiring the anesthesiologist to shake hands with each patient—the “warm hands” test—to make sure he or she is normothermic during surgery. Patients are kept warm with the same blankets post procedure in order to ensure proper blood flow to the wound area and thus prevent infection. The hospital has also increased the temperature in its eight operating rooms, and purchased jackets and vests with pockets for cold packs to keep the staff and surgeons comfortable, Mr. Schrader said.