Anderson, Deverick J. MD; Sexton, Daniel J. MD
Duke University Medical Center, Durham, NC 27710.
D.J.A. is the recipient of the Pfizer Fellowship in Infectious Diseases.
Address correspondence and reprint requests to Deverick J. Anderson, MD, Duke University Medical Center, DUMC Box 3605, Durham, NC 27710. E-mail: email@example.com
Health care-associated infections (HAIs) increase length of hospitalization, hospital costs, and the risk of liability claims and are directly linked to an increased risk of death.1 As everyone knows, health care is becoming increasingly complex: the elderly population is growing; there is widespread use of immunosuppressive medications; and organ transplantation and invasive devices are more common.2 These trends are putting steadily increasing pressure on the behemoth known as the US health care system.
We believe that 4 additional factors have simultaneously converged to directly threaten the average American hospital's ability to survive. First, patient safety is now in the spotlight of the media. Thanks to innumerable news stories and articles, many-if not most-patients now worry about getting hurt while hospitalized. Next, public reporting of infection rates is now mandated in a few states, and others are soon to follow. Third, reimbursement to hospitals for the treatment of patients with HAI is already low and likely to decrease further. Finally, infections due to multidrug resistant organisms are more frequent and, in many cases, more severe. Although some may interpret this landscape as bleak, we believe that these challenges represent numerous professional opportunities for infectious disease specialists.
In 1999, the Institute of Medicine's report on medical errors concluded that one in 25 hospitalized patients experienced at least 1 serious adverse event directly related to their medical therapy and that over half of these events were secondary to preventable medical errors.3 Although all HAI do not represent medical errors, it is undeniably true that many HAI can be prevented by attention to simple but often ignored practices. Three of 6 quality improvement initiatives included in the Institute for Healthcare Improvement's (IHI's) 100,000 Lives campaign focused on process measures designed to prevent ventilator-associated pneumonia, healthcare-associated bloodstream infection, and surgical-site infection.4 Furthermore, 1 intervention of IHI's recently released 5 Million Lives campaign focuses on process measures to decrease the spread of methicillin-resistant Staphylococcus aureus (MRSA).5 The Surgical Infection Prevention (SIP) project and Surgical Care Improvement Project (SCIP) have already improved outcomes for surgical patients in participating hospitals by focusing on process measures.6 These initiatives and successes make it highly likely that hospitals that develop systems and practices recommended by the IHI, SIP, and SCIP will, in turn, reduce their patients' risk of HAIs by substantial amounts.
The IHI, SIP, and SCIP projects have been so successful that some of the process measures they have advocated are now included in regulatory requirements of accreditation organizations. Indeed, the Joint Commission on Accreditation of Healthcare Organizations includes the prevention of HAI as one of its recommended patient safety goals and has adopted the 3 SIP performance measures as a "core measures set."7 Thus, infection control programs can no longer confine their focus to rates and numbers; they must now concentrate on improving process as well. However, the leadership, oversight, education, and supervision required to develop systems that install and monitor such processes will not happen because an administrator orders it. We believe that infectious disease specialists are the ideal persons to provide leadership, oversight, education, and supervision to these efforts.
Public reporting of rates of HAI is no longer considered extreme or far-fetched by most of the public, the media, or by policy makers. As of December 1, 2006, state legislatures in 15 states have written laws requiring hospitals to measure and publicly report their rates of HAI.8 Seven states currently have study bills under evaluation, and 17 states have active legislation under consideration. The rationale for such reporting is caused in part by the fact that HAI are generally considered to be one of the few "hard" outcomes available to the social scientists and politicians who want to do something about improving the safety of hospitalized patients. In addition, the CDC's definitions for HAIs are well known, almost universally used, and provide binary (yes/no) data.9 Although the public may not universally comprehend the implications of incorrectly prescribing or dosing an antiarrhythmic medication, the term "infection" is well known, and its implications are well understood.
Advocates of public reporting argue that patients have a right to be informed about their risk of developing HAI. This knowledge should subsequently empower consumers to make more informed choices about their health care. Finally, and perhaps most importantly, public reporting is supposed to improve overall healthcare quality because hospitals will be more likely to implement better practices if patients choose hospitals with better quality of care (including lower infection rates).
Many physicians and administrators still consider public reporting a bad idea and a threat to the status quo. These skeptics are correct in emphasizing that no published studies prove that public reporting of rates of HAI improves patient outcomes. Additionally, public reporting of crude unadjusted rates for interhospital comparisons can and will undoubtedly lead to inaccurate and potentially misleading conclusions regarding the care provided by individual institutions.10 Because of these concerns, organizations such as the Society for Healthcare Epidemiology of America and the Healthcare Infection Control Practices Advisory Committee recommend reporting existing outcome measures that incorporate risk adjustment or device-associated infection rates.11,12 These arguments have merit, but we think they are unlikely to turn the tide against public reporting. Rather, hospitals that invest in strong infection control programs staffed by trained and qualified people with the necessary time and resources to institute prevention programs and monitor and trend outcomes are more likely, in our opinion, to succeed financially than those that do not. Infectious disease specialists are the most qualified people to lead such programs and are missing a wonderful professional and financial opportunity if they ignore these opportunities.
Recent changes in reimbursement and the emergence of incentive-based payment systems have created even greater financial strain on hospitals. Again, the best and most logical response to this challenge is to develop and support a strong and effective infection control program. Not only are most of the costs of HAI not reimbursed at present,13 reimbursement for the care of patients with these complications is likely to become even less reimbursable in the future.14 Indeed, the Centers for Medicare and Medicaid Services recently proposed rules to eliminate any form of enhanced payment for the occurrence of a preventable HAI.14 Furthermore, as incentive-based payment systems (ie, "pay for performance") arise, hospitals that fall in the lower quartile of performance indicators may find that their revenues are progressively less than their costs even if there has been nominal improvement in their local rates. Infection control programs can save money for hospitals, and infectious disease specialists trained in epidemiology are the most qualified people to lead such programs. Infectious disease specialists who ignore these opportunities are missing a reliable professional opportunity.
The final and, to some clinicians, perhaps the most relevant trend is the seemingly relentless increase in rates of infection due to resistant pathogens. For example, more than half of all Staphylococcus aureus isolates are now methicillin resistant, and approximately 30% of enterococcal isolates are vancomycin resistant in National Nosocomial Infections Surveillance hospitals.15 To make matters worse, community-acquired MRSA has emerged as the most common cause of culturable skin and soft tissue infections.16 These strains of MRSA are also becoming common nosocomial pathogens in some hospitals.17 Thus, there is a simultaneous need for infection control in hospitals and in the community, prisons, locker rooms, and individual houses. We believe that there are numerous professional opportunities for infectious disease specialists to help meet these challenges.
In view of the threats and trends previously mentioned, many hospitals need to strengthen and improve their existing infection control programs to survive in the coming decades. Other hospitals need to completely redesign their existing program and provide money, management, and support to professionals who have the skills and commitment to reducing the risk of HAI. Some community hospitals might consider a third option: joining an infection control network. Community hospitals in infection control networks have access to sophisticated data analysis and metrics, easy access to experts in infection control, and unique opportunities to share successful programs and processes related to infection prevention. For example, the Duke Infection Control Outreach Network is a network of 36 community hospitals throughout the southeastern United States. In hospitals that have been members of Duke Infection Control Outreach Network for at least 3 years, annual rates of health care-associated bloodstream infection decreased by 23%, rates of MRSA infection and colonization decreased by 22%, and rates of ventilator-associated pneumonia decreased by 40%.18
We are convinced that the above trends and developments are clear-cut opportunities for some, if not all, infectious disease specialists in community and academic practice. Obviously, some infectious disease specialists may choose to provide excellent clinical care and simply provide support and encouragement to others who work in infection control. However, infectious disease specialists who choose to take on these challenges can and should expect to receive appropriate monetary rewards for their efforts.
The skills required for success in infection control are based on a thorough understanding of the diagnosis and pathogenesis of nosocomial infections; an understanding of the basic principles of administrative management, teamwork and education; and a commitment to leadership. The winds of change are already blowing, and we firmly believe that working in infection control can lead to positive outcomes for patients that, in turn, lead to a deep and genuine sense of professional accomplishment.
1. Jarvis WR. Selected aspects of the socioeconomic impact of nosocomial infections: morbidity, mortality, cost, and prevention. Infect Control Hosp Epidemiol. 1996;17(8):552-557.
2. Weinstein RA. Nosocomial infection update. Emerg Infect Dis. 1998;4(3):416-420.
3. Kohn LT, Corrigan JM, Donaldson MS; Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
5. Institute for Healthcare Improvement. Protecting 5 Million Patients from Harm: Some is not a number. Soon is not a time. Available at: http://www.ihi.org/IHI/programs/campaign
. Accessed December 30, 2006.
6. Dellinger EP, Hausmann SM, Bratzler DW, et al. Hospitals collaborate to decrease surgical site infections. Am J Surg. 2005;190(1):9-15.
7. Joint Commission on Accreditation of Healthcare Organizations. Joint Commission Standards; 2006.
8. Association for Professionals in Infection Control and Epidemiology. Mandatory Public Reporting of Healthcare-Associated Infections. Available at: http://www.apic.org
. Accessed December 1, 2006.
9. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control. 1999;27(2):97-132. quiz 133-134; discussion 196.
10. Nosocomial infection rates for interhospital comparison: limitations and possible solutions. A Report from the National Nosocomial Infections Surveillance (NNIS) System. Infect Control Hosp Epidemiol. 1991;12(10):609-621.
11. McKibben L, Horan T, Tokars JI, et al. Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee. Am J Infect Control. 2005;33(4):217-226.
12. Wong ES, Rupp ME, Mermel L, et al. Public disclosure of healthcare-associated infections: the role of the Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol. 2005;26(2):210-212.
13. Haley RW, White JW, Culver DH, et al. The financial incentive for hospitals to prevent nosocomial infections under the prospective payment system. An empirical determination from a nationally representative sample. JAMA. 1987;257(12):1611-1614.
14. Medicare program; prospective payment system for long-term care hospitals RY 2007: annual payment rate updates, policy changes, and clarification. Final rule. Fed Regist. 2006;71(92):27797-27939.
15. National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004;32(8):470-485.
16. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med. 2006;355(7):666-674.
17. Gonzalez BE, Rueda AM, Shelburne SA III, et al. Community-associated strains of methicillin-resistant Staphylococcus aureus as the cause of healthcare-associated infection. Infect Control Hosp Epidemiol. 2006;27(10):1051-1056.
18. Kaye KS, Engemann JJ, Fulmer EM, et al. Favorable impact of an infection control network on nosocomial infection rates in community hospitals. Infect Control Hosp Epidemiol. 2006;27(3):228-232.
© 2007 Lippincott Williams & Wilkins, Inc.