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Can Infections Be Prevented In The Hospital Setting?

No one wants to become infected during their hospital stay. Unfortunately it’s not possible to guarantee that it won’t happen. Bacteria are everywhere. We carry them on our skin, in our bodies (especially our digestive tract), and they live in food, clothing, and anything we touch. When we undergo surgery, we cut through the skin/blood barrier that keep the bacteria out, making us vulnerable to inadvertent invasion.

There are ways to reduce the risk of infection (sterile surgical technique, appropriate wound care, and personal hygiene) but the risk is not zero. For the risk to be zero, one would have to begin with a “sterile” patient – a patient who carries no bacteria on or in their body. Since that will never happen, I’m afraid that hospital acquired infections are here to stay.

However, with government-sponsored health insurance programs on the brink of bankruptcy, decreasing expenditures is a high priority. Therefore, Medicare is suggesting that there are certain events that should never happen in the hospital and that they will no longer compensate hospitals for care associated with these events. Although I certainly agree that operating on the wrong body part is  appropriately classified as a ”never event,” the list has become so long that it includes things that cannot possibly be prevented in all cases (things like catching a cold, developing a blood clot, falling, or becoming infected).

What will result from listing infections as a ”never event?” Will it encourage hospitals to improve their infection control processes? Maybe. But here’s what I imagine is more likely to happen:

1. More prophylactic antibiotics will be given to patients to reduce the risk of infection, resulting in higher rates of serious drug reactions. Stronger medicine (with broader coverage) will be preferentially selected - further encouraging the development of drug resistant strains of bacteria.

2. Patients who become infected will be transferred to another facility as quickly as possible. The accepting facility will be compensated for the care of the patient since the “never event” didn’t happen at their hospital. Transferring care in the middle of a serious illness increases the risk for other complications, including miscommunications and medication errors.

3. Since Medicare has set the expectation that hospital acquired infections are 100% preventable, anyone who contracts one will be able to sue the hospital. This will deplete the hospitals of their thin operating margins, causing them to cut programs – probably first for the poor and underserved.

4. Additional testing may be done for any surgical admission – nasal swabs (and potentially rectal swabs or urethral swabs) will be used to document the fact that the patient arrived at the hospital colonized by certain bacteria and therefore did not contract a new infection during their hospital stay.

5. Convoluted documentation methods will abound, so that any patient who becomes infected will receive antibiotics for “prophylaxis” and his fevers will be explained as the usual “post-op” central fevers. All staff will be encouraged to carefully document that the patient is being treated prophylactically only, and does not have an infection. In fact, it’s possible that blood cultures will not be drawn so that there will be no documentation of sepsis. Patients who really do have serious infections will receive appropriate care very late (since the first few days will be spent trying to manage the infection without documenting it or identifying the organism). This could paradoxically result in higher death rates.

6. Patients at higher risk for infection (such as those who are immunocompromised – see my research study on risk factors for line infections here) may be passed over for surgical procedures. This risk aversion could negatively impact health outcomes for vulnerable populations (such as cancer patients or HIV+ individuals).

I could go on theorizing, but you get the picture. In my opinion, the “never events” strategy is fatally flawed and will result in excessive litigation, ping-ponging of patient care, over-use of antibiotics, increases in adverse drug events, a rise in multi-drug resistant bacteria, and further reduction of services to the poor. A more reasonable approach would have been to document infection rates at the most hygienic facilities, and offer incentives for others to strive for similar rates.

The “never events” strategy is destined to do more harm than good for patients with hospital acquired infections, though the medical malpractice attorneys may enjoy a new income stream. This is just one more reason why we should never say never.

***

See Buckeye Surgeon’s take on this topic and his coverage of Jerome Groopman’s article for the New Yorker on the rise of drug resistant “super bugs.”

See Dr. Rich’s take on never events here.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.


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5 Responses to “Can Infections Be Prevented In The Hospital Setting?”

  1. bluedevildoc says:

    Dr. Scherger–

    I agree with you that the infection control bundles are revolutionary, and should be applied in all hospitals to greatly decrease VAP, central line infections, etc.  The idea that ALL infections are 100% preventable with these measures is obviously ridiculous.  This is not a contrarian view.  This is reality.  If Medicare wants to make sure that participating hospitals use these bundles, fine.  If they don’t want to pay for infections acquired in the absence of best practice, fine.  But to label all hospital acquired infections as NEVER events is just what Val says it is–a cost-cutting dodge.  Find me a bundle that will prevent all hospital-acquired infection, not just those limited areas you mentioned that have evidence-based bundles.  It doesn’t exist.  In the ED we see hundreds of patients a year now with seemingly spontaneous MRSA abscesses.  To think that we can prevent patients with MRSA colonization from getting an infected surgical wound in every case is ludicrous, and that is just one limited example.  I won’t even go into labeling DVT/PE and falls as NEVER events.  That is even more ridiculous.  Complications in the absence of best practice are regrettable, and perhaps Medicare would be justified in not paying in these situations..  Treating all complications as avoidable, however,  is neither realistic nor honest.

  2. Dr. Scherger says:

    Val, while I respect your contrarian view here, I think you are missing something.  We know from the IHI coordinated Save 100,000 Lives campaign that some hospital acquired infections can be taken down to zero with a simple bundle of best practice techniques.  These include central line infections, ventilator pneumonia, and surgical site infections.  Hospitals all over the country and around the world have accomplished this, with maybe one such infection every 6 months compared with 4-5 every month.  Yet, physicians often want to keep doing things “their way”. and refuse to cooperate.  Rather than your reactionary criticism of this government initiative, we should to go after physicians that refuse to cooperate with best practice.  The IOM Quality Chasm report correctly noted that the DRG reimbursement to hospitals actually rewards for complications, even the avoidable ones.  They called for payment based on quality and safety.  That is where this is coming from.  Overall, this is a good trend and will save lives, not just money.

  3. bluedevildoc says:

    Dr. Scherger, I agree that this is an emotional topic for those of us immersed in clinical medicine.  The idea that we may not be reimbursed for unavoidable complications is difficult to accept.  I agree with you on many points, most importantly with the idea that we should all be applying these infection control bundles to try to avoid hospital-acquired infections.  I also agree that the results are revolutionary.  I believe, though, that not all infections are avoidable, even with best practices in place.  They should be very rare, much more so than they are today, but I do not believe it is realistic to claim that evry infection is an avoidable complication.  Nothing is perfect.  Why should Medicare not pay for the costs of an infection acquired despite best practice?

    If Medicare wants to use economic incentives, even draconian ones such as witholding reimburement, to drive the acceptance of evidence-based guidelines proven to improve patient safety and outcomes, great.  I simply disagree with the entire concept of “never” events.  Again, nothing is perfect.  We see this day in and day out, in medicine and in every area of life.  Things happen, and to think that we can exert absolute control is the epitome of hubris.  Demanding it is at best unrealistic and at worst dishonest.

    What about the other “never” events, such as DVT/PE and in-hospital falls as I mentioned in my previous post?  Do you agree that these are completely avoidable complications?  At least with infection control we have impressive evidence that we can almost completely eliminate VAP and line infections.  ALMOST completely.  Find me a study anywhere that shows DVT can be completely eliminated with proper prophylaxis.  Show me how we can prevent every fall.  Should we restrain every demented elderly patient in bed so they do not wander and fall?  If Medicare says these things should never happen, then they should show us how we can prevent them from ever happening, or at least point to someone else who has come up with just such a plan, backed by evidence.

    I’ll stop here because I am starting to repeat myself, but one thing does bear repeating: promoting best practice is admirable, both from an economic and more importantly from a patient safety standpoint.  Saying that we have reached the point where we can prevent every complication of medical care and hospitalization is either pie-in-the-sky, unrealistic idealism or crass economic dishonesty.  I believe that it is the latter.

  4. Dr. Scherger says:

    Blue Devil, you are using your emotions and not looking at the data.  Go to the Institute for Healthcare Improvement (ihi.org) website and you will see the experience hospitals have with the use of these infection control bundles.  We doctors have been historically very sloppy, and we resist change or the realization that we cause infections.  Look what happened to maternal mortality with we started washing our hands.  Sure, MRSA rolls into the ER every day, but it should not happen with proper sterile technique.  Yes, there are exceptions to NEVER policies, but the weight of the evidence supports not getting extra payment for these complications.  Remember, the surgery is still paid for, not the complications.  We do not pay airlines extra when they lose our bags and deliver them to our home.   I say losing our bags should be a never event.  In best practice, it has become much less common.

  5. DrB44 says:

    As a hospitalist in suburban Dallas, I see a lot of hospital acquired UTIs for geriatric patients who are immobile and incontinent of urine and as a result, have a foley catheter placed.  The elderly often fall at home and break a hip or develop delirum from a pneumonia.  These patients are usually incontinent and often have foley catheters placed to keep them from urinating on themselves multiple times a day.  Sometimes they then develop a UTI after having the foley placed.  As part of Medicare’s proposed policy, these UTIs are considered “errors” because they are hospital acquired infections.

    In a effort to reduce this “error” I could take the foleys out of all of my patients, but then they would be at greater risk of skin breakdown, bedsores and skin fungal infections–all “errors” as well according to Medicare.

    In a effort to address this “rock-and-a-hard-place” situation, I think we should take Medicare out of it.  Patients should pay a portion of their bill–including the extra costs associated with “errors.”  Once the patients and their familes see the actual charges associated with “errors,” then real change will start to happen.  They will demand process improvement and vote with their feet when choosing hospitals.  One would have hoped that the medical community would have led these process improvements, but collectively, physician inaction is usually the rule.

    We can fix hospital acquired UTIs–foley out, diligent and persistent padding and bedding changes and frequent, on-the-clock patient turning–but that requires a multidisciplary approach that is currently not effectively implemented.  Change can happen, but it needs to start with patients–not Medicare.  see more on my blog http://www.compassphs.com/blog

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