American College of Physicians: Internal Medicine — Doctors for Adults ®


Use ready resources to stem hospital-acquired infections

System-wide innovations—not more education—may be the answer to reducing the rate of deadly infections

From the December ACP Observer, copyright © 2005 by the American College of Physicians.

By Gina Shaw

PHILADELPHIA—Hospital-based infections are all too common, affecting some 2 million patients every year.

They are also costly, both in terms of lives—causing as many as 100,000 patient deaths every year—and health care resources, eating up an estimated annual $3.5 billion in direct costs. And according to a study in the August 2003 issue of Journal of Hospital Infection, between 20% and 60% of hospital-acquired infections are preventable.

Sanjay Saint, ACP Member, explains that as many as 60% of all hospital-acquired infections are preventable.

At a presentation sponsored by Hospitalist Conferences USA, patient safety expert Sanjay Saint, ACP Member, focused on some of the worst culprits among deadly infections. He urged physicians to use resources already available in their hospital to turn that tide.

"Rather than focusing solely on physician education," said Dr. Saint, a hospitalist at the Ann Arbor VA Medical Center and director of the Ann Arbor VA/University of Michigan Patient Safety Enhancement Program in Ann Arbor, Mich., "we need to develop systems solutions to prevent infections, using components of the hospital system that are already in place."

He pointed out, for instance, that one of the simplest, most effective ways to prevent nosocomial infections is through handwashing. But despite extensive educational campaigns, research has found that handwashing compliance rates among health care professionals is only around 50%.

Instead of piling on more education, studies have found that implementing approaches such as strategically placing sinks between the patient's door and bed, using alcohol-based handrub solutions and enlisting patients to ask providers if they have washed their hands can boost compliance rates.

With that in mind, Dr. Saint focused on preventing infections related to devices, such as urinary and central venous catheters and endotracheal tubes. Because these three areas account for many preventable infections, he said, they offer physicians a real chance to significantly cut a hospital's rate of acquired infections.

Catheters: lost in place?

Urinary tract infections (UTIs), Dr. Saint said, account for the lion's share—40%—of all hospital-acquired infections, and the vast majority can be traced to urinary catheters. With some 25% of patients receiving a urinary catheter at some point during their hospital stay, the risk of infection is relatively high: Some 5% per day develop bacteriuria, while between 5% and 20% of those will go on to develop UTI symptoms. As many as 3% will develop the far more serious bacteremia.

"UTI prevention rule No. 1 is: Make sure the patient really needs the catheter," Dr. Saint said. As many as 20% of urinary catheters initially ordered may not be appropriate, based on indications defined by the Centers for Disease Control and Prevention. As time goes on, that rate can climb to nearly 50%.

Why so many? Sometimes catheters can be "lost in place," Dr. Saint said. In a 2000 survey he conducted with colleagues, 38% of attending physicians were unaware their patients still had catheters—and in nearly as many cases, there was no documentation of the catheter anywhere in the medical record.

"We call that phenomenon the 'immaculate catheterization,'" he quipped.

For the between 10% and 15% of hospitals operating with computerized order entry systems, the best way to reduce urethral catheterization seems to be a simple computerized reminder. One Seattle study found that a pop-up screen reminding physicians to consider removing a patient's catheter, set to appear after 72 hours of use, reduced catheterization duration by three days. Written reminders, Dr. Saint said, reduce use duration as well, but by only one day.

Hospitals can also decrease catheter-caused UTI infection rates by using closed drainage systems only and employing "condom catheters" in male patients who can cooperate with their use. (Those include men who are not cognitively impaired or acutely confused.)

Time on the vent

Another major infection is ventilator-associated pneumonia (VAP). For every day on the vent, between 1% and 3% of patients will develop pneumonia, adding up to between 10% and 25% of mechanically ventilated patients overall, Dr. Saint pointed out. "It's a high-cost complication."

Of many possible methods to prevent VAP, Dr. Saint focused on two: semi-recumbent positioning and subglottic secretion drainage. The first couldn't be simpler; you merely elevate the head of the bed to 45 degrees while the patient is on a ventilator, rather than keeping the bed in a fully supine position. The semi-recumbent position should theoretically reduce aspiration of oral and gastric secretions.

In fact, three studies—one randomized trial and two cross-over studies—all showed benefits, with significantly lower rates of ventilator-associated pneumonia in semi-recumbent patients. "There appear to be no adverse effects, although patients with recent abdominal or neurological surgery and those with shock were excluded from the studies," Dr. Saint said. "Unless there are clear contraindications, it makes sense to place ventilated patients in a semi-recumbent position."

Less straightforward, he said, is the question of subglottic secretion drainage. By removing secretions that accumulate above the endotracheal tube cuff, can you reduce aspiration and lower the risk of pneumonia? Overall, the answer appears to be "yes," he said. A meta-analysis of five randomized clinical trials published in the January 2005 issue of American Journal of Medicine found that drainage reduced VAP risk by about 50%.

"But the case is not closed," said Dr. Saint. He noted that most studies to date exclude patients who were on the ventilator for less than three days—and that the decline in VAP rates shown in the studies didn't appear to correspond to any effects on mortality rate.

"Additional randomized trials are needed," he said, "but until then you should consider this intervention in patients requiring more than three days of ventilation if your VAP rate is very high."

Bacteremia suspects

If you want to root out an often deadly hospital-acquired bacteremia that costs some $3,000 a day to treat, look no further than your patient's vascular catheter, Dr. Saint said. There are 150,000 cases of catheter-related bloodstream infection in the United States every year, with a disturbing attributable mortality rate of between 10% and 30%.

Much of that risk, he noted, stems from placement. Peripheral venous and peripheral arterial catheters have a daily incidence of local infection of less than 2% (the rate for venous is slightly lower), while central venous catheters pose almost twice that risk, at 3.3% per day.

What's more, femoral catheterization poses a substantially higher infection risk than subclavian catheterization. In a randomized controlled trial conducted in eight French intensive care units, 19.8% of patients with femoral catheters developed infections, while only 4.5% of those with subclavian catheters did so. Rates of sepsis and thrombotic complications were also significantly higher for patients with femoral catheters.

"Avoid femoral catheterization whenever possible," Dr. Saint said, "and remove these catheters sooner."

One apparently simple way to reduce catheter-related infection is to use maximum sterile barriers. Studies have found that the use of masks, along with sterile large drape, gown and gloves during central line insertion, reduces the infection rate--and yet, said Dr. Saint, compliance is poor.

"Educational interventions can help," he pointed out. "A before-and-after evaluation of an educational intervention aimed at students and interns found a 32% increase in the use of maximum barriers and a corresponding 28% decrease in infections."

To better prevent these and other such hospital-acquired infections, Dr. Saint recommended taking a page from the cardiologists' playbook.

"That means multicenter trials of these interventions," he said. "Single-center studies are not enough." At the same time, he said, "Hospitalists can and should take the lead in reducing hospital-acquired infection in our institutions. We understand the systems issues, and we know how to make them work using multidisciplinary teams."

Gina Shaw is a freelance health care writer based in Montclair, N.J.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.


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