Nine reasons why we might be fighting a “LOSING BATTLE” against Healthcare Associated Infections (HAIs)
Healthcare Associated Infections (HAIs) are the infections that patients contract while receiving healthcare. According to the Centers for Disease Control and Prevention (CDC), it is estimated that on any given day, 1 in 25 patients visiting hospitals contracts HAI. In 2011, around 75,000 people died from an estimated 722,000 cases of infections. The biggest concern is the way these infections are spreading in hospital premises. Take for example the case of spread of Ebola in a Houston hospital- the caregiver contracted the infection while attending to an Ebola patient. While Ebola is an extreme case, take the case of 11 deaths due to Klebsiella outbreak at the National Institutes of Health’s clinical center or the spread of Middle East Respiratory Syndrome Virus (MERS) in a South Korean hospital. A report states that more than 70 cases of MERS (of a total of 145 cases) were traced back to the hospital.
According to a 2009 CDC report, the overall direct medical costs of HAI to U.S. hospitals ranges from $35.7–45 billion. The same study reported that the savings from preventing these infections using known preventive measure range from $5.7–6.8 billion (~20%). This means at least a third of HAIs are considered preventable by taking appropriate preventive measures. The CDC has identified HAI as a “winnable battle”.
In order to address the problem, the Affordable Care Act (ACA) attached stipulations for hospitals with high rates of infections. As a result, the Centers for Medicare and Medicaid Services reduced the payment by1% to 724 hospitals in 2015, and 758 hospitals in 2016.
An obvious question arises from this observation. Can we actually win this battle against infections in hospitals, as suggested by the CDC? Maybe there is a need for deeper understanding of the causes of HAIs in the hospitals. In this article, I would like to bring your attention to some of my observations of the reasons why we might be fighting a losing battle against HAIs:
1. U.S. Healthcare system continues to be reactionary: As a nation, we spent about $3 trillion in 2015 on our healthcare system. For the amount of money we are spending, we expect our hospitals to be safer for the patients and the healthcare professionals (HCPs), which is not exactly the case. Part of the reason is that our investments have mostly been reactionary. We mostly tend to act on a problem once an issue results in consequences like the death of a patient. Just like our aging infrastructure, there has been a complacent approach in our health care system that believes in the concept- “If it ain’t broke, don’t fix it”.
Regarding HAIs, we have a good understanding about the different kinds of infections (Catheter Associated Urinary Track Infection-CAUTI; Surgical Site Infection-SSI, Ventilated Associated Pneumonia, etc.). However, we have not paid much attention to various causes/carriers of pathogens that cause these infections. Some of the not-so-obvious harbors of pathogens such as the HVAC systems, sinks in patient rooms, protective gear such as lead aprons, etc., are overlooked. Hospital administrators try to dismiss such sources of infections by saying that there is no proof that the pathogens growing in HVAC or others are causing infections. There is a clear need for identifying every possible source of infection and eliminating them from the system if we want to win this battle against HAIs.
2. Habits of HCPs: Take for example the issue of hand washing by HCPs. Hand washing is one of the simplest and most efficient ways of preventing infections in hospitals. In spite of several studies that show the benefits of hand washing, HCPs are not washing their hands as often as they should. According to the CDC, on average, HCPs wash their hands less than half the time they should. Hospitals have decided to solve the problem by providing hand-sanitizing equipment all over hospitals. Some facilities have installed cameras to monitor HCPs wash their hands. There is a need for changing habits by HCPs.
3. Lack of technologies: Development of new technologies has helped improve our healthcare system tremendously. Everything from new life- saving drugs to robot-assisted surgeries and 3D printed organs have transformed how we treat patients. However, we need to realize that there is a need for a lot more technologies to keep our patients and HCPs safer. Take, for example, the much-touted hand-washing problem. Can we imagine washing our hands 40–50 times a day with soap and other chemicals? The resulting skin damage could be painful, and we should not impose it on anyone! There is a clear need for a better technology for hand sanitizing in hospitals. Another example is the case of the HVAC systems that process the airflow in hospitals. There are no proper ways to disinfect the HVAC systems. It is such an easy way of spreading airborne infections and clearly needs new technologies for disinfection.
4. Overworked HCPs: While it is easy to blame HCPs for infections in hospitals, we should acknowledge that we overwork our HCPs and as a result, they are constantly under fatigue. Most hospitals expect our HCPs to work longer and perform better. They tend to make mistakes when they are tired, like any of us. We need to manage their workloads better and provide appropriate support to our HCPs.
5. Lack of oversight: In the past couple of decades, our hospitals have evolved into complex systems that have made it harder for resource management and monitor existing protocols. Because of an increase in the number of personnel, equipment, and related resources in hospitals, it is almost impossible to track the execution of existing processes. For example, the protocols associated with sterilization and disinfection of devices and equipment could often be compromised. Hospital management decides to scrutinize the practices and take action only when fatalities happen. There is a need to develop ways to monitor the execution of policies and protocols in hospitals.
For example, in 2015 two patients died due to infections caused by carbapenem-resistant Enterobacteriaceae (CRE) that were spread by improperly sterilized endoscopes. The first problem was that these scopes in question called duodenoscopes did not have approval by the FDA. The hospitals and healthcare professionals previously knew the problems with the design and also difficulties in cleaning these endoscopes, and should have worked with the manufacturer to address the issue before the deaths happened. Appropriate protocols and checks in place could prevent such incidents from happening in the first place.
6. Evolving antibiotic resistance: The discovery of Penicillin had opened a new era of life-saving drugs. Ever since then, several antibiotics have been discovered and used to save lives. The downside to discovering the magical powers of these antibiotics has been the over prescription of these antibiotics. The overprescription resulted in the evolution of antibiotic-resistant bacteria, which is a worldwide concern, as more of these antibiotic resistant bacteria are evolving, resulting in deaths, pain, and increased spending.
7. The World is flattening: As stated in Thomas Friedman’s book “The world is flat” states, globalization continues to shrink and flatten the world. Trade and travel are resulting in moving a lot more goods and people around the globe. While a lot of good has resulted from these developments, it also helped with moving pathogens and resulting infections to spread much faster around the world. In May 2016, there was a report of a multidrug- resistant strain of E.coli (Colistin-resistant mcr-1 E.coli) in the U.S. Its existence was first reported only in November 2015 in China, and in a few months, seen in the US. A patient with a new strain of influenza can get on a plane in China and bring it over to the U.S. or any other part of the world. Infectious pathogens such as Ebola, antibiotic resistant tuberculosis, MERS, etc., continue to enter the US and other countries in the world through food and travelers. The lowering of barriers to travel is going to become a great challenge shortly, as we don’t have tools to identify and isolate such pathogen carriers.
8. Lack of funding for preventive measures: Most hospitals deal with constricted budgetary issues. It has been hard to convince hospital managements to invest in preventive measures. Hospital management tends to be reactive to situations as they arise. Several studies have shown that investing in preventive measures pays off in the long run. There is a need to evaluate the emerging threats from antibiotic resistant bacteria and other pathogens that could result in HAIs and invest in the preventive measures, rather than trying to fight them.
9. Lack of awareness amongst patients: Most of our population does not think of HAIs unless an infection affects them or their loved ones, which is a natural human tendency. Even a simple visit to an emergency room or a visit to the hospital can result in contracting HAIs. Even well-respected hospitals are no exception! Take for example the case of Ginny, who went in for a minor surgery for her leg, and was supposed to be released in 2 days. It ended up being a two-month-long stay in the ICU, multiple surgeries, loss of leg and eye sight in the right eye. Another case is that of the CEO of Overstock.com, Patrick Byrne, who got infected with Hepatitis C when he was receiving treatment for his head injury under less than a sterile condition.
With increased life expectancy, people are spending more time in long-term care facilities and getting procedures such as knee and hip replacements performed. Older individuals are more immunocompromised and have an increased chance of contracting infections. According to the CDC, 1 to 3 million serious infections occur every year in long-term care facilities. Awareness of such HAIs can help us take certain preventive measures and be in a heightened state of alert. You can always check out your hospital infection scores.
Conclusion
HAIs are clearly an imminent threat to healthcare systems not only in the U.S. but also around the world. As CDC suggests, HAIs could be a “winnable battle”, but could easily be lost if we do not take appropriate measures. There is a clear need for more technologies to be developed, to keep these patients and HCPs safer.
At Nosocom Solutions, we are researching the various causes of HAIs in hospitals, and developing new technologies that can provide faster and efficient disinfection/sterilization of various devices and equipment used in healthcare facilities. In my future posts, I will be writing about specific causes of infections that we identified in hospitals, and talk about specific measures we can be taking to address the problems.
