CAUTION: Your I.V. may be Dangerous to your Health

The seriously ill go to the hospital with the hope of becoming well again and thankfully most do.  Often serious illness is a result of disease and in some cases infectious and transmittable disease.  As a result hospitals are a breeding ground for some of the most virulent microorganisms.  Unfortunately, being a patient or even visiting a hospital can pose a serious health risk.

Today, the vast majority of hospitalized patients will receive some form of IV therapy which requires the insertion of a tube, also known as a catheter, directly into the bloodstream.  Attached to the end of the catheter (external to the body) is typically found a needleless valve.  This catheter and needleless valve combination provide a readily available route for drawing blood or delivering fluids or medications into your bloodstream. Unfortunately, improved access also creates a direct pathway for microorganisms to enter the body and to potentially create a bloodstream infection.

A bloodstream infection, or BSI, is systemic and can result in increases in hospital stay of 20 days or more adding significant cost to the patient’s care. Worse yet, roughly 20% of all people that get a BSI will die. As a result, this serious issue is the focus of many new initiatives in hospitals to address catheter -related bloodstream infections.

The scope of this problem is massive. More than 360 million I.V. catheters are used in the US each year. While the focus of most of today’s BSI efforts are focused on a specific type of catheters known as central line catheters, all catheters carry the risk of bloodstream infection.

Understanding proper catheter insertion and maintenance techniques is vital in the effort to reduce BSI rates. Check out the infographic [below] for a quick summary of the common organisms that invade catheters through the needleless valves and the measures that can prevent contamination.

In 2002, the New Jersey Hospital Association launched its Institute for Quality and Patient Safety with the intention of increasing quality and safety within hospitals. Task forces tackle problems ranging from the reduction of infection rates to quality healthcare for patients. These efforts have brought recognition and praise for increased quality to the New Jersey hospitals.

Because of these changes, the hospitals have increased their performance and have surpassed national scores in the 2012 Hospital Performance Report, scoring 15 out of 25 recommended measures. Each of the hospitals have scored at least 93 out of 100 on treatment for heart attacks and had fewer central-line associated bloodstream infections (CLABSI) All this hard work has ranked New Jersey ninth in the nation in AHQR’s Best Performing States report, which assesses overall implemented measures.

NJHA and member hospitals are part of a federal “hospital engagement network” (HEN), created by Centers for Medicare and Medicaid Services. This group works to increase the quality of healthcare while making it more affordable. The sixty-two acute care hospitals involved are seeing good results. The group has decided on two goals:

1. Prevent patients from becoming injured or sicker.  The group is aiming to decrease healthcare related problems by 40 percent by the end of 2013, compared to 2010. In doing so, there would be 1.8 million fewer patient injuries, saving over 60,000 lives.
2. Keep the healing process free of complications. The goal by the end of 2013 is to eliminate preventable complications between care settings by 20 percent from 2010, in order to prevent hospital readmissions. This could mean 1.6 million patients would recover without additional illness or complication.

Overall, the goal is safer healthcare, however other benefits include savings in healthcare costs and benefits to employers who provide health insurance.

A year into New Jersey’s initiative, results are good; care has been improved and costs have been reduced.  Measures were taken to prevent complications to central line-associated blood stream infections (CLABSI), including surgical site infections and catheter associated urinary tract infections. More hospitals are becoming involved and there has been a reduction in infections by 73 percent. Patients and family members are able to access Partnership for Patients website at www.njha.com/pfp for more information.

The New Hampshire Department of Health and Human Services  (DHHS), Division of Public Health Services (DPHS) released the 2011 Healthcare-Associated Infections (HAIs) report, which included 31 hospitals in New Hampshire. This report assesses certain HAIs such as central line-associated bloodstream infections (CLABSI) and heart, colon and knee surgical site infections.  The report includes hospitals’ compliance with mandated measures of preventing infection.

The report shows that New Hampshire’s infection rates are improving compared to the nation. HAIs in New Hampshire hospitals were 40% lower than the national average; central line-associated bloodstream infections decreased 42% and surgical site infections decreased 40%. The report also stated that statewide, compliance to four infection-prevention measures were at a high 95.7%. Antimicrobial prophylaxis was given more accurately and staff influenza vaccination rates increased, thus reducing infections.

http://www.dhhs.state.nh.us/.

The hospital-acquired infection: carbapenem-resistant enterobacteriaceae, or CRE, has spread across 42 states, including Texas, but has not managed to reach Dallas County. The infection is common in hospitals and long-term care facilities. Germs normal in the digestive track cause the drug-resistant infections. The fact that these germs are resistant to last-resort drugs called carbapenems, means they kill up to half of the patients who develop bloodstream infections. Because it is not easy to identify these specific germs, hospitals are not required to notify local or state health officials. While the infection is common, it’s not showing much increase within hospital facilities, however all health officials need to work together to stop the spread of the infection.

In Texas, there have been 8,000 to 9,000 deaths due to the 200,000 or so health care associated infections. CRE is not a reportable infection in Texas. In 2011, Texas hospitals had 44 percent fewer central-line associated bloodstream infections (CLABSI) than was expected. By implementing measures and maintaining cleanliness, about 60 percent of the infections are preventable. Currently Texas does not have a statewide infection-prevention program, but one is underway in order to battle the CRE infections. For the time being, CRE patients are being identified and isolated.

Link: http://www.dallasnews.com/

Atlanta Journal and Constitution investigated on threat to public health — hospital-acquired infections – that, until now, has escaped vigorous scrutiny by the state’s top health officials.

The news agency reported that in January of 2013, Georgia’s hospitals were required for the first time to start reporting their cases of common but potentially deadly infections to the state Department of Public Health. Until now, Georgia had no hospital-specific data on these infections.

Georgia public health officials have ambitious plans. They want to identify facilities that need to improve and help them get there. They want to push for more appropriate use of antibiotics, a key part of combating infections. They want to keep doctors informed of the latest threats. They also want the state to start checking the data for accuracy.

The paper exposed the risks posed in the healing arts by human touch saying, “a surgeon’s hands perform miracles; a nurse’s hands save lives. But what clings to the hands of both can also kill.” About 1 in 20 patients gets an infection while seeking medical treatment, and the losses are staggering: an estimated 100,000 deaths every year and $30 billion in annual health care costs. Georgia has made less progress than the vast majority of states when it comes to combating central line-associated bloodstream infections, which are the focus of a national prevention effort.

For years, doctors thought these infections were unavoidable. But recent research has proven just the opposite. With new central line infection prevention protocols in place and a staff that follows the rules with every patient every time, many hospitals have achieved remarkably low infection rates. Yet, that doesn’t mean every hospital is doing what needs to be done. An estimated 30,000 patients across the nation die every year from central line-associated bloodstream infections, even though researchers believe a majority of those infections can be averted.

‘What’s been wrong with our health system’

At Grady Memorial Hospital, the gigantic safety-net hospital in downtown Atlanta, CEO John Haupert is quick to acknowledge that his hospital was late to the game when it comes to preventing infections largely due to a deep financial crisis that threatened to close its doors. Hospital CEOs of the past paid more attention to financial reports than infection statistics. But that is changing, and Haupert is part of that new wave. Unlike some hospital executives in town, he doesn’t brush off Grady’s numbers. Today, Grady’s incidence of central line infections is about half of what it was a year ago, according to data provided by the hospital.

Atlanta Journal and Constitution (GA), April 28, 2013

Link: http://www.ajc.com/news/news/georgia-ranks-near-bottom-on-hospital-infections/nXZbm/

In April 2013, U.S. News Weekly reported on national efforts to reduce medical errors. Specifically, it explored the efforts of Richard Brilli, chief medical officer at Nationwide Children’s Hospital in Columbus, Ohio, to eliminate preventable harm to patients by 2013, by making patient safety central to every medical and surgical protocol. Brilli and colleagues created what they call a preventable-harm index, a simple list of all hospital-acquired infections, adverse drug events, cardiac arrests, major surgical complications, hospital-acquired pressure ulcers and serious falls, with the total being patients who were injured but shouldn’t have been. When mistakes occur, hospital staffers are encouraged to report them. Each report triggers a review, often leading to changes in protocols, procedures or technology. Anyone who needs added training gets it; anyone found to have taken a shortcut could be reprimanded. Those who advance the cause, whether they’re clerks or heart surgeons, are acclaimed as “Zero Heroes.”

There’s further proof from Michigan that zero harm may be an attainable goal. In just 18 months, a partnership between the Michigan Health and Hospital Association and Johns Hopkins University, known as the Keystone Project, reduced the rate of bloodstream infections by two-thirds among patients in intensive care units receiving central lines, the catheters that carry medicines and nutrients directly into blood vessels. That translates into more than 1,500 lives, and at least $100 million, saved each year. About one-quarter of the ICUs have eliminated the infections altogether.

U.S. News Weekly, April 19, 2013; Volume 5; Issue 16

A woman claims she was infected with a rare blood infection during her stay at Winchester Medical Center in 2010.  She filed a medical malpractice lawsuit for $800,000, accusing the nurses who were working of negligence. She claims they gave her an IV that contained bacteria associated with strep throat.

The woman had gone into the medical center March 28 complaining of problems related to bowel obstruction; within the treatment process she received a catheter in her left arm, through which she received fluids.  She was released on March 31, 2010.

The woman’s arm became red and tender once the IV was removed, she returned to the hospital on April 2^nd.  The results of her blood cultures came back positive for streptococcus pyrogenes. It is rare to have the bacteria in the form of a blood infection, especially with no signs of the bacteria in her throat.  The woman’s physician diagnosed her with septic thrombo-phlebitis and metastic septic arthritis of her right knee.

The complaint says that workers at the hospital infected the woman through either handling the IV incorrectly, injecting fluids into the IV, or flushing the IV while contaminated.

Because of the infection, the woman had to undergo numerous procedures including a knee aspiration and washout and the placement of a subclavian catheter for long-term antibiotic treatment.

The lawsuit claims that the hospital is responsible for providing patients with a clean environment as well as clean hospital supplies and equipment, such as needles and catheters, but failed to do so. Due to the lower standard of care, the patient’s IV was infected with the strep bacteria.

Link: http://www.nvdaily.com/news/2012/04/woman-sues-hospital-over-blood-infection.php

Infusion therapy, although seemingly a simple and non-risky therapy, can be exceedingly complex. From selecting the appropriate vasculature, to ensuring the appropriate tubing is utilized, a number of practices and technologies plus the skill levels of health care practitioners are to be considered in the achievement of excellent patient care. Given the complexities, new technology in the field of infusion therapy therefore needs to be assessed within the clinical setting in which it will be utilized.

Background: The University Hospital of Northern British Columbia (UHNBC) utilized an opaque positive displacement intravenous (IV) line connector in 2011 and for several years previously. With concerns generated in the United States surrounding positive displacement and the potential increased risk for infection, as well as the training requirements related to ensuring that a proper clamping sequence was followed, a neutral displacement IV connector was implemented in October 2011.

Methods: Catheter-related blood stream infections and catheter occlusions were monitored at UHNBC for 4 months before (June through September 2011) and 4 months after (November 2011 through February 2012) the implementation of the neutral displacement IV connector by the Parenteral Services nursing team. A staff survey was conducted that reviewed the satisfaction with the newly implemented IV connector.

Results: The results of tracking catheter occlusions with a neutral displacement IV connector showed an average of 4.04 occlusions that required tissue plasminogen activator per 1,000 catheter days, compared with 5.47 occlusions that required tissue plasminogen activator per 1,000 catheter days with the positive displacement IV connector. During the evaluation period there was a 26% decrease in catheter occlusions with the implementation of the neutral displacement IV connector. Blood stream infection rates remained at zero for the entire evaluation with both displacement types of IV connectors. Nursing staff members were satisfied with the newly implemented IV connector.

Conclusions: UHNBC will continue to utilize the neutral displacement IV connector hospital-wide, and continues to monitor both catheter occlusions and catheter-related blood stream infections. Following UHNBC, facilities in the rest of Northern Health have implemented the neutral displacement IV connector.

Journal of the Association for Vascular Access, April 1, 2013; Volume 18; Issue 1

Link: http://www.avajournal.com/article/S1552-8855(12)00182-1/fulltext

The hospital purchasing organization Premier has announced some big news in quality improvement: over 300 participating hospitals have saved billions by preventing additional infections to patients.

The QUEST initiative launched in 2008, since then hospitals have saved around 92,000 lives and saved $9.1 billion in costs preventing the need for additional care. Hospitals have become successful by sharing data and tips on best practices for care. The initiative focused on preventing cases of hospital-acquired sepsis, a blood infection that leads to major organ failure and death. Hospitals were able to reduce mortality rates by 23 percent, about 6,800 lives. Some hospitals like, UCSF Medical Center in San Francisco, are using electronic mannequins that mimic sepsis symptoms to help train staff to catch the infection early.

QUEST hospitals are also focusing on minimizing central-line associated blood stream infections (CLABSI), urinary tract infections, and falls and pressure ulcers, all of which are on the decline.  With this improvement, hospitals have been able to reduce the mean cost per patient by $1,110.  The savings were mainly due to the fact that patients spend less time in the hospital, thus reducing labor costs, but costs have remained flat for over three quarters.

Link: http://www.healthcareitnews.com/news/data-sharing-initiative-reduces-deaths

In New Haven, Connecticut, a 511-licencsed-bed Hospital of Saint Raphael had one of the worst CLABSI rates in the state. The hospital merged with the 1,519-licenced-bed Yale New Haven Hospital and was able to turn it around and become a hospital to emulate. The goal of vice president and chief medical officer, Alan Kliger, MD, was to start over and pledged to have a hospital with zero infections.

Kliger and his team at YNHH Saint Raphael Campus won a Partnership in Prevention award for eradicating healthcare-associated infections. Bloodstream infections were reduced so drastically by utilizing the Institute for Healthcare Improvement “bundle” which includes sterilizing caps for needleless iv ports, gowns, gloves and masks, cleaning of skin and insertion sites among other items on the checklist.

The hospital kept its focus on eliminating infection in order to reduce delays of recovery for patients and to save money for the hospital.  Studies found that each hospital CLABSI cost the hospital anywhere between $16,550 and $32,462 depending on the severity on the infection.

The CLABSI bundle was not enough, Kliger created a board with four subcommittees, each group focused on a separate area, central line preparation and insertion, line access, line maintenance and line removal.  Each group found specific issues that needed improvement, such as how long a line should stay in and how to perform valve disinfection.  This reeducation process was simple, but necessary for improvement. Medical staff had to learn how not to contaminate lines, something as simple as putting gloves on properly.

Detailed checklists were made for each individual patient, “avoid entering” signs were put up outside patient’s doors when a central line was used. In the end Kliger had to change the culture in the hospital to be successful.

http://www.healthleadersmedia.com/print/QUA-289932/How-One-Hospital-Zapped-Infection-Rates