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The future is now: Patients are consumers in a new era of hospital infection prevention
"The choice of infection control is something every CEO should make."
— Lisa McGiffert, director of the Safe Patient Project at the Consumers Union, publisher of Consumer Reports
For better or worse, the era of consumer-driven infection prevention arrived when the March 2010 issue of Consumer Reports (CR) hit the newsstands.
All the caveats and concerns about whether infection rate disclosures will lead to unintended consequences were more or less rendered moot. For starters, there's a guy on the CR cover snowboarding out of giant TV screen. Boxed teasers along the top of the cover promise reports inside on vacuum cleaners, interior paints, and yes, "Hospital Germs: Hidden Dangers." Inside, under the more ominous title "Deadly Infections," are data from 10 states that are publicly reporting central line-associated bloodstream infections.1 Hospitals were cited by name, some honored for achieving zero infections and others identified for having some percentage below or above — in some cases, way above — the national average. One gets the sense, infection preventionists, that we're not in Kansas anymore.
"This is the first stream of data that we have [put] out there, "says Lisa McGiffert, director of Consumers Union's Safe Patient Project. "We have been working around the country on these infection rate-reporting laws, and pretty much every state is starting with bloodstream infections in the ICU. Our intent at the Consumer Reports Ratings Center is to continue to update this on a quarterly basis and bring in the states that weren't included in all data sets. This is a beginning."
The article is a paradigm step beyond the "dirty little secret" hospital infections exposé many a veteran IP has seen suddenly appear in his or her local newspaper. This is something completely different, the beginning of ongoing national infection rate disclosures that may finally close the loop between the patient — uh, the consumer — and the hospital "C-suite."
Some of the hospitals with higher rates immediately issued caveats and qualifiers — arguments about old data, the severity of patient illness, and the like — but this is clearly the future, albeit a work in progress. The Yonkers, NY-based Consumers Union — publishers of CR — has the clout in the marketplace to completely alter the way hospital executives perceive infection prevention.
'Public is going to make this happen'
"We felt it was important for people to see in this article that many hospitals have reached the goal of zero when it comes to bloodstream infections in ICUs, and that is an achievable goal," McGiffert tells Hospital Infection Control & Prevention. "We also believe it's very important to call out the low performers. We're not alone in that. There are other [quality] experts that have talked to us about the importance of doing that."
Indeed, nobody in a position of authority wants to see that "don't buy" dark moon symbol next to a picture of their hospital instead of a toaster. The symbols actually weren't used in the infection rate report, but you don't need a weatherman to know which way the wind is blowing. The point is, consumer-patients understand and trust CR, which will influence their purchasing decisions in health care as it has on every other product and commodity. The key for infection prevention programs is to be positioned as the answer to the problem.
"Every single day, the leaders of hospitals choose what to spend their money on," McGiffert says. "Sometimes they chose to raise salaries for the highest-level administrators, build a parking lot, or add a wing that is going to bring in more money. The choice of infection control is something every CEO should make. It is a fundamental issue of safety. I think the public is going to have to be the group that makes this happen — that demands that it happen."
Kathy Warye, CEO of the Association for Professionals in Infection Control and Epidemiology (APIC), immediately seized on this point when the CR issue hit the streets.
"Prevention can only occur when top leaders target zero as their goal, invest in their infection prevention programs to assure the resources needed for optimal programs — including resources necessary to track, monitor, and publicly report these infections — and make infection prevention and control everyone's job across the institution," she said in a statement. "Health care leaders must understand that the cost of infections erodes the bottom line, and they need to allocate the resources to infection prevention making it an institutionwide priority. At a time when these deadly infections still present a risk to patients, infection prevention departments at health care facilities need to be growing, not shrinking. Unfortunately, a 2009 APIC survey showed that 41% of hospitals in the United States are cutting staff, resources and education for infection prevention in response to the economic downturn."
'A giant step'
In a concession to the widespread influence of the popular American consumer magazine, other major infection groups immediately issued largely supportive statements. Joining APIC were the Society for Health Care Epidemiology of America (SHEA) and the Centers for Disease Control and Prevention.
"We have to take a step back and realize how quickly CDC, SHEA, and APIC all came out with press releases on this," says William Jarvis, MD, a former leading CDC hospital outbreak investigator who is now a private epidemiology consultant for Jason and Jarvis Associates in Hilton Head, SC. "If we go back to say, 2002 or so, when the Consumers Union first started pushing for this — nobody was for it. This is a giant step in the right direction. Are there limitations to it? Absolutely. Can we improve it? Absolutely."
The CR data are from hospitals that publicly report their central-line bloodstream infection rates as a result of state laws and hospitals that voluntarily report to the Leapfrog Group, a Washington, DC-based nonprofit that works with large employers and purchasers of health care to measure and publicly report on hospital quality. There are now infection rate disclosure laws in 27 states, and 17 of the states have published that information, the report noted.
"The state reports and the Leapfrog reports have been out there, but what we did is put it all together and present it in a way that people can understand," McGiffert says. "That's the element that has been missing. And we are doing it in a way that reaches people. Often these state reports are buried on some web site. I hope it will help call attention to the fact that some hospitals are doing a better job than others, and it will have an impact on [infection prevention] resources."
Central-line BSIs cause at least 30% of the estimated 99,000 annual hospital infection-related deaths in the United States and add an average $42,000 to the hospital bill of each ICU patient infected, the report states. Though it did not tie it directly to the infection rates reported, the CR article also takes hospitals to task for not adopting the highly publicized central insertion checklist developed by Peter Pronovost, MD, PhD, and colleagues at Johns Hopkins.2
Used by clinicians to ensure aseptic technique during catheter insertion, the checklist has become one of the more well-known aspects of a program that is frequently cited as proof that health care-associated infections (HAIs) are preventable rather than inevitable. Last year, U.S. Department of Health and Human Services Secretary Kathleen Sebelius called on hospitals to use the checklist to reduce their rates of central-line infections in ICUs by 75% over the next three years. However, implementation of the checklist is going slowly, particularly in states that don't have rate disclosure laws, the CR report states.
"We don't really have widespread information about which states are using the bloodstream infection checklist, but we feel that it is important for the public to know that zero is not impossible," McGiffert says. "That's why we brought the Pronovost checklist in. There are still too many hospitals that don't have a well-coordinated, organized, comprehensive, resourced infection control department. That's what it takes. This involves everyone that works in the hospital — the doctors, the CEOs, the CFOs."
In the report, which used 2008 data or the most recently available, CR listed "bottom performers" such as North General Hospital in New York City, which had a central line-associated bloodstream infection rate 394% higher than the national average.
The findings were "out of date and presented a misleading snapshot of our hospital," Samuel J. Daniel, MD, CEO of North General stated in a letter shared with HIC. "Here are the most recent facts. North General only had three central-line bacterial infections in 2009 — with none in the third quarter [latest data available]."
For its part, CR stands by its report and findings, but McGiffert concedes that "old data" are a recurrent issue, and there should eventually be better analytical tools available than the "standardized infection ratio" used for the report.
"Every time we come out with something like this, there are always [complaints] that 'you got it wrong; the data are old,'" she says. "Of course, the data are always old, which is a major issue that we have to work on. I know that people at CR are going back to look at the data, but these issues have come up even on process measures."
Also citing old data and recent improvements was Regional Medical Center in Memphis, TN, which CR reported had a central-line BSI rate 238% higher than the national average. Interestingly, in making the point to HIC, an epidemiologist at the facility underscored the importance of the burgeoning consumer advocacy movement to infection prevention.
"We're not sure where they got the 238% — and we saw a rather dramatic drop in 2009 — but all this reporting is very good," says Mack Land, MD, an infectious disease physician at the hospital. "It certainly focuses the attention of leadership and the board on infection prevention. We get a little boost out of that, and it makes everybody, individually in each unit, realize that this reporting is going to continue and we need to get in line. Our goal is zero central-line BSIs or as close to that as we can get."
Amid these invigorated quests for zero, there remains the lingering question of whether this public disclosure will translate to pressure not to report infections.
"I have heard anecdotally from infection preventionists that now the CEOs are aware that they should be at zero, they are demanding zero but they are not coming forth with the money [to improve the program]," McGiffert says. "You have to put your resources toward something you want to happen."
Jarvis feels state legislatures missed an opportunity by not requiring specific resources as infection rate disclosure laws were enacted.
"It's been very disappointing that not a single one of those pieces of [state] legislation required an increase in infection control personnel to do it," he says. "Basically, they're telling IPs to do more with less or static resources. The other thing I have certainly heard as I consult around the country are reports of gamesmanship about definitions. [For example], not calling it a catheter-related BSI until the patient is out of the ICU, so it really doesn't count. If you're sitting at zero for six months, you really don't want one."
Concurring was William Schaffner, MD, chairman of the department of preventive medicine at the Vanderbilt University Medical Center in Nashville, TN.
"As we in infection control go out to each of the units, they want to quibble about these infections because they make them look bad," he says. "Rather then having unit personnel focus on what they can do to prevent infections, we find them fighting about the 'report card.'"
Reiterating the point that all personnel must be involved in day-to-day infection prevention, Schaffner says the CR report and the era of transparency it heralds must be met with a new attitude in hospitals.
"We in medicine have to adopt a new mindset, particularly about bloodstream infections in ICUs," he says. "Peter Pronovost has now shown us that this checklist, rigorously applied, works — it drives down infection rates. There are hospitals that haven't even thought about that yet, let alone implemented it. If something like this [CR report] grabs the attention of people who have power and the authority to insist on the implementation of good infection control practices, we are on the right road — though there may be a lot of bumps."
(Editor's note: For more information on the hospital listings in the CR report go to www.ConsumerReportsHealth.org.)