Hospital infections: deadly, preventable

At risk: Older adults in long-term care, particularly those who must take antibiotics for a long time. Half of cases occur in people under 65, but 90 percent of deaths occur in people over 65.

Symptoms: Fever, diarrhea, nausea, loss of appetite, abdominal pain and soreness.

How it spreads: c. diff is found in feces; people who touch contaminated surfaces or items and then touch their mouths or mucous membranes may contract infection. Healthcare workers spread bacteria to patients or contaminate surfaces through hand contact.

Carbapenem-resistant Enterobacteriaceae (CRE)

First noted in the U.S. in 2001, CRE kills up to 50 percent of those it infects. Carbapenems are antibiotics that treat serious infections. Enterobacteriaceae includes E. coli and Klebsiella. Some CRE does not respond to any antibiotic.

At risk: Patients using ventilators, urinary catheters or central lines, those taking long courses of antibiotics and those with surgical or other wounds.

Symptoms: Depends on the infection. CRE may cause pneumonia, urinary tract infections, bloodstream infections, wound infections and meningitis.

How it spreads: Contact with a wound by an infected person or device.

Methicillin-resistant Staphylococcus aureus (MRSA)

Outside the hospital, typically infects the skin. In the hospital, "invasive" MRSA infections, which enter the body through wounds or incisions, can cause bloodstream infections or pneumonia.

At risk: Older adults in long-term care; people with weakened immunity; people who have invasive medical tubing (urinary catheters, central lines).

Symptoms: MRSA skin infections create a pustule or boil. Invasive MRSA causes a variety of disorders.

How it spreads: Hospital staff members who neglect to clean their hands --- or use contaminated devices --- can spread MRSA from patient to patient.

Vancomycin-resistant Enterococci (VRE)

Resists the drug most often prescribed to treat it (vancomycin). The bacteria are present in the intestines and the female genital tract, where it usually exists without causing illness.

At risk: Surgical patients or others with catheters or central lines.

Symptoms: Fever and chills, frequent urination, abdominal pain or tenderness.

How it spreads: Health care workers with contaminated hands can spread VRE. The germ can also be spread directly to people after they touch contaminated surfaces.

Within days of her husband's hospitalization, Tammy Gustafsson noticed the signs popping up on other patients' doors at DeKalb Medical Center. STOP. CONTACT PRECAUTIONS. This means the patient within has acquired a dangerous infection.

As her husband battled acute pancreatitis, Gustafsson worried that he was at risk of infection, too. She says she frequently saw hospital staff taking shortcuts on sanitation protocols, but believes her complaints went unheeded.

Before long, Bjorn Gustafsson got a STOP sign of his own. He had contracted a dangerous hospital bug that travels from one patient to the next on the hands of doctors and nurses.

"All of January I was supposed to die, " said Gustafsson, whose fever spiked to 105 during the worst of his illness.

The healing arts almost always involve touch. 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.

Even some of the state's most highly regarded hospitals stand out in the data for poor results compared to hospitals nationwide, according to a review by The Atlanta Journal-Constitution.

"Health care-associated infections are a huge problem, and they are largely preventable, " said Dr. Tom Frieden, the director of the U.S. Centers for Disease Control and Prevention in Atlanta, which has set national goals for dramatically reducing these infections. "It costs lives, and it costs money."

For years, doctors thought these infections were unavoidable. But recent research has proven just the opposite. With new protocols in place and a staff that follows the rules with every patient, every time, many hospitals have achieved remarkably low infection rates.

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.

For just that one type of bloodstream infection, "we're talking about a public health problem the size of breast cancer or prostate cancer that is completely solvable, " said Dr. Peter Pronovost, the researcher from Johns Hopkins University who demonstrated that these infections are far more preventable than anyone imagined.

When Pronovost tallies all the kinds of preventable harm done to patients, he estimates upward of 200,000 deaths a year. Seeing the battle scenes in the movie "Lincoln" got Pronovost thinking about death tolls in the war versus those in the hospital.

"More people are dying per year from errors now than died per year in the Civil War, " he said. "How do we tolerate that?"

'Surprise --- I got an infection'

Many states have required public reporting of hospital infection rates for years. Georgia never has.

But new federal disclosure requirements are finally starting to raise the curtain on this data in Georgia. That disclosure alone may help to save the lives of some patients.

"Doctors --- we went to medical school. We're very competitive people, and we do not want to be at the bottom of the pack, " said Frieden, the CDC director. "It's very motivating to the hospital and to doctors to have numbers publicly reported. And of course, the public has a right to know."

What Georgians can find out about their hospitals' safety records is still limited to a few narrow measures hospitals are now required to report to the CDC's National Healthcare Safety Network.

Some of the state's hospitals are leaders on infection prevention. Georgia as a whole, however, ranks among the bottom 10 states in reducing central-line infections. This is the only measure so far on which the public has a full year of data.

Bjorn and Tammy Gustafsson know how serious these infections can get.

"So many times, I almost lost him, " Tammy said.

Medical trauma was new for the Gustafssons, who are in their 40s and have enjoyed good health. But in December 2011, Bjorn was admitted to the hospital with severe abdominal pain and was diagnosed with acute pancreatitis --- most likely caused by a gallstone getting lodged in his pancreatic duct.

DeKalb Medical Center would not discuss Gustafsson's case, citing privacy. But the top doctor there said the hospital has made great progress on preventing infections in the past 12 to 18 months.

Dr. Roy "Reg" Gilbreath, the system's new chief medical officer, said the hospital formed teams of doctors, nurses and other staffers to come up with strategies for cutting back on infections. In addition, "secret shoppers" monitor whether staffers are keeping their hands clean, and Gilbreath says the results are good.

DeKalb Medical's leadership said it encourages patients to speak out when they have questions or concerns about care and the hospital takes those comments seriously.

Bjorn and Tammy Gustafsson do not think of themselves as paranoid germophobes. But he was in serious condition and might require days, if not weeks, in the hospital. Having seen that other patients on her husband's floor had serious infections, Tammy began scouring the Internet for information on how to protect him --- and watching the staff.

"They are in and out of the room and some would do the sanitizer and some wouldn't, " Tammy said of hospital staff. "There were certain people who would never follow the protocols at all."

Her husband added, "It was an imminent threat, and surprise --- I got an infection."

Days from being released from the hospital, Bjorn came down with an infection caused by the bacteria VRE --- vancomycin-resistant enterococcus --- a drug-resistant germ found in health care settings. His fever soared. He was already weak, and the infection left him barely able to get out of bed.

After multiple hospitalizations and eventually going to South Carolina for treatment, where they say he got better care, Bjorn Gustafsson beat back VRE. These days, he's back at work as a software engineer and is doing fine.

But the couple came away from their experience believing that hospitals should be held to higher standards and penalized if they do not keep patients safe.

"Someone always has to pay for the problem, " Tammy said.

"In our case it was our health insurance that had to pay for the additional care, the really expensive medicine, and we paid with lost wages and more medical expenses. The hospital gave my husband the infection and then we turned around and paid them to get rid of the infection."

'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.

That is evident in the most recent data available to the public, which shows that Grady is lagging behind in controlling central line infections.

At the time when patient safety programs were taking hold in many hospitals, Grady was deep in a financial crisis that threatened to close its doors. That made it difficult for Grady to ramp up the prevention programs that other hospitals were embracing.

Haupert said that when he was hired to run Grady 18 months ago, he asked what the hospital needed to cut infections. He said Grady has already seen its numbers improve dramatically, and he's confident it can be a national leader in quality.

"I do think we can do it, " he said. "I do think the improvements we have already seen tell us we can get there."

Grady's incidence of central line infections is about half of what it was a year ago, according to data provided by the hospital.

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.

"Health systems --- small, large, rural, big --- time's up, " he said. "You've got to be transparent, and you have got to prove to the community that you are driving improvement and that you are providing safe care. You can't hide behind, 'Oh, the data is no good. Oh, our patients are sicker.' That's over. That's part of what's been wrong with our health system. For the money we spend on our health system in this country, we should have the best possible outcomes."

'We have driven our rates lower and lower'

If you make the rounds and talk to the white-coated experts leading Atlanta's hospitals, you will hear the same things about patient safety.

Most now endorse proven protocols and checklists that are known to work. The real challenge: doing it right with every patient every time. That's hard to pull off in hospital systems that have thousands of employees attending to hundreds of patients every day.

Everybody has a role to play. At some hospitals, nurses no longer have to wait for a doctor's orders before deciding that it's time to remove a patient's catheter. (A catheter that stays in too long increases the chances of infection.) Any staff member needs to have the authority to correct a doctor who makes a mistake. And every busy staffer must resist the temptation to take a shortcut, even if it means spending more time putting on gowns and gloves than it will take to check a monitor in the room of a patient with an infection.

The WellStar Health System, with hospitals in Cobb, Douglas and Paulding counties, prides itself on creating this kind of culture. The system started implementing the new protocols in earnest six years ago and saw dramatic results almost immediately. Today, WellStar's Kennestone and Cobb hospitals have some of the lowest incidences of central line infections in Georgia.

"Gradually, over time, we have driven our rates lower and lower to as close to zero as we can get them, " said Dr. Marcia Delk, WellStar's chief quality officer.

While achieving strong results on central line infections, WellStar is also using its teams to combat other threats, whether it's a unique sanitation system to kill a certain kind of bacteria; new protocols to cut down on surgical site infections; or an aggressive program to make sure patients are getting the right antibiotics at the right time --- a crucial element of controlling infections.

When asked to talk about prevention programs, most hospitals bring in their top infection control doctors for an interview.

But WellStar Cobb Hospital lined up its chief medical officer, its infectious disease doctor, an ICU doctor, floor nurses, nursing supervisors, clinical pharmacists and a team of nurses focused on infection prevention.

This sort of culture --- staff members at every level engaged in infection prevention --- saves lives, experts say.

"It's not only the nurse's job, it's not only the CEO's job, it's not only the ICU or the pharmacist, " said Pronovost, of Johns Hopkins. "You have to align toward a common goal and erase those lines that divide us and work together. That wasn't the norm in health care."

'It's nowhere near enough, and we're not satisfied'

Every hospital will say it is making progress. But how well each hospital is doing can be challenging to judge as a consumer.

Dr. Leigh Hamby, Piedmont's chief quality officer, said Piedmont's results are consistently improving. The latest data reviewed by the AJC shows Piedmont posts a strong performance for controlling surgical site infections for colon surgeries, but is relatively weak when it comes to preventing catheter-associated urinary tract infections.

Perhaps the ultimate measure of whether a hospital's approach to infection prevention is reliable: Do doctors feel completely at ease while their own family members are hospitalized?

"Until we feel comfortable flying on the same airplane we fly our patients on, our work is not done here, " Hamby said.

The new numbers suggest a strong performance at Emory's flagship hospital on Clifton Road for preventing central line-associated bloodstream infections, but a relatively weak performance for preventing catheter-associated urinary tract infections. Emory Midtown is flagged in the data for poor results on surgical site infections related to colon surgeries.

Emory cautioned against putting too much stock in the statistics reported by the federal government. Dr. William Bornstein, chief quality and medical officer for Emory Healthcare, said comparing one hospital to another may not be appropriate.

"We don't think the data are up to the task of deciding whether to get care here or there, " Bornstein said. "So our position on public reporting is we support it. We just want it to be presented in a way that doesn't mislead folks."

Emory's quality gurus supplied data to show that they have achieved improvements in patient safety on many key measures. For example, the rate of surgical site infections decreased at Emory Midtown in recent months after it updated antibiotic regimens, improved monitoring of doctor-specific infection rates and had senior surgeons observe techniques and give feedback to those with the highest infection rates.

Bornstein said he prefers to compare Emory to other academic medical centers that also take on complicated cases. But he said Emory still has work to do.

"If there is a hospital in America that thinks they are good enough, I would say that's probably a dangerous place, " he said. "We think we have made pretty extraordinary progress, but it's nowhere near enough and we're not satisfied. We don't want any patients to get infections."

'The thing that almost killed me'

Ellen Hargett, president of the Georgia Association for Healthcare Quality, was a hospital quality nurse when she was diagnosed with uterine cancer in 2007.

During the course of her treatment, this infection control nurse developed an infection.

"Everybody is fearful about cancer, and cancer is not a good thing, " Hargett said. "But I'm going to tell you the thing that almost killed me is people not washing their hands."

When she talks to groups of nurses, she often asks: How many of you have infected someone?

Usually no hands go up.

"Then I'll say, how many of you have ever breached hand-hygiene precautions or isolation precautions?"

At that point, most nurses will raise their hands.

"Then I say, 'Then you have infected someone, we just don't know it, ' " she said.

To the patient, the consequences of that infection may be incalculable. But Hargett says there is one cost you can track. She decided to tally up the costs of her illnesses.

Her insurer spent about $79,000 to treat her cancer.

Clearing up the infection: $239,000.

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A child's death led doctors to change

Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins University School of Medicine, has become well-known at hospitals nationwide for developing a proven method of reducing deadly infections associated with central lines. His checklist and changes to hospital culture led to astounding decreases in these infections in a landmark study conducted in Michigan. The protocol is now being used across the U.S. He recently spoke with the AJC's Carrie Teegardin by phone. This is an edited transcript of his remarks.

Q. What first made you challenge the conventional wisdom that most hospital infections were not preventable?

A. What really made it happen was a little girl, Josie King, died in my hospital at 18 months of a catheter infection, and she looked hauntingly like my daughter. She died on my birthday. Her mother, an amazing woman, Sorrel King, was working with the hospital, and she came to me (months later) and looked me in the eye and said, "Could you tell me my daughter would be less likely to die now than a year ago?" In many senses, I made excuses: "Well, I'm doing this, I'm doing that." And she cut me off and said, "Peter, I don't care what you're doing. That's your job. Just get your infection rates down." It was really an epiphany for me, truly like a Paul on the road to Damascus. And I said, "Sorrel, I can't give you an answer, but you deserve one and I will." And that's what really drove it. I started looking at Hopkins' rates and our rates were sky high, and it was really humbling, and I said, "I don't want to be killing little girls."

Q. Tell us more about how your program changed the culture in hospitals?

A. We changed the social norms from "these infections are inevitable, " which was the common mental model. It was my own mental model when I started as a doc and I was causing these infections. It changed to say, "Not only are they preventable, but I am empowered to do something about it." Many clinicians are completely disempowered and they feel like they are a cog in the wheel and say, "I'm just a nurse or a doc. Who am I to think I can change it?" What we have seen is, it is almost magic in their eyes when that switch goes off and they say, "I get it. I could actually do this." It's that belief system that either holds them back or launches dramatic improvements.

Q. What's the strongest motivator to get hospitals to improve?

A. The federal government's main approach to improving quality has been pay for performance, in other words an economic model, (and) there is essentially no data that it works. What I call extrinsic motivations --- either pay for performance or public reporting (requiring hospitals to provide a public accounting of their infection rates) --- haven't really realized improvements. The project we led was all intrinsic motivations. That is not to say pay for performance and public reporting don't have a role, but I think it has to supplement, not supplant, intrinsic motivations. If you have the tribe believing this is a big problem and we can solve it, then pay for performance or public reporting is like gasoline on it. It will accelerate it. If the tribe doesn't believe they can solve it, if you haven't garnered that intrinsic motivation, you can do all the pay for performance you want and that won't translate into measurable improvements.

Q. What's the most important factor in improving patient safety?

A. There's a famous physician who was kind of the father of quality improvement, and when he was on his deathbed he was interviewed. "OK, what's the secret of quality now that you have devoted your life to it and you have been a patient?" He said the secret of quality is love: if you have love, you change the system. It may sound corny, but it's true --- love your patients, love your colleagues, love your profession. The magic is not in the checklist.

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Infection control lags in Georgia

Health inspectors across Georgia swoop into every restaurant kitchen to demand cleanliness. They dip test strips into public pools to make sure the water is safe and monitor septic tanks for contamination of the environment.

But until now, one gigantic threat to public health --- hospital-acquired infections --- has escaped vigorous scrutiny by the state's top health officials.

In January, 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. Many states have required such reports for years and even share them with the public. Some states also have teams of workers devoted to cleaning up hospitals with high infection rates while auditing hospitals' reports to make sure nobody is fudging the numbers.

You don't have to look far to see how rudimentary Georgia's program is. Tennessee's effort to control hospital infections employs 10 people; Georgia's has one. Alabama requires public reporting of hospital infections and issues an annual report. In Georgia, the state does not permit the public to see the data it is collecting.

Until now, Georgia had no hospital-specific data on these infections. As of January, however, hospitals are sharing the same data with the state that they must now report to the federal government.

"Our vision in Georgia is to be able to eliminate preventable HAIs, " said Dr. Cherie Drenzek, Georgia's top epidemiologist. An HAI is a healthcare-associated infection.

As part of its HAI program, Tennessee has required hospitals to report infection rates to the state health department since 2008, and the state produces a thick hospital-specific report every year for the public.

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.

"We consider data accuracy and data validation to be one of our primary roles, " Drenzek said.

With just one employee working full-time on the effort, however, Drenzek acknowledges that Georgia's efforts will be challenged by its limited resources. She said the department is trying to join with other institutions to combat the problem and already has an expert advisory committee.

"We cannot do it alone, " Drenzek said. "We recognize that."