Hospital Acquired Infection
Hospital acquired infections, also known as nosocomial infections, are a growing problem in the U.S., however there are steps that healthcare systems can do to protect patients, and actions that you can take to protect yourself.
Hospital Acquired Infection Statistics
It's a paradox. People go into the hospital to get well. Yet, every year in the U.S. over 2 million of them go into hospitals and get sick with a hospital-acquired infection. The outcome can be deadly. Over 100,000 patients die from these infections each year – more than car accidents, breast cancer and AIDS combined – according to the Committee to Reduce Infection Deaths (RID). And, they're expensive. It's been estimated that patients who contract an infection in the hospital stay an average of 20.6 days compared with 4.5 days for other patients, and their hospital stays cost six times more. The estimates for society as a whole range from $5 to $30.5 billion every year.
If these numbers surprise you, you're not alone. The topic has gotten sporadic exposure in the press, but since many states don't require hospitals to tally and report infections, they're just not high profile enough to stay on our radar.
When you stop to consider it, the prevalence of hospital contracted infections makes sense. Hospitals house large numbers of people who are sick: some with communicable diseases and many with poorly functioning immune systems. Medical devices, like catheters, and surgical procedures provide easy routes for infection to enter the body. Most importantly, there's a plethora of ways for pathogens to spread as medical staff move from patient to patient and visitors come to call.
What is a Hospital Acquired Infection?
A nosocomial, or hospital-acquired, infection is exactly what it sounds like – an infection that happens as a result of treatment in a hospital but is secondary to a patient's original admitting diagnosis. Infections are considered hospital-acquired if they first appear 48 hours or more after hospital admission or within 30 days after discharge. All hospitalized patients are at risk of acquiring them but some people are at greater risk than others: premature babies, young children, the elderly, the severely ill, and those with chronic conditions or undergoing treatments that undermine the immune system. These infections are most commonly caused by bacteria but can also spring from viruses, fungi, or parasites. Frighteningly, many of them are caused by multidrug-resistant superbugs such as methicillin-resistant staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE).
Medical professionals admit there's been a mindset that hospital-acquired infections are simply bad luck and something to be expected. Fortunately, that attitude is changing. While not all hospital-acquired infections can be prevented, the vast majority of them can. Thanks to rigorously implemented infection prevention procedures, many hospitals have demonstrated dramatic improvements.
Prevention of Hospital Acquired Infections
It turns out that preventive measures are fairly straightforward. For the most part, they come down to basics including:
- Thorough hand washing or use of alcohol rubs by all medical personnel before each patient contact
- Wearing gloves, aprons or gowns in appropriate circumstances
- Thorough environmental cleaning
- Proper sterilization techniques of all instruments
- Screening patients for disease causing germs and isolating those with contagious conditions
- Judicious use of catheters and ventilators and special procedures in inserting and maintaining them
- Careful use of anti-microbial agents, such as antibiotics, including:
- Giving preventive antibiotics in the hour before surgery
- Choosing the right antibiotic
- Ending antibiotics on time to avoid the breeding of antibiotic-resistant bacteria
The most-used justification for not implementing the Centers for Disease Control and Prevention (CDC) and Joint Commission On Accreditation of Healthcare Organizations (JCAHO) infection control guidelines is that money is stretched too thin to put more of it into infection control. In reality, these costs are dwarfed compared to those associated with prolonged hospitalizations, additional surgical interventions and medications required for treatment of infected patients.
Today, patient-focused advocacy groups are calling for more stringent and clearer guidelines than those already in place, as well as increased government oversight. A 2008 report from the Government Accountability Office suggests that Medicare and the CDC, in particular, should establish clear guidelines as to which infection-control practices they consider to be most important and that federal regulators should do more to push hospitals to meet those standards. Some consumer advocates say the situation won't improve dramatically until hospitals are required to make their infection rates public. While many states* have reacted by passing legislation to make reporting mandatory, opponents worry that it will be difficult to fairly compare hospitals. Hospitals that look harder for problems may have higher rates but not necessarily have more infections and those that routinely treat higher risk patients will be at a disadvantage.
Given the situation, what can you do as a patient to better your odds of avoiding a hospital-acquired infection? Get educated. Ask questions. Observe your healthcare workers. Speak up. Don't worry about being assertive. A clean environment and good infection control practices are your right. After all, it's your life.
* Nineteen states (as of March 2008) require reporting of hospital-acquired infections and some have additional laws that specifically require MRSA reporting. The states are Colorado, Connecticut, Delaware, Florida, Illinois, Maryland, Minnesota, Missouri, New Hampshire, New York, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Vermont and Washington.
- A hospital-acquired, or nosocomial, infection is an infection that happens as a result of treatment in a hospital but is secondary to a patient's original admitting diagnosis. Infections are considered hospital-acquired if they first appear 48 hours or more after hospital admission or within 30 days after discharge.
- Infections contracted in hospitals are the fourth largest killer in the U.S. Every year in this country, two million patients contract infections in hospitals and an estimated 100,000 die as a result - more than car accidents, breast cancer and AIDS combined.
- The estimated costs for hospital-acquired infections in the U.S. range from a $5 to $30.5 billion annually. Patients who acquired an infection spent more time in the hospital - an average of 20.6 days compared with 4.5 days for other patients, and their hospital stays cost six times more - $185,260 compared with $31,389.
- Patients who developed an infection while in the hospital had a higher death rate - 12.9 percent --compared with 2.3 percent for patients who didn't have an infection.
- All hospitalized patients are at risk of acquiring infections but some people are at greater risk than others: premature babies, young children, the elderly, the severely ill, and those with chronic conditions or undergoing treatments that undermine the immune system.
- These infections are most commonly caused by bacteria (Link to glossary and anchor to word) but can also spring from viruses, fungi, or parasites.
- Many hospital-acquired infections are caused by bacteria that have become resistant to the broad-spectrum antibiotics. Methicillin-resistant staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) are the most common.
- Studies have found that three-fourths of surfaces in hospitals are infected with MRSA, a potent antibiotic-resistant bacterium that causes some 94,000 invasive infections in the U.S. each year, resulting in almost 19,000 deaths.
- Organisms acquired in the hospital can be transmitted throughout the community through discharged patients, visitors and staff.
- The Centers for Disease Control and Prevention (CDC) lists the 4 most common hospital-acquired infections as:
- Urinary tract infections (UTI) 32%
- Surgical wound infections 22%
- Pneumonia (lung infections)15%
- Bloodstream infections 14%
- While not all hospital-acquired infections can be prevented, the vast majority of them can.
- The most important preventative measure is proper hand washing.
- A 2007 study of 1,256 hospitals by Leapfrog Group concluded the vast majority of hospitals don't take all of the recommended steps needed to prevent hospital-acquired infections.
- Risk for infection goes up with the number of procedures performed.
- 98% of surgical site infections can be attributed to microbes entering the wound at the time of surgery.
- Intubation tubes, catheters, surgical drains and tracheostomy tubes all bypass the body's natural lines of defense against pathogens and provide an easy route for infection.
- The longer the hospital stay the higher risk there is of contracting an infection.
- Infections erode hospital profits. When hospitals invest in proven precautions, they're rewarded with as much as tenfold financial return.
Ask Your Doctor
This list of questions is a good starting point for discussion with your doctor; however, it is not a comprehensive list.
· What are my risks for getting an infection while in the hospital?
· What can I do to reduce my risk?
· Should I be vaccinated against diseases that cause respiratory infections, including influenza and pneumonia?
· Should I shower with an antimicrobial agent the week before my procedure?
· Should I be tested for methicillin-resistant staphylococcus aureus (MRSA) and treated, if necessary, prior to my procedure?
· What is your rate of infections for patients you treat in the hospital?
· What is the track record for this hospital? This unit?
o How does it compare to other hospitals?
o What protocols do they have in place to control infections?
· How long will I be in the hospital? Can anything be done to shorten my time there?
· Is the use of an antibiotic indicated for my procedure?
· Can anything be done to avoid the use of catheters? If not:
o Do you use antibiotic-impregnated or silver-chlorhexidine coated catheters to reduce infections?
o Can anything be done to shorten the time I need them?
· Can anything be done to keep me warm during surgery? (Studies have shown your immune system is impaired if your body falls below 96.8 degrees.)
· Can you limit the number of people in the operating room?
· Will you be monitoring my glucose (sugar) levels during and after surgery? (Patients with controlled glucose levels are better equipped to resist infection.)
· How do you suggest I remind staff to do things according to protocol without offending them?
Key Point 1
Of all illnesses, infections are among the most common cause of death in U.S. hospitals. Hospital acquired infections are now recognized as a major cause of sickness and death.
Infectious diseases are the third leading cause of death in the U.S.; hospital-acquired infections are the fourth, translating to 100,000 deaths every year. All together, about two million patients – or about one in 20 – contract an infection after they're admitted to a hospital. A surviving patient with a very serious infection can end up enduring weeks, months or years of treatment and rehabilitation. And, organisms acquired in the hospital can be transmitted throughout the community through discharged patients, visitors and staff.
Healthcare professionals don't really have a handle on whether hospital-acquired infections are on the rise or are being conquered. In a 2007 report, the Centers for Disease Prevention and Control (CDC) cited declines in rates of centralline associated bloodstream infections and surgical site infections observed among certain hospitals from about 1992 to 2004 as a positive trend. However, a number of factors point to a potential for the problem to worsen before it gets better. Numbers have been notoriously underreported, and as data gathering and submission improves for more hospitals, the numbers will rise. As microbes develop new survival tactics to resist drug treatments, they are becoming more virulent. Finally, we are constantly coming into contact with newly identified microbes – just since 1976, scientists have identified approximately 30 new pathogens. In either event, reporting will never account for all cases. It's a time-consuming process that's becoming more difficult with today's shorter hospital stays and no standard procedure for tracking patients after discharge.
When a microbe – such as a virus, bacterium, fungus, or parasite – enters your body, it can remain dormant, be quickly killed by your immune system or multiply and produce an acute infection. If you're otherwise healthy and get an acute infection, your immune system may still claim victory or medical treatment may be needed. If not, one of two things can happen – a state of balance may be achieved producing a chronic infection or the microbes can continue to multiply and overwhelm your body's defenses.
Infections can be localized (limited to a specific part of the body) or generalized (one that enters the bloodstream and causes systemic symptoms). Localized infections can result in serious tissue damage, but the real danger occurs when an infection moves from a localized area into the bloodstream and turns into a systemic infection. A systemic infection can be life-threatening, affecting the lungs, bones, joints, heart, and central nervous system.
The CDC lists the 4 most common hospital-acquired infections as:
- Urinary tract infections (UTI) 32%
- Surgical wound infections 22%
- Pneumonia (lung infections)15%
- Bloodstream infections 14%
Bacteria that cause the most troublesome hospital infections are those that have become resistant to the broad-spectrum antibiotics long used to treat them. One of the faults lies with our heavy – and often inappropriate – use of antibiotics. When you take an antibiotic, the drug kills susceptible bacteria and can leave behind those that can resist it. The survivors multiply, creating a new bacterial strain that the old antibiotic can't kill.
Studies have shown contamination rates of MRSA on surfaces in hospitals from 10 percent to much higher. MRSA is a potent antibiotic-resistant bacterium that causes some 94,000 invasive infections in the U.S. each year, resulting in almost 19,000 deaths. Get more information about superbugs by reading the Second Opinion episode on Antibiotic Use
Common Risk Factors
Factors that contribute to hospital-acquired infection include:
- The condition of a patient upon admission. Those who are already in a poor state of health can become infected more easily.
- Patients who bring infections with them. This is especially likely for patients who are transferred among various health care institutions or from among different rooms within a hospital.
- The number of procedures performed:
- Surgical procedures: Microbes can enter the incision at the time of surgery, usually from bacteria already in or on the patient. Also, major surgery can stress a patient's body and lower their natural resistance to infection.
- Procedures involving invasive devices: Iintubation tubes, catheters, surgical drains and tracheostomy tubes all bypass the body's natural lines of defense against pathogens and provide an easy route for infection.
- Length of hospital stay. The longer the hospital stay the higher risk there is of contracting an infection.
- Treatments that leave patients vulnerable to infection:
- Immunosuppression and antacid treatment undermine the body's defenses.
- Antimicrobial therapy may remove competitive flora and leave resistant organisms.
- The prolonged use of antibiotics may reduce the effectiveness of a patient's own immune system.
- Contamination in hospital environmental systems such as air-conditioning and water systems.
- Multi-bed rooms where patients and visitors come in close contact with one another.
- Understaffed units. Studies have shown that in busy units, even basic hand-washing can get lost in the rush to treat patients.
- Insufficient knowledge of or resistance by healthcare providers to practice the most effective ways to prevent infection. (See Key Point #2 for more information on what healthcare providers can do to reduce infections risks.)
Key Point 2
Hand washing by hospital staff, patients and visitors is an effective way to prevent hospital acquired infections. Screening and environmental cleaning are very important but are not effective without hand washing.
After decades of less than stellar performance, an increasing number of hospitals are making significant changes to rein in hospital-acquired infections. Consumer advocates say we've had the knowledge to prevent these infections for some time but we've lacked the will to do it. Two major forces are fueling the drive to improve – a more focused approach to quality of care and a growing recognition by hospital administrators that these infections eat into earnings. Studies have shown that when hospitals invest in proven precautions, they're rewarded with as much as tenfold financial return.
Hospitals are proving that infections are preventable through rigorous hand hygiene, meticulous cleaning of equipment and rooms in between patient use, and testing incoming patients to identify those carrying dangerous bacteria. They've been achieving and spreading effective change by letting employees know infection control is an institutional priority and by taking an interdisciplinary approach, involving everyone from house staff to nurses to physicians. They've built a sense of ownership in departments by appointing teams to create standardized procedures and hands-on training programs, enforcing compliance, testing cleanliness, monitoring results, and rewarding positive behaviors and results.
Even though hand washing is the number one defense against infection, recent studies have suggested an average of 50% of doctors and nurses do not adequately wash their hands between patient contacts. Meaningful actions that hospitals are taking include
- Educating all staff about and requiring them to comply with the recommended guidelines CDC five-step process for hand washing
- Encouraging visitors and patients to follow the same procedures as hospital staff
- Ensuring convenient access to hand hygiene supplies:
- Adding sinks
- Providing alcohol-based hand rubs that are less irritating than antiseptic or non-antiseptic detergents
- Promoting the use of hand lotions to help protect the skin and reduce microbial shedding
- Requiring the proper use of sterile gloves:
- Removing gloves between patient encounters and prior to touching surfaces
- Removing gloves between dirty and clean body site care for the same patient
- Disposing of gloves after a single use
- Washing hands after glove removal
- Prohibiting artificial nails for all patient care providers who work with high risk patients
Cleaning, Disinfection and Sterilization
Previous contamination of a hospital care area is a strong predictor of future infection according to a study published in Clinical Infectious Diseases. Unfortunately, another study has revealed that nearly three-quarters of patients' rooms are contaminated with MRSA. Hospitals are upgrading their methods for cleaning rooms, like using new microfiber mopping systems and paying particular attention to the highest bacteria carriers – TV remote controls, toilet bowl handles, bathroom doors and call buttons. The protocols for disinfecting and sterilizing isolation hospital rooms are set at a higher standard. For instance, isolation room curtains and blinds are routinely removed for cleaning; carpets are steam cleaned; surfaces are drenched in disinfectant for several minutes, not just sprayed and wiped.
Anything that moves from patient to patient is a potential source of infection-causing microbes – people, ventilators, humidifiers, blood pressure cuffs, EKG leads, stethoscopes, wheelchairs, IV poles, commodes, glucometers, stretchers and more. Hospitals divide reusable medical equipment into three groups of risk: high, intermediate and low. High risk items are sterilized; intermediate items are disinfected; low risk items are cleaned.
Clothing can be a virtual conveyor belt for infections. Studies have shown that when doctors and nurses lean over a patient with MRSA, their coats and uniforms pick up bacteria 65 percent of the time, and carry it to other patients. One researcher found that neckties worn by clinicians are an overlooked hazard. Even when doctors washed their hands after patient examination, they also frequently adjusted their neckties. Healthcare workers use sterile gowns, gloves, masks, and barriers for intermediate and high risk situations.
Hospitals are also being more proactive in looking for and destroying pathogen reservoirs such as those in heating ventilation and air conditioning systems and installing HEPA air filtration in areas that house high-risk patients.
Use of Invasive Procedures
Some of the technological advances that save our lives can also increase the likelihood that we'll get an infection. Common procedures that increase our risk of hospital-acquired infections include:
- Urinary bladder catheterization
- Respiratory procedures such as intubation or mechanical ventilation
- Surgery and the dressing or drainage of surgical wounds
- Gastric drainage tubes into the stomach through the nose or mouth
- Intravenous (IV) procedures for delivery of medication, transfusion, or nutrition
Meaningful actions that hospitals are taking include:
- Using catheters and tubes judiciously and for as short a period of time as possible
- Pre-preparing "insertion bundles" – a series of precautionary steps and related materials packaged together
- Using sterile barrier precautions during device insertion
- Using catheters impregnated with antiseptic/antibiotics
- Changing catheters and dressings on time: i.e. peripheral IV catheters every 72 hours and central line dressings every week
- Keeping skin around dressings and intravenous catheters dry
- Before surgery:
- Having a patient shower preoperatively with an antimicrobial agent (Link to glossary and anchor to word)
- Administering antibiotics just prior to surgery
- Removing hair with clippers rather than shaving area (shaving can cause microscopic skin abrasions)
- For patients on ventilators:
- Learning proper suctioning technique
- Keeping the head of the patient's bed upright at 30-45 degrees
Screening and Isolation
Infection-causing micro-organisms may already be present in the patient's body at the time they're admitted. Some hospitals have instituted programs using new, same-day molecular testing to screen patients to determine if they're infected with methicillin-resistant staphylococcus aureus (MRSA) or are colonized with the bacteria but are not yet infected. If the test is positive for the bacteria, the patient gets nasal antibiotic ointments and is carefully washed for a few days. Some patients are put in isolation rooms. The efficacy of screening to reduce hospital-acquired infections is still being studied.
Key Point 3
While the burden of decreasing the number of hospital acquired infection cases lies with the healthcare system, patients can also take steps to protect themselves.
Hospital staffs are not the only ones who can take measures to prevent infections. Equally crucial in preventing hospital-acquired infection is the general public – you and I.
In the hospital and out, your best bet for fighting infection is to be otherwise healthy. You can prepare for planned procedures. If you're overweight, losing weight will reduce your risk of infection following surgery. If you have diabetes, make sure it's under control before having surgery. If you're a smoker, consider a smoking cessation program. Smokers are three times as likely to develop a surgical-site infection or lung infection as nonsmokers, and have significantly slower recoveries and longer hospital stays. Identify and seek treatment for any infections you may have before surgery. This includes all infections, not just those near the portion of your body undergoing surgery. Postpone elective operations until the infections are gone.
While in the hospital, relatively well patients can advocate for themselves. Very ill patients may need a family member or friend to advocate for them.
Job one is to get educated so you can knowledgeably observe your healthcare workers. Knowing the risks can significantly improve your odds.
Job two is to speak up. This isn't the time to be complacent.
• Prior to admission, ask your doctor if you need to be vaccinated against diseases that cause respiratory infections, including influenza and pneumonia.
• If you're diabetic, be sure that you and your doctor discuss the best way to control your blood sugar before, during, and after your hospital stay. High blood sugar increases the risk of infection.
• Let doctors and nurses know that you're concerned about preventing infections while receiving care.
• Ask for hospital data. If it's discrepant, ask your doctor about the hospital's infection control program.
• Don't hesitate to remind hospital staff about keeping their hands clean while caring for you. This includes washing their hands with soap and water or using an alcohol-based hand rub before working with you
• Ask anyone who is coughing to wear a mask or to stay more than six feet away from you.
• Let your nurse know if your gowns and linens are soiled.
• Before your doctor or nurse puts a stethoscope to your chest, ask that the diaphragm (flat surface) be wiped with alcohol.
• If you have a dressing on a wound, let your nurse know promptly if it becomes loose or wet.
• Ask your doctor to avoid using a urinary-tract catheter if at all possible.
• If catheters or tubes are needed:
o Ask your doctor to use one that's antibiotic-impregnated or coated with an antimicrobial agent.
o Make sure that it's inserted and removed under clean conditions and ask your doctor how often it should be changed.
o Let your nurse know promptly if it becomes wet, loose or dislodged.
o Make sure it comes out as soon as it's no longer needed.
• If you're having surgery:
o Ask your doctor about showering with an antimicrobial agent for the week before the procedure.
o Ask to be tested for methicillin-resistant staphylococcus aureus (MRSA) and treated, if necessary, prior to your procedure.
o On the day of your surgery, remind the surgeon about any planned preventative antibiotics
o Don't allow the surgical site to be shaven. If hair needs to be removed it should be done with clippers so there are no nicks in the skin through which bacteria can enter.
o Ask your doctor about keeping you warm during surgery. Studies have shown your immune system is impaired if your body falls below 96.8 degrees.
o Ask that your surgeon limit the number of people (including medical students) in the operating room. The more people who are present, the higher your risk of infection.
o Ask your surgeon to monitor your glucose (sugar) levels during and after surgery. Patients with controlled glucose levels are better equipped to resist infection.
Take these additional steps only you can control:
- If your child is in the hospital, bring his or her own toys.
- If friends or relatives feel ill, ask them not to visit.
- When visitors come, ask them to clean their hands in the same manner as hospital staff.
- Clean your own hands in the same manner as hospital staff.
- Do not set food or utensils on furniture or bed sheets.
- Pay attention to symptoms that may indicate an infection: unexpected pain, chills, fever, drainage, or increased inflammation of a surgical wound, and let your care team know. If any of these occur after you've been discharged from the hospital, contact your doctor right away.
Finally, be persistent. It all comes down to paying attention and having the courage to demand the best in cleanliness – the same as you do in demanding competence in your doctors and nurses. Healthcare improvement specialists concede that medical workers can sometimes be defensive when challenged by patients or their families. A universal truth in good communication, however, is that how you say something can be as important as what you say. You can preface your requests or comments by telling them that you've been reading about all the work being done to prevent hospital infections. You can let them know that your questions are about your commitment to being a part of your own healthcare team.
Conduct an off-site search for Hospital Acquired Infection information from MedlinePlus. These up-to-date search results are based on search terms specific to Second Opinion Key Points.