In a year when quality and infection control in healthcare has been top-of-mind for healthcare executives as these two elements are increasingly tied to their organizations' bottom lines, it was difficult to choose just five events to highlight in this "year in review" piece. But the Becker's Clinical Quality and Infection Control editorial team did just that.
For reference, we did something similar in the middle of 2015. In that piece, we listed the following five stories:
- Superbug infections linked to duodenoscopes
- Hospital Compare star ratings launch
- Risk of low-volume surgeries uncovered
- Ebola treatment and preparation in the U.S.
- Antibiotic resistance in focus
Building on those, here are five more infection control and patient safety stories from 2015 that affected hospitals, resulted in changed processes or uncovered new safety risks. They are presented in no particular order.
Plague on the rise
Even though many people consider the plague to be a medieval problem, the U.S. has seen several plague cases within its borders this year. The plague is caused by the bacterium Yersinia pestis and generally spreads to humans when they are bit by a rodent flea or they handle an animal with the plague. According to the CDC, 16 cases of plague have been reported in the U.S. through Nov. 16, and four of those people have died.
That is well above the usual number of U.S. plague cases: According to CDC data, the annual number of plague cases has ranged from one to 17 between 2001 and 2012, with the median being just three cases per year.
"It is unclear why the number of cases in 2015 is higher than usual," the CDC said in a report issued at the end of August, but it did encourage healthcare workers to consider a plague diagnosis when patients present with common signs or symptoms of plague, have traveled to the western U.S., and have been in proximity with rodents and their habitats or with ill domestic animals.
Fortunately, since the dawn of the antibiotic era, plague mortality has fallen from as high as 93 percent down to 16 percent. The key to survival is early treatment with an antibiotic such as aminoglycosides, fluoroquinolones or doxycycline.
Misdiagnosis under the microscope
Misdiagnosis and diagnostic errors were thrust into the national spotlight in September when the Institute of Medicine released its report "Improving Diagnosis in Health Care."
To quote the IOM, "Most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences." The report estimates that diagnostic errors account for 6 to 17 percent of hospital adverse events and about 10 percent of patient deaths.
As such, ensuring accurate diagnoses is a major patient safety issue for physicians and provider organizations to address.
The IOM report also stresses the importance of measuring diagnostic errors in healthcare so the industry can establish the frequency of the problem, assess education and training efforts and create a framework for accountability, among other benefits. However, as experts pointed out in a JAMA viewpoint article in November, doing so can be difficult.
"Diagnostic errors are particularly difficult to measure accurately," the JAMA viewpoint piece reads, because the diagnostic process is so complex. "Developing good measures will require investments in research and the agreement of stakeholders to use the beset measures."
Endoscope reprocessing risks
Earlier this year, news broke that patients at multiple hospitals had been falling ill with superbug infections linked to improperly reprocessed duodenoscopes, a specific type of scope which one expert even called "almost impossible" to clean correctly. In fact, a study published in the American Journal of Infection Control in August found that after manual cleaning, 92 percent of studied endoscopes had microbial residue that exceeded benchmarks.
The U.S. Department of Justice responded to the issue by taking legal action against scope manufacturers and having organizations like the CDC issue updated protocol on how to safely reprocess duodenoscopes. Some hospitals even moved away from reprocessing and toward full sterilization instead.
Since this summer, more stories have come out about different endoscopes being improperly cleaned. For instance, a hospital in California discovered an endoscope used for colonoscopies had been cleaned improperly during a seven-year period, putting about 5,000 patients at increased risk of infection.
Then, in November, the U.S. Food and Drug Administration issued a recall of all automated endoscope reprocessing machines manufactured by Custom Ultrasonics, totaling about 2,800 machines. The FDA cited continued violations by Custom Ultrasonics that could put patients at increased risk of infection, including the company's inability to verify the machines could properly wash and disinfect endoscopes.
To top things off, the ECRI Institute listed "inadequate cleaning of flexible endoscopes before disinfection" and the risk it poses to spread harmful pathogens at the top of its "2016 Top 10 Health Technology Hazards" list issued in November.
Legionnaires' disease outbreaks abound
Legionella, a bacterium occurring naturally in the environment, usually in warm water, has wreaked havoc on cities and healthcare organizations alike this year. The bacterium causes Legionnaires' disease, or legionellosis, which people can acquire when they breathe in a mist or vapor contaminated with the bacteria. Elderly people, current and former smokers, people with weak immune systems and those with chronic lung diseases are at increased risk of being infected.
This year, New York City experienced a Legionnaires' disease outbreak tied to contaminated water-cooling towers in the Bronx. The outbreak killed 12 people and sickened hundreds. Other hospitals also reported the presence of Legionella in their water systems or isolated instances of the illness within their facility this year — for instance, a Veterans Affairs hospital in Phoenix relocated 20 of its patients after discovering the bacteria in its water system in August.
According to the CDC, anywhere from 8,000 to 18,000 people in the U.S. are hospitalized annually due to Legionnaires' disease, but that number has been steadily increasing, according to a study published this year in the Journal of Public Health Management and Practice. The study found the number of reported cases of Legionnaires' disease in the U.S. more than tripled between 2001 and 2012.
"Legionellosis deserves a higher public health priority for research and policy development," the study concludes. "We recommend a formal and comprehensive review of national public health guidelines for prevention of legionellosis."
NTM infections emerge as risk of open-heart surgery
Heater-cooler devices used during open-heart surgeries have recently been identified as a potential patient safety hazard by both the FDA and the CDC because the devices have been linked to nontuberculous mycobacterium infections.
NTM are slow-growing bacteria naturally found in water and soil. Water in the heater-cooler devices can become contaminated with NTM bacteria and then become airborne through a vent on the device, thus potentially transmitting it to patients. The infections can take multiple years to manifest in patients, and they can be deadly.
Two hospitals — WellSpan York (Pa.) Hospital and Penn State Hershey Medical Center — contacted thousands of open-heart surgery patients in October and November to inform them of the infection risk. Five open-heart surgery WellSpan York Hospital patients have died, and experts consider the NTM infections a "contributing factor" to their death.
The FDA has issued a safety communication, "Nontuberculous Mycobacterium Infections Associated with Heater-Cooler Devices," addressing issues with safe use of the device, and CDC issued interim practical guidance on such devices.
"The most important action to protect patients will be to remove contaminated heater-cooler devices from operating rooms and ensure that those in service are correctly maintained," according to the CDC. Both WellSpan York Hospital and Penn State Hershey have done so.