Rabih Darouiche, MD, director of the center for prostheses infection at Baylor College of Medicine and founder of the Multidisciplinary Alliance Against Device-Related Infections, discusses tactics to decrease hospital-acquired infections.
Q: Where do you see gaps in the way hospitals attempt to prevent hospital- acquired infections?
RD: That's a very good question. As you probably know, there are almost two million cases of healthcare-acquired infections in the States, and there has been major interest over the past decade in reducing such infections. However, as we have started from the beginning, our approaches have not been perfect. If I were to divide the reasons into groups as to why we continue to see some gaps in the way hospitals attempt to prevent hospital-acquired infections, the groups would be financial and scientific.
In regards to the [financial] category, it really focuses primarily on how hospital administrators regard the benefit and the financial impact of introducing new, potentially more protective approaches against infection. So far in most hospitals, including ours, hospital administrators focus on the additional cost of these newer but potentially more protective approaches. And we see that in the way finance is being fragmented within individual hospitals. So for example, pharmacy has its own budget, radiology has its own budget, acquisition has its own budget, nursing has its own budget, and each department or sector within an individual hospital is trying to protect its own territory. Therefore, we are being prevented from potentially acquiring devices or drugs that are more protective against infection, but cost more than the traditional drugs or devices we have been using.
The best way to fix that gap is to focus on the cost savings rather than on the additional cost. For example, we just published in Jan. 2010 the results of a [clinical trial] which demonstrated that using a more expensive antiseptic preparation to clean the skin of the patient for surgery reduces the rate of surgical site infection by 40 percent, as compared to a cheaper antiseptic preparation we have been using for several decades based on no clinical evidence. Although it can cost two to three times more than what we used for decades, the cost savings are tremendous — not only per potential case of surgical site infection, but to the hospital. We looked in a variety of hospitals, and the cost savings are anywhere between hundreds of thousands to a few million dollars.
Q: How fast can hospitals expect to see those savings?
RD: It's essentially almost instantaneous, because since we're talking about surgical site infections, the vast majority of these infections occur within 30 days of surgery. Within a month of using a more protective but more expensive versus a less protective but less expensive antiseptic preparation, you are going to realize the cost savings. Infection is black or white; there shouldn't be anything grey about it. I'm not talking about improving quality of life for people or the function of somebody's leg after implanting a joint prosthesis, where you have to follow those patients for years after surgery. The benefits of [more protective antiseptic preparations] will be demonstrated within 30 days of implementation.
Q: Studies are published regularly espousing the benefits of particular infection-control devices or methods, and hospitals have limited funds. Where should administrators start when deciding where to allocate their money?
RD: If I were a hospital administrator, and I wanted to focus on cost savings but [also] focus on improving patient care, I would at least initially focus on infections that either commonly occur or infections that … should they occur, result in major consequences. Let me give you some examples. In terms of the first group, since we are talking about surgical site infections, surgeons perform about 30 million procedures in the United States every year, and these collectively result in anywhere from 300,000-500,000 cases of surgical site infections. That's huge if you're thinking from the perspective of the whole country. It's also very important if you're thinking from the perspective of an individual hospital, because even the smallest hospitals with surgical capabilities are going to perform thousands of surgeries every year. If you are able to reduce the rate of infection from, let's say, 10 percent to five percent, that translates to a large absolute number of preventable cases of infection.
Now [let's take] the second group, which is infections that may not necessarily occur as frequently, but if they do occur, result in major consequences [such as] major morbidity or even mortality. Take the case of catheter-related bloodstream infections. Yes, it is true that if you apply the usual models of infection control and abide by sterile techniques, you can reduce infection rates. Yet there are a number of studies that have shown if you introduce those infection control models and sterile techniques and fully implement them, you witness a dip in the rate of infection, but it does not become zero. Some reports have shown that if you introduce a clinically protective, surface-modified antimicrobial catheter, it can result in an additional dip in the rate of infection. That's important, because the mortality associated with [catheter-related bloodstream infections] is five to 25 percent, and the cost of treatment can be anything from $10,000-$60,000.
Q: You mentioned another gap in the prevention of hospital-acquired infections — a scientific gap.
RD: Yes, this has to do with the fact that one size does not always fit all. In other words, if you are thinking about systemic antibiotic prophylaxis, which is usually introduced around the time of surgical manipulation, there are some hospitals [where the instance of MRSA is minimal]. For those hospitals, they have the scientific foundation to continue to give antiobiotic prophylaxis that does not include coverage against MRSA. They continue to give cefazolin, as opposed to an agent active against MRSA like vancomycin. With hospitals that have a low prevalence of MRSA, cefazolin may work well, but it doesn't necessarily work well in a hospital where prevalence is high. In our own hospitals, MRSA is becoming much more prevalent — not only for hospital-acquired strains, but also for community-acquired strains. Therefore in these hospitals, cefazolin is probably an inferior drug for prevention of infection for patients embarking on surgical manipulation.
Q: While hospitals are buckling down on hospital-acquired infections, it's a big task. Are there any "quick fixes" that can be made as a start?
RD: Now, although "quick fixes" — like [improving] hand-washing, for example — can work, they are more likely to be quickly abandoned than fixes that take time to implement. So let's talk about hand-washing. Hand-washing is one of the most important elements of creating a sterile environment; it's something everybody should utilize in any scenario where it's indicated. Unfortunately, we are humans, we are overworked and we tend to adhere more to quick fixes like hand-washing when we have been recently educated and reminded about it. Or when we realize personnel from the infection control department are actually watching us.
Q: Taking the example of hand-washing, then, do you have recommendations for improving the process long-term?
RD: I think continued education and training are very important. But I also think that … as healthcare providers — whether physicians, nurses, physician assistants or any kind of providers that work to improve patient care — I think we should realize the advantages of hand-washing and other quick fixes in our own hospitals. So it would be ideal for the individual hospital to provide data on the rates of certain infections, on the rate of transmission of certain organisms, within the hospital. As opposed to simply being told in education programs that there was an article that showed [the efficacy of] a certain approach, it would induce providers to continue to abide by these fixes if we show data from our own hospital that shows that if we continue to implement hand-washing, the rate of infection will continue to be low. The literature has a plethora of publications indicating that when an education program is instituted at a particular facility, rates of compliance go up and rates of infection go down. But within three to six months, rates of compliance go down rates of infection go up.
Q: Every hospital struggles with providers who seem unwilling to adapt to institutional changes. Are there ways to enforce these "best practices"?
RD: You know, no hospital has enough personnel and infection control departments to be everywhere and look at everybody. Therefore, the healthcare providers have to become convinced that what they are doing is good for patient care. The infection control personnel cannot act as the police. The people inside the facility should realize that whether or not they are being watched, they are doing the right thing.
Q: Are there other technologies hospitals can implement to decrease the incidence of HAIs?
RD: Yes. If you take all cases of healthcare-acquired infections, you will find out that half of those are caused by devices. The most common form of device-related infections is a catheter-related urinary tract infection. Although very common, there are difficulties in curbing the rate of infection associated with bladder catheters for a number of reasons. There is a very high concentration of bacteria in the bladder that can overwhelm the ability of any microbial [protection] in preventing catheter-associated UTIs. In contrast, vascular catheters and a variety of surgical implants are exposed to a very low concentration of bladder bacteria. These are the devices that are likely to benefit more clinically from being surface-modified.
Q: Are these devices also more expensive, as we discussed earlier? When do cost savings kick in?
RD: Those clinically protected, surface-modified catheters are certainly more expensive, but again, the significant impact on morbidity and mortality is generally very much cost-saving. Unlike the quick fixes like hand-washing, this is an approach where it's going to take you some time to realize the financial and medical impact of utilizing clinically protected, modified devices. You cannot introduce a new device and think that in a month or two, you're going to see results. You have to be patient. [For example,] there are short- and long-term catheters, and the short-term catheters remain in place for 7-10 days, while the long-term remain in place for month so even years. Surgical implants … can often become infected months or years after implementation.
Read more on hospital-acquired infections:
-Study: Private Rooms in ICUs Reduce Infection Rates
-Hospitals to Begin Reporting Bloodstream Infections
-Parkland Memorial Executives Get $38M for Shorter ED Waits, Lower Infection Rate
Q: Where do you see gaps in the way hospitals attempt to prevent hospital- acquired infections?
RD: That's a very good question. As you probably know, there are almost two million cases of healthcare-acquired infections in the States, and there has been major interest over the past decade in reducing such infections. However, as we have started from the beginning, our approaches have not been perfect. If I were to divide the reasons into groups as to why we continue to see some gaps in the way hospitals attempt to prevent hospital-acquired infections, the groups would be financial and scientific.
In regards to the [financial] category, it really focuses primarily on how hospital administrators regard the benefit and the financial impact of introducing new, potentially more protective approaches against infection. So far in most hospitals, including ours, hospital administrators focus on the additional cost of these newer but potentially more protective approaches. And we see that in the way finance is being fragmented within individual hospitals. So for example, pharmacy has its own budget, radiology has its own budget, acquisition has its own budget, nursing has its own budget, and each department or sector within an individual hospital is trying to protect its own territory. Therefore, we are being prevented from potentially acquiring devices or drugs that are more protective against infection, but cost more than the traditional drugs or devices we have been using.
The best way to fix that gap is to focus on the cost savings rather than on the additional cost. For example, we just published in Jan. 2010 the results of a [clinical trial] which demonstrated that using a more expensive antiseptic preparation to clean the skin of the patient for surgery reduces the rate of surgical site infection by 40 percent, as compared to a cheaper antiseptic preparation we have been using for several decades based on no clinical evidence. Although it can cost two to three times more than what we used for decades, the cost savings are tremendous — not only per potential case of surgical site infection, but to the hospital. We looked in a variety of hospitals, and the cost savings are anywhere between hundreds of thousands to a few million dollars.
Q: How fast can hospitals expect to see those savings?
RD: It's essentially almost instantaneous, because since we're talking about surgical site infections, the vast majority of these infections occur within 30 days of surgery. Within a month of using a more protective but more expensive versus a less protective but less expensive antiseptic preparation, you are going to realize the cost savings. Infection is black or white; there shouldn't be anything grey about it. I'm not talking about improving quality of life for people or the function of somebody's leg after implanting a joint prosthesis, where you have to follow those patients for years after surgery. The benefits of [more protective antiseptic preparations] will be demonstrated within 30 days of implementation.
Q: Studies are published regularly espousing the benefits of particular infection-control devices or methods, and hospitals have limited funds. Where should administrators start when deciding where to allocate their money?
RD: If I were a hospital administrator, and I wanted to focus on cost savings but [also] focus on improving patient care, I would at least initially focus on infections that either commonly occur or infections that … should they occur, result in major consequences. Let me give you some examples. In terms of the first group, since we are talking about surgical site infections, surgeons perform about 30 million procedures in the United States every year, and these collectively result in anywhere from 300,000-500,000 cases of surgical site infections. That's huge if you're thinking from the perspective of the whole country. It's also very important if you're thinking from the perspective of an individual hospital, because even the smallest hospitals with surgical capabilities are going to perform thousands of surgeries every year. If you are able to reduce the rate of infection from, let's say, 10 percent to five percent, that translates to a large absolute number of preventable cases of infection.
Now [let's take] the second group, which is infections that may not necessarily occur as frequently, but if they do occur, result in major consequences [such as] major morbidity or even mortality. Take the case of catheter-related bloodstream infections. Yes, it is true that if you apply the usual models of infection control and abide by sterile techniques, you can reduce infection rates. Yet there are a number of studies that have shown if you introduce those infection control models and sterile techniques and fully implement them, you witness a dip in the rate of infection, but it does not become zero. Some reports have shown that if you introduce a clinically protective, surface-modified antimicrobial catheter, it can result in an additional dip in the rate of infection. That's important, because the mortality associated with [catheter-related bloodstream infections] is five to 25 percent, and the cost of treatment can be anything from $10,000-$60,000.
Q: You mentioned another gap in the prevention of hospital-acquired infections — a scientific gap.
RD: Yes, this has to do with the fact that one size does not always fit all. In other words, if you are thinking about systemic antibiotic prophylaxis, which is usually introduced around the time of surgical manipulation, there are some hospitals [where the instance of MRSA is minimal]. For those hospitals, they have the scientific foundation to continue to give antiobiotic prophylaxis that does not include coverage against MRSA. They continue to give cefazolin, as opposed to an agent active against MRSA like vancomycin. With hospitals that have a low prevalence of MRSA, cefazolin may work well, but it doesn't necessarily work well in a hospital where prevalence is high. In our own hospitals, MRSA is becoming much more prevalent — not only for hospital-acquired strains, but also for community-acquired strains. Therefore in these hospitals, cefazolin is probably an inferior drug for prevention of infection for patients embarking on surgical manipulation.
Q: While hospitals are buckling down on hospital-acquired infections, it's a big task. Are there any "quick fixes" that can be made as a start?
RD: Now, although "quick fixes" — like [improving] hand-washing, for example — can work, they are more likely to be quickly abandoned than fixes that take time to implement. So let's talk about hand-washing. Hand-washing is one of the most important elements of creating a sterile environment; it's something everybody should utilize in any scenario where it's indicated. Unfortunately, we are humans, we are overworked and we tend to adhere more to quick fixes like hand-washing when we have been recently educated and reminded about it. Or when we realize personnel from the infection control department are actually watching us.
Q: Taking the example of hand-washing, then, do you have recommendations for improving the process long-term?
RD: I think continued education and training are very important. But I also think that … as healthcare providers — whether physicians, nurses, physician assistants or any kind of providers that work to improve patient care — I think we should realize the advantages of hand-washing and other quick fixes in our own hospitals. So it would be ideal for the individual hospital to provide data on the rates of certain infections, on the rate of transmission of certain organisms, within the hospital. As opposed to simply being told in education programs that there was an article that showed [the efficacy of] a certain approach, it would induce providers to continue to abide by these fixes if we show data from our own hospital that shows that if we continue to implement hand-washing, the rate of infection will continue to be low. The literature has a plethora of publications indicating that when an education program is instituted at a particular facility, rates of compliance go up and rates of infection go down. But within three to six months, rates of compliance go down rates of infection go up.
Q: Every hospital struggles with providers who seem unwilling to adapt to institutional changes. Are there ways to enforce these "best practices"?
RD: You know, no hospital has enough personnel and infection control departments to be everywhere and look at everybody. Therefore, the healthcare providers have to become convinced that what they are doing is good for patient care. The infection control personnel cannot act as the police. The people inside the facility should realize that whether or not they are being watched, they are doing the right thing.
Q: Are there other technologies hospitals can implement to decrease the incidence of HAIs?
RD: Yes. If you take all cases of healthcare-acquired infections, you will find out that half of those are caused by devices. The most common form of device-related infections is a catheter-related urinary tract infection. Although very common, there are difficulties in curbing the rate of infection associated with bladder catheters for a number of reasons. There is a very high concentration of bacteria in the bladder that can overwhelm the ability of any microbial [protection] in preventing catheter-associated UTIs. In contrast, vascular catheters and a variety of surgical implants are exposed to a very low concentration of bladder bacteria. These are the devices that are likely to benefit more clinically from being surface-modified.
Q: Are these devices also more expensive, as we discussed earlier? When do cost savings kick in?
RD: Those clinically protected, surface-modified catheters are certainly more expensive, but again, the significant impact on morbidity and mortality is generally very much cost-saving. Unlike the quick fixes like hand-washing, this is an approach where it's going to take you some time to realize the financial and medical impact of utilizing clinically protected, modified devices. You cannot introduce a new device and think that in a month or two, you're going to see results. You have to be patient. [For example,] there are short- and long-term catheters, and the short-term catheters remain in place for 7-10 days, while the long-term remain in place for month so even years. Surgical implants … can often become infected months or years after implementation.
Read more on hospital-acquired infections:
-Study: Private Rooms in ICUs Reduce Infection Rates
-Hospitals to Begin Reporting Bloodstream Infections
-Parkland Memorial Executives Get $38M for Shorter ED Waits, Lower Infection Rate