Health Groups Issue Stricter Infection Guidelines

The New York Times
Printer Friendly Format Sponsored By

October 9, 2008
Health Groups Issue Stricter Infection Guidelines
By KEVIN SACK

Hoping to improve infection control in hospitals, the nation’s top epidemiological societies joined Tuesday with the American Hospital Association and The Joint Commission, which accredits hospitals, to issue a compendium of guidelines for preventing six lethal conditions.

The unified backing of the hospital association and the accrediting agency should give the recommendations some teeth. The joint commission’s vice president, Dr. Robert A. Wise, said his agency would spend the next year studying which guidelines it would add to its accrediting standards in 2010.

The recommended practices, like vigorous hand-washing before the insertion of catheters and warnings against using razors to remove hair before surgery, do not vary in significant ways from the encyclopedic guidelines issued and revised over the last two decades by a government advisory panel.

But their authors said they have been written more clearly and concisely, with advice not only on what hospitals should do, but also on what they should not, and on secondary approaches to try if first-line measures do not lower infection rates.

The president of the 5,000-member hospital association, Richard J. Umbdenstock, said the guidelines, which were two years in the making, represented the first “professional consensus” on strategies to minimize infections. “As of today, the nation’s infection control team has a common playbook,” he said at a news conference in Washington.

The other groups supporting the guidelines are the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, and the Association for Professionals in Infection Control and Epidemiology.

Epidemiologists contend that the challenge in reducing hospital infections, which are said to attack one of every 22 patients, has not been a dearth of guidelines but a lack of adherence.

A survey of hospitals last year by The Leapfrog Group, which advocates for health-care quality, found that 87 percent did not consistently follow infection control guidelines. Studies have found that half of hospital workers do not follow hand-washing protocols. And epidemiologists in hospitals around the country have found that an intense focus on cleanliness and prevention can lead to significant reductions in infection rates.

“Too often where we fail is not in the knowledge but in the execution,” said Dr. Patrick J. Brennan, chair of the federal Healthcare Infection Control Practices Advisory Committee, which supports the effort.

Dr. Wise said his accrediting agency finds vast variation in hospital infection control practices.

“The same hospital which does great at inserting a central line and maintaining that central line might do poorly in the way it handles urinary catheters, not keeping track of who has them, how long have they been in and are they being checked daily to see whether they should be withdrawn,” he said. “All hospitals are partially effective. Few hospitals are completely effective.”

The federal Centers for Disease Control and Prevention, which also endorses the new guidelines, estimates that there are 1.7 million infection cases a year in hospitals, and that 99,000 patients die after contracting them (though the infection alone may not be the cause). It projects the cost of treating hospital infections at $20 billion a year.

With new research making a compelling case that infections are often preventable, many hospitals have become more aggressive. They also have been prodded by new policies by Medicare and other insurers to not pay for the added cost of treating patients who develop certain infections.

But a persistent problem, hospital officials say, has been the difficulty of translating guidelines into practice.

“One of the reasons hospitals are having difficulty now is that when they look at guidelines they are drinking from a fire hose,” Dr. Wise said. “There are thousands of these things and they don’t quite know what to do with them.”

The six conditions covered in the guidelines, which run six to 16 pages, are central-line associated bloodstream infections, ventilator-associated pneumonia, catheter-associated urinary tract infections, surgical site infections, Methicillin-resistant Staphylococcus aureus, or MRSA, and Clostridium difficile, an intestinal bacteria.

Dr. David C. Classen, an epidemiologist at the University of Utah and a lead author, said his team surveyed existing recommendations and research before deciding which practices were based in solid science. Some of the existing guidelines had not been updated in years, he said.

Among the additions were recommendations that patients with ventilators be kept in raised hospital beds and that they receive regular antiseptic oral care.

The group did not change standard practices for controlling MRSA, a virulent drug-resistant bacteria that may contribute to 19,000 deaths a year. They recommend universal testing of patients for MRSA on admission — so that infected patients might be isolated and treated with special precautions — only if less burdensome efforts fail to reduce infection rates.

Some hospitals have had great success with prevention programs that include universal screening. But other researchers argue that vigilant hand-washing and other precautions can be just as effective and less expensive while better caring for infected patients. The guidelines’ authors said the science remained inconclusive.

Dr. Lance R. Peterson, an epidemiologist at NorthShore University HealthSystem in Chicago, which saw a 70 percent reduction in MRSA cases after two years of screening all patients, said the existing standard was routinely ignored. Most hospitals, he said, were not measuring whether their infection rates were declining and evaluating whether to take more aggressive steps.

“It’s easier not to do something abut it if you don’t think you have a problem,” he said.