This report originally appeared in the August 2011 issue of DOTmed Business News

Most people enter a hospital assuming they will leave healed and disease-free. Unfortunately, for more than a million and a half patients a year, that is not the case. But the situation is improving and experts believe that 2012 will deliver much better results.

According to the Centers for Disease Control and Prevention, Health care-associated infections (HAIs), are one of the most common complications of hospital care. The best data available, released in 2002, suggests 1.7 million HAIs occur each year, resulting in approximately 99,000 deaths annually, says Dr. James I. Cleeman, senior medical officer, Center for Quality Improvement and Patient Safety Agency for Healthcare Research and Quality. Rates have gone down somewhat since then and the CDC estimates that currently one in 20 hospital patients get an HAI on any particular day.

HAIs affect patients in traditional hospital settings as well as outpatient surgery centers, long-term care facilities, rehabilitation centers and community clinics. As the AHQR points out, babies, the elderly and the seriously ill are at greatest risk; HAI rates in adult and pediatric intensive care units are approximately three times higher than elsewhere in the hospital.

And HAIs are nothing to sneeze at; they are one of the top 10 leading causes of death in the United States. The CDC estimates that HAIs cost the country between $28 billion and $33 billion a year in excess health care costs. “HAIs are deadly, costly and mostly preventable,” says Cleeman.

Part of the cost challenge for hospitals is that the Centers for Medicare & Medicaid Services has instituted a policy of refusing to reimburse hospitals for certain preventable infections, according to Mike Mitka of the American Medical Association). These non-reimbursables often include HAIs. There are signs private insurers are following suit.

Superman and superbugs
Part of the problem is the increase in bacteria that are resistant to antibiotics. “Unfortunately, we have less than optimal use of antibiotics,” says Cleeman. “Then, the bacteria become exposed to the antibiotics and build up a resistance to it. The broader spectrum the antibiotics,” he notes, “the greater the risk because it affects more types of bacteria.” Scientists refer to these super-bugs as Multi-Drug Resistant Organisms (MDROs).

Probably the two most well-known MDROs are MRSA, a staph infection, and Clostridium difficile, which come from receiving too many antibiotics. Both are notoriously difficult to treat.

Another way scientists look at MDROs is by infection site – or how the bug is transmitted. Hospitals employ a wide variety of invasive devices and procedures to treat patients. Some of these techniques can leave behind unwanted guests.

The four most common sites of hospital-associated infections are: central line-associated bloodstream infection (CLABSI), surgical site infection (SSI), catheter-associated urinary tract infection (CAUTI), and ventilator-associated pneumonia (VAP); VAP accounts for a large proportion of HAIs.

Where do these bacteria hide? Right out in the open – and all over the health care facility, suggests research. A study conducted by researchers from Indiana University, TriHealth Laboratory and Xavier University found that 85 percent of mattresses and bed decks contain a variety of bacteria, even after being disinfected by housekeeping staff.

On the mend
The good news is that rates of MRSA are coming down. In the decade between 1992 and 2003, notes Cleeman, hospital-onset MRSA dropped by 28 percent. “The decrease is probably because of our ability to detect the bug, isolate the patient and decolonize the bacteria (in other words, remove MRSA) – as well as our efforts at prevention.”

Dr. John Jernigan, director of the CDC’s Office of HAI Prevention Research and Evaluation, agrees. “More of the advances in prevention can be attributed to better implementation of existing recommendations than to new developments,” he explains. These recommendations include hand hygiene, approaches for inserting certain medical devices, pre-operative practices and contact precautions.

The CDC is conducting research on HAI prevention by investigating and analyzing outbreaks and by collaborating with academic researchers through five epicenters around the country. These epicenters are looking into ways to disinfect hospital rooms, tests to identify patients who truly need antibiotics, use of probiotics (benign germs that can crowd out the more harmful ones), use of topical microbials to decrease patient risk and regional approaches to preventing the spread of MDROs. To date, health care providers look at the individual facility; patients, though, can carry HAIs, for instance, from a hospital to a nursing home or from one hospital to another, notes Jernigan.

Implementation on the CUSP
According to the Joint Commission, there’s no single way to combat HAIs. Rather, the health care certification organization recommends “bundling” or implementing several changes at the same time. For instance, to prevent surgical site infections, the Joint Commission proposes maintaining glucose control and avoiding shaving the surgical site.

The U.S. Department of Health and Human Services, which includes AHQR, has developed a four-pronged approach to implementing evidence-based practices, explains Cleeman. Called Comprehensive Unit-based Safety Program (CUSP), the system focuses on communication, teamwork and leadership within the individual health care facility.

CUSP consists of five steps:
• Educate staff on the science of safety.
• Assess the current patient safety culture.
• Partner with a senior hospital executive to improve communications and provide leadership.
• Analyze any problems that arise – and learn from them.
• Use a series of tools, including checklists, to improve teamwork and communication.

Thus far, approximately 990 hospitals in 45 states have started using the CUSP approach. “Using CUSP, rates of CLABSI have dropped by 35 percent in one year. We’ve prevented 430 cases of CPASI, 180 deaths and approximately $7 million in excess medical costs,” says Cleeman.

And that’s with fewer than 20 percent of U.S. hospitals participating. “Between research efforts and implementation efforts,” Cleeman adds, “the problem of HAIs promises to be improved significantly in 2012.”

Fighting the good fight
Research efforts are resulting in a number of products to help hospitals decrease HAIs. Typically, each addresses a small piece of the larger puzzle.

For instance, where do patients spend much of their time in a hospital? In the bed. “It’s the patient’s largest touch point,” says Bruce Rippe, COO and co-founder of Trinity Guardion, a manufacturer of bed protection systems.

“Studies link mattresses to HAIs,” says Dr. Edmond A. Hooker, associate professor of health services at Xavier University. “Studies show that if a previous patient had MRSA or C diff, the next patient is twice as likely to get that infection. Part of that is because mattresses, compared to floors, are much more porous – and much harder to clean.”

To address this, Trinity Guardion offers a launderable polyurethane bed cover system that contains an encapsulated anti-microbial silver additive and encompasses both mattress and bed deck. The cover provides an impermeable barrier between the patient and the mattress, protecting the patient from any bacteria that might have been left behind by a previous patient. “If the patient prevents one MRSA infection, it has paid for itself,” says Rippe.

Another approach is to zap the whole room with bacteria-killing light rays. Xenex’s PX-UV device uses xenon pulse technology, in a portable vacuum cleaner-sized device, to kill microorganisms without contact or chemicals. Users wheel the machine into the room, leave, hit the “on’ button via remote control and the UV pulse of the lamp penetrates cell walls fusing the DNA of the microorganisms. All in no more than 10 minutes.

A study published in Infection Control and Hospital Epidemiology found that the ultraviolet device reduced contamination found on 75 surfaces in 12 inpatient rooms and eliminated VRE, or vancomycin-resistant enterococci, a common MDRO, altogether.

“We are very encouraged by the results of this study, which demonstrated that our Xenex room disinfection system is 20 times more effective in killing dangerous pathogens like VRE,” says Mark Stibich, chief scientific officer of Xenex and one of the study’s authors.

The device has been recognized as “green” by Practice Green Health, a national organization for health care institutions committed to implementing sustainable, eco-friendly practices.

But the big question is: will the device reduce HAIs? An initial answer is available at Cooley Dickinson Hospital; in the first year of using the PX-UV device, the hospital experienced an 82 percent reduction in C diff infections. “This decrease translates to many more people leaving the hospital safer and with better outcomes,” says Dr. Joanne Levin, the hospital’s medical director of infection prevention.

Other hospitals and health care facilities opt to focus on testing.
Facilities interested in testing individual surfaces to determine whether they are really as clean as they look can turn to Midbrook Medical’s MediCount ATP Testing System. Users swab a surface and place the swab into a handheld unit. The unit measures the amount of ATP on the surface, which shows, by association, how much bacteria is present. Users can set acceptable thresholds for various surfaces; typically, for instance, patient room touch surfaces should have less bacteria than the sofa in the visitor’s lounge.

This information enables health care facilities to audit and adjust their cleaning processes, retrain operators if necessary, and quarantine or reprocess items that require additional cleaning. With heightened awareness, these and other new tools, as well as the CUSP implementation system, researchers and health care administrators are confident that rates of hospital-acquired infections will improve.

Yet another approach is offered by bioMérieux. Its NucliSENS Easy Q MRSA test can detect seven types of MRSA , including the most common strains. It uses nasal samples for identification and provides results within three hours.

“Almost all HAIs are preventable and rapid detection is key in preventing further spread of the infection,” says Narayan Krishnaswami, global product manager of Nosocomial Infections for bioMerieux.

But one tool won’t do it all alone. “We compare it to seatbelts and airbags in cars,” says Xenex’s Stibich. “The seatbelt manufacturers assume there will be airbags – and the airbag manufacturers assume there will be seatbelts.”

So far, the recipe is making a difference. “The problem of hospital-associated infections promises to be improved significantly,”says AHQR’s Cleeman.

Cross your fingers.