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Slashing hospital-acquired infections

New infection control techniques diminish infamous foes.

Hospitals can be risky places for sick people - because they're full of sick people. It can be tough to prevent germs from hopping from one patient to another by airborne transmission, unwashed hands or a contaminated device or bedrail. That's why about three percent of those who enter a hospital in the US develop an infection while they're there, and why nearly 100,000 succumb to a hospital-acquired infection annually.

It's also why Northwell Health has a massive program to prevent and control hospital-acquired infection. The US Center for Medicare and Medicaid Services (CMS) tracks rates of certain infections. In its five-star quality rating system, CMS bases a hospital's score on infection rates and other measures, such as the rate of pressure ulcers.

"Northwell has made tremendous progress in the past four or five years in bringing down some of the most problematic infections," said Mark Jarrett, MD, the health system's chief quality officer and associate chief medical officer. "We've raised awareness dramatically and put effective programs in place. But we can't stand still because the right number for hospital-acquired infections is zero."

It's a daunting challenge, because there are so many kinds of pathogens and so many ways they can attack the body. So Northwell's infection prevention team is constantly devising new strategies. One of the most effective has been a rethinking of routine practices. For instance, it used to be almost automatic for patients to have a catheter placed to drain urine from the bladder, said Donna Armellino, RN, DNP, the health system's vice president for infection prevention. That changed when health care professionals realized that a catheter can function as a highway for a microbe to enter a new and welcoming neighborhood.

"At one point, in many departments, if you didn't have an IV and a Foley catheter, the feeling was you didn't get the right care," said Dr. Armellino. "Now, the health care team is only going to give a patient a catheter if it's truly needed, and will ask every day whether it can come out."

quotation mark We have to be on our toes and we have to be creative. It’s tough to get to zero, but that’s our aim.
Donna Armellino

New protections

There's been a similar change in standard operating procedure when it comes to patients getting a central line - an IV that traditionally is placed into one of the body's large veins, like the jugular vein in the neck or chest area or the femoral vein in the groin. A central line delivers medicine quickly, but it can also ferry dangerous germs into the bloodstream. So medical teams now avoid placing a central line when they can. If you need a central line, they give preference to placement in the neck or chest instead of the germ-friendly groin, and remove it as soon as possible.

Upending old routines has made a big difference. The health system decreased the rate of catheter-associated urinary tract infections (CAUTI) by nearly 70 percent from 2012 to 2017. In roughly the same period, Northwell reduced central line-associated bloodstream infections (CLABSI) by 40 percent. "A CAUTI can set off a downward spiral for a fragile patient and CLABSIs have a high mortality rate," Dr. Armellino said. "So we know the steps we've taken have saved lives."

Surgical site infections are also a big focus. The infection team bundles a number of changes together because many elements before, during and after an operation can help microbes gain a foothold.

The infection-control team worked with colorectal surgeon Anthony Antonacci, MD, the health system's vice president for surgical quality, to introduce the bundled procedures for colon surgery. Every patient now gets oral antibiotics before an operation, followed by another dose at the time of incision. Throughout surgery, the anesthesiologist monitors temperature and blood sugar because immune cells become less active when body temperature drops or blood sugar rises. When it's time to close up, the surgeon uses a fresh pair of sterile gloves and a new, sterile instrument tray.

"All the instruments you've been using are already contaminated from inside the body, so now you're going to use them to close the wound?" said Dr. Armellino. "It makes more sense to finish with freshly sterile gloved hands and unused sterile instruments."

Infections started dropping as soon as the bundle was in place, she said. In just one year, surgical site infections after colon procedures dropped by more than 25 percent. A similar approach is already being implemented for abdominal hysterectomy.

Rigorous, ongoing work

Northwell has also slashed infection rates with Clostridium difficile (C. diff), bacteria that's on the rise across the country, partly because of overuse of antibiotics. The Healthcare Association of New York State recently recognized Northwell's campaign for appropriate antibiotic use with its 2018 Pinnacle Award for Quality and Patient Safety.

A C. diff infection causes diarrhea and colon inflammation and can be shockingly aggressive, said Bruce Farber, MD, chief of infectious disease at North Shore University Hospital. A few years ago, he and his team struggled to save a man who was admitted with the infection. The 50-year-old had been generally healthy, but developed C. diff after his physician gave him antibiotics for an upper respiratory infection.

"I'll never forget it," Dr. Farber said. "He had to have his colon removed to save his life. He survived, but at what a price."

Dr. Farber has been part of the push to bring down hospital-acquired C. diff infection through moves such as putting more emphasis on isolating infected patients, and by cleaning rooms approach to rooms even more rigorously before a new patient is brought in.

The efforts paid off. Northwell has cut the C. diff infection rate by 56 percent since 2011. Plans are also underway to roll out PurpleSun, the new ultraviolet light-based cleaning technology that kills C. diff and fully disinfects surfaces in 90 seconds. Northwell has invested in PurpleSun, which is expected to hit the market early next year.

More infection control strategies are under development. One of Dr. Armellino's priorities is a set of care bundles that target the rate of bloodstream infection with methicillin-resistant Staphylococcus aureus (MRSA), another nasty microbe that can grow quickly and become life-threatening. One measure will provide a daily antiseptic bath to anyone who has a central line, in case skin is colonized with MRSA. Patients at higher risk, like those who are receiving hemodialysis through a central line, may get the daily bath plus an antibiotic nasal ointment, because many people carry MRSA in their nose.

Infection rates are moving in the right direction, said Dr. Armellino, but the fight won't be over any time soon. Organisms are constantly evolving, with some becoming more virulent or resistant to antibiotics. "We have to be on our toes and we have to be creative," she said. "It's tough to get to zero, but that's our aim."

Northwell's commitment to quality has resulted in numerous initiatives that have reduced hospital-acquired infections.
Learn more about our efforts.