Download Hospital-Onset Infections

QUALITY GRAND ROUNDS
Series Editors: Robert M. Wachter, MD; Kaveh G. Shojania, MD;
Sanjay Saint, MD, MPH; Amy J. Markowitz, JD; and Mark Smith, MD, MBA
Academia and Clinic
Hospital-Onset Infections: A Patient Safety Issue
Julie Louise Gerberding, MD, MPH*
Hospital-onset infections, particularly those involving the urinary
tract, lung, and bloodstream, are common and costly and cause
substantial morbidity. This article analyzes the case of a 78-yearold man with lung cancer who died after developing hospitalonset pneumonia and urinary catheter–related infection during
hospitalization for elective removal of a cerebellar metastasis.
The field of infection control could benefit by adopting several approaches advocated by patient safety adherents, such as
root-cause analysis. For example, hospital-onset infections that
are implicated as attributable causes of death should perhaps be
reviewed by local infection control teams regardless of the insti-
tution’s overall infection rates. The patient safety movement can
also learn from the traditions of infection control and hospital
epidemiology. Specifically, applying infection control– based practices to safety problems may enhance safety. Such practices include establishing clear definitions of adverse events, standardizing methods for detecting and reporting events, creating
appropriate rate adjustments for case-mix differences, instituting
evidence-based intervention programs, and relying on skilled professionals to promote ongoing improvements in care.
“Quality Grand Rounds” is a series of articles and companion conferences designed to explore a range of quality issues
and medical errors. Presenting actual cases drawn from institutions around the United States, the articles integrate traditional medical case histories with results of root-cause analyses
and, where appropriate, anonymous interviews with the involved patients, physicians, nurses, and risk managers. Cases
do not come from the discussants’ home institutions.
mained. After removal of the Foley catheter, the patient was
unable to void. A straight urinary catheter was inserted, and
700 mL of clear yellow urine was removed. The patient required another straight urinary catheterization 4 hours later,
and 500 mL of urine was removed. Thereafter, the patient
was able to void into a urinal without difficulty. Other than
the preoperative dose of vancomycin, the patient did not receive antibiotics.
CHRONOLOGY
RISKS FOR INFECTIOUS COMPLICATIONS
HOSPITALIZATION
OF
EVENTS
Tom Reilly (a pseudonym), a 78-year-old man with stage
IV non–small-cell lung cancer and chronic obstructive pulmonary disease, developed several infections during hospitalization for elective surgical resection of a single cerebellar metastasis. On the day of his surgery, Mr. Reilly was brought to the
operating room, where an arterial line, a standard Foley catheter, and two large-gauge peripheral intravenous lines were
placed and a single intravenous dose of vancomycin was administered. An oral endotracheal tube was inserted. A craniotomy was performed, and a cerebellar mass, 2 cm ⫻ 1 cm,
was excised. Because the patient was slow to revive after surgery, computed tomography of the head was performed, revealing a large subdural hematoma in the posterior fossa. The
patient underwent evacuation of the hematoma in the operating room and was then admitted to the neurologic intensive
care unit.
On the second day of hospitalization, the endotracheal
tube was removed without complications. Mr. Reilly was easily
roused and was oriented to person, place, and time. On the
third day, he was alert and remained oriented but developed
new dysphagia and dysarthria. A swallowing study documented that he lacked a gag reflex and had difficulty clearing
secretions. Because the risk for aspiration was high, he was
given nothing by mouth and a Dobbhoff feeding tube was
ordered. At this time, the Foley catheter and the arterial catheter were removed; one peripheral intravenous catheter re-
Ann Intern Med. 2002;137:665-670.
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For the author affiliation and current author address, see end of text.
DURING
This elderly patient with noncurable metastatic lung
cancer underwent a palliative intracranial surgical procedure requiring postoperative intensive care. Even with
flawless care, he was prone to developing serious infectious
complications as a consequence of both endogenous risk
factors (those that were intrinsic to his underlying health
status) and exogenous risk factors (those that were attributable to the structure and processes of his complex medical care).
Data from the National Nosocomial Infections Surveillance (NNIS) System of the U.S. Centers for Disease
Control and Prevention (CDC) provide an aggregate view
of the frequency of common infections among hospitalized
patients in the United States (Table) (1, 2). Infection incidence rates are presented as device-specific incidence densities (number of infections per device-days ⫻ 1000) to adjust for the two most powerful predictors of infection risk:
length of hospital stay and use of invasive devices.
Urinary tract infections are the most common hospital-onset infections; they account for approximately 40%
of such infections in the United States (3, 4). More than
80% of urinary tract infections are associated with an indwelling urinary catheter, and risk increases with duration
of catheterization. Mr. Reilly was at risk for urinary tract
infection because he was elderly, had a history of malignancy, and had had a urinary catheter in place for more
*This paper was prepared by Julie Louise Gerberding, MD, MPH, for the Quality Grand Rounds series. Sanjay Saint, MD, MPH, and Kaveh Shojania, MD, prepared the case for presentation.
© 2002 American College of Physicians–American Society of Internal Medicine 665
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Hospital-Onset Infections: A Patient Safety Issue
Table. Incidence of Infection in the Intensive Care Unit from
January 1995 to April 2000, according to the National
Nosocomial Infections Surveillance System
Type of
Intensive
Care Unit
Type of Infection
Medical
Ventilator-associated pneumonia
Catheter-associated urinary tract
infection
Vascular catheter–associated
bloodstream infection
Ventilator-associated pneumonia
Catheter-associated urinary tract
infection
Vascular catheter–associated
bloodstream infection
Surgical
Pooled Mean
Infection Incidence
Density*
6.4
5.9
5.3
12.1
4.3
4.9
* Pooled mean infection incidence density ⫽ number of infections per devicedays ⫻ 1000.
than 24 hours (5). He was also at increased risk for catheter-related urinary tract infection because he did not receive systemic antibiotics effective against gram-negative
bacilli (5–7). However, administration of prophylactic antibiotics solely to reduce the risk for catheter-related urinary tract infection is not currently recommended for most
hospitalized patients (8).
Pneumonia, the second most common hospital-onset
infection, is associated with high mortality rates, increased
length of stay, and increased resource utilization (9 –11).
Pneumonia was recently found to be the leading cause of
nosocomial infection in medical–surgical intensive care
units, accounting for 31% of all hospital-onset infections
(1). Mr. Reilly had at least five endogenous risk factors for
pneumonia (chronic pulmonary disease, severe underlying
illness, older age, impaired airway reflexes, and male sex)
(11–14) and at least two major exogenous risk factors (mechanical ventilation and nasoenteric intubation). Nasoenteric intubation is particularly hazardous in patients with
impaired airway reflexes (11–14). Several strategies to decrease pneumonia rates in such patients have been investigated. Nasotranspyloric intubation (that is, advancing the
feeding tube into the small intestine) has no clear-cut advantage compared with nasogastric intubation in preventing aspiration or other adverse events (15–17). Some evidence favors the use of enterostomy (gastrostomy or
jejunostomy) to reduce aspiration risk, especially when
neurologic recovery is unlikely, but the overall protective
effect is small (18 –21). Proper placement and management
of the feeding tube is a more important issue in preventing
aspiration. Tube misplacement, tube displacement, unrecognized ileus, gastric distension, and supine patient positioning commonly contribute to hospital-onset aspiration
pneumonia (13, 14, 22).
Vascular catheter–related bloodstream infections are
less common than urinary tract infections or pneumonia
but greatly affect outcomes and costs of care (23, 24). Endogenous risk factors that might have increased Mr. Reil666 15 October 2002 Annals of Internal Medicine Volume 137 • Number 8
ly’s risk for vascular catheter–related infection include his
age and the severity of his underlying illness. Mr. Reilly
had at least one intravascular catheter in place during his
entire hospitalization, increasing the risk for vascular catheter–related infection. The risk was minimized, however,
because he received peripheral (rather than central) venous
and arterial vascular catheters (25). Other common exogenous risk factors, such as errors in intravascular catheter
insertion and management and low nurse-to-patient ratio,
were not documented in this case (26).
Surgical site infections are uncommon after neurosurgery (27), especially if intraoperative antimicrobial prophylaxis for staphylococcal infection is provided (28, 29). The
current infection rate after craniotomy, according to the
NNIS System, is approximately 1 surgical site infection per
100 surgeries for patients without special risk factors. This
rate doubles for patients with risk factors, including a contaminated, dirty, or infected wound; prolonged surgery; or
a preoperative risk class greater than II, according to American Society of Anesthesiologists criteria (27). Mr. Reilly
had a preoperative risk class of IV, increasing his infection
risk (27).
In summary, Mr. Reilly was at high risk for deviceassociated and procedure-associated hospital-onset infections. Implementation of evidence-based interventions
aimed at prevention should have been a high priority
throughout his hospitalization.
CHRONOLOGY
OF
EVENTS, CONTINUED
On the fourth day of hospitalization, the previously ordered Dobbhoff feeding tube was inserted and enteral nutrition was provided. Mr. Reilly received nothing by mouth. He
was alert and able to sit upright in a chair. The next day, he
was afebrile and neurologically stable but continued to have
dysphagia and dysarthria. He was transferred from the intensive care unit to a regular ward.
On the sixth day of hospitalization, Mr. Reilly developed
a temperature of 38 °C despite receiving 6 mg of dexamethasone intravenously every 6 hours after surgery. He was also
noted to have increased upper airway secretions. Aggressive
clearance of pulmonary secretions was requested because the
surgical team believed that the low-grade fever was probably
due to postoperative atelectasis or an acute exacerbation of
chronic bronchitis. Chest radiography and urinalysis were ordered, but several hours elapsed before they were performed,
and the physicians did not review the results until the next
day. Urine and blood cultures were also ordered. Empirical
antimicrobial treatment was not prescribed, and the patient
was not evaluated for possible pulmonary embolism.
On the seventh day of hospitalization, Mr. Reilly’s temperature was 39.2 °C. His heart rate was 120 beats/min, his
blood pressure was 115/53 mm Hg, and his respiratory rate
was 30 breaths/min. Arterial blood oxygen saturation was
96% on 4 L of supplemental oxygen delivered by nasal canula.
The urinalysis and chest radiograph obtained the previous day
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Hospital-Onset Infections: A Patient Safety Issue
were reviewed, and the results were found to be abnormal.
The urinalysis revealed 25 to 50 leukocytes per high-power
field and many bacteria. The chest radiograph showed consolidations in the right upper lobe and both lower lobes (Figure).
A sputum Gram stain revealed a moderate number of polymorphonuclear leukocytes; no organisms were noted. The urine
and blood cultures obtained on the previous day grew gramnegative bacilli; final identification was pending. Intravenous
piperacillin and gentamicin were administered.
DELAYED INITIATION
OF
OF
EVENTS, CONTINUED
On the eighth day of hospitalization, Mr. Reilly had a
temperature of 39.7 °C. His heart rate was 140 beats/min, his
respiratory rate was 40 breaths/min, and his blood pressure
was 125/88 mm Hg. Arterial blood oxygen saturation was
85% on 4 L of supplemental oxygen delivered by nasal canula.
He was transferred to the medical intensive care unit. A chest
radiograph again revealed consolidations in the right upper
lobe and both lower lobes consistent with pneumonia that had
worsened compared with the previous radiograph. The blood
culture drawn on the sixth day of hospitalization was growing
Klebsiella oxytoca, and the urine culture was growing K.
oxytoca and Escherichia coli. A sputum culture obtained on
the seventh day of hospitalization grew two species of Pseudomonas aeruginosa. The patient’s antimicrobial therapy was
changed to clindamycin, ceftazidime, and gentamicin to cover
hospital-onset urinary tract infection and pneumonia.
www.annals.org
Figure. Chest radiograph obtained on the sixth day of
hospitalization.
ANTIMICROBIAL THERAPY
Mr. Reilly developed clinical, microbiological, and radiographic evidence of infection on the sixth day of hospitalization but did not begin receiving antimicrobial therapy
for 24 hours. Given his increased risk for pneumonia and
urinary tract infection, the failure to start antimicrobial
therapy when fever was first noted seems to be an error of
omission (30), especially because he was receiving dexamethasone therapy (31, 32). The team caring for Mr.
Reilly probably underestimated the importance of lowgrade fever in a patient receiving systemic corticosteroids.
Prompt initiation of appropriate antimicrobial therapy
improves survival and decreases length of stay in patients
with bacteremia (33, 34). All institutions could benefit
from a careful internal review of how hospital-onset infections are managed. If treatment delays are common, the
institution should seek to improve the systems of care, not
simply individual clinicians’ responses to suspected infection. Inquiries might be made about the sequence of events
after fevers are noted, including time elapsed until patients
are evaluated, when tests are ordered, when they are performed, when results become available, and when results
are communicated and acted on. Communication networks could also be evaluated to ensure that no barriers
obstruct the timely flow of information from one person or
service to another. Factors such as inadequate staffing,
competing priorities, and fatigue should also be considered.
CHRONOLOGY
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On the ninth day of hospitalization, Mr. Reilly was intubated to improve his oxygenation. A rapid taper of dexamethasone was initiated. One blood culture drawn on the
seventh day of hospitalization grew coagulase-negative staphylococci. Because of persistent fever, vancomycin was added.
Nevertheless, the patient’s fever and respiratory failure continued over the next few days. On the 14th day of hospitalization, Mr. Reilly’s family requested that he receive comfort care
only. His endotracheal tube was removed, and he was discharged to home hospice. He died soon afterward.
ARE NOSOCOMIAL INFECTIONS MEDICAL ERRORS?
This patient, who had an underlying and ultimately
fatal metastatic malignancy, underwent a palliative neurosurgical procedure and developed two serious infections
that resulted in death. Did these infections and their outcome reflect deficiencies in the quality of health care Mr.
Reilly received? Were they a consequence of medical errors
(and therefore preventable), or were they unfortunate but
unavoidable complications of tertiary care for this severely
ill patient?
The answers to these questions are far from clear. Although some interventions may have reduced Mr. Reilly’s
risk for infection, it is also possible that his course would
not have been substantially altered despite the initiation of
evidence-based guidelines. Nevertheless, it is important to
15 October 2002 Annals of Internal Medicine Volume 137 • Number 8 667
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Hospital-Onset Infections: A Patient Safety Issue
monitor the incidence of nosocomial infections in health
care settings in an attempt to minimize their occurrence.
Rates of hospital-onset infection have been measured
for more than 30 years. The NNIS System and similar
infection monitoring systems compare the observed infection rate in a given hospital with the aggregate rate observed in a cohort of similar facilities. The NNIS System
currently reports “benchmark” (that is, comparison) hospitalonset infection rates based on the experience of more than
300 hospitals that use standardized and validated methods
to voluntarily and confidentially report infections to the
CDC. In theory, hospitals whose infection rates compare
poorly with NNIS benchmarks should be motivated to
identify preventable causes of infection and target interventions to prevent systematic errors, unless other explanations
for the increased rate are evident. The 30% to 40% decline
in infection rates reported by NNIS System hospitals in the
past decade suggests that this monitoring and benchmarking approach can be effective in promoting patient safety
and preventing some medical errors (2).
Data from the NNIS System have generally been used
to motivate institutions with higher-than-expected infection rates to strive for the relevant national benchmark
rate. With this approach, the preventability of infections
acquired by individual patients has not been routinely assessed unless the institution’s overall rates are high or increasing. This monitoring and benchmarking approach is
most useful when achieving a “zero rate” is not a realistic
expectation or when the preventable fraction of infections
(that is, the fraction due to medical errors) is unknown.
The result may be both an underestimation of the preventable fraction and missed opportunities to discover new prevention strategies. Unless all institutions continuously
strive to reduce their infection rates, there may be little
motivation for better-than-average performers to improve,
a situation that could lead to a “culture of complacency.” A
continuous quality improvement model, in which institutions practice an ongoing cycle of event tracking and process improvement, is recommended for infection control
activities (2) and has also been applied in some hospitals
seeking to reduce serious medication errors (35, 36). A
mindset that the current error rate can always be decreased
almost certainly explains the fact that other complex industries routinely achieve error rates far below equivalent
benchmarks in health care (37). A more aggressive approach to NNIS-type data would prompt institutions with
already successful infection control programs to strive for
rates even further below current benchmarks, while underperforming institutions would be encouraged to incorporate proven strategies to reach the comparison or benchmark rate. This approach may yield more robust
reductions in infection rates than those achieved by our
present focus on “underperforming” institutions.
The recent Institute of Medicine report (38) highlighting the relationship among medical errors, adverse events,
and health care quality has encouraged new approaches to
668 15 October 2002 Annals of Internal Medicine Volume 137 • Number 8
patient safety and infection prevention. Altering the
premise that “many infections are inevitable, although
some can be prevented” to “each infection is potentially
preventable unless proven otherwise” is consistent with the
expectations of patients and the Institute of Medicine. Perhaps hospital-onset infections that cause or contribute to
death or other serious adverse consequences should serve as
red flags that trigger close scrutiny of the safety and appropriateness of medical treatment, regardless of the institution’s overall infection rates.
In addition, although it is not practical or even useful
to perform a root-cause analysis of every hospital-onset infection, the local infection control team or other appropriate hospital personnel should review infections that cause
substantial harm or are implicated as an attributable cause
of death. When preventable causes are suspected, a rootcause analysis to identify factors inherent in the system or
processes of care that contributed to the errors should be
considered. The analysis starts with an event (for example,
urinary catheter–associated sepsis) and progressively moves
the focus of evaluation from special causes in clinical processes (for example, use of aseptic technique during catheter insertion) to common causes in organizational processes
(for example, reduced staffing ratios) to identify potential
interventions for prevention.
Evaluating errors that cause serious adverse events and
sentinel events requires time, skill, and tact on the part of
the infection control team, quality management staff, and
other health care personnel. No data as yet demonstrate
that root-cause analysis improves on results attributed to
traditional benchmarking and infection control methods.
Nevertheless, careful evaluation of the factors contributing
to fatal infections and similar adverse events may lead to
important systems changes and improved patient safety.
As one element in such a review, it is reasonable to ask
whether an anti-infective urinary catheter would have
made a difference in preventing Mr. Reilly’s septicemia.
Several types of anti-infective catheters are available; the
best studied are urinary catheters coated with silver alloy,
although catheters coated with minocycline–rifampin are
also available (39). A meta-analysis of eight trials found a
significant reduction in bacteriuria rates in patients given
silver alloy catheters compared with standard catheters
(40), and this finding has been duplicated in more recent
studies (41, 42). The effect of the catheters on reducing
more important outcomes, such as septicemia and death, is
unclear. However, recent studies suggest that patients such
as Mr. Reilly, who have indwelling urinary catheters for 2
to 10 days, are likely to derive both clinical and economic
benefits from the silver alloy catheter (40, 43, 44).
WHAT CAN PATIENT SAFETY AND INFECTION CONTROL
EFFORTS DRAW FROM EACH OTHER?
Modern patient safety practices, such as root-cause
analyses and continuous quality improvement, can enwww.annals.org
Hospital-Onset Infections: A Patient Safety Issue
hance the field of infection control. The patient safety
movement can also learn much from the traditions of infection control and hospital epidemiology. Precise and
valid definitions of infection-related adverse events, standardized methods for detecting and reporting events, confidentiality protections, appropriate rate adjustments for
institutional and case-mix differences, and evidence-based
intervention programs come to mind. Perhaps most important, reliance on skilled professionals to promote ongoing
improvements in care has contributed to the 30-year track
record of success in infection prevention and control.
Analogously, in approaching patient safety, standard
definitions should be used as much as possible when discussing adverse events and preventability. Health care organizations should be encouraged to pool data on adverse
events in a central repository to permit benchmarking, and
such data should be appropriately adjusted and reported.
Finally, institutions should consider hiring dedicated,
trained patient safety officers (comparable to infection control practitioners), as has been done in many Veterans Affairs hospitals (45).
THE INSTITUTIONAL RESPONSE
The institution’s infection control committee implemented several strategies to prevent catheter-associated urinary tract infections. First, after reviewing data showing
that catheters are inappropriately used in approximately
one third of patients (46, 47), that approximately 50% of
catheter days are not medically necessary (47), and that
attending physicians are unaware of catheter use in approximately 40% of cases (48), the hospital instituted a pilot
program of urinary catheter stop orders. In addition, silver
alloy urinary catheters are being used in targeted high-risk
areas and patients. Although silver alloy catheters cost approximately $5 more per unit, they may be cost-effective in
patients who are at high risk for urinary tract infection and
require catheterization for at least 2 days (43). Use of these
catheters will at first be limited to patients in the intensive
care units and on the hematology– oncology wards. The
hospital will perform a before-and-after evaluation to assess
effectiveness.
The hospital’s infection control committee began an
intensive educational program highlighting prevention of
nosocomial pneumonia, especially in ventilated patients.
On the basis of the evidence (49), directives included elevation of the head of the bed, strict adherence to hand
washing before and after contact with patients, aseptic
management of endotracheal tubes, and extubation as soon
as possible.
CONCLUSIONS
The institution should be commended for taking action. Systematic examination of events, relevant processes
of care, and prevention options is an excellent contemporary model for preventing infections and promoting pawww.annals.org
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tient safety. Nevertheless, a before-and-after evaluation in a
single hospital will not usually have adequate statistical
power to detect a meaningful difference. When a difference
is detected, secular changes may be contributory. We need
large, multicenter studies to assess novel strategies for patient safety enhancement.
From the Office of the Director, Centers for Disease Control and Prevention, Atlanta, Georgia.
Grant Support: Funding for the Quality Grand Rounds series is sup-
ported by the California HealthCare Foundation as part of its Quality
Initiative.
Requests for Single Reprints: Julie Louise Gerberding, MD, MPH,
1600 Clifton Road MS A07, Atlanta, GA 30333; e-mail, Jgerberding
@cdc.gov.
Excerpts of the question-and-answer session and excerpts of an interview
with the chair of the institution’s infection control committee are available at www.annals.org.
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39. Darouiche RO, Smith JA Jr, Hanna H, Dhabuwala CB, Steiner MS,
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40. Saint S, Elmore JG, Sullivan SD, Emerson SS, Koepsell TD. The efficacy of
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41. Karchmer TB, Giannetta ET, Muto CA, Strain BA, Farr BM. A randomized crossover study of silver-coated urinary catheters in hospitalized patients.
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42. Maki DG, Knasinski V, Halvorson K, Tambyah PA. A novel silver-hydrogel-impregnated indwelling urinary catheter reduces catheter-related urinary tract
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QUESTIONS
AND
ANSWERS
FROM THE
CONFERENCE
An Audience Member: What is the experience with
computerized systems to improve or decrease the rate of
hospital-onset infections?
Dr. Gerberding: In theory, computerized provider order entry with on-line decision support should be a major
prevention strategy. Hospitals that have adequate systems,
such as LDS Hospital in Salt Lake City, Utah, have shown
important improvements in antimicrobial utilization and
patient outcomes (50). Unfortunately, only a few hospitals
have them. Our role at CDC is to identify the best ways to
support improved decisions and then to work with vendors
to make these systems more widely available.
Dr. Robert M. Wachter (Moderator): At the practical
level, a hospital may say that it can introduce a more effective urinary catheter but that it will cost $5 more per
catheter. There’s a humanitarian case to do that, but is
there a business case to do it?
Dr. Gerberding: The available data suggest that use of
silver alloy–impregnated catheters is cost-effective in certain high-risk patient populations, but additional research
is needed to determine the true economic impact for hospitals, health care purchasers, and society. Ultimately, prevention requires that all components of the care system be
optimized, including indications for device use, product
selection, insertion and care protocols, and prompt removal of devices.
In this specific case, it is unclear whether any of these
interventions would have influenced the ultimate outcome.
For example, we do not know if this patient would have
definitely benefited from the use of a silver alloy catheter as
he received a catheter for about 2 days, the minimum
amount of time when silver alloy catheters have been
shown to provide clinical and economic benefits. Similarly,
although the urinary catheter stop order is an interesting
idea, it probably would not have influenced his outcome
because of the short duration of catheterization.
INTERVIEW EXCERPTS
On 6 September 2000, Quality Grand Rounds managing editor Amy J. Markowitz, JD, conducted an interview with Dr. D., medical director of infection control and
chair of the hospital’s infection control committee. Following are excerpts of that interview.
Ms. Markowitz: What is your committee’s philosophy
of infection control?
Dr. D.: We’re designed to do a number of different
things. We do targeted surveillance and collect information
about infections occurring in our hospital. We target highrisk procedures and patient populations. We look primarily
at the intensive care unit, where most of our hospitalacquired infection occurs.
Ms. Markowitz: What typically triggers an investigation?
Dr. D.: There are several ways that we can institute an
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investigation. Sometimes we get a call from a practitioner
who notices an unusual cluster or number of infections;
the other is through our active surveillance. We have data
on normally occurring rates, and if we see a change in types
of organisms we would institute an investigation.
Ms. Markowitz: How do you determine when to institute an intervention based on the data that you are collecting?
Dr. D.: We analyze our rates of infection and we compare them to benchmarks from the NNIS System provided
by the CDC. We pick a threshold that we think we should
be able to achieve. The NNIS System provides a pooled
mean for all the hospitals that are reporting but also gives
you a percentile ranking as to how many hospitals have
infection rates at which benchmarks. We generally use the
50th percentile, but our hospital now has made the very
aggressive decision to work for the 25th percentile for
bloodstream infections.
Ms. Markowitz: What measures has the hospital taken
to decrease the risk of hospital-acquired resistant infection?
Dr. D.: We have a number of different programs in
place. Let’s start with antibiotic restrictions. Through the
pharmacy and therapeutics committee, we have an antibiotic subcommittee that monitors and sets guidelines for use
of antibiotics. The pharmacy has dedicated pharmacists
who are directed to watch the use of all our restricted
agents and make sure that antimicrobial use is appropriate.
They have the authority to discontinue antibiotics if it’s
felt that the antibiotic was unnecessary.
Ms. Markowitz: How is that protocol carried out?
Dr. D.: The pharmacist leaves a note in the chart that
says the physician has 24 hours to either discontinue the
antibiotic or get approval from the infectious disease consult service. So there is always another physician group to
monitor the decision, and physicians are given that 24hour period, during which time they usually resolve the
situation. We find that the pharmacists almost never have
to write an order to discontinue the antibiotic.
Ms. Markowitz: How has your compliance been, and
how are you measuring your success?
Dr. D.: We measure our success in two different ways.
Number one, by tracking the use of restricted antimicrobials. We saw it go down significantly in the first year of
the program. There are still improvements to be made.
The second way is to follow antibiotic resistance patterns
and monitor key indicator organisms. If the microbiology
lab identifies an antibiotic-resistant organism that we are
concerned about, we will initiate special precautions, similar to contact precautions. We call them our antibioticresistant precautions.
Ms. Markowitz: What does this include and who is
notified?
Dr. D.: The microbiology laboratory contacts the physicians taking care of the patients. The patient is placed
into a private room, and anybody entering the room to
care for the patient puts on a mask, gown, and gloves, and
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any device or equipment that goes between patients has to
be disinfected. The final thing that has been instituted is a
patient transfer policy, which is designed to try to decrease
the number of transfers around the hospital of patients
with resistant organisms.
Ms. Markowitz: How do you measure your progress
with that intervention?
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Annals of Internal Medicine Volume • Number
Dr. D.: We’re following incidence of vancomycinresistant enterococcus infection.
50. Evans RS, Pestotnik SL, Classen DC, Clemmer TP, Weaver LK, Orme JF
Jr, et al. A computer-assisted management program for antibiotics and other
antiinfective agents. N Engl J Med. 1998;338:232-8. [PMID: 9435330]
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