Clostridium difficile bacteria are responsible for one of seven types of healthcare-associated … [+]
It’s no secret anymore that Defense Secretary Lloyd Austin’s long hospitalization was caused by an infection following prostate cancer surgery at Walter Reed National Military Medical Center.
However, the effectiveness of the national effort to radically reduce healthcare-associated infections is, if not exactly a secret, something the latest data from the Centers for Disease Control and Prevention (CDC) obscures as much as reveals.
Preventing HAIs is a “top priority,” the CDC declares, because they “can have devastating effects on physical, mental/emotional, and financial health…[and] cost billions of dollars in added expenses to the health care system.”
Nonetheless, the most recent CDC hospital survey assessing HAI prevalence was in 2015. Even taking into account the interruption caused by the Covid pandemic, that doesn’t sound like a “top priority.”
Secretary Austin’s infection seems to have been caused by a urine leak, a rare but known surgical complication. The much-more common category of catheter-associated urinary tract infections is one of seven infection types tracked by the CDC as part of a larger federal infection-reduction effort. Unfortunately, the annual CDC progress report omits or downplays crucial information related to that effort’s success or failure.
Focus for a moment on CAUTIs (urinary tract infections), which afflict an estimated half-million patients annually. The CDC reports a 12 percent decrease between 2021 and 2022. More broadly, almost all infection rates improved from a 2015 baseline.
While that seems like good news, it’s like a mutual fund boasting how well their shares performed in just the most recent year. For a proper perspective, you need the bigger picture. When you do that here, the perspective changes.
“We have lost years of progress during the pandemic,” Debra Houry, now chief medical officer of the CDC, said at a November, 2022 patient safety meeting sponsored by the Department of Health and Human Services. The numbers in one CDC table bear her out.
Over a seven-year period, hospital infections caused by the possibly life-threatening C. difficile bacteria dropped 52 percent, a significant achievement. Next came CAUTIs which, despite that 12 percent drop from 2021 to 2022, in seven years decreased a total of just 30 percent.
At the other end of the spectrum surgical site infections after abdominal hysterectomy inched down just 5 percent in seven years. And while ventilator-associated events were down in 2022 compared to 2021, they actually jumped 19 percent over the seven-year period, likely due to Covid.
Perhaps the most interesting data relates to central-line associated bloodstream infections, which are costly and dangerous. While the prevalence dropped 16 percent in seven years, the missing context here is the possible reduction reported in a 2006 article in the New England Journal of Medicine. An effort among a group of 108 Michigan hospitals slashed CLABSIs in intensive care units to zero at many hospitals within three months. After 18 months, 70 hospitals had a close-to-zero rate.
What is the CDC’s goal for each of these infections? They exist, but this “progress report” doesn’t provide them. And while the baseline is 2015, this is (also unmentioned) a continuation of an effort that originally began with a 2010 baseline.
Finally, while the frequency of infections is typically expressed as you would expect – say, 1 in 100 operations – the CDC uses a measure called the “Standardized Infection Ratio.” The SIR compares the “expected” infection rate to the “actual” rate. Doing exactly as expected would be 1.00. What has happened to the actual rate of infections? You can’t tell.
The U.S. commercial airline industry has gone nearly 15 years without a fatal crash, or more than 100 million flights. Would flying be as safe if the industry promised to reduce the “actual” number of crashes compared to the “expected” number in 100 million flights? And perhaps reset that “expected” figure every few years?
Reducing infections requires a disciplined adherence to clinical protocols and the expertise to spot problems and address them. On the front lines of care, infection control professionals have long felt unappreciated. The Association for Professionals in Infection Control and Epidemiology recently launched an online calculator meant to help members fight back against endemic understaffing. The first version of that risk-based calculator utilizes an algorithm that analyzes the medical literature in order to help infection control leaders “make the case for adequate staff and resources to protect patients.”
So much for “First, do no harm.”
In early 2022, Lee Fleisher, then the chief medical officer of the Centers for Medicare & Medicaid Services, told the New England Journal of Medicine the nation needed a national patient safety strategy that “promotes radical transparency.” That need remains urgent.
Many hospital groups say their industry is committed to “zero harm,” but good intentions aren’t good enough. The public should be given clear and timely evidence that the results match the rhetoric.
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