Infection Control and Hospital Epidemiology: A Growth Opportunity in Medicine

Abstract

Health care-associated infections (HAIs) increase length of hospitalization, hospital costs, and the risk of liability claims and are directly linked to an increased risk of death.1 As everyone knows, health care is becoming increasingly complex: the elderly population is growing; there is widespread use of immunosuppressive medications; and organ transplantation and invasive devices are more common.2 These trends are putting steadily increasing pressure on the behemoth known as the US health care system. We believe that 4 additional factors have simultaneously converged to directly threaten the average American hospital's ability to survive. First, patient safety is now in the spotlight of the media. Thanks to innumerable news stories and articles, many-if not most-patients now worry about getting hurt while hospitalized. Next, public reporting of infection rates is now mandated in a few states, and others are soon to follow. Third, reimbursement to hospitals for the treatment of patients with HAI is already low and likely to decrease further. Finally, infections due to multidrug resistant organisms are more frequent and, in many cases, more severe. Although some may interpret this landscape as bleak, we believe that these challenges represent numerous professional opportunities for infectious disease specialists. In 1999, the Institute of Medicine's report on medical errors concluded that one in 25 hospitalized patients experienced at least 1 serious adverse event directly related to their medical therapy and that over half of these events were secondary to preventable medical errors.3 Although all HAI do not represent medical errors, it is undeniably true that many HAI can be prevented by attention to simple but often ignored practices. Three of 6 quality improvement initiatives included in the Institute for Healthcare Improvement's (IHI's) 100,000 Lives campaign focused on process measures designed to prevent ventilator-associated pneumonia, healthcare-associated bloodstream infection, and surgical-site infection.4 Furthermore, 1 intervention of IHI's recently released 5 Million Lives campaign focuses on process measures to decrease the spread of methicillin-resistant Staphylococcus aureus (MRSA).5 The Surgical Infection Prevention (SIP) project and Surgical Care Improvement Project (SCIP) have already improved outcomes for surgical patients in participating hospitals by focusing on process measures.6 These initiatives and successes make it highly likely that hospitals that develop systems and practices recommended by the IHI, SIP, and SCIP will, in turn, reduce their patients' risk of HAIs by substantial amounts. The IHI, SIP, and SCIP projects have been so successful that some of the process measures they have advocated are now included in regulatory requirements of accreditation organizations. Indeed, the Joint Commission on Accreditation of Healthcare Organizations includes the prevention of HAI as one of its recommended patient safety goals and has adopted the 3 SIP performance measures as a "core measures set."7 Thus, infection control programs can no longer confine their focus to rates and numbers; they must now concentrate on improving process as well. However, the leadership, oversight, education, and supervision required to develop systems that install and monitor such processes will not happen because an administrator orders it. We believe that infectious disease specialists are the ideal persons to provide leadership, oversight, education, and supervision to these efforts. Public reporting of rates of HAI is no longer considered extreme or far-fetched by most of the public, the media, or by policy makers. As of December 1, 2006, state legislatures in 15 states have written laws requiring hospitals to measure and publicly report their rates of HAI.8 Seven states currently have study bills under evaluation, and 17 states have active legislation under consideration. The rationale for such reporting is caused in part by the fact that HAI are generally considered to be one of the few "hard" outcomes available to the social scientists and politicians who want to do something about improving the safety of hospitalized patients. In addition, the CDC's definitions for HAIs are well known, almost universally used, and provide binary (yes/no) data.9 Although the public may not universally comprehend the implications of incorrectly prescribing or dosing an antiarrhythmic medication, the term "infection" is well known, and its implications are well understood. Advocates of public reporting argue that patients have a right to be informed about their risk of developing HAI. This knowledge should subsequently empower consumers to make more informed choices about their health care. Finally, and perhaps most importantly, public reporting is supposed to improve overall healthcare quality because hospitals will be more likely to implement better practices if patients choose hospitals with better quality of care