does keeping hospital infection metrics promote unsafe practices

At this year’s annual meeting of the American College of Gastroenterology, there was an interesting juxtaposition of two recent studies about the prevention of hospital-acquired Clostridium difficile (C. diff) colitis.

One study found that a simple but comprehensive infection control plan can significantly reduce the incidence of C. diff colitis in hospital settings. The other study found that the very quality metrics many hospitals use to prevent hospital-acquired pneumonia and post-operative infections may be contributing to higher rates of C. diff illness.

This points out a major theme in today’s world of patient safety: The substitution of antibiotic use for basic infection prevention measures. Quality health care doesn’t require complex medical research. Most doctor and hospital negligence could be remediated with care, common sense, and attention to detail.

How Do Hospital Policies Contribute to C. Diff Infection Rates?

C. diff is an intestinal bacterium that occurs naturally in healthy people. After using antibiotics, however, the level of C. diff in some patients becomes elevated, causing symptoms ranging from diarrhea to a potentially life-threatening inflammation of the colon. This is called C. diff colitis or antibiotic-associated colitis.

Preventing C. diff infection has become an important patient safety topic in recent years because, like many hospital-acquired infections, it has become more frequent and can become antibiotic resistant.

Nationwide, nearly 500,000 people contract C. diff colitis in hospitals and nursing homes every year, and about 30,000 of them die.

The good news, as demonstrated in the first study, is that reducing the rate of C. diff illness can be accomplished by taking relatively simple steps. Integris Baptist Medical Center in Oklahoma City reduced its C. diff rate by 40 percent in only three months after implementing effective infection control measures.

  • For example, the hospital moved patient-room trash cans from the back of the room to near the door. That way, when health care staff removed their gowns and gloves they could throw them away without subsequently having to pass through the patient area and risking re-contamination.
  • A simple policy change now allows nurses who suspect C. diff to order stool samples without having to track down a doctor first. That encouraged early detection and isolation of infected patients.

However, doctors and hospitals don’t always consider basic infection-control procedures as their first option, as shown in the second study.

The researchers examined how doctors and hospital staff at Bronx-Lebanon Hospital Center in New York City responded when hospital quality metrics recommended by the Joint Commission and Centers for Medicare & Medicaid Services were introduced in 2004. The metrics were intended to encourage practices that prevent hospital-acquired pneumonia and surgical infections.

Surprisingly, the C. diff rates at Bronx-Lebanon more than tripled after the hospital implemented the quality metrics — likely because the rate at which its doctors prescribed antibiotics rose by 80 percent.

The CMMS quality measures “have led to a substantial increase in antibiotic usage,” the study concluded. “We believe this has resulted in an increase in Clostridium difficile infections in our patient population.”

While we don’t know precisely what caused Bronx-Lebanon to dramatically increase its rate of antibiotic prescriptions after the quality measures were introduced, it should be noted that many of the techniques used to prevent C. diff infection would also be effective against other types of infections. Over-prescription of antibiotics is not a replacement for basic infection-prevention measures and, as these studies show, can put patients’ health at risk.

Source: American Medical News, “Preventive measures shown to cut hospital C. diff rates,” Kevin B. O’Reilly, November 1, 2010

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