Getting The Bugs Out
Area Hospitals Far Apart in Applying Infection-Control Measures

By Ben Harder
Special to The Washington Post
Tuesday, September 25, 2007

Five years ago, Ruby Burns of Laurel underwent surgery to replace two disks in her neck. But the replacements apparently weren't all that entered her body that day. Burns, then 41 and a former hospital chaplain, developed a staphylococcus infection that formed an abscess on her spine at the site of the surgery. After months of undiagnosed pain and immobility, doctors determined the cause of her symptoms and removed the abscess. Before the second operation -- at a different hospital -- the doctors did something the original surgical team had failed to do, Burns says: They gave her an antibiotic.

Each year, an estimated 1.7 million hospital patients develop infections, each of which adds thousands of dollars to the cost of treatment. And some patients pay the highest price: Hospital infections kill approximately 99,000 Americans a year. The Centers for Disease Control and Prevention is the source of these estimates; actual numbers are unknown because hospitals in most states are not required to tally and report infections.

In an analysis to be made public today, Consumers Union compared data compiled by the federal Centers for Medicare and Medicaid Services (CMS) showing compliance with infection-control measures for most hospitals in Maryland and Virginia. (Similar data are available for District hospitals, but the nonprofit group -- the publisher of Consumer Reports magazine -- did not include those in its analysis.)

CU, which is advocating for a bill before Congress that would require hospitals to publish their infection rates, found that the hospitals in both states generally performed about as well as hospitals nationwide. But among hospitals in each state, says CU's Bill Vaughan, adherence to three measures of practice quality varied greatly.

The three infection-control measures are: how often preventive antibiotics are given in the hour before surgery, how often the right antibiotic is chosen and how often the drug therapy is halted within 24 hours.

"Certain hospitals are more diligent than others in making sure these practices are being followed," says Lisa McGiffert, manager for Consumers Union's "Stop Hospital Infections" campaign.

Giving patients an appropriate antibiotic in the hour before surgery has been found to reduce infection risks, as has good hand-washing and other practices. Yet not all hospitals perform such preventive measures with consistency.

For example, Sentara Leigh Hospital in Norfolk reported that it gave 97 percent of its surgery patients preventive antibiotics in the hour prior to their operations -- the highest percentage reported in Virginia. At the other extreme, Norton Community Hospital in southwestern Virginia took that step in just 22 percent of surgical cases it reported to CMS.

Ending antibiotics on time is equally critical: Therapy that lasts longer than a day can breed antibiotic-resistant bacteria, making any infection that does occur more dangerous. In the District, Howard University Hospital ended antibiotic therapy within a day of operating in 86 percent of cases; Georgetown University Hospital reported doing so in just 56 percent of cases. On the same measure, Maryland hospitals ranged from a high of 95 percent (St. Mary's in Leonardtown) to a low of 20 percent (Garrett County Memorial in Oakland).Those numbers, which became available last week, reflect cases treated between January and December 2006.

Richard Goldberg, Georgetown's chief medical officer, said he was "on board with the spirit of the standard," which calls for the last dose of an antibiotic to be given 24 hours after a surgical incision is made. But, he added, "if you're over by five minutes," as sometimes happens at Georgetown, "it's considered that you haven't complied with the standard. We don't want to play a game of eliminating the third dose. But theoretically a hospital could do that and look very good. We've chosen not to do that."

The data are freely accessible at the Web site http://www.hospitalcompare.hhs.gov, which is maintained by CMS. (To get to the data -- a several-step process -- click on "state" at the lower right of the home page. Next, select the state you want. Then check the boxes for the hospitals in which you're interested. Then click on "surgical care," check all three boxes and click on "view graphs.")

Patients in any hospital can speak up to better the odds that infection-control protocol will be followed, said infection-control expert Michael Tapper.

"Where patients see hospital data that is discrepant," he said, "it's perfectly appropriate for the patient to ask the surgeon: 'Can you address this? Can you reassure me, if antibiotics are necessary, that I'm going to get them in a timely fashion?' "

Tapper, a hospital epidemiologist in New York who speaks for the Infectious Diseases Society of America, says any number of glitches can interfere with good practice. A surgical team may neglect to order a necessary drug, for example, or the drug may be ordered but not delivered on time. "To be effective, the drugs have to be given before the skin incision is made," he says.

Often, the problem is not that the drug gets forgotten but that it gets administered too soon and then excreted by the patient, says Dale Bratzler, principal clinical coordinator of the Oklahoma Foundation for Medical Quality.

Antibiotics, he says, "can't be started until the patient is rolling into or [already] in the operating room. Otherwise, there are just too many opportunities for [surgical] delay."

Practices surrounding the use of antibiotics aren't the only factors in preventing post-surgical infections. But the CMS database does not include such basic measures as doctors' hand hygiene. It also doesn't track the actual frequency of hospital-acquired infections, says Tammy Lundstrom, an infection-control specialist at Providence Hospital in Southfield, Mich. Laws recently passed in Maryland, Virginia and other states will require hospitals to track and publicly report certain kinds of infections.

CMS also recently announced that, beginning in 2009, it will stop reimbursing hospitals for the costs of treating certain hospital-acquired infections. That move is intended to put financial pressure on the institutions to improve their infection-control practices.

For now, the three CMS measures provide a partial window on how far some hospitals have to go. "These measures are indicators of how well the hospitals' infection-control programs are being implemented," McGiffert says. "But they don't tell us the results of those programs. The infection rates are what we're interested in." ¿

Ben Harder is the deputy health editor at U.S. News & World Report and usnews.com.