THCB

Safe Doctors, Unsafe Patients: A Tale of Two Infections

flying cadeuciiCall it a tale of two infections. It’s the story of how hospitals have blocked transmission of a dangerous infection that patients can give doctors, while a hospital-caused infection that can kill patients continues to be widely tolerated. It involves saved lives and endangered ones ­– and also of billions of dollars spent needlessly due to unsafe care.

The infection that’s been conquered is occupational transmission to doctors and other health care workers of HIV, the virus that causes AIDS. When AIDS first burst on the scene in the early 1980s, it was “disfiguring, debilitating, stigmatizing and inevitably fatal,” in the words of Dr. Paul Volberding, a treatment pioneer. With the disease’s spread poorly understood, “the fear of contagion [was] hanging over our heads,” Volberding recalled.

However, once the mode of transmission was identified– exposure to HIV-infected blood or other bodily fluids – precautions were rapidly put into place. From 1985 through 2013, there were just 58 confirmed cases of occupationally acquired HIV infection reported to the Centers for Disease Control and Prevention (CDC), according to a Jan. 9 CDC report. Since 1999, there’s been only one confirmed case of occupational transmission, involving a lab tech infected via a needle puncture in 2008.

Reported occupational infection “has become rare,” the CDC concluded, likely due to prevention strategies and “improved technologies and training.”

At the same time hospitals were eliminating the danger of patients infecting health care workers with HIV, most were doing little to stop the dangerous infections hospitals can give patients. In 1999, the Institute of Medicine (IOM) issued a landmark report declaring that 44,000 to 98,000 patients died each year from infections and other preventable medical errors in hospitals. This “epidemic,” as the IOM put it, killed more Americans than breast cancer or AIDS. (Later research put the preventable deaths at from 210,000 to more than 400,000 annually.)

Yet by 2008, the same year as the last reported occupational exposure to HIV, studies would show that most hospitals had done very little to prevent patient harm. That year, however, the Agency for Healthcare Research and Quality launched an ambitious effort to fight one particularly expensive and dangerous infection that, like HIV, was extensively studied. It’s called a central-line associated bloodstream infection, or CLABSI.

Bloodstream infections from catheters placed deep into a sick patient’s torso have a higher mortality rate than typhoid fever or malaria. They’re also the most costly of healthcare-associated infections, costing an average $46,000 per patient. The good news was that a five-step “checklist” approach, including such simple items as hand-washing and cleaning the patient’s skin with a disinfectant, was startlingly effective at CLABSI prevention. A study of checklist use in the New England Journal of Medicine documented how a large group of hospitalsreduced CLABSIs by nearly 70 percent in just 18 months. During that brief time, they saved more than 1,500 lives and nearly $200 million, researchers estimated. Many of the hospitals eliminated CLABSIs altogether.

So did hospitals everywhere rush to conquer CLABSIs the way they’d triumphed over occupational HIV transmission? Not quite. The latest CDC report, also issued in early January, shows that during the five-year period from 2008 to 2013 CLABSIS declined only 46 percent. What happened?

As I’ve previously written, the CDC calls CLABSI elimination a “winnable” battle but refuses to set zero CLABSIs as a formal goal. Yet despite that leniency, hospital data I obtained from the Medicare program show that in fiscal 2013, 1,197 hospitals ­– 42 percent of acute-care hospitals treating adults and reporting to the CDC – had zero CLABSIs in their intensive care units.

Indeed, though the CDC concedes in its latest report that “specific steps to prevent” CLABSIs could reduce them “by more than 70 percent” from a baseline rate, its own goal for Sept. 30, 2015 is just a 60 percent reduction in the base rate. Given the progress by hospitals so far, that’s unlikely to be met.

So this is the human cost of this tale of two infections: when it comes to doctors, nurses and other workers being endangered by the patient-transmitted HIV virus, hospitals have been extraordinarily safe: in a nearly 30-year period, just 24 nurses and not one physician suffered a confirmed infection. (Similarly, the recent Ebola threat has mobilized the CDC and hospitals.) By comparison, 1,300 patients died preventable deaths from hospital-caused CLABSIs in fiscal 2012 alone, according to research in theAmerican Journal of Medical Quality. Many more suffered infection but recovered.

As for the financial impact, the medical costs of treating health care workers infected by needlesticks for all types of bloodborne pathogens (such as HIV and hepatitis) amounted to $107 million in 2004, the latest research available. Estimates of the medical costs of CLABSIs vary, but $2 billion in 2012 dollars is a conservative one.

While there are valid reasons CLABSI prevention can sometimes fall short, the power of the exact kind of procedures that halted occupational HIV has been repeatedly demonstrated. As recently as last fall’smeeting of the Infectious Disease Society of America, one hospital said it prevented CLABSIs by improving hand hygiene. Another credited success to boosting compliance with a “bundle” of CDC recommendations to 85 percent from 66 percent.

Just one question remains: if doctors, nurses and hospital staff were the ones being harmed, would today’s rate of deaths and injuries from CLABSIs constitute a crisis for the CDC or anyone else?

 

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Perryplaton20William Palmer MDCatherineBrad F Recent comment authors
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platon20
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platon20

I have to laugh at people like Michael Millenson. Outsiders who pretend that they made all these discoveries about “dangerous doctors” and outed them to the public. Line infections were recognized by DOCTORS as a problem long before Millenson took them on as his pet project. His website claims he is a “health care expert” but the closest he has ever come to treating a patient was visiting somebody in the hospital. Who do you think invented the CLABSI checklist? Hint — it wasnt a journalist, it was a DOCTOR. So you can moan and gripe all you want about… Read more »

Perry
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Perry

“When AIDS first burst on the scene in the early 1980s, it was “disfiguring, debilitating, stigmatizing and inevitably fatal,” in the words of Dr. Paul Volberding, a treatment pioneer. ”

Wow, what do you know? A doctor!

William Palmer MD
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William Palmer MD

Catherine, I’m not exactly doing these catheter insertions. I’m a retired pathologist and I see their results, failures and successes. But I am amazed they do as well as they do. Everything we stick into humans that is a foreign body eventually gets infected if it communicates to the outside world. I have seen the agonizing struggle to keep ports open in TPN, in dialysis, in sepsis interventions, in pheresis and other applications and the ingenuity and care in the teams that do this stuff does deserves praise. Almost no area in medicine has improved so much in such a… Read more »

Catherine
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Catherine

Let me get this straight… Dr. Palmer wants to be congratulated for doing his job, in the profession he chose. Imagine if all industries felt this way. For example, should airline pilots expect us to be “amazed” if they don’t kill their passengers despite all the potential risks (mechanical failures, inclement weather, etc). Sounds absurd doesn’t it? The public has a reasonable expectation to not be killed by people doing their jobs. Drop the arrogant attitude and maybe you’ll see the bigger picture.

William Palmer MD
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William Palmer MD

Millenson needs to stop writing and think. Where do you think the bacteria come from to cause a central line infection? Could they come from the hospital evnironment touching the skin near the line and then progress down the outside of the line until the line enters the vein and then into the vein and finally the blood stream? Is this the only way? Think some more. Could the bacteria arise from the patient’s own skin? Have you heard that we carry bacteria deep in our skin? How deep in the skin do hospital disinfectants penetrate? Can they reach the… Read more »

allan
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allan

An important topic that should be discussed has been trivialized in an adolescent fashion. The whine insinuating doctors don’t care takes this blog to a low point.

Dr. Joseph
Guest

“However, once the mode of transmission was identified– exposure to HIV-infected blood or other bodily fluids – precautions were rapidly put into place. From 1985 through 2013, there were just 58 confirmed cases of occupationally acquired HIV infection reported to the Centers for Disease Control and Prevention (CDC), according to a Jan. 9 CDC report. Since 1999, there’s been only one confirmed case of occupational transmission, involving a lab tech infected via a needle puncture in 2008.”

Its great information thanks

Dr. Marriya
Guest

I can’t imagine this…!

Dr. Vader
Guest

Are you insinuating that doctors protect themselves while cravenly leaving patients at risk? Your title certainly implies as much

And the comparison between HIV/AIDS and CLASBIs is a poor one.
The latter is a far more complex challenge — as you acknowledge

I believe you are well-intentioned in your desire to protect patients but your clear hostility towards doctors and federal agencies who don’t agree with you undermines the credibility of your argument, and is frankly insulting …

Brad F
Guest

Highlighting the inadvertent sticks and unfortunate transmissions overlooks the hundreds of thousands of intravenous procedures and blood draws docs had with HIV/AIDS patients during the 90s. I was one of those docs–when phlebotomists were “unable” to get the blood and folks painted patients with the infection with a scarlet letter. The ratio of harm to benefit appears difft from this vantage point. Many folks sacrificed.

I get your point, completely, but I would have preferred another analogy.

Catherine
Guest
Catherine

The author does not need to insinuate “that doctors protect themselves while cravenly leaving patients at risk”… it’s a fact. I recently lost my father, who was relatively healthy at 65 years old, to a hospital acquired infection. His death was 100% preventable if only he had not walked through those hospital doors for a minor, routine procedure. I find it insulting that health care “professionals” are willing to ignore the facts if the truth makes them look bad. I hope this article opens some eyes.