Comprehensive review finds hospitals don't follow infection prevention rules
While most hospitals have polices in place to prevent health care-associated infections, clinicians often fail to follow evidence-based guidelines established to prevent these infections, according to new research from Columbia University School of Nursing published in the American Journal of Infection Control. The study, the most comprehensive review of infection control efforts at U.S. hospitals in more than three decades, found lax compliance even in intensive care units where patients are more likely to be treated with devices linked to preventable infections - such as central lines, urinary catheters and ventilators.
A team led by Patricia Stone, PhD, MPH, RN, FAAN, Centennial Professor of Health Policy at Columbia Nursing, investigated compliance with evidence-based policies to prevent infection in 1,653 ICUs at 975 hospitals nationwide. The study focused on three of the most common preventable infections - central line-associated bloodstream infections, ventilator-associated pneumonia, and catheter-associated urinary tract infections. Despite decades of research establishing best practices for prevention of these infections, approximately one in 10 hospitals lack checklists to prevent bloodstream infections, and one in four lack checklists to help avoid pneumonia in ventilator patients. Even worse, these checklists are followed only about half of the time, the study found.
"Hospitals aren't following the rules they put in place themselves to keep patients safe," says Stone, who has published extensive research on health care-associated infections and has contributed to prevention guidelines issued by The Joint Commission, which oversees accreditation for U.S. hospitals, nursing homes, and other health facilities. "Rules don't keep patients from dying unless they're enforced."
Health care-associated infections kill an estimated 100,000 Americans a year and create approximately $33 billion in excess medical costs. The U.S. Centers for Disease Control and Prevention first linked infection rates to prevention programs in the 1970s. Research since then has shown that checklists and other targeted infection control practices can make a significant dent in infection rates - but only if compliance rates among clinicians are also high.
Compliance could be improved with two solutions most hospitals aren't using - electronic monitoring systems and staff certified in infection control. The study found that only about one-third of the ICUs have an electronic surveillance system to track compliance with infection-prevention policies at the clinician level. Electronic monitoring systems that offer report cards on compliance have been proven effective at getting clinicians to follow the rules, lowering infection rates, previous research has found. At the same time, more than one-third of hospitals also failed to employ a full-time clinician certified in infection prevention to supervise compliance, the study found.
"Every hospital should see this research as a call to action - it's just unconscionable that we're not doing every single thing we can, every day, for every patient, to avoid preventable infections," Stone says.
For central-line associated bloodstream infections, or CLABSI, the study found that more than 90 percent of ICUs had checklists for sterile insertion but the policies were followed only about half of the time. Catheters, also known as a central line, deliver life-saving medicines and nutrition. Without proper insertion, utilization, and maintenance, catheters can also transmit deadly infections to the bloodstream. Simple infection prevention measures include hand washing before handling the catheter and immediately changing the dressing around the central line if it gets wet or dirty.
Compliance rates were no better for preventing ventilator-associated pneumonia, or VAP, the study found. Overall, three in four ICUs had checklists for protecting against infections linked to ventilators, machines that force air into the lungs when patients can't breathe on their own. The ICUs followed their own checklists just half the time. Keeping patients elevated in bed, with the head higher than the feet, is one simple precaution that can help prevent pneumonia.
Patients with urinary catheters fared even worse, the study found. Guidelines to prevent catheter-associated urinary tract infections, or CAUTI, are newer, and there aren't universally accepted checklists to follow at the bedside. About one third of hospitals had no prevention polices in place to prevent these infections. Even at hospitals that did establish some guidelines, the measures were followed less than 30 percent of the time.
"We've come a long way in understanding what causes health care-associated infections and how to prevent them," Stone says. "This study shows we still have a long way to go in compliance with well-established, life-saving and cost-saving measures that we know will lower infection rates."