The Leapfrog Group: HAI prevention efforts still have a long way to go

87% of hospitals surveyed do not yet meet its standards

In a stark reminder of just how far some hospitals have to go in improving patient safety, The Leapfrog Group, a Washington, DC-based patient safety organization, reports that 87% of the 1,256 hospitals that participated in its annual Hospital Quality and Safety Survey do not have all of the requisite policies in place to prevent many of the most common hospital-acquired infections (HAIs).

A breakdown of the responses further illustrates how far short of the Leapfrog goals the participating hospitals fall. Leapfrog reports the following level of full compliance with its recommended standards for prevention:

Infection type or preventive practice
% hospitals with full compliance
Aspiration and ventilator-associated pneumonia
38.5%
Central venous catheter-related bloodstream infection
35.4%
Surgical site infection
32.3%
Influenza
30.7%
Hand hygiene
35.6%

According to Leapfrog, 2 million people every year contract an infection during their care, and 90,000 of them die. HAIs, says the organization, add, on average, more than $15,000 to a patient's hospital bill, amounting to more than $30 billion a year in avoidable costs.

These findings take on even greater significance in light of the Aug. 18, 2007, announcement by the Centers for Medicare & Medicaid Services that it will no longer reimburse the additional costs incurred by certain hospital-acquired conditions.

In addition to inquiring about the aforementioned infections, the survey also asked about hand washing hygiene, which many experts cite as a key to preventing all HAIs. Leapfrog specifically asked about issues such as tracking the frequency and severity of the infection in question, management accountability, its ability to reduce the preventable infection, investment in improvement, and whether it is taking further action to detect and prevent the infection.

Safety culture is critical

A number of observers say the development of a safety culture is essential to reducing HAIs. In a Sept. 18 press conference reporting on the major findings of the survey (other findings may be found in the box following this story), Leapfrog CEO Suzanne Delbanco, PhD, told HBQI: "I think we are still dealing with working toward a broad cultural shift — getting a system in place that can institutionalize the processes we know [work]."

Kathy Schumacher, MSA, director of quality, safety, standards, and outcomes at William Beaumont Hospital in Royal Oak, MI, agrees. "I would say the hospital culture can be the biggest barrier," she asserts. "We have a strong patient safety culture here that lends to improvement efforts. There is a great deal of medical leadership support in addressing these issues."

That broad support, she continues, is an essential foundation for success. "You could put together and implement all the programs you want, but if you do not have the backing from leadership, you are almost spinning your wheels," she insists.

That culture change also requires a change in perception. "Historically, doctors have believed that complications are just part of health care," says Schumacher. "But we now know they are preventable, and can be reduced to zero."

Patrice L. Spath, of Brown-Spath & Associates in Forest Grove, OR, concurs. "I truly believe all hospitals are trying to reduce their rate of HAIs, so if we start from that premise, what are the challenges that still lie ahead? I guess the biggest is changing staff and physician perception that a zero percent infection rate is not achievable."

If people are satisfied with reducing infections to two or three a year, Spath says, "then they won't dig into their processes to see how they can eliminate those few that do occur."

Overcoming these attitudes is difficult, Spath concedes, but is not impossible. "You really must set quality goals in your organization," she asserts, again noting that the example must be set at the top. She cites the example of Thomas Royer, MD, president and CEO of Christus Health, a Texas-based not-for-profit system.

"He recently said that we can prevent HAIs," Spath shares. "This made me realize that unless leaders have the vision of 'zero,' then they can make excuses for not digging deeper. He is a physician, and he could easily have said that there are patients who will get infections no matter what we do. It's an attitude that really needs to permeate the organization."

News not all bad

While the challenge is indeed a large one, Maryanne McGuckin, DrScED, head of McGuckin Methods International Inc., an Ardmore, PA-based consulting firm that provides education, research, and measurement services for infection control issues, sees light at the end of the tunnel.

"A lot has happened in the last couple of years to change what is happening with infection control," she insists. "The greatest driving force is public awareness."

Now there are more than 40 states that have mandatory reporting of HAIs, McGuckin notes. "Last December, we did a large telephone survey and asked patients what they felt were the most important things to look for in a hospital.

"The first thing they said was the hospital had to be physically clean. But second, with 85%, was a low infection rate."

Of the areas cited in the Leapfrog survey, McGuckin says, "we have improved by leaps and bounds" in the prevention of central venous catheter-related bloodstream infections. "There are hospitals out there documenting zero incidents."

How did they achieve that success? "People went back to 'Nursing 101' — basic techniques," she says. "For example, for central venous catheters, you have to make sure the right insertion techniques are in place."

Wash those hands

While there are specific interventions that can be followed to prevent each of the HAIs addressed by Leapfrog, "the foundation of all of them is hand hygiene compliance," asserts McGuckin. "If you walk into any hospital in the U.S. you will see less than 50% compliance."

McGuckin says that one of the keys to improving compliance in this area is to empower the patient to remind health care workers to wash their hands. "We tell the workers that they need to go in to that patient and say, 'You need to remind me to wash,'" says McGuckin. "When we ask the workers, they say '[they are concerned about] skin irritation; I'd rather put on gloves.'" Since the patient is there "24/7," she says, patient empowerment is the key to improvement.

When a patient is admitted to one of her client hospitals, they are given either a brochure or a CD that says to them, "We want you to be part of our team; ask us to wash our hands."

"It's so simple, so cost-effective," McGuckin says. "In a 300-bed hospital it's less than the cost of one infection."

The next step "is that you have to measure what you do," she continues. "If you do not measure, you do not improve." Her company updates client hospitals on their performance every month. "I can tell you that when hospitals join us, their compliance rate is often under 20%, but we can increase that by over 50% in about five months."

After performance is measured, feedback is given to the health care worker. "We tell them, for example, that compliance on their unit was only 20%," McGuckin shares. "This is something concrete they can look at and react to."

Launching a campaign

At Beaumont, Schumacher reports, an entire "campaign" is under way to improve hand washing compliance. "It really focuses around staff education, collecting observations and data, measuring our compliance, and putting in place interventions to increase compliance, then measuring again to see if we made improvements," she explains, adding that "standardization is the key, wherever you can achieve it."

The campaign also includes some "fun" things, she says. "For example, we have an annual 'zoo day' for all our employees," she relates. "We had a hand hygiene booth there, and gave out sample hand sanitizers. We asked employees to wash their hands, and we talked to them and their families about it." This event, she says, "created huge amounts of awareness; you have to take the message to the staff."

Speaking of the staff, in the education program, they also are taught why good hand hygiene is important for them and their families, as well as for the patients. "We need to look at how it impacts each and every one of us," she explains.

Other interventions included placing hand sanitizer stations around the hospital for visitors. "When they walk into the hospital they will see one," she notes. Schumacher also put on a patient safety "Town Hall" dedicated to hand hygiene.

The program is only six months old, so Schumacher has no hard data yet to demonstrate results. However, she continues to bring more people on board — not just nurses, but ancillary staff. "Everyone who comes in contact with that patient needs to be part of the campaign," she explains.

When it comes to broader improvement in nationwide compliance rates, McGuckin recommends getting the public involved. "If we have public disclosure of infection rates, we should also have [public disclosure] of hand hygiene," she insists. "After all, if a hospital has high infection rates, you should look at their hand hygiene."

Finally, she concludes, hand washing "is one of the techniques that has to be 100%."

[For more information, contact:

Suzanne Delbanco, PhD, CEO, The Leapfrog Group, c/o Academy Health, Suite 701-L, 1801 K Street, NW, Washington, DC 20006. Phone: (202) 292-6713. Fax: (202) 292-6813. E-mail: info@leapfroggroup.org.

Maryanne McGuckin, McGuckin Methods International Inc., Ardmore, PA. E-mail: mcguckin@hhreports.com.

Kathy Schumacher, Director of Quality, Safety, Standards, and Outcomes, William Beaumont Hospital, 3601 W. 13 Mile Rd., Royal Oak, MI 48073. Phone: (248) 898-1012.

Patrice L. Spath, Brown-Spath & Associates, P.O. Box 721, Forest Grove, OR 97116. Phone: (503) 357-9185. E-mail: Patrice@brownspath.com.]