IC programs may forge link across continuum of care

Focus on acute care, CDC official says

Though buffeted by ongoing changes in the health care delivery system, infection control programs may eventually emerge as a vital link across the expanding continuum of care, reports William Jarvis, MD, acting director of the hospital infections program at the Centers for Disease Control and Prevention.

Comparing the current situation with that found during the mid-1970s, Jarvis highlighted the dramatic changes in health care delivery recently in Orlando at the annual conference of the Society for Healthcare Epidemiology of America (SHEA).

"Back in the 1970s, the acute care facility was literally the be-all and end-all," he said. "It was the focus of all health care epidemiology. Home care virtually didn't exist, long-term care was just beginning, and outpatient and ambulatory facilities were a minority part of the health care system delivery. That situation has changed dramatically. Now the acute care facility is no longer the center of attention. In fact, it is becoming smaller and smaller. Home care is growing enormously. Long-term care is also growing and is going to grow even more."

Jarvis compared current statistics with data from 1975, gathered by the CDC for the Study on the Efficacy of Nosocomial Infection Control (SENIC).¹ While overall hospital admissions have only dropped about 5%, total patient-days have dropped dramatically. Some 300 million total patient days in 1975 dropped 36% to 190 million days in 1995, he noted.

"We are moving our patients quicker and quicker out of the hospital setting," he said. "Length of stay has dramatically changed from 7.9 [days] to 5.3 days - a 33% decrease."

A corresponding trend finds inpatient surgical procedures dropping 27% over the 20-year period, from 18 million down to 13 million, he added. About half of all surgeries are now done in the outpatient setting, he adds.

"When we look at the nosocomial infection rate and we use patient days as a denominator, we can see that the problem we are facing on a day in/day out basis is not decreasing," he told SHEA attendees.

Indeed, the infection rate increased 36% since 1975, from 7.2 infections to 9.8 infections per 1,000 patient days, he noted. Contributing factors include a greater numbers of patients under intensive care and rapid discharge of less severely ill patients, he noted.

"This is resulting in a patient population in the inpatient setting that is of increasing severity of illness, with more immunocompromised patients, more invasive procedures, more invasive devices, higher risks for infection," he said.

By the same token, shorter stays for many patients make it difficult to capture all infections in surveillance data, he added.

"We really need to focus our surveillance in the acute care setting because we are going to have a lot of other responsibilities and we are being pulled in so many directions that are we are not going to be able to accomplish the task if we don't," he said. "We need to focus on high-risk patients and populations. We really need to focus on risk-adjusted rates. We know for intra- and inter-hospital comparisons that those are critical."

While stretched thin by the expanding health care spectrum, infection control also can be a common link to all settings, he added.

"My vision for the future is that the one commonality across all of these settings is infection control," Jarvis said. ". . . Our one hope is that as integrated health care becomes a reality, administrators are going to understand that regardless of where the patient gets an infection in that system, it costs them money. In which case, infection control becomes a critical element for the prevention of these infections."

^Reference

1. Haley RW, Culver DH, White JW, et al. The nationwide nosocomial infection rate: A need for vital statistics. Am J Epidemiol 1985; 121:159-167.