According to the World Health Organization (WHO), at any given time, healthcare-associated infections affect between 3.5% and 12% of patients in developed countries, and between 5.7% and 19.1% of patients in low and middle-income countries. In the United States, the Centers for Disease Control and Prevention (CDC) estimates roughly 1.7 million hospital-associated infections cause or contribute to 99,000 deaths each year. 

I recently had the chance to explore this issue in more depth with Russell Ryono, who has over 30 years of experience as an infection preventionist and pharmacist at the US Department of Veterans Affairs (VA). The following is a transcript of our conversation, edited for the flow of conversation.

Dr. Russell Ryono

Q. Why do Hospital Acquired Infections seem to be more of an issue now than in the past?

A. The situation nowadays is much more complex. We now have IV lines that are put in for weeks and months, whereas before they were expected to pull it out in three or four days. With the medications now, it’s the same sort of thing.  We are keeping permanent central lines in place and you can get chemotherapy on an outpatient basis, whereas before, patients had to be kept as inpatients. 

Q. How does the bacteria then spread through the hospital? 

A. For Hospital Acquired Infections, if the patient has these bacteria and then is touching his or her face or body and then touches the central line or other equipment which is then handled by a nurse, the bacteria can start spreading through the hospital.

Q. Why are these infections more of a problem in a hospital as opposed to say, a coffee shop?

A. In the hospital you have a population whose health is compromised; most patients have a weakened immune system due to their underlying illness or as a result of the treatment they are receiving in the hospital. At a coffee shop, people there are fairly healthy, so they don’t have the compromised immune systems as in hospitals. Hospital patients are surrounded by other people who could be introducing other bugs, and these bugs are going from one sick person to the next. It’s the same nurses in each hospital and, as much as they’re trying to wash their hands, they are handling the same equipment and they are going from one sick person to the next, each with a compromised immune system.

Q. Why is this becoming more of a focus now than in the past?

A. When I started working in infection prevention at the VA, we were just looking at bloodstream infections, urinary tract infections and ventilator associated pneumonia  in the ICU – that’s it! By the time I left a few decades later, we had to look for bloodstream infections and central line infections throughout the entire hospital. We also had to look at MRSA (which are antibiotic resistant) infections and keep track of how many of those patients were tested and when they were admitted. C. Difficile is another one, as well as multidrug resistant organisms. We had to look for reportable diseases, to look at printouts from positive cultures, printouts for MRSA lab tests, and all the patients in the intensive care unit. The list is getting much bigger, the load is becoming overwhelming, and that’s where I think automated tools help tremendously.

Healthcare systems now are much more invested in outcomes. So, let’s say for example you get admitted for a heart attack. The insurance companies will reimburse the hospital for the heart attack procedure, but if you get an infection while you’re being treated for the heart attack, the hospital doesn’t get reimbursement for pneumonia treatment. They’re going to say: “No, this patient was not there for pneumonia!” and the hospital has to eat those costs. So that’s why I think hospitals now are working with all these accreditation agencies and they are asking: “What are we doing to prevent these bad outcomes from happening?” 

In addition, the list of potential adverse outcomes is getting bigger and bigger. So, for example, if you put in a central line or an IV line and you get a bloodstream infection as a result, the insurance companies won’t reimburse hospitals. Hospitals are now publishing their infection rates, so you can compare Stanford’s rates versus Kaiser’s rates, for example, and administrators see a strong need to keep on top of this. The infection preventionist now has to look at bloodstream infections, which could then spread to urinary catheters, and then spread to ventilators. We also have multi drug-resistant organisms like MRSA (a difficult to treat ‘superbug’). 

Q. Can you give an example of how technology can help hospitals manage this complexity? 

A. I think infection prevention software like PraedAlert helps both within a hospital and between hospitals. Within a hospital, you are able to identify issues faster. Let’s say you are an infection preventionist and you have a tool like PraedAlert. When you walk in first thing in the morning, the system will alert you that here are the top 20 patients who need your attention. The scoring system will help rank these patients from highest risk to lowest. It will also alert you if they need some sort of an intervention and base the recommendation on previous actions. So, if you did a culture test, what was the result? Do you need to start them on something else? If there’s an infection starting, do you need to report this as a bloodstream infection? It just makes it easier for you to track all these moving pieces, otherwise they quickly become needles in the haystack. Having all the information managed in one place gives you the ability to notice trends and to look at the data through different angles. You might see for example a spike in C Diff during certain weeks, so you could ask what happened, or what changed?  

The system also makes it easier for you to compare and share learning between hospitals. If for example you see from the results that another hospital has a system in place where they’re managing their MRSA or C. Difficile outbreak better than the rest, you would want to talk to them and see what protocols they are following.

By leveraging this technology and automating processes, you free up your infection preventionists and other specialists to focus on their highest priority, which is the treatment of patients. If they are spending a lot of their time running around trying to get access to siloed information, or filling up spreadsheets or paperwork, these are all lost hours that could be better spent attending to patients.  These frontline clinicians need to be empowered to focus their energies on identifying patients who need review and on antimicrobial stewardship efforts. 

PostScript

We hope you enjoyed Part 1 of this ongoing discussion with Russell Ryono.  In future posts, we will continue the conversation on Hospital Acquired Infections, as well as explore other topics. If you have any questions you would like to ask Russell for next time, please send us an email or you can also drop a note in the comments section of the article.