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Bug busting gets the spotlight
"For those of us in infection control, it's exciting,"says Thomas R. Talbot, M.D., M.P.H., who became Vanderbilt's chief epidemiologist in July. Physicians in his field have been accustomed to going about their jobs without much fanfare or notice, more or less out-of-sight, out-of-mind. "It's something that, now – in the last two or three years – from the highest level of the hospital, it's of supreme interest."

And with good reason. The increased interest has been sparked by some pretty startling statistics about the rate of illness and death caused by hospital-acquired infections, and by the outcry those figures have prompted in a bevy of circles.

The first painful volley to hit the health care system may have been a 1999 report by the Institute of Medicine, which tagged medical errors as the eighth leading cause of death in the United States. Then hospital-acquired infections took center stage. A 2005 report by the nonprofit Committee to Reduce Infection Deaths (RID) revealed that hospital-acquired infections – HAIs – are the fourth largest cause of death in America, killing as many people as AIDS, breast cancer and auto accidents combined. Until recently, these traditionally were called "nosocomial infections."

While many who had toiled tirelessly to serve and protect patients may have felt unfairly maligned by these negative assessments, statistics on the government's Centers for Disease Control and Prevention Web site, put it into perspective: "In hospitals alone, HAIs account for an estimated 2 million infections, 90,000 deaths, and $4.5 billion in excess health care costs annually."

Maybe that's one reason why Talbot and his renowned mentor, William Schaffner, M.D., now probably are recognized by many more people on a daily basis. They, and a number of their colleagues, have examined procedures and promoted programs that are involving staff at all levels in a "zero tolerance"assault on HAIs at Vanderbilt University Medical Center.

And while Talbot thinks that "zero"goal may not be attainable, he's committed to working toward it. That includes handing out movie coupons to reward hand washing and heaping awards on staff members who show leadership in infection control practices.

Shooting for the moon
"I've often gotten nervous at the idea of zero tolerance because there are uncontrollable patient factors – such as obesity, diabetes or smoking history that can increase a patient's risk for infections,"explains Talbot. "But I'm saying it and making a case for exceptions."

The reality is that patients carry bugs that can cause threatening infections into the hospital on and in their bodies. And pathogens – while they don't necessarily cause illness – lurk everywhere, and even more so where sick people come together. They're on bed rails and stethoscopes, in the air when someone sneezes, transferred at the touch of a mother's hands. With a certain synergy of circumstances – say a bug happens upon a patient with a suppressed immune system, a chronic disease or a surgical incision – these pathogens can stop simply hanging out and cause an infection, sometimes with very serious, even fatal, results.

The most successful way to prevent that in hospitals is for every person who serves patients to understand how different pathogens do their dirty work, and how humans can beat them at that game. And, just as your mother told you, hand washing – performed every time in the proper manner – has been shown to be the biggest stick out there.

A hand hygiene campaign has increased adherence by 40 percent at the Vanderbilt University Hospital and 60 percent at the Monroe Carell Jr. Children's Hospital at Vanderbilt. Revised procedures for inserting central venous catheters in the intensive care units have significantly reduced the number of associated bloodstream infections, saving lives and somewhere between $1.3 million and $3.9 million in health care costs. Other targeted efforts have helped push down the incidence of ventilator-associated pneumonia and stopped the spread of an aggressive antibiotic-resistant pathogen.

Vanderbilt has been sharing its successful programs and procedures with other professionals to help promote positive change in hospitals across the nation.

"We want to become a national leader in this area,"says Talbot, and praise from inspecting agencies and national recognition from colleagues has already proven that to be true. The Medical Center continues to benchmark its infection rates against national data provided by the CDC, which are derived from voluntary reports from more than 300 hospitals around the country.

Vanderbilt's emphasis on infection control has shown up in staffing, as well. The Medical Center now has six spots for infection-control practitioners – the nurses Talbot calls the unsung heroes of this story – up from three in 2002. Two epidemiologist positions also have been added since then, including one now held at the children's hospital by Jake Nania, M.D. Talbot says more infection experts probably will be needed when Vanderbilt opens its planned third bed tower, targeted for 2012.

But it is a never-ending, day-in-and-day-out battle, when the smallest break in the infection-control chain can create a pathway for pathogens to cause trouble.

"Everything we as caregivers are doing, we have to do at 100 percent, all the time,"Talbot observes. "We have to rely on everybody in the institution to do the right thing."

"The control of infection is everybody's business,"says Schaffner, who switched jobs with Talbot this year and now serves as associate hospital epidemiologist as well as chair of the Department of Preventive Medicine. But, he adds, the infection-control specialist has to keep an eye on all the potential trouble spots, from the hospital kitchen to the intensive care units.

"We have to be the most comprehensive – remain alert to everything everyone is doing,"says Schaffner, who thinks Vanderbilt has a top reputation in the infection-control field.

"We're really trying to partner with the front line,"explains Talbot, who admits infection-control specialists – often appearing when things get messy – sometimes have been considered the "bad guys."He sees himself as a "benevolent meddler,"keeping a watchful eye over the infection-control practices of a dedicated staff that cares for patients every day with the very best intentions.

"The epidemiologist is always looking at the bigger picture; the physician is looking at the front line,"he says.

Interventions like those at Vanderbilt are making a dent locally in the number and severity of HAIs. But even with the heightened attention on the issue nationwide, the overall HAI rate has remained much the same for the past few decades. This has drawn the ire of consumer groups, public officials and others who think the system isn't working well enough.

Schaffner, who for well over three decades manned the Medical Center's front lines against infection, sees a more positive side to this statistic. Hospital patients today are much sicker and receive treatments that are much more invasive, he explains. Considering those factors, the flat 5 percent to 6 percent overall HAI rate may be laudable, he says.

"That's not a sign of failure; that's a sign of success,"he says. Infection rates would be "through the roof,"he explains, if procedures to prevent them had not significantly improved as the patient population and treatments have changed.

Talbot sees the same paradox, but he admits some criticism may be justified.

"We do have a sense we can get the rates lower,"he says.

The outside's looking in
That expectation – that hospitals could be doing better at controlling infections that cause illness and death – is being voiced not only in many medical circles, but also in state capitals across the country. More than a dozen states have mandated reporting of HAIs, and Tennessee joined that group this year with a law that was in large part crafted by Vicki Brinsko, R.N., infection control coordinator at Vanderbilt. Some of the laws have mandated the publication of hospital infection "report cards,"which some consumer groups say will protect patients and exert more pressure for improvement. Tennessee's law requires public reporting of HAIs by hospital, but the specifics of that are not yet in place.

Talbot sees some pitfalls with these public numbers.

"We've got to make sure everyone uses the same definition,"he says, which seems easy, but if you read the CDC guidelines about identifying various infections you quickly realize it isn't. Differences among hospitals have to be accounted for, since some treat patients who are much sicker and perform many more invasive procedures, Talbot explains. And, of course, every hospital has to be equally diligent in identifying and reporting infection outbreaks, he says.

"One of my biggest concerns is that we have transparency of data,"Talbot explains. "We could do a disservice with misinformation."

It may be more effective to compare "process measures,"he explains, since these activities and procedures – meant to stop pathogens in their tracks – are the key to success in infection control.

And looming in the shadows is the threat that private insurers and other health care payers may begin to more closely scrutinize costs associated with patient infections, and perhaps refuse to pay if they believe the hospital didn't take proper steps to prevent them.

Pathogens playing hide- and-seek
These pressures to make a bigger dent in the HAI problem will no doubt be heightened by the reality that some of the pathogens that threaten patients have become resistant to the antibiotics that used to knock them out. Schaffner remembers the decades after World War II, when people thought antibiotics had made infection a trivial aspect of the practice of medicine. Even though microbiology experts warned then that the pathogens would adjust if antibiotics were used too often or too long, in many cases, that's exactly what happened, he says.

And still today, in many developing countries, antibiotics are available over the counter, so people can use them whenever and however they choose.

"That's an ideal way to promote resistance,"Schaffner explains.

And lest we think these morphing menaces are the only threat: "We recognize how, thinking globally, we are in an era of continuously emerging infections,"he explains. One obvious example is HIV and AIDS, first recognized in the 1970s.

Talbot tries not to lose sleep over potential superbugs, putting his faith in continual education, staff collaboration and the willingness of those who serve patients to adopt the behaviors – both small and large – that keep infection contained. He says he probably is more bothered by the need for a nationwide hand washing campaign and by the reluctance of some health care workers to get an influenza vaccination.

The bugs just aren't going away, he says.

"Viruses and bacteria are smart. They'll survive,"he observes ruefully.

The public conception that new drugs certainly will be developed to fix the problem is ill-placed when it comes to antibiotics, say these infection experts, because drug companies are interested in bigger sellers.

"Antibiotic development is not very lucrative,"explains Talbot. "Right now there are not many antibiotics in development."Because of this, the Infectious Diseases Society of America is promoting an urgent "Bad Bugs, No Drugs" campaign to raise awareness and encourage policymakers to take steps to spur pharmaceutical research and development of new antibiotics.

Schaffner, whose office wall holds old quarantine signs that warned folks away from houses where diphtheria, typhoid fever and polio were present, worries on a more global level. He cautions that the deadly diseases that vaccines have eradicated in much of the world must be kept in the box and given no toehold back in by people who didn't live through the injury and death they caused.

"These diseases and these infectious agents are still out there in the world,"he warns. "This barrier of protection must be maintained."

Both Talbot and Schaffner hold the hope that the commitment of medical professionals and the knowledge being gained every day will help humans win this battle, and even see us through the pandemics and bioterrorism attacks that many predict for the future. The key is to keep an eye on what comes next, Schaffner says.

"The question is what's going to happen next year,"he advises. "That's what we don't know." VM


Saving lives one
pop-up at a time

New guidelines cut bloodstream infections

A bad houseguest

Driving the train



Members of VUMC's infection control team – Tom Talbot, M.D., M.P.H., Jake Nania, M.D., Vicki Brinsko, R.N., and William Schaffner, M.D.





These pressures to make a bigger dent in the HAI problem will no doubt be heightened by the reality that some of the pathogens that threaten patients have become resistant to the antibiotics that used to knock them out.

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