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Public Reporting of Healthcare Associated Infections – Part 2 of 2

Posted on by CDC's Safe Healthcare Blog

Lisa McGiffert
Campaign Director for Consumers Union’s Safe Patient Project

Consumers lead effort on public reporting of healthcare-associated infections

Lisa McGiffert
Lisa McGiffert

In 2004, Kerry O’Connell fell off of a ladder while painting his house and cracked his hand’s radial head that required surgery to replace it with a titanium implant. This was the first of eight surgeries – during one he got an antibiotic resistant infection.

There was no way for him to find information about his hospital’s infection rate and even worse, he was “completely astounded” by “the medical community’s reaction when things go wrong. Taking responsibility is out of the question.” At that time, there was generally a cultural acceptance of infections as an occasional outcome of surgery. Today that complacency is changing, and much of the impetus came from public reporting laws.

In 2003, Consumers Union launched our Stop Hospital Infections campaign (now the Safe Patient Project) to push for state laws requiring disclosure of hospital-acquired infection rates. We connected with people in many states, like Kerry in Colorado, and together created a consumer movement to eliminate medical harm. To date, 19 states have issued public hospital infection reports and consumers like Kerry are serving on the state advisory committees that developed them.

Public reporting has changed the health care environment. These consumer-driven state initiatives led to local media coverage with patient stories that put a human face on infection statistics, education about their preventability and a demand for accountability. As a result, many in the health care community reconsidered the inevitability of this deadly problem. Fortunately, numerous efforts to help hospitals learn how to reduce harm were being launched at the same time as the public reporting movement was sweeping the country.

For patients, information about infections is a fundamental indicator of a hospital’s safety and this information allows them to make more informed choices. It can stimulate conversations with their doctors and inform policymakers of the financial and human costs of these preventable injuries.

The reports inform hospitals about how they compare with other hospitals and that can stimulate changes and conversations among doctors, nurses and CEOs. The requirement to actively identify and report infections forces an end to a “don’t ask, don’t tell” mentality that has prevailed for decades. And finally, these reports are catalysts for hospitals to engage in prevention strategies and to share their successes with others in the community.

Consumers now support a national system to reveal infections occurring in every U.S. hospital. Our comments to the federal government on the proposed regulations to do just that should be given strong consideration out of respect for the millions of people who are infected every year in our nation’s hospitals.

Posted on by CDC's Safe Healthcare Blog

11 comments on “Public Reporting of Healthcare Associated Infections – Part 2 of 2”

Comments listed below are posted by individuals not associated with CDC, unless otherwise stated. These comments do not represent the official views of CDC, and CDC does not guarantee that any information posted by individuals on this site is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. Read more about our comment policy ».

    Hello Lisa McGiffert,

    I really appreciate your efforts that you are doing for Consumers Union’s Safe Patient Project.

    Jennifer

    The simpler to perform but superior European standards for testing the efficacy of alcohol hand rubs should become the U.S. norm. The data is clear that 70% weight/w is better than 62% w/w. No 62% ethoh W/W product would pass European testing, and therefore 62 % w/w ehyl acohol hand santizers cannot be sold in Europe as a medical hand rub. Unless we all advocate cleansing hands the right way, at the right times, with THE RIGHT STUFF we will not be providing best practice for U.S. patients. The U.S. government and regulatory agencies still give hospitals the choice between best and not best methods of hand hygiene This signals to the weaker institutions among us that 3/4 measures are OK. This deception is very destructive since the best way to perform hand hygiene has been brought to their attention and rejected.

    In 1991, my husband was one of thirteen patients to have surgery that day. Nine of those patients got Staph infection because the medical instruments that were used in those surgeries were NOT cleaned properly in the hospitals Autoclave. Last year, my friend told me her mother had Breast Cancer and was going in for surgery in a few days. I told her to make sure that her mother was not going to go to that same hospital. She spoke to her father and found out she was sceduled to go to the same hospital. He called the hospital to inquire about the problem. To my suprise, the hospital invited them to come down and see the new equipment and assure the family that they didn’t have anything to worry about. Finally, after 20 years of this same thing happening to other patients, the hospital got a new Autoclave and retrained their staff on proper procedures.

    We applaud the CDC’s efforts to reach out to healthcare consumers by featuring the patient perspective in this blog series. Collectively, patient advocates have been pushing for transparency for several years because as victims we know that if we had only been armed with better information, our or our loved ones lives may have taken a different (healthier) course.

    Now, our mission is MRSA screening, decolonization, and isolation (ADI). The evidence is overwhelming that it reduces MRSA rates and many studies have shown that when you reduce MRSA, you also reduce the infectious disease load of other HAI’s.

    HCUP statistics show that infections were among the most rapidly increasing reasons for hospitalizations between 1997 and 2007 and that septicemia was responsible for almost all (94%) of the increase in costs of infectious conditions (from $4.1 billion in ’97 to $12.3 billion in 2007.) The US Septicemia death rate is at #10 in leading causes at
    34, 828 lives lost per year.

    How can we sit by and allow hospitals to not screen and then isolate patients when so many lives and long term patient harm are at stake? As Mr. Berwick from IHI has said “Some is not a number, soon is not a time.”

    A $10 nose swab could save many, many healthcare dollars and precious lives; that alone is reason enough.

    We urge the CDC to use all of it’s power, knowledge, and expertise to set a national standard for preventing the spread of MRSA in our nation’s hospitals….now. Each day that goes by that we don’t act, more patients will be unnecessarily harmed or die as a result.

    In my 5 years of researching the infection problem I have read hundreds of studies on how to prevent infections and almost as many on treatment options for those unlucky souls who get an HAI, but I have yet to find a single study on how it feels to be infected and the great emotional and psychological trauma of infections for both victims and their families. The most common verb Healthcare authors use to describe infectious impact is “Devastating”, a good descriptor though a bit narrow. My experience was that the two primary emotions were unrelenting fear and isolation induced loneliness. I developed some suggestions for caregivers to address this that I call:
    Prescription Empathy
    Always tell the patient what organism he has been blessed with.
    Tell the patient the most likely ways he contracted his infection.
    Lay out in detail the Good, the Bad, and the Ugly prognosis.
    Spend time with us in the Isolation Ward. (The loneliest place on Earth)
    Give us some solid clues on how to prevent this next time.
    Waive the out of pocket bills.
    Learn to express genuine remorse.
    Never ever send survey form letters to known victims.

    Love Thy Infected Patient (Even the very difficult ones)

    Caregiver’s can do a lot to make infections a little less “devastating” and much less fearful. The beauty is that nothing on my list requires research or legislation… just and open heart and a little time.

    Public reporting of healthcare related infections is a crucial part of the process of allowing patients to decide which hospitals they want to go to for non-emergency treatment. Every hospital in the country should be doing this. We are now moving into a new era of medical service delivery where doctors and hospitals are grouped into networks andpatients can only go to hospitals or doctors that are in the network they are in; so this makes knowing the infection rates even more important now as a determinant on if they want to stay in the network they are in now or change to a different one. Those in charge at each medical service delivery network have an obligation to report to all patients in their network in an objective way the number and kinds of healthcare related infections taking place in the network and what specific steps are being taken to reduce or eliminate them, and to explane the information in a way and format most patients they have can understand. Best wishes, Michael E. Bailey.

    What a great way to share experiences – and to think CDC is finally noticing all of us who have been fatally injured by the HOSPITAL ACQUIRED STAPH INFECTIONS: I’m so proud to have friends on this web site sharing our true horror stories! My prayer is that one day all of the associated infections can be stamped out so that all patients everywhere can be safer. Keep up the good work Kerry, and Lisa – I’m so proud of both of you.

    Thank you for your Voice to all of the families who have lost a loved one to a Hospital Acquired Infection that could have been prevented. We must continue to tell the public & government this is NOT Acceptable and it will not be tollerated.

    I understand the frustration. I advocate in loving memory of my Mother, Ruth Burns an LPN Nurse whom passed in 2007 from Acinetobacter baumii that was obtained in an out patient surgery.

    Advocate – OH & NC
    Kacia Warren

    Thank you for this blog post on the importance of public reporting of hospital infections. Patient advocates have long been convinced that public reporting is a vital component of a comprehensive strategy to improve patient safety and quality. Reporting provides the raw data that allows us to know the scope of the problem, to identify trends and outbreaks and to find solutions and evaluate the efficacy of our interventions in a timely manner.

    There is also another side to this issue that is rarely discussed – the physical and emotional toll on those who have suffered these infections and then looked for facts, support and action. To this end, our group the Empowered Patient Coalition has released a patient reporting survey with detailed questions on infections, their causes and the aftermath from the patient’s point of view on our website at http://www.EmpoweredPatientCoalition.org. Thank you to Consumers Union for continuing to lead the way on this important issue.

    Julia Hallisy
    The Empowered Patient Coalition

    Lisa does a fine job of summarizing the consumer-driven journey that is finally starting to bring accountability and learning from healthcare acquired infections. No reporting system is better than the veracity of reporting, and it may take a stiff stick to ensure that hospitals are truthfully reporting the infections they give to their patients. I’m reminded of the National Practioner Data Bank (formed in the early 199s). Based on my readings, hospitals have done a solid job of manipulating around this law, thereby reporting very few physicians that should have been reported. Apparently, there is no stick to hold over hospitals. In Texas 63 % of all hospitals have never reported a physician into this databank in the 17 years of its existence.

    I can only hope that once a capable means of reporting infections is in place, we can persuade hospitals to report the adverse events that occur in their facilities. A recent report from the DHHS inspector general found that a tiny fraction of adverse events are the subject of an internal investigation in hospitals. Our journey to attain safe healthcare has only just begun. But it IS a beginning.

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