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Through the Tennessee Center for Patient Safety, more than 100 Tennessee hospitals have formed a collaborative effort to reduce healthcare-acquired infections (HAIs).

In June, the Tennessee Hospital Association (THA) outlined the state’s plans in a letter to Congress in response to a request by the U.S. House of Representatives Committee on Oversight and Government Reform that state associations report on the measures their hospitals are taking to combat HAIs.

In the letter addressed to Committee Chair Rep. Henry Waxman (D-CA), THA President Craig Becker said 117 hospitals had agreed to implement measures that mirror a program originating at Johns Hopkins, which has proven to be successful in more than 200 hospitals and was recognized for its efficacy by the New England Journal of Medicine.

Always a clinical concern, several of the most prevalent types of infections and conditions are now also a key financial concern as a reduction in Medicare reimbursement begins October 1 (see box).

In a 2007 report, the Centers for Disease Control and Prevention (CDC) estimated that in American hospitals alone, HAIs account for 1.7 million infections and 99,000 associated deaths each year. More than 80 percent of these infections are linked to four areas:

• 32 percent of all healthcare-associated infection are urinary tract infections,

• 22 percent are surgical site infections,

• 15 percent are pneumonia (lung infections), and

• 14 percent are bloodstream infections.

Although lung and bloodstream infections make up less than 30 percent of HAIs, they combine to cause more than two-thirds of the deaths. The CDC Public Health Report estimated 36,000 deaths attributable to pneumonia and 31,000 deaths linked to bloodstream infections.

Becker said he believes Tennessee has been very proactive in terms of instituting programming to increase quality and patient safety. Last year, with a grant from the Blue Cross-Blue Shield of Tennessee Health Foundation, the THA formed the Tennessee Center for Patient Safety. Since then, several programs have been initiated that focus on evidence-based best practices to improve outcomes.

Becker said effectively addressing the issue of infection would take a three-pronged approach.

“The problem has been all along … and still is … whether or not the infection is hospital acquired or community acquired,” he noted, adding the first step in the process would be to make that determination.

Currently, he explained, two tests are available, one relatively expensive but with fairly quick answers and the other less expensive but with a longer lead time for results. Any testing upon admission would be the financial responsibility of the hospital. However, Becker pointed out, the cost of testing could be minimal in comparison to what hospitals stand to lose in reimbursements for care if the facility fails to document that a patient had an infection upon admittance.

Becker said that while some hospitals are routinely testing most everyone who is admitted, others have opted to only screen patients that have been statistically shown to have a higher risk for infections such as those with renal failure or who are being transferred from a skilled nursing facility.

The second step, he continued, is to break the cycle of infection. At some point it matters less about where the infection was acquired and more about the patient’s health.

“The community safety issue is much more important,” Becker stated.

The third step requires changing the culture.

“This is the tougher one because it’s a longer term project and also calls for changing learned behaviors,” he noted. “With physicians, you have to show them a lot of data … and rightfully so … to get them to change their minds.”

One example is the continuing trend to over-prescribe antibiotics. Although significant amounts of evidence exist showing the harm of such overuse, including the rise in antibiotic-resistant bacteria, it’s difficult to change engrained behaviors.

To help ensure hospitals participating in the Tennessee collaborative effort stay on track, the Tennessee Center for Patient Safety has engaged the services of Peter Pronovost, MD, and Chris Goeschel, RN, from the Johns Hopkins School of Medicine and School of Nursing to serve as expert faculty and coaches over the next two years. The program specifically targets issues linked to surgical care, MRSA and central-line bloodstream infections.

“We’ve created teams within each of the hospitals, headed by nurses generally and with a physician partnership, to look at each of these infections,” Becker said. “We have developed different protocols, that have been proven, that can reduce these infections almost down to nothing.”

Becker added that whereas it used to be “business as usual” to have some instances of HAIs every year, there are hospitals that have now gone a year or more with zero occurrence by rigorously implementing best practices.

In addition to the focus on HAIs, the Tennessee Center for Patient Safety has also implemented other programming that places the state on the forefront of the national quality movement.

Becker said a “wildly successful” example has been the Surgical Care Improvement Project piloted at Saint Francis Hospital in Memphis and Mountain States Health Alliance in East Tennessee in partnership with the Tennessee Chapter of the American College of Surgeons. The demonstration project, which is designed to reduce surgical complications, is now in the process of expanding to seven hospitals in the state. The national goal is to reduce surgical morbidity and mortality by 25 percent by the year 2010.

Although Tennessee hospitals are close to the national average on several key indicators such as providing a prophylactic antibiotic within an hour prior to incision, administering the right antibiotic and discontinuing use of the antibiotic within 24 hours after surgery, the state was still 6-15 percent below the ACS achievable benchmarks based on voluntary reporting for the second quarter of 2007. There also remains a significant adherence gap between low performers and high performers within the state when it comes to implementing evidence-based practice recommendations. For more information on the state project, go to www.tnpatientsafety.com and click on Tennessee SCIP, or for information on the national program, go to www.medqic.org/scip.

The organization has also been nationally recognized for the Tennessee Rural Hospital Patient Safety Demonstration Project to improve safety and outcomes in small, rural facilities by implementing a set of interventions at eight hospitals across the state. Tennessee received the Rural Health Quality Award in 2007, presented by the National Rural Health Association.

Becker said the hard work is paying off, not only through national awards, but also in terms of improved statistics, including gains in the CMS National Quality Indicators report.

“We’re seeing an improvement in Tennessee’s numbers,” he said. “We’re convinced in part it is because people are more focused on it (quality) and because of our programs.”

With the October 1 deadline looming, healthcare facilities are more eager than ever to make sure they are doing everything necessary to control HAIs.

“It shouldn’t be all about the money,” said Becker. “It should also be about patient safety … but clearly money motivates. If it motivates people to do the right thing, I’m all for it.”



August 2008

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