Physician, wash thy hands

About $30 billion is spent each year treating the 1.7 million hospital-acquired infections that kill almost 100,000 patients.

Clostridium difficile, a bacteria that can cause life-threatening diarrhea, has overtaken MRSA as the number one HAI. On average, a hospitalized patient in the United States has more than a 1 percent chance of acquiring the infection.

In Kentucky, the reported chances are even higher but the data is incomplete because Kentucky does not require reporting.

The U.S. Centers for Disease Control and Prevention have asked states for plans addressing the epidemic of hospital-acquired infections. They can be viewed at http://www.cdc.gov/hai/HAIstatePlans.html.

Kentucky's plan reports that our state has no "mandatory public reporting requirement for HAIs. Therefore, individual HAIs are not reportable to public health officials in Kentucky. Outbreaks of HAIs are reportable in Kentucky, as all outbreaks are reportable."

Kentucky should generate hospital-specific information to be viewed by the public. At the very least, the frequency of these infections needs to be reported on a statewide and health department district level.

A goal of Kentucky's plan is to publicly report aggregate data, but with the caveat that "individual HAIs are presently not reportable to public health officials in Kentucky." This needs to change.

The requirement to report outbreaks is an interesting one. The state has told me that an outbreak is two cases. With the high incidence of C. diff. and MRSA infections, one wonders how many outbreaks have been reported in Kentucky.

Can Kentucky do better? Yes. The few Kentucky hospitals that report C. diff. infection rates have found it in approximately two percent of their hospitalized patients.

Alcohol-based hand washing dispensers have permeated hospitals and can often be found outside every patient's room. They are quickly becoming the preferred method of hand hygiene. But alcohol does not kill C. diff., which is spread by spores. It takes mechanical removal from hands using soap and water and daily cleaning of high-contact areas in patient rooms using bleach.

MRSA is also a growing problem. Up to 5 percent of all patients are now estimated to be carriers. Does this cause infections? Yes. The major source of MRSA infections in hospitals is community strains.

The Veterans Administration recently released a national study in response to a congressional inquiry. The VA system instituted a MRSA prevention directive (VHA 2007-002) which included universal surveillance/screening cultures, contact precautions and hand hygiene.

The results were outstanding, with an ICU MRSA infection rate decreasing 76 percent (0.39 infections per 1,000 bed days of care). In the non-ICU setting the infection rate dropped by 28 percent (0.46 infections per 1,000 bed days of care).

Any project should require measurement of the baseline problem, intervention and measurement of the improvement.

Kentucky's plan ideally would have stated: Kentucky's Central Line Blood Stream Infection rate is currently unknown because it's not tracked. We are going to educate all facilities in the use of checklists and expect our infection rate to fall by 50 percent."

Checklists have been reported to reduce CLBSI by up to 82 percent. As it is now, the Kentucky report relies heavily on future planning and since Kentucky does not measure individual HAIs, accurate and comparable data is unlikely to be generated, which will hinder the monitoring and correction of the problem.

In 2008, when I wrote my first op-ed on this subject, 20 states required public reporting. Public reporting is now required by 27 states and is supported by the CDC and major national medical organizations including the Association for Professionals in Infection Control and Epidemiology, the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America.

The CDC's director of HAI prevention, Dr. Arjun Srinivasan, says that increased transparency and public reporting are an important part of preventing and eliminating health care-assoicated infections.

Kentucky needs to follow suit. Nationally, the problem of hospital-acquired infections is increasing at greater than expected rates.

Kentucky needs to not only blame our unhealthy lifestyles for our poor health statistics but also look at our state health policies.

The initiation of mandatory reporting of HAIs may just take a regulation or health department mandate, or it may require legislative action to require public reporting by all health care facilities.