Call it a tale of two infections. It’s the story of how hospitals have blocked transmission of a dangerous infection that patients can give doctors, while a hospital-caused infection that can kill patients continues to be widely tolerated. It involves saved lives and endangered ones – and also of billions of dollars spent needlessly due to unsafe care.
The infection that’s been conquered is occupational transmission to doctors and other health care workers of HIV, the virus that causes AIDS. When AIDS first burst on the scene in the early 1980s, it was “disfiguring, debilitating, stigmatizing and inevitably fatal,” in the words of Dr. Paul Volberding, a treatment pioneer. With the disease’s spread poorly understood, “the fear of contagion [was] hanging over our heads,” Volberding recalled.
However, once the mode of transmission was identified– exposure to HIV-infected blood or other bodily fluids – precautions were rapidly put into place. From 1985 through 2013, there were just 58 confirmed cases of occupationally acquired HIV infection reported to the Centers for Disease Control and Prevention (CDC), according to a Jan. 9 CDC report. Since 1999, there’s been only one confirmed case of occupational transmission, involving a lab tech infected via a needle puncture in 2008.
Reported occupational infection “has become rare,” the CDC concluded, likely due to prevention strategies and “improved technologies and training.”
At the same time hospitals were eliminating the danger of patients infecting health care workers with HIV, most were doing little to stop the dangerous infections hospitals can give patients. In 1999, the Institute of Medicine (IOM) issued a landmark report declaring that 44,000 to 98,000 patients died each year from infections and other preventable medical errors in hospitals. This “epidemic,” as the IOM put it, killed more Americans than breast cancer or AIDS. (Later research put the preventable deaths at from 210,000 to more than 400,000 annually.)
Yet by 2008, the same year as the last reported occupational exposure to HIV, studies would show that most hospitals had done very little to prevent patient harm. That year, however, the Agency for Healthcare Research and Quality launched an ambitious effort to fight one particularly expensive and dangerous infection that, like HIV, was extensively studied. It’s called a central-line associated bloodstream infection, or CLABSI.
Bloodstream infections from catheters placed deep into a sick patient’s torso have a higher mortality rate than typhoid fever or malaria. They’re also the most costly of healthcare-associated infections, costing an average $46,000 per patient. The good news was that a five-step “checklist” approach, including such simple items as hand-washing and cleaning the patient’s skin with a disinfectant, was startlingly effective at CLABSI prevention. A study of checklist use in the New England Journal of Medicine documented how a large group of hospitalsreduced CLABSIs by nearly 70 percent in just 18 months. During that brief time, they saved more than 1,500 lives and nearly $200 million, researchers estimated. Many of the hospitals eliminated CLABSIs altogether.
So did hospitals everywhere rush to conquer CLABSIs the way they’d triumphed over occupational HIV transmission? Not quite. The latest CDC report, also issued in early January, shows that during the five-year period from 2008 to 2013 CLABSIS declined only 46 percent. What happened?
As I’ve previously written, the CDC calls CLABSI elimination a “winnable” battle but refuses to set zero CLABSIs as a formal goal. Yet despite that leniency, hospital data I obtained from the Medicare program show that in fiscal 2013, 1,197 hospitals – 42 percent of acute-care hospitals treating adults and reporting to the CDC – had zero CLABSIs in their intensive care units.
Indeed, though the CDC concedes in its latest report that “specific steps to prevent” CLABSIs could reduce them “by more than 70 percent” from a baseline rate, its own goal for Sept. 30, 2015 is just a 60 percent reduction in the base rate. Given the progress by hospitals so far, that’s unlikely to be met.
So this is the human cost of this tale of two infections: when it comes to doctors, nurses and other workers being endangered by the patient-transmitted HIV virus, hospitals have been extraordinarily safe: in a nearly 30-year period, just 24 nurses and not one physician suffered a confirmed infection. (Similarly, the recent Ebola threat has mobilized the CDC and hospitals.) By comparison, 1,300 patients died preventable deaths from hospital-caused CLABSIs in fiscal 2012 alone, according to research in the American Journal of Medical Quality. Many more suffered infection but recovered.
As for the financial impact, the medical costs of treating health care workers infected by needlesticks for all types of bloodborne pathogens (such as HIV and hepatitis) amounted to $107 million in 2004, the latest research available. Estimates of the medical costs of CLABSIs vary, but $2 billion in 2012 dollars is a conservative one.
While there are valid reasons CLABSI prevention can sometimes fall short, the power of the exact kind of procedures that halted occupational HIV has been repeatedly demonstrated. As recently as last fall’s meeting of the Infectious Disease Society of America, one hospital said it prevented CLABSIs by improving hand hygiene. Another credited success to boosting compliance with a “bundle” of CDC recommendations to 85 percent from 66 percent.
Just one question remains: if doctors, nurses and hospital staff were the ones being harmed, would today’s rate of deaths and injuries from CLABSIs constitute a crisis for the CDC or anyone else?
