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Saskia v. Popescu, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist with Phoenix Children's Hospital. During her work as an infection preventionist she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She is currently a PhD candidate in Biodefense at George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in Infection Control.

Stanford Hospital—A Canary in A Coal Mine

JUL 14, 2017 | SASKIA V. POPESCU
On July 11, 2017, Stanford Healthcare became embroiled in a public debate with the members of Service Employees International Union-United Healthcare Workers West (SEIU-UHW). Stanford Healthcare’s associate chief medical officer Ann Weinacker, MD, was forced to publicly respond to comments made during the Tuesday press conference held by the union workers. During this press conference, union workers claimed that the healthcare system had high rates of healthcare-associated infections due to inadequate staffing and training.

The union leaders and workers cited the financial penalties the hospital was hit with in 2016 and 2017 as a result of hospital-acquired infections. These financial penalties come in the form of only partial reimbursement from the Centers for Medicaid and Medicare (CMS).
 
Hospitals depend on CMS reimbursement of expenses for patient care. Following the 2008 non-payment rule, this reimbursement is now linked with quality of care. In short, CMS decided that it would no longer pay for additional medical care that was a result of poor hospital practices and sub-par quality management. When hospitals have high rates of hospital-acquired conditions—including certain hospital-acquired infections, ranging from surgical site infections to catheter-associated urinary tract infections—as a penalty, their reimbursement from CMS can be reduced by 1%. This rule is meant to incentivize hospitals to prevent such conditions and infections and improve the quality of care.
 
In their press conference, the union leaders highlighted these financial hits as proof that the quality of care at the hospital is poor and not enough measures are being done for patient safety. Moreover, they pointed to publicly reported data that show the rates of Clostridium difficile (C. diff) infections have risen, which puts patients and staff at risk. 
 
California is one of many states that requires hospitals to publicly report their data on hospital-acquired infections as well as incidence of laboratory-identified hospital-onset C. diff infections and methicillin-resistant Staphylococcus aureus (MRSA) infections in the bloodstream. The data the union employees highlighted show an uptick in cases for Stanford Hospital, which the employees are citing as evidence that the hospital has systematically failed to staff departments appropriately and provide adequate breaks. In addition, they say the data are proof that the hospital pushes environmental services staff to rush through cleaning of rooms to the point where the quality is decreased. 

Although this event has garnered much public attention, it’s important to be mindful of the rates of infections that are being thrown around. (Brace yourself, we’re about to go down a rabbit hole…)
 
Some hospitals present internal data in terms of years or quarters and in terms of rates. How they present their data is an internal decision, and whichever method they use, that is how the data is presented data for key stakeholders.
 
On the other hand, all data reported through the Center for Disease Control and Prevention (CDC)’s National Healthcare Safety Network (NHSN) for federal reporting and reimbursement requirements, uses a Standardized Infection Ratio (SIR). Using SIRs as a benchmarking tool is a relatively new aspect of hospital reporting, but it’s vital to note that rates and SIRs cannot be compared. SIRS are newer data comparison markers that utilize observed versus expected infections. SIRS are the actual number of hospital-acquired infections divided by the number of expected infections, which is a predicted number based off baseline data from the standard population during a period of time. Rates on the other hand, are the number of cases over the number at risk of the event during a specific time. The key difference is that SIRs adjust for patients of varying risks within a facility and compare the actual number of healthcare-associated infections reported within the baseline of United States cases; it is a much more accurate measurement tool. And so, although the article points to rates and then SIRS, it’s important to note that these two numbers cannot be compared and to do so would be misleading. In addition, many of the rates that are highlighted come from non-linear years (like 2011 and 2014) and are quite old. That doesn’t paint a particularly clear picture.

One aspect that can be seen by looking at just rates is an increase in C. diff rates for the hospital and an exhaustive list of worker complaints about an assembly-line mentality that treats necessary safety practices, such as cleaning and disinfection, as a lower priority. Many of the union members cite directives to push to make everything happen faster and with that comes safety failures. Although Stanford cites these claims as bargaining tactics for a new contract, the union workers are using the data to point to outcomes that are a result of patient safety failures. Some of the examples they use include, unknowingly being exposed to tuberculosis and pressure to clean rooms faster than proper disinfection methods allow for. The union workers also report poor compliance with posting isolation signage outside of patients’ rooms, alerting healthcare workers that personal protective equipment and specific cleaning practices are required.

The sad part in all of this is that these are common issues across most hospitals. Talk to any nurse and they will tell you that on several occasions, they’ve been told after the fact that a patient needed isolation. Ask an environmental services worker and they will agree that there is always pressure to clean a room faster to help turn over the room for the next patient. Better yet, I dare you to talk to an infection preventionist or member of a hospital’s infection control team. They will probably give you the same response I had, which was “ok, well those happen everywhere—Stanford just got caught.”
 
Sure, all the data is reported through NHSN and made publicly available, but few people even bother to research and read the data prior to seeking medical care. Those hospitals who do not meet the requirements may even be hit with CMS reimbursement penalties, but when this happens (and it happens a lot), it typically doesn’t receive much media attention. Of the handful of infection preventionists I’ve talked to about this report, not one was surprised. Sadly, it’s common practice that patients aren’t properly isolated or that signage isn’t up all the time. And, although some hospitals are utilizing newer and more effective technologies such as UV-disinfection equipment to help disinfect rooms, this practice still adds time to the clock between patient discharge and the next admission.
 
The healthcare industry is always in a battle against cutting costs, keeping patients safe, and maintaining high patient satisfaction; all while following federal regulations and requirements. Despite the alarmist nature that comes across in the media coverage on the Stanford case, we need to realize that this is only a glimpse through the window that is healthcare infection control and the struggle to follow best practices while working in an increasingly stressful environment. In this case, Stanford Health Care is the canary in the coal mine, alerting us that there’s a problem. They just happened to get the media scrutiny that comes with being pulled into a union debate involving the safety of employees. Unfortunately, Stanford Health Care is not the only canary—in fact, it is only one in a whole flock who have been giving us warnings of infection control and patient safety failures for decades. The question is, are we finally ready to listen?  
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