Infection control programs at community hospitals, identified as having fewer than 500 beds and a minimal healthcare worker education program, are lagging behind bigger institutions, which is compromising infection control and patient care.
“A few years ago, we did a study of infection control in community hospitals. There were three main problems identified: leadership, access to infectious disease (ID) specialists, and limited resources and personnel for infection control. Only about 1 in 4 of the hospitals had an ID specialist on staff, and of those, only 1 in 4 were paid for infection control supervision. These findings haven’t changed much since then,” said Daniel Sexton, MD, Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University Medical Center, Chapel Hill, North Carolina, during his session at the annual conference of the Infectious Diseases Society of America (IDSA) in New Orleans, Louisiana.
Community hospitals are challenged by understaffed and underfunded microbiology labs, the burdens of regulatory mandates, the “enormous and largely unrecognized problem” of inadequate continuing education, and data problems.
Data problems are, by far, the biggest challenge. “Non-validated and/or inaccurate data lead to lack of trust and overt dismissal of problems. There is a lack of meaningful benchmarking of results. Key data elements are not collected and data are not widely shared with staff and leadership. Data are not consistently used to drive performance improvement,” said Dr. Sexton in his presentation.
A tangible example is the spread of carbapenem-resistant Enterobacteriaceae (CRE) in community hospitals. A survey of 25 hospitals from 2008 through 2012 revealed a 5-fold increased rate of CRE. Hospitals with microbiology labs that were using acceptable CRE detection methods had rates 8 times higher than hospitals that did not; this meant that many infections were being missed in the hospitals with poorer infrastructure and data reporting.
Another big problem lies in the education of healthcare workers. In many community hospitals, continuing education is not a priority, due to lack of resources, time, and/or resolve. The result can be a core of workers who rely on what Dr. Sexton terms “confidently held misinformation.”
“I think it’s true, pretty much across the United States, that the education of healthcare workers is abysmal. I don’t think any other large industry does a poorer job of educating its people. The general rule is that [hospital administration] gives an orientation for about an hour, gives a slide show, ends with an update on infection prevention, and then they are good to go. They have that checked off,” Dr. Sexton explained.
One disastrous consequence is that about one-quarter of healthcare workers believe wrong information and these beliefs persist in the absence of accurate information. “Incorrect/suboptimal/toxic therapies are commonly prescribed. Many ID clinicians lack training in how to establish and effectively run an antibiotic stewardship program. The result is that antibiotic overuse/misuse is common, and the problem has remained unchanged for the past 4 to 5 years,” said Dr. Sexton.
In a study consisting of 562 patients with methicillin-resistant Staphylococcus aureus
bloodstream infection in 10 community hospitals, 52% of the patients did not receive a drug active against the pathogen within 24 hours of drawing blood cultures. According to Dr. Sexton, “That’s no better than a coin toss.”
A challenge is changing the focus of hospital administration and workers from a reactive, ‘stay out of trouble’ stance to a proactive outlook.
“Somehow the status quo needs to change so that healthcare workers are educated at the same level as people who work for Apple and people who test the jet engines before you take off,” said Dr. Sexton.
The problem of inaccurate data is not going away, especially in a future that features broader uptake of technologies like whole genome sequencing and machine learning, reliance on electronic communication including telemedicine, and more regulations and rules.
“I believe that we can reprogram and retread large numbers of clinicians who are 5, 10, 15, 20, or more years into their practice to give them the skill set that they need so they can prove their newly-acquired credentials by setting up effective hospital programs. Antimicrobial stewardship programs can work, and they will work, and will be so much better if people are trained using a business model of best-based training,” Dr. Sexton concluded.
Daniel Sexton: Editor, UpToDate; Consultant: Johnson & Johnson; Advisory Boards and Stock Options: Magnolia Medical Technologies, Sterilis; Other: Joint Educational Pilot Program: Knowledge Factor
- Photos and tape of IDSA presentation
- Anderson DJ et al. Infect Control Hosp Epidemiol 2008 29:S51-61
- Herzke CA et al. Infect Control Hosp Epidemiol 2009 30:1057-1061
Healthcare epidemiology and antimicrobial stewardship in community hospitals: Musings about the present and future
Brian Hoyle, PhD, is a medical and science writer and editor from Halifax, Nova Scotia, Canada. He has been a full-time freelance writer/editor for over 15 years. Prior to that, he was a research microbiologist and lab manager of a provincial government water testing lab. He can be reached at firstname.lastname@example.org.
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