A Response to the Compendium of Strategies to Fight HAIs

Consensus can make for progress. Or it can make for empty promises. The release of the "Compendium of Strategies" announced recently by the Joint Commisssion, the AHA, SHEA and APIC makes for a little of both. Agreement achieved by these diverse groups may do little to stop infections from killing more than 100,000 Americans a year.

For instance, the compendium fails to call on hospitals to routinely screen incoming patients for MRSA, even though a 2007 study conducted by APIC warned that "MRSA is endemic in virtually all U.S. healthcare facilities."  Instead, the compendium deems screening necessary only if infections exceed "institutional goals," an ambiguous phrase meaning whatever a hospital is willing to live with. 

To prevent MRSA from being carried to patients, the compendium says patients' rooms should be cleaned "with approved disinfectants at appropriate dilutions for the appropriate amount of contact time."  This vagueness will not correct the quick spray and wipe common in most hospitals.  In a 2007 survey of hospitals from D.C. to Boston, more than half the surfaces in patients' room that were supposed to be disinfected after a patient was discharged were left untouched by cleaners. Cleaning is important because as long as frequently touched surfaces are left heavily contaminated with bacteria, caregivers’ hands will become re-contaminated seconds after they wash them. At Stamford Hospital in Connecticut, supervisors mark surfaces with an invisible substance detectable by a black light, and check after a room is deemed ready to make sure all surfaces have been disinfected with bleach. Why didn’t the compendium authors provide specific recommendations of this nature?

The compendium applies the same nebulous standard in the use of antimicrobial central-line catheters, recommending them only when the incidence of CLABSI exceeds "institutional goals." CLABSI cost as much as $57,000 to treat and result in death at least 12 percent of the time. Antimicrobial catheters are like airbags or anti-lock brakes, back-up devices that compensate for human fallibility. They cost $35 more than an untreated catheter – about the same as a hospital charges for T.V. and phone rental for two days – and they are proven to reduce infection risk to nearly zero. Again, the compendium's authors fail to take aggressive action to prevent infections.

Healthcare is the only industry where safety rules are treated as recommendations. Infection prevention experts know that dirty hands are the number one cause of infection deaths. Doctors don't clean their hands before treating patients more than half the time. Yet the compendium offers no recommendation to discipline chronic offenders.

Amazingly, the compendium does not take the CDC to task for failing to provide meaningful data on the size of the HAI problem. Instead, the compendium cites the CDC’s old figure of 1.7 million HAIs per year. The truth is several times that number.  In June 2007, the APIC nationwide survey found that 2.4 percent of hospital patients were contracting MRSA hospitals acquired infections, or about 880,000 a year.  That’s from one superbug. CDC data show that MRSA accounts for only 8 percent of all hospital infections, a proportion confirmed by Emory University researchers. Clearly many millions of patients are contracting infections in hospitals. 

The compendium gets some things right. The work on C. diff, an emerging superbug hitting American hospitals by storm, is particularly clear.  And the authors rightfully say we have the scientific knowledge to prevent infections. What has been lacking is the will.

Alas, there is too little in the compendium to change that. What are your thoughts on the matter?