By John Palmer
Just when you thought it was safer to go into America’s hospitals as a patient, the CDC has some bad news for you.
A March Vital Signs report from the organization indicates that healthcare-acquired diseases, formerly thought to be on the decline in U.S. hospitals, have started to make a comeback. The data has prompted the CDC to encourage hospitals to take action in defense against outbreaks of bacterial infections such as methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible Staphylococcus aureus (MSSA).
The new CDC data show that U.S. rates of hospital-onset MRSA infections dropped 17% for each year from 2005 until 2013, but those declines then leveled off and have remained stagnant. In addition, MSSA has begun rising in U.S. communities, especially in crowded cities where sharing of needles and personal items among homeless communities are on the rise amidst the opioid epidemic.
More than 119,000 bloodstream staph infections occurred in 2017, resulting in 20,000 deaths. About one in 10 serious staph infections in 2016, or 9%, occurred in people who inject drugs such as opioids, CDC data suggest—that number is up from 4% in 2011.
In contrast, U.S. Veterans Affairs medical centers reduced rates of MRSA by 55% and MSSA by 12%, through addition of steps such as screening new patients.
MRSA and staph aren’t the only infections that hospitals have been fighting. The CDC notes that the prevalence of Clostridium difficile (C. diff), a bacterial infection of the gastrointestinal system primarily found in hospitals, continues to be much higher than once thought, affecting up to 500,000 people annually. Many cases have been showing up in medical clinic offices, despite the infection historically appearing in hospitals.
Hospitals have been fighting a battle with C. diff for years, and it’s become a somewhat common—though obviously unacceptable—aftereffect of increased antibiotic use. But the latest CDC revelation means C. diff is being found, and perhaps transmitted, in healthcare facilities previously assumed to be safe from it. In the past, clinics were viewed as generally not in danger from C. diff because of the quicker turnover and lower acuity of patients seen there.
According to the CDC, healthcare facilities can make MRSA and MSSA prevention a priority by assessing the facility’s staph infection data, implementing prevention actions, and evaluating progress. Many hospitals have indeed prevented the spread of infection, and the CDC says ongoing assessment of facility data and implementation of prevention strategies are critical to this success.
In addition, the CDC says healthcare facilities can help stop staph in its tracks by implementing the following steps, as stated in the report:
- Follow current recommendations for preventing device- and procedure-related infections.
- Use contact precautions (e.g., gloves and gowns) for resistant infections. Consider actions including screening high-risk patients and decolonization of germs during high-risk periods, such as ICU stays, surgery, or device use.
- Treat infections appropriately and rapidly if they do occur.
- Educate patients about ways to avoid infection and spread, and about early signs of sepsis.
The Society for Healthcare Epidemiology of America (SHEA) said the CDC data highlights the need for evidence-based interventions to improve patient care and lessen the risk posed by MRSA and MSSA.
“The report highlights the critical impact made by dedicated healthcare epidemiologists working with their hospital and health system partners to protect patients over the last decade. It also shows that there is more work to be done,” said SHEA President Hilary Babcock, MD, MPH, in a release. “For MRSA and MSSA, no single prevention approach works in all situations. Combination, or bundled, interventions are usually the best approach. Which strategies will have the biggest impact may depend on the local context. SHEA urges expanded funding support for research into what interventions are most effective in what settings, so that infection prevention programs can continue to reduce these infections in patients across healthcare settings.”
The efforts described in the CDC’s report reflect SHEA’s practice recommendations released in the “Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2014 Update,” an article series that details evidence-based strategies to combat the spread of healthcare-associated infections (HAI).
These recommendations include the following, as stated in the SHEA release:
- Conduct a MRSA risk assessment. Hospitals should focus on preventing opportunities for MRSA transmission and on estimating facility-specific MRSA burden and rates of transmission and infection.
- Implement a MRSA monitoring program and track rates. The program should focus on identifying any patient with a current MRSA infection or prior history of infection and provide mechanisms for tracking hospital-onset MRSA cases. Laboratory alerts should be sent to notify healthcare personnel of patients with MRSA.
- Ensure compliance with hand hygiene recommendations. Healthcare personnel should perform hand hygiene in accordance with CDC or World Health Organization recommendations.
- Ensure proper cleaning and disinfection of equipment and the environment. Because contamination can be widespread within a MRSA patient’s environment, optimal cleaning and disinfection procedures should be employed.
- Educate healthcare personnel, patients, and families about MRSA. Communicate the risk posed by MRSA and stress everyone’s role in prevention, transmission, and compliance with recommended precautions.
- Implement an alert system. Hospitals should have a notification system for patients with laboratory-identified MRSA or those readmitted with MRSA to allow prompt initiation of control measures.
Higher infection rates carry a cost. Some 800 U.S. hospitals are poised to have their Medicare reimbursement cut this year because of higher rates of infections and patient injuries, federal records show. That number is the highest since the federal government’s 2014 launch of the Hospital-Acquired Condition (HAC) Reduction Program, created by the Affordable Care Act (ACA). Under the program, 1,756 hospitals have been penalized at least once, according to published statistics from Kaiser Health.
The penalties cause hospitals to compete against one another to prevent incidents such as infections, blood clots, sepsis, pressure injuries, hip fractures, and other complications. Each year, the 25% of general hospitals with the highest rates of preventable conditions are punished, even if their records have improved from the previous year.
Under the newest sanctions published on Medicare.gov, each hospital will lose about 1% of its Medicare payments for patients discharged between October 2018 and September 2019. That loss is in addition to other penalties created by the ACA, such as annual payment reductions for hospitals with too many readmissions.
Hospital patients suffered an avoidable injury in nine of every 100 patient stays in 2016, or about 2.7 million injuries, according to a June 2017 report from the federal Agency for Healthcare Research and Quality (AHRQ). Those included a bad reaction to medication, an injury from a procedure, a fall, or an infection.
The frequency of complications has been dropping in hospitals. The AHRQ report found an overall 8% decrease from 2014 to 2016. However, during that time, the report also found a jump in the numbers of urinary tract infections in patients with catheters, as well as the numbers of pressure injuries.
The hospital industry has protested the HAC penalties, saying the program’s design creates an arbitrary cutoff for punishment.
According to data from the American Hospital Association (AHA), of the 768 hospitals penalized in 2017, only 40.6% had scores that statistically differed from the threshold penalty score, according to a blog post from Nancy Foster, vice president for quality and patient safety policy for the AHA.
“The performance of the other 59.4% was not statistically different from that of the hospitals at the threshold that escaped the penalty,” Foster wrote. “In other words, the majority of hospitals receiving a HAC penalty have performance indistinguishable from those that are not being penalized.”
Foster says in her blog that because of the statutory requirement that 25% of hospitals be penalized each year, receiving a penalty is more a result of random chance than a true judgment of a facility’s care quality.
“The Centers for Medicare & Medicaid Services (CMS) must set a ‘cut point’ score for penalties each year, regardless of whether that score reflects a statistically meaningful threshold for poor performance,” she wrote.
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at firstname.lastname@example.org.
The reasons for the declines in hospital-onset MRSA bloodstream infections might be attributable to a variety of infection control efforts, including improvements in preventing device- and procedure-associated infections (15–17), as well as efforts to interrupt MRSA transmission in the hospital setting (5,18).
Antimicrobial resistance patterns among MRSA and MSSA, and changing resistance trends among overall S. aureus isolates, 2008–2017. It is notable that a descending trend was observed in the overall MRSA rate, which dropped remarkably from 83.5% (643/770) in 2008 to 54.2% (228/421) in 2017 (p < . 0001) (Figure 2(a)).
MRSA is a type of bacteria that's resistant to several widely used antibiotics. This means infections with MRSA can be harder to treat than other bacterial infections. The full name of MRSA is methicillin-resistant Staphylococcus aureus. You might have heard it called a "superbug".
How common is MRSA? Approximately 5% of patients in U.S. hospitals carry MRSA in their nose or on their skin.