Why Do Preventable Infections and Conditions Continue to Cause Harm?

Updated: May 9, 2019

Written by Paul Gallese


It’s time to act urgently and decisively to assure patient safety.


As members of the Vitalacy team we work with healthcare organizations to reduce the persistent increase of healthcare-acquired infections and conditions (HAIs and HACs) and assure patient safety, we hear many stories about the significant and lasting impact these adverse events have on patients and families.


Hospitals are meant to provide safe refuge from illness; therefore, acquiring a new infection or condition that could have been prevented can be physically and emotionally devastating for a patient and family.


Our recently published white paper, Finding New Ways to Prevent Healthcare-Acquired Infections and Conditions, details the continual increase of HAIs and HACs, despite all of the patient safety initiatives and awareness programs emphasizing infection control and hand hygiene. The paper also covers how Vitalacy works with organizations wishing to reduce these infections and conditions and enhance patient safety by implementing automated workflow monitoring solutions that improve the efficacy of nurse rounding and hand hygiene compliance.


I also had the opportunity to read an interesting article on the Institute for Healthcare Improvement (IHI) website. This thoughtful piece, titled “Addressing the Long-Term Impact of Patient Harm,” was written by Dr. Sigall K. Bell from the Institute of Professional and Ethical Practice, an organization affiliated with Boston Children’s Hospital.


Patient harm has long-term impacts – psychological, social and behavioral, physical and financial

Dr. Bell outlines the long-term impacts of harmful events such as HAIs and HACs. He writes, “These effects unfold in their homes, families, and communities, often long after they leave the hospital, and can have huge individual and societal costs.” He describes a study by Madelene Ottosen (2018) and Eric Thomas from the University of Texas Houston-Memorial Hermann Center for Healthcare Quality and Safety. They found that patients and families often describe the long-term impacts of medical errors as lasting five to 10 years, or even longer. The researchers placed the impacts into four categories: psychological, social and behavioral, physical, and financial. A National Opinion Research Center/IHI survey (2017) found that 73 percent of patients experiencing harmful events reported some form of long-term impact.


HACs and HAIs continue to exact an overwhelming toll

Unfortunately, overwhelming evidence shows that the devastating effects of HAIs and HACs are not abating. A 2017 survey by Castlight Health and the Leapfrog Group found HAIs rising across all five types examined in a survey: central line associated bloodstream infections (CLABSI), catheter associated urinary tract infections (CAUTI), surgical site infection after colon surgery (SSI: Colon), methicillin-resistant Staphylococcus aureus (MRSA), and Clostridium difficile (C. diff.).


The Agency for Healthcare Quality and Research (AHRQ) reaches a similar conclusion about this rising incidence in its 2017 report titled, “Estimating the Additional Hospital Inpatient Cost and Mortality Associated with Selected Hospital-Acquired Conditions.” The report includes CLASBI, CAUTI, surgical site infections, and C. diff. – as well as falls, pressure ulcers and venous thromboembolism (VTE) – on its top 10 HACs list. AHRQ reports that HACs continue to cause a financial burden and contribute significantly to inpatient mortality and morbidity across the United States.


HAIs affect about 1 of 25 hospitalized patients in the U.S. per year, according to the Center for Disease Control and Prevention (CDC, 2017). About 1.7 million HAIs occur in U.S. hospitals each year, resulting in 99,000 deaths and an estimated $35 billion to $45 billion in healthcare costs in 2007 dollars, the CDC reports (CDC, 2009). The federal agency estimates the average annual patient cost to a hospital for HAIs to be $18,581 and indicates a potential savings of $5.7 billion to $6.8 billion if only 20 percent of HAIs could be prevented.


Healthcare organizations being held accountable

As healthcare organizations come to grips with the damaging effects of these adverse impacts, the Centers for Medicare and Medicaid Services and Joint Commission are holding them accountable for poor health outcomes relating to HACs. Medicare began assessing a 5 percent financial penalty on reimbursement for hospitals ranking in the worst-performing quartile on HACs though its Hospital-Acquired Condition Reduction Program (CMS, 2018). In 2018, Joint Commission surveyors began reporting individual failures to perform hand hygiene in the process of direct patient care (The Joint Commission, 2017).


As consumers become more aware of the adverse impact of HAIs and HACs, they too are demanding accountability. For example, the Patient Safety Movement Foundation identifies HAIs as a challenge and has begun to give five-star rankings to hospitals committing to eliminating preventable deaths. The Joint Commission’s Quality Check program, Consumer Reports’ hospital ratings, and Medicare Hospital Compare all monitor hospital performance on preventing infections and publish results publicly. Increasing numbers of individuals have lost family and friends to HAIs, and they too demand action.


For too long, healthcare’s poor safety record has been accepted as normal when a similar record in industries such as air travel, auto manufacturing, or food delivery would result in public outrage.


It’s time to act urgently and decisively to assure patient safety

Healthcare organizations must innovate to assure compliance with hand hygiene and other patient safety initiatives that can decrease infection rates and associated costs. Methodologies currently used in most healthcare settings are simply costly and not completely effective. Healthcare leaders truly committed to a safety culture must implement systems that provide necessary information and insights for management to take preventive actions in real-time.


Learn more about how new approaches to automated workflow monitoring from Vitalacy can reduce preventable adverse hospital events by reading our patient safety white paper, “Finding New Ways to Prevent Healthcare-Acquired Infections and Conditions.”


References

Agency for Healthcare Research and Quality (AHRQ). Final report: Estimating the additional hospital inpatient cost and mortality associated with selected hospital-acquired conditions. AHRQ publication No. 18-0011-EF, November 2017.


Bell, S. Addressing the long-term impact of patient harm. Institute for Healthcare Improvement blog, March 7, 2019.


Castlight and The Leapfrog Group. Healthcare-Associated Infections. Data by hospital on nationally reported metrics (2017).


Centers for Disease Control and Prevention (CDC). Clean Hands Count for Safe Healthcare. May 5, 2017.


Centers for Disease Control and Prevention (CDC). The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. March 2009.


NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute. Americans’ Experiences with Medical Errors and Views on Patient Safety. Cambridge, MA: Institute for Healthcare Improvement and NORC at the University of Chicago; 2017.


Ottoson, M, et al: Long-term impacts faced by patients and families after harmful healthcare events. Journal of Patient Safety, Jan. 17, 2018.


The Joint Commission. Update: Citing observations of hand hygiene noncompliance (2017).


Medicare.gov. Hospital Compare. Hospital-Acquired Condition Reduction Program (2018).

Vitalacy, Inc. Finding new ways to prevent healthcare-acquired infections and conditions (2019).

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