Earlier this year, two patients at the Ronald Reagan UCLA Medical Center died because of infections they acquired at the hospital. Another 179 patients were potentially exposed to the lethal bacteria.
The UCLA outbreak — and similar ones in Seattle and Chicago hospitals — have been linked to bacteria that were transferred between patients due to unclean duodenoscopes, devices inserted down the throat to diagnose certain gut conditions and cancers. Since the outbreak, UCLA has said it will no longer be using that model of scope.
One lawsuit filed as a result of a death in the UCLA outbreak alleges that although Olympus redesigned its duodenoscope, the company still provided cleaning instructions for the old model, the Los Angeles Times reported.
In March, the U.S. Food and Drug Administration (FDA) released new guidelines for how reusable medical devices, such as scopes and catheters, should be cleaned. It also warned that following manufacturer cleaning instructions may still not guarantee a device is free of contaminants.
The bacterium involved in the UCLA, Seattle, and Chicago hospital outbreaks is known as carbapenem-resistant Enterobacteriaceae (CRE). It’s developed defenses against the toughest antibiotics in existence. It’s commonly found in a person’s digestive tract, but is kept in check by other gut bacteria.
However, if the balance between good and bad gut bacteria is thrown off by antibiotics, CRE can thrive. CRE infections are fatal in about half of cases, earning it the nickname “the nightmare bacteria.”
Bacterial Infections on the Rise
Other strains of drug-resistant bacteria — such as C. difficile and MRSA — have been problematic for infection control specialists and hospitals. From 2001 to 2010, C. diff infections nearly doubled to 8.2 infections for every 1,000 adult patients, according to the American Journal of Infection Control.
These infections also double hospital readmission rates and the length of stays, according to the Association for Professionals in Infection Control and Epidemiology.
Healthcare-associated infections, or HAIs, are among the most common sources of preventable medical harm.
According to the U.S. Centers for Disease Control and Prevention (CDC), on any given day, 1 in 25 hospital patients has an HAI, and more than half are contracted outside of the intensive care unit. There were an estimated 722,000 HAIs in 2011. About 75,000 of those infections were fatal.
Experts say the problem of preventing HAI lies in controlling exposure to bacteria and viruses by ensuring hospital rooms and equipment are properly sanitized for each patient.
These bugs can quickly spread in a healthcare setting, whether lying dormant in the nooks and crannies of medical devices, hard-to-clean parts of a hospital room, staff and patient garments, a doctor’s stethoscope, or even dust particles in the air.
Dr. Michael Shannon, former deputy surgeon general of Canada, said it only takes eight hours for dangerous bacteria to repopulate a room after it’s been cleaned with traditional methods.
“Universally, there’s a problem with device cleaning. There are certain bacteria that are ubiquitous and some are extremely difficult to kill with traditional cleansers,” Shannon said. “Unlike any other war the U.S. has engaged in when they have superior weapons technology, in this war, they’re fighting with muskets.”
Contaminants Are Common in Hospitals
Hospitals are gathering places for the sick 24 hours a day, seven days a week, so preventing infections in a healthcare setting isn’t as a simple as changing bed sheets and using a little bleach.
“It’s not that easy. It if were, we would have fixed it by now,” said Jerzy Kaczor, project director for Soyring Consulting, a healthcare consulting firm. “Typically, it’s not a single factor. It’s a breakdown in several processes or teams.”
Experts say small slips can create big problems for patients and hospitals. These can include mistakes in the antiseptic process, including surgical teams, environmental cleaners, and those responsible for maintaining ventilation in a room.
When consulting with hospitals during an outbreak, Kaczor’s team closely examines how employees are trained to clean equipment that could spread bacteria and viruses among patients.
“You should be following those training their staff and following up annually,” he said. “There’s a certain technique to how you clean.”
Thom Wellington, co-founder of Infection Control University and chief executive officer of Wellington Environmental, said contamination can come from a variety of sources, including dust, skin, and even remnants of dead insects.
One hospital Wellington consulted for had a string of surgical site infections. Upon investigation, they determined the problem was the doctor. He had been swimming regularly and the chlorine dried his skin, allowing skin cells to shed into an open surgical wound and infect patients.
Besides direct contact, experts have determined that vibrations caused by construction crews or demolition outside a hospital can have an impact on how bacteria travel through a facility. To combat these problems, he said, hospitals need to adopt strict protocols for the training of everyone in a hospital, even contract maintenance workers.
“No one keeps track of all those people coming in and out,” Wellington said. “We see that hospitals need to step up their games and act like a corporation. Mistakes happen in every industry, but we don’t want them in hospitals.”
Hospital Infections Become Higher Priority
Hospital infections were once considered part of the cost of doing business in healthcare.
However, the CDC estimated the annual cost of HAIs in the United States to be between $28 billion and $45 billion in 2009.
Dr. James McKinnell, an infectious disease specialist with the Los Angeles Biomedical Research Institute, said while doctors have a moral and ethical incentive to keep patients safe, hospitals have historically dedicated limited resources to infection prevention.
“It’s hard to incentivize hospitals to do so. That’s a cost no one wants to pay,” he said. “We have to understand that what we’re doing has a cost-benefit. We can waste a ton of money doing nothing without someone behind the wheel.”
But incentives began in 2006 when President George W. Bush sought to reduce the federal deficit by reducing Medicare expenses. At the time, medical errors were costing $17 billion to $29 billion a year, with the majority of costs going to insurance companies or Medicare.
Now, treatment for preventable infections from catheters and certain surgeries are no longer reimbursed by the government through Medicare, shifting the financial burden to hospitals.
The latest CDC report on HAIs does show improvements in infection rates for common medical procedures. According to a report issued in March, the largest decrease, 46 percent, was for central line-associated bloodstream infections (CLABs), or infections caused by tubes inserted in large veins.
A 2013 study published in JAMA Internal Medicine found CLAB infections were the most costly, at an average of $45,814 per case. The average cost of treating an HAI in the United States is $26,000.
“As hospitals realize savings from prevention of these complications under payment reforms, they may be more likely to invest in such strategies,” the researchers stated.
Before the change in who fronts the bill for an HAI, recommendations by hospital infection control specialists were often ignored by administrators, Wellington said.
“We’re now seeing a shift because they are now part of outcomes and the financial outcome of the hospital,” he said.
New Technology to Combat a Growing Threat
Now that hospitals are being financially penalized for their mistakes, infection prevention is becoming a higher priority and hospitals are seeking ways to more effectively decontaminate a room, especially during an outbreak.
UCLA has announced it’s now sending instruments for off-site cleaning using an automated machine that sterilizes through an ethylene oxide gas. This allows delicate machinery to be cleaned without damage.
One form of disinfectant technology that will likely become more common in the near future is gas-dispensing robots. Robots take human error out of the equation, and the gas can penetrate hard-to-clean areas.
“Hospitals today, no matter what kind of protocols they use, even on a good day, they’re only able to get a 99 percent kill of all microorganisms in a room,” said Ed Marshall, chief executive officer of Medizone, a company that specializes in healthcare decontamination.
The 99 percent kill is known as two-log. A three-log kill is 99.9 percent, which is common in conventional cleaning techniques.
Even bacteria left after a three-log kill can spawn again, giving bugs like C. diff a chance to take over a room. A patient staying in a room that previously hosted a person with a C. diff infection is 2.5 times more likely to get the same infection, in what’s known as “sick room syndrome,” Marshall said.
Completely disinfecting a room requires more than disinfecting surfaces a patient touched. It includes all surfaces, including machinery, instruments, walls, ceilings, and even under a bed.
But Marshall and Shannon, who is also president of Medizone, say their use of ozone-hydrogen peroxide in their AsepticSure system provides the only available six-log kill, with no living bacteria remaining.
It’s dispensed using an automated machine they say can disinfect a room full of equipment in one cleaning. The system is currently in the application process for approval by the Environmental Protection Agency.
“The only way to completely stop an infection is to get a 100 percent kill,” Marshall said.