UC Davis Medical Center struggles with infections

Dr. Jonathan Pierce, center, instructs medical students on proper procedure for inserting a central line catheter. (Autumn Cruz/Sacramento Bee)

Hospitalization too often puts patients at risk.

They can contract infections from the insertion, maintenance and removal of urinary catheters as well as central line catheters that are placed in large veins to make it easier to administer medicine and fluids.

They can also get sick from a variety of antibiotic-resistant bugs, including Clostridium difficile and Methicillin-resistant Staphylococcus aureus (MRSA).

An estimated 12,000 Californians die annually from these preventable infections, according to state Department of Public Health statistics.

State and federal statistics show that UC Davis Medical Center struggles more than most other local hospitals with high infection rates, especially those related to catheters.

Officials at a range of medical centers said comparing infection data is unfair because hospitals are so different in size, patient population, specialized treatment units and severity of illnesses – and even the way they chart contacts with their patients.

Behind the statistics are lessons to be learned. Consider two local medical facilities, UC Davis Medical Center and Sacramento’s  Veterans Affairs Hospital – one a tale of trying to overcome trouble, one a tale of success.

UC Davis

In UC Davis' eerie-looking Center for Virtual Care simulation suite, filled with soft plastic upper torsos and disembodied mannequin heads, Dr. Jonathan Pierce instructed four pediatric residents on proper central line insertion.

"You've got it, but look at your angle of attack," he told one resident, feeding a needle into a torso. "If you miss the vein, where are you going? You're going to go into the chest."

The class is part of the hospital's plan to reduce infections, a problem acknowledged by hospital officials and reflected in the California Department of Public Health data collected from more than 300 hospitals for infection rates for 2009 and the first quarter of 2010.

The data indicate that among the 38 Level 1 and Level 2 trauma centers listed in the report, UC Davis Medical Center had the second-highest rate of intensive care unit central line-related bloodstream infections. And it had the third-highest rate among the state's 56 hospitals listed in the report as teaching facilities.

According to federal data for fee-for-service Medicare patients collected from October 2008 to June 2010, the medical center was the sixth-highest among the nation's large hospitals (10,000 or more discharges for the time period) in both its central line and urinary tract infection rates.

For the sprawling 645-bed acute-care hospital – the region's only Level 1 trauma center, with 11 ICUs, a burn unit and a National Cancer Institute-designated cancer center – the issues are complex.

"I'm not defensive. I'm extremely proactive," said the center's chief medical officer, Dr. Allan Siefkin.  "If we have one infection, we want to have zero."

Among the reasons he offers for UC Davis' high numbers: Because it's a teaching hospital, more people make notations in each patient's chart, leading to the possibility of incorrect documentation.

And the medical center tends to see the region's sickest, most grievously injured patients. Its highest number of central line infections occurs in the burn unit, he says. Almost one quarter of UC Davis' patients transfer in from other hospitals, requiring higher levels of care.

Hospital officials said the medical center has long maintained a rigorous program for preventing infections, including procedures such as hand hygiene and appropriate draping, as well as the use of gowns and gloves.

A team of nine registered nurses and a manager reviews every hospital-acquired infection case, Siefkin said, and a quality-of-care committee analyzes patient safety concerns each week.

The Center for Virtual Care, which opened in 2003, helps standardize nurse and physician training on how central lines are inserted and their dressings changed. In the past, most American doctors learned the process by watching it once or twice.

"We're a long way from the old philosophy of 'See one, do one, teach one,' " said the center's operations director, Betsy Bencken.

Because most catheter infections occur more than a week after insertion, Siefkin said, the hospital urges its medical staff to remove them sooner. Without documentation of ongoing need, for example, nurses can now remove urinary catheters after 48 hours without waiting for doctors' orders.

Amid this change in medical culture, the center said it has made progress. In the past two years, its own statistics show that its rate of laboratory-confirmed urinary tract infections has decreased by half, from 4.5 infections to two per 1,000 catheter device days. And its central line infection rate dropped from four per 1,000 in 2007 to 2.25 per 1,000 last year.

In comparison, national Medicare statistics – for a population that's elderly and frail – indicate rates for both infections of less than .4 per 1000.

Next year, Siefkin said, UC Davis' medical staff will receive a paid incentive to remove central lines more quickly. "Will that work?" he said. "I don't know if it'll have any impact. The truth is, they do it for the patients, but this will remind them."

Sacramento VA

On a smaller scale, a local hospital has found answers. The 190-bed Sacramento VA Medical Center has taken aggressive steps that have lowered its rates of MRSA and central line-associated bloodstream infections to zero.

"The time of more aggressive infection control is here," said Dr. Harold Burger, the epidemiologist in charge of the hospital's infection control committee. "The public rightly demands this."

The local efforts are part of a four-year, systemwide Veterans Affairs campaign to wipe out potentially deadly bugs, which has resulted in a 62 percent drop in the VA’s  MRSA rate across the country. (Because VA hospitals are federal facilities, their data aren't compiled in state statistics.)

The VA’s success – in Sacramento and its 152 other hospitals – has wide implications for care at other hospitals. The campaign's primary measure? Getting people to wash their hands.

The Centers for Disease Control and Prevention considers hand hygiene – a health care basic yet one that can be overlooked – to be the cornerstone of reducing all hospital infection rates.

The Sacramento VA consistently markets good hand hygiene to its employees, patients and visitors, said spokeswoman Robin Jackson.

Posters urge families to tell medical staff to wash their hands. A "secret shopper" surveillance effort encourages observers to monitor fellow employees' hand-washing and even provides a script for reminding them to do so.

A 2009 infection control fair included a poster and slogan contest, and a campaign that year recognized individual employees' good hand hygiene. A newer campaign encouraged staff, patients, families and visitors to be aware of hand-washing and included a brochure entitled, “Hand Hygine Saves Lives.”

Like other VA hospitals, the Sacramento center also swabs patients for MRSA as they enter the hospital, isolating those who test positive.

Simple measures, but they're working. "You've got to understand this is part of the medical scene today," Burger said. "If you put in the resources to decrease infections, everybody benefits. It's the obvious thing to do."

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