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Centers for Disease Control and Prevention

Ebola raises concerns over hospitals' infection controls

Peter Eisler and Meghan Hoyer
USA TODAY

Clarification: An earlier version of this story mis-stated investigators' final conclusion on the cause of death for two patients who died at Advocate Lutheran General Hospital in Park Ridge, Ill., in 2013.

As public health authorities race to assess the U.S. medical system's ability to contain Ebola, the track record of the nation's hospitals in controlling other infections suggests a lot of them aren't prepared.

From small, rural hospitals to sprawling urban medical centers, infection control has been a persistent and vexing problem in U.S. health care for decades.

Mathew Jacob, a maternal newborn nursing student, has help removing a gown during a refresher course on personal protective equipment procedure taught at the Brookhaven College School of Nursing in Farmers Branch, Texas, Tuesday Oct. 14, 2014. Nursing, EMS and radiological sciences students will all take the refresh course. A second Dallas hospital worker has tested positive for Ebola, pointing to lapses beyond how one individual may have donned and removed personal protective garb.

Many hospitals handle these cases without incident. But lapses in procedures to isolate contagious patients, to protect health care workers from dangerous bacteria and viruses, and to clean contaminated equipment consistently rank among the most common deficiencies cited in hospital inspections and accreditation reviews.

The ability of hospitals to control infections has become a focal point in the response to Ebola, underscored by news that a second nurse at a Dallas hospital contracted the disease after caring for a man who died from the disease last week. Investigators are trying to determine how protective measures failed to prevent the nurses' contamination.

About one in every 25 patients get an infection while being treated in a U.S. hospital, which translates to more than 700,000 hospital-associated illnesses each year, according to data from the Centers for Disease Control and Prevention. In 2011, about 75,000 patients died from those infections, or more than twice the number killed in auto accidents.

Virtually all those infections are transmitted via contaminated equipment, rooms or caregivers — problems that would pose grave threats in treating patients with Ebola, which is both more deadly and more contagious than many of the bugs commonly spread in hospitals.

Says William Jarvis, former head of the health care infection division at the CDC: "With something like Ebola, there's no room for error."

"I definitely worry" about most hospitals' ability to handle Ebola cases safely, says William Jarvis, former head of the health care infection division at the CDC. "You can get away with breaks in (infection control) technique a lot of the time with other blood-borne pathogens that are not that readily transmittable; with something like Ebola, there's no room for error."

DIRTY HANDS, DIRTY EQUIPMENT

Hospital inspection records reviewed by USA TODAY show a wide range of problems.

Many violations involve health care workers failing to disinfect their hands or use protective gear properly — gloves, gowns, masks and other items that must be donned and removed in very precise ways. In one case, more than 60 personnel at a single hospital were cited for failing to use face masks properly.

In other instances, surveyors observed personnel tracking blood across floors, wiping down equipment with dirty rags, using blood-testing equipment on successive patients without proper disinfection and failing to change "high-touch" room curtains for more than a year.

"There is very little discipline in a lot of hospitals around infection control," says Leah Binder, president of the Leapfrog Group, a consortium of corporations and other health care purchasers that tracks hospital quality.

"There is very little discipline in a lot of hospitals around infection control," says Leah Binder, president of the Leapfrog Group, a consortium of corporations and other health care purchasers that tracks hospital quality. "If an Ebola patient walks into a hospital that has a high rate of infection for other (illnesses) … they are going to be woefully unprepared for an infection with so little room for error."

USA TODAY reviewed inspection and accreditation data, academic studies and reports by medical associations to assess how hospitals handle infected patients. Many have driven down infection rates substantially with improved staff training, proven housekeeping protocols and quality assurance regimens. But many others continue to have problems:

• More than 250 hospitals surveyed by state and federal regulators from January 2011 through June 2014 were cited for deficiencies in infection control, according to data obtained from the U.S. Centers for Medicare and Medicaid Services. Those hospitals accounted for nearly 15% of 1,815 that were cited for any sort of violation. The facilities cited for infection control lapses were in 44 states, with the highest number in Texas (23), California (16) and Florida (16).

• In the first half of this year, infection control deficiencies were cited in about half of the hospital reviews conducted by the Joint Commission, which accredits more than 75% of the nation's hospitals. Those deficiencies, among the top five issues cited in the commission's reviews, related to hospitals' failure to adequately reduce infection risks linked to medical equipment, devices and supplies, such as sterilization of surgical instruments and proper disinfection of endoscopes.

• In a 2013 Leapfrog survey of more than 1,400 hospitals, more than 30% reported that they did not meet the group's standards for hand-washing education and compliance policies. Though hand hygiene is widely considered to be the most important component of infection-control programs, studies repeatedly have shown that compliance at many hospitals hovers below 70%.

• More than a third of all U.S. hospitals do not have a certified infection prevention specialist on staff, according to a study this year in the American Journal of Infection Control. The Association for Professionals in Infection Control recommends that every hospital have at least one certified infection specialist.

"We know that health care-associated infections are something that U.S. health care facilities continue to struggle with, and we know that things as simple as hand hygiene are not always adhered to," says CDC spokesman Abbigail Tumpey. "So, when we're talking about the complexities of caring for a patient with Ebola, we have to make sure facilities treating them are fully prepared, with practiced procedures and strict infection control protocols that they are going to adhere to."

GOOD NEWS, BAD NEWS

There are plenty of hospitals that do a good job with infection control, and many others have improved substantially in recent years. Medical literature is replete with accounts of hospitals that have lowered infection rates considerably with improved training and better oversight.

The 722,000 infections acquired in hospitals during 2011 represented a decline of 58% from a decade earlier, when the annual number stood at 1.7 million. The number of deaths linked to those infections dropped nearly 25% over the same period.

"The challenges, in some cases, with (infection control) is that we don't know the perfect strategy," says Nancy Foster, the American Hospital Association's vice president for quality and patient safety. "The success we've exhibited over the last couple of years has really been the effect of learning from each other, where hospitals are sharing … the strategies (they've) employed to drive down infection rates."

But even where everyone knows the rules, such as hand-washing and room disinfection, not everyone abides by those standards.

In some cases, weak compliance is a matter of inadequately trained staff or limited resources, says Ana Pujols McKee, the Joint Commission's executive vice president and chief medical officer. But even when all the right equipment and procedures are in place, she adds, infection control is a constant challenge.

"There are a lot of highly technical processes that require precision, each and every time, and there is absolutely zero room for variation," McKee says. "There are high-performing organizations where this is hard-wired into the way they operate … (and) there are some organizations that struggle."

Hospital surveys by state and federal regulators offer plenty of examples:

• More than 60 staff members at Kansas Surgery & Recovery Center in Wichita were observed using surgical masks improperly during a 2012 survey, with most leaving them dangling around their necks as they moved between public and sterilized spaces. The center provided training on use of surgical masks; a follow-up visit found no violations.

• Our Lady of Bellefonte Hospital in Ashland, Ky., was placed in immediate jeopardy of losing its Medicare accreditation in 2012 after inspectors found staff failing to properly disinfect glucometers between uses on successive patients. Within days, the hospital retrained more than 100 nursing staff on glucometer cleaning procedures; ultimately, all members of the nursing staff were retrained.

• At Bakersfield Memorial Hospital in California, surveyors in 2013 observed a technician fail to use shoe covers, tracking blood through an operating room. He and another technician used a bloodstained cloth to clean an equipment cart. A nurse who failed to wear a mask during a patient's biopsy explained the lapse by saying, "I'm very careful." Hospital officials said they retrained staff and strengthened protocols.

• At Houston Methodist Willowbrook Hospital, a 2013 survey found that curtains at the entrance to patient rooms hadn't been cleaned for over a year, despite being "high-touch" areas for patients, medical providers and visitors. After the inspection, the hospital wrote a new policy addressing curtain care, including timetables for cleaning and disinfecting.

• The infection control officer at Fairway Medical Center in Covington, La., "had not obtained any type of certification, and had not received any training or ongoing education in infection control," according to a 2013 survey. The survey was performed after a gastric bypass patient acquired catheter and bloodstream infections, causing cerebral bleeding. The hospital subsequently contracted an outside firm to improve its infection control.

• After at least a half-dozen patients at Advocate Lutheran General Hospital in Park Ridge, Ill., in 2013 were sickened by bacteria found on hospital endoscopes, surveyors found that staff were cleaning them with detergents and brushes not recommended by the manufacturer. The hospital changed its cleaning procedures and added a gas sterilization process; the bacteria have not been found since.

"It seems a bit shaky to base our defense against Ebola on an industry sector that frankly does not seem up to the challenge," says John Santa, a physician and former health system administrator who now heads the Consumer Reports Health Ratings Center.

"It is likely a subset of hospitals can provide optimal care to an Ebola patient and optimal protection to their employees," he adds. The challenge for the CDC is "to identify that subset and figure out mechanisms to get patients with Ebola or at risk of Ebola to those hospitals."

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