Ten hospitals in the St. Louis area logged infection rates in 2009 that were worse than the national average in one or more of their intensive care units, according to data the hospitals provide state health officials.
In addition, 12 area hospitals posted infection rates last year that were worse than the national average for one or more types of surgery for various patient risk groups.
The Post-Dispatch reviewed hospital data from 2005 through 2009, the first years the information was made public after Missouri began requiring hospitals to release infection rates for their intensive care units and three types of surgeries.
Though the numbers cover a small portion of hospital operations, the data provide the most direct way for the public to review how well hospitals are preventing patient infections.
The stakes are high for both the patient and the hospital.
Almost 100,000 people die each year from health care associated infections, more than the toll from car crashes and breast cancer, according to the Centers for Disease Control and Prevention. One out of every 22 patients who checks into a hospital acquires an infection of some sort.
"For decades, we thought those deaths were inevitable, the result of caring for sick patients," said Dr. Peter Pronovost, who specializes in patient safety at Johns Hopkins University School of Medicine in Baltimore. "We now know that most of those deaths are preventable with focused efforts."
Even in their mildest form, health care associated infections can aggravate an illness, prolong recovery and increase the cost of medical care. Some infections require intensive treatment with antibiotics, diagnostic testing and additional surgery.
Hospitals of all types - whether urban or rural, academic or private - are in a constant battle to prevent potentially life-threatening infections. Barnes-Jewish Hospital, the area's largest medical center, has reported infection rates worse than the national average for five consecutive years in its coronary intensive care unit.
"We're not happy with our (infection) rates in any category, but we're continually improving," said Dr. John Lynch, chief medical officer at Barnes-Jewish. "Over time, all these rates are dropping for the patient."
Many of the 21 area hospitals that were reviewed have reported infection rates worse than the national average for at least two consecutive years in either an intensive care unit or for a specific surgery. On the positive side, more than half of the hospitals, including Barnes-Jewish, have shown improvement in one or more categories.
At St. John's Mercy Medical Center in Creve Coeur, the hospital's coronary intensive care unit and its combined medical/surgical intensive care unit recorded rates of central line bloodstream infections that were better than the national average for each of the five years that were reviewed. (A central line is an intravenous tube that delivers medicines and fluids.)
Still, St. John's infection rates in recent years have been worse than the national average for hip repair surgeries and abdominal hysterectomies for patients of various risk groups.
Among midsized hospitals, St. Mary's Medical Center has logged infection rates worse than the national average for four of the last five years in its surgical intensive care unit and its medical, or nonsurgical, ICU. St. Louis University Hospital reported infection rates worse than the national average for the last three years in its medical ICU.
Smaller hospitals reported few if any infections, but some had infection rates worse than the national average because of their low patient volumes.
Hospitals that lag the national average for infection rates must make prevention a greater priority, Pronovost said. To continually perform poorly against the national average suggests that a hospital's leadership simply doesn't get it, he added.
"Even large academic medical centers, even large hospitals, have been able to dramatically reduce these infections with a combination of accountability for measuring the rates, ensuring that patients receive best practices, and most difficultly, changing the culture of medicine."
A 2004 Missouri law requires hospitals and outpatient surgical centers to collect and report certain infection data to the state Department of Health and Senior Services, which posts the information online for consumers.
"It's a form of competition," said Rep. Rob Schaaf, R-St. Joseph, a family physician who sponsored the legislation. "When one hospital sees another hospital with a lower infection rate, they do what they can do to improve."
Mixed results
The infection rates of intensive care units vary significantly.
Barnes-Jewish Hospital's infection rate in its surgical intensive care unit is exemplary, but the hospital's coronary intensive care unit lags behind.
Dr. David Warren, the hospital's epidemiologist and a faculty member at Washington University School of Medicine, attributed the coronary unit's higher infection rates to the high-risk nature of its cases, which includes cancer patients, transplant patients and others with underlying chronic conditions.
"One of the challenges we face in the (coronary unit) is the patient population," Warren said. "We're a center for congestive heart failure. We see a lot of patients who are on the list for heart transplants."
There are numerous factors that might influence infection rates. Smaller rural hospitals generally have better infection rates than larger, urban hospitals that see more complicated trauma cases. Also, patients treated at academic medical centers are likely to be sicker or require more complex medical care.
There are 16 beds in Barnes-Jewish Hospital's coronary intensive care unit, whose case load includes patients who suffer heart attacks and severe heart failure. No surgeries are performed there, but the staff does cardiac catheterizations.
"The (infection) rates have actually come down this year," said Warren, who provided data indicating that the coronary unit's infection rate matches the national average this year. "We've reviewed their insertion techniques, how nurses access their catheters, how they clean them, how they draw blood cultures. We've been working with that staff."
Barnes-Jewish also has struggled to reduce infections linked to its hip repair surgeries. In three of the last four years, its infection rates for these surgeries have been worse than the national rate for higher-risk patients. For lower- and moderate-risk patients, Barnes-Jewish's rates have been better than the national average since 2006.
St. Mary's Health Center outperformed Barnes-Jewish on hip repair infection rates four years in a row for higher-risk patients and in three of the last four years for lower- and moderate-risk patients.
Barnes-Jewish surgeons "are acutely aware of their (infection) rates," said Warren. He noted that the hospital's orthopedic surgeons performed more complex procedures than other local hospitals, and that many of its patients had undergone previous hip repair surgeries.
"Because we're an academic referral center," he said, "our surgeons take patients that community orthopedists would not operate on."
Lynch explained that national infection rates do not make adjustments for socioeconomic factors. Barnes-Jewish serves many low-income patients who may be less able to take their post-operative medication, which can trigger infections. The hospital's higher infection rates also may be a consequence of its superior reporting of infections, Lynch said.
"A lot of hospitals can't look that clearly at the data," he said. "We do active surveillance in all the ICUs. We don't miss anything."
St. Mary's Health Center, which is run by the nonprofit SSM Health Care system, has its own issues with infections.
In each of the last four years from 2006 through 2009, St. Mary's surgical intensive care unit logged a worse central line infection rate than the surgical ICU of Barnes-Jewish. St. Mary's rate was more than three times the national average in 2008.
Similarly, St. Mary's medical intensive care unit posted a worse infection rate than the medical ICU of Barnes-Jewish for five years straight. In 2007, St. Mary's medical ICU's infection rate was nearly four times the national rate.
St. Mary's surgical and medical ICUs performed better in 2009 but still posted infections rates that were slightly worse than the national average, though relatively equal to hospitals of its size.
"Those numbers are unacceptable to us," said Dr. Kevin Johnson, the SSM system's chief medical officer, noting that St. Mary's infection rates in the last 18 months have improved significantly. He provided data indicating that the hospital has had only one central line infection in the last six months.
"St. Mary's has taken a very aggressive approach on this and has implemented all the best practices," Johnson said. "The national average doesn't mean anything. We want zero infections."
A hospital's higher infection rate for a specific procedure does not necessarily mean lower quality of care.
From 2005 through 2009, Missouri Baptist reported no infections in its neonatal intensive care unit. And for two years in a row, Thomson Reuters has named Missouri Baptist one of America's 100 best hospitals. Barnes-Jewish, in turn, was recently ranked No. 8 in the nation by U.S. News & World Report's Honor Roll of America's Best Hospitals.
resistant bacteria
The proliferation in recent years of antibiotic-resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) has magnified the risk of infection for hospital patients.
Such bacteria can spread from one patient to another, and even survive for extended periods of time on hospital walls and fixtures. Some patients, including the elderly and those who suffer from cancer, diabetes, and compromised immune systems, are especially vulnerable to infections.
Bacteria can invade a patient's bloodstream or fester in the area of surgery. Infections can occur when needles, tubes or scalpels are inserted through a person's skin, normally the body's shield against bacteria and other organisms.
Bloodstream infections are often associated with a central line that is inserted near the patient's heart or into a large vein or artery. Many surgical site infections are superficial, involving the skin only; some are deeper and more pernicious.
Infections associated with coronary artery bypass surgery are among the most potentially dangerous. Studies indicate that these infections can often cause death and that patients who survive tend to be more prone to additional illness. In 2008, Medicare stopped reimbursing hospitals for coronary artery bypass surgeries that resulted in infection.
In two of the last three years, Missouri Baptist Medical Center reported the worst local infection rate for higher-risk patients who undergo a coronary artery bypass graft, a form of open-heart surgery. In 2008, its infection rate of 9.4 patients per 100 procedures among higher-risk patients was nearly twice the national average. For moderate-risk patients, its infection rates have been consistently better than the national average for these surgeries.
Dr. Timothy Ranney, chief medical officer at Missouri Baptist, said hospital officials began to investigate the situation four years ago but found no specific root cause. The higher infection rate persisted in 2007 and 2008 despite quality improvement measures, Ranney said. The infection rate improved last year.
"The ideal is zero," Ranney said. "Patients recover quickly without complications of any kind."
other infections
Missouri law requires hospitals to provide data to the state for infections that occur in intensive care units, or infections that follow three specific surgeries - abdominal hysterectomy, coronary artery bypass graft and hip repair.
Most infections, however, occur in hospital wards that are not part of intensive care units, consumer advocates say. Also, they note, infections are associated with numerous surgical and medical procedures that are not covered by the state's reporting law.
"Unless the patient or the patient's loved one falls into one of the narrow categories being reported on, the data is not going to be that helpful," said Karen Roth, research director at the St. Louis Area Business Health Coalition, a nonprofit group whose members include some of the area's largest employers.
For example, Missouri hospitals are not required to report those infections that occur outside of the ICU on hospital floors where central line catheters are used to care for the acutely ill, or for patients who require long-term delivery of intravenous medications or nutrition.
Similarly, other states have focused on infections associated with different surgeries, including knee replacement, spinal fusion, Caesarean section, colon, gallbladder and vaginal hysterectomy surgeries.
Although Missouri provides at least some means to review hospitals' ability to prevent infections, more needs to be done, said Lisa McGiffert, director of Consumers Union's national Safe Patient Project.
"We definitely believe its time to move out of the ICU and get the rest of the hospital."
