Secondhand woes

The Baltimore Sun had an article this week on reprocessing of single-use devices. This was quite a controversial topic for hospital epidemiologists about 10 years ago, but I hadn't heard much about it recently. Now there's a new argument for it--it's good for the environment. I also think the green argument could be used to encourage alternatives to contact precautions giving the vast amount of consumables it requires. Anyway, in 2001, I wrote a piece about reprocessing of single-used devices that has survived multiple hard-drive to hard-drive transfers but I never did anything with it. So I dug it out and pasted it below.

Secondhand Woes

Healthcare is not the profitable venture it once was and hospitals in the United States have fallen on hard times. In an attempt to stay afloat, hospitals have looked long and hard at ways to reduce cost. To that end, healthcare consulting firms have advised hospitals on numerous ways to cut corners, going so far as to recommend that bed linens not be changed on a daily basis.

One area of cost savings that hospitals have found quite tempting to explore is the re-use of medical devices that are labeled by the manufacturer for single use only. Obviously manufacturers of medical devices have an incentive to label products as single use so that more devices will need to be purchased. However, some devices should be used one time only based on the type of materials used in manufacturing or by a design so intricate that cleaning of the device is not feasible. Nonetheless, many single-use devices can be appropriately sterilized without damaging the integrity of the product, and reused without difficulty. Consider the case of the $600 catheters that are used by cardiologists to test the heart for abnormal rhythms. These catheters are typically inserted into a major blood vessel and threaded into the heart. Many hospitals have found that the reuse of these catheters after sterilization can result in significant cost savings. This is only one example of the hundreds of products labeled as “single use” that can be reused after appropriate reprocessing.

In response to the increasing frequency with which single-use devices are being reused in hospitals, the FDA has issued guidelines to standardize the cleaning and sterilization process so that the reused devices are safe for patients. This will heighten the accountability of hospitals and businesses that provide reprocessing services.

As a physician trained in infectious diseases, microbiology and public health, I must admit that I am bothered more by the ethical issues surrounding reuse of devices labeled as single use only, than I am about the potential for the transmission of infectious diseases via these devices.

Clearly, there does exist a small risk of transmission of infectious diseases via reused devices. However, it seems likely that this risk is no higher than for the thousands of devices designed for reuse, and which are, in fact, routinely reused after sterilization. Most surgical instruments, for example, are reused on a daily basis in hospitals without any problem. Of course, any process that involves humans is inherently prone to error and therefore entails some risk.

The ethical questions surrounding reuse of single use devices are, I believe, more challenging. First, do patients have the right to know if their procedure will involve the reuse of a product designed and labeled for single use? If they have this right, do they have the right to request that a new device be used for their procedure? And what do we do when patients refuse to accept a used device?

The ethical quagmires don’t end there. Much of the cost savings that can be generated by reusing devices occurs by charging all patients the cost of a new device, even though some patients will not get a new device. How many of us would be willing to pay the factory sticker price for a used automobile? Moreover, how incensed would we be if we paid the sticker price for a car we thought was new, but was not? We have laws that prevent this type of fraudulent activity.

Lastly, which patients will receive the new devices and which ones will get the reused? Could it be that indigent patients will end up with the hand-me-downs, while insurance-card-carrying patients will get the shiny, new ones?

The ethical questions are really not that difficult to resolve. First, hospitals should inform patients on admission about their policy for reuse of single-use devices and supplement this with a brochure that gives patients who want more detail the information they need. Physicians performing procedures involving these devices should ensure that patients understand the issues. Secondly, it is imperative that hospitals that decide to reuse devices develop a system that insures that the selection of a device for a patient is done in a completely random manner. In this way, the corporate executive stands the same chance of receiving the used device as does the man who lives under the bridge. Lastly, the charges for devices must be adjusted to reflect the number of times a product can be used. If a product can be reused five times, then the charge for the product should be the new charge divided by five, plus the cost of reprocessing. If hospitals prorate the charges, the financial impetus to reuse devices may melt away.

The patient must come first. And putting patients first requires honest dialogue. Healthcare administrators must not allow the bottom line and deceptive practices to be guideposts for the way that we provide care because the doctor-patient relationship is too precious to be subjected to harm by dishonesty. What’s best for the patient is, in the end, what’s best for all of us.

Move over, MRSA!

This morning's New York Times has a piece by Andrew Pollack on healthcare associated infections. That in itself is not a surprise anymore since the general public is quite interested in the topic. What is surprising is that the article isn't about MRSA--it's about Acinetobacter and the lack of effective drugs to treat multidrug resistant gram-negative organisms. Could this be a harbinger that the fixation on MRSA is starting to wane? Pollack remains, to my knowledge, the only journalist that has linked the frenzy to culture inpatients for MRSA with big profits by the companies who manufacture the MRSA testing kits.

Preventing nosocomial bloodstream infections in children

As is the case in many areas of health care, there is less published literature on nosocomial infection prevention in children than in adults. So it is nice to see some multicenter data on central-line associated bloodstream infection (CLABSI) prevention in kids. The bottom line: in 29 pediatric intensive care units (PICUs) across the U.S., implementation of bundles for line insertion and maintenance resulted in a 43% reduction in CLABSI rate (from 5.4 to 3.1 infections per 1000 central line days). One of the interesting findings from this study was that adherence to the “maintenance bundle” seemed to be more important for CLABSI prevention than did adherence to the “insertion bundle”. See here for what each bundle included.

Designing out the bugs, take 2

Mike posted last week on a UK design competition for products that might improve infection control in hospitals. Now there is a newly designed keyboard that can be easily cleaned with a disinfecting wipe because it's totally flat. There's a trackpad on the keyboard, thus removing another source of contamination - the mouse. The cleankeys keyboard can be purchased here. The cheapest version sells for $400. Hopefully with scale, the price will come down.

Importance of Family

This isn't a typical post. I'm not linking to any new research findings. Rather, I wanted to refer you to a story I just read on Paul Levy's blog about a friend of his who just died from synovial sarcoma. The story is really the remarks the deceased's daughter gave at his memorial service. She describes how she and her dad worked together to fight his disease; she would read the literature and sift through the statistics and give her dad just the information he needed to keep fighting. I found it particularly moving.

There may be some lessons in there about how families can prevent their loved-ones from developing an HAI. Perhaps we need to figure out ways to engage family members to be constantly vigilant of hand hygiene and glove compliance, for instance. The literature seems to suggest that a continuous Hawthorne effect is the most effective way to improve compliance with hand hygiene. If we can empower daughters and sons and mothers and fathers, like this daughter was empowered, it could make a big difference.

Compliance with contact precautions: Not so much

Elaine Larson's group has a new study in the American Journal of Infection Control that examines compliance with contact precautions at 3 hospitals in New York City. She found that 15% of patients who had indications for contact precautions were actually not isolated. For patients who were isolated, hand hygiene by healthcare workers on room entry was very low at 22% and on room exit at 59%. Compliance with gowns was 71% and with gloves 72%.

With the compliance levels demonstrated here it seems unlikely that these hospitals could be successfully preventing infections. I am increasingly convinced that effective infection prevention hinges on high levels of compliance with very basic practices. It's not rocket science.

HAIs: An even bigger problem than we thought?

Our fellow blogger, Eli, has co-authored an interesting study in this month’s Archives of Internal Medicine. Using a national administrative database that contains 69 million hospital discharges, the investigators examined the attributable outcomes associated with two hospital-acquired infections—sepsis and pneumonia. The outcomes were stratified as to whether they occurred in association with a surgical procedure or not. When sepsis occurred post-operatively, it added on average 11 days to the hospital stay and $33,000 to the cost of care, and carried a nearly 20% attributable mortality. Post-operative pneumonia on average added 14 days to the stay and $46,000 to the cost of care, and had an attributable mortality of 11%. For cases not associated with surgical procedures, when adjusted for the preinfection length of stay, sepsis on average added 2 days to length of stay at an additional cost of $6,000, and was associated with an attributable mortality of 16%. Hospital acquired pneumonia in nonsurgical patients added 4 days to length of stay on average, added $11,000 to the cost of care, and had an attributable mortality of 10%. Extrapolating to the US population, the investigators estimated that these two conditions account for over 2 million hospital days, $8 billion in costs, and 48,000 deaths.

Diving into the murky sea of administrative data is a perilous business, but the authors of this paper took great pains to use diagnoses for which validation has been shown to be high level and were careful in their methods to minimize bias and confounding (the methods section of the paper is about twice as long as the results). The incidence of each of these complications is about 1% or less, which makes it difficult for the average clinician to assess impact in their patients. Importantly, what this study does not tell us is the fraction of these cases that are preventable. However, even if only a quarter are preventable, this paper tells us that healthcare associated infections are a big, big problem, and those of us who work in infection prevention have a very long journey ahead. 

Lastly, this study should remind us that our targets should be infections not organisms. This problem is too big to tackle one organism at a time. To the patient with life-threatening sepsis, it matters little whether the cause is MRSA, MSSA, or a multidrug-resistant gram negative rod. Multipotent interventions driven to high levels of compliance will be necessary to ultimately bring these infections to the irreducible minimum.