Authors: Jamie Riggs, Elisa Chimonides
Elisa Chimonides is the Manager of the Quality, Safety and Clinical Adoption team at the University Health Network. Elisa has expertise in large-scale organizational change initiatives, improvement science, and change management. She has her Master’s of Health Administration from the University of Toronto’s Institute for Health Policy Management and Evaluation program and is a Project Management Professional (PMP).
It’s another Friday morning on the ward, and you are looking forward to discharging one of your patients home to spend time in their garden over the weekend. Ms. Jones is an 83-year-old lady admitted a few days ago with what turned out to be a urinary tract infection. Initially weak and slightly confused, after some IV fluids and oral antibiotics, she has been back to her peppy self over the past day. As you start your rounds for the morning, one of the medical students mentions that Ms. Jones seems more confused than yesterday, and that furthermore she looks like she has a bruise on her side. Walking into the room just as the nurse is finishing a set of vital signs, you notice a temperature of 38.1 flash up on the thermometer.
Welcome to the HiQuiPs Patient Safety Primer. In partnership with experts in Quality, Patient Safety and Clinical Adoption from the University Health Network (UHN), a healthcare organization in Toronto, we aim to bring you succinct, high-yield posts exploring issues that continue to be associated with significant morbidity and mortality for patients: adverse drug events, surgical site infections, falls and more!
Hospital Acquired Infections
A common theme throughout each of these posts will be the focus on hospital acquired conditions. Simply stated, hospital acquired conditions are issues that a patient develops while being treated for something else. Perhaps the most common and well studied of these hospital acquired conditions are a group of adverse events known as healthcare associated infections. A healthcare associated infection is an infection that develops as a result of exposure to a healthcare facility or procedure. (1) Common examples include infections associated with central lines and indwelling urinary catheters, both topics that will be featured in upcoming posts.
How big is this problem?
Taken as a group, healthcare associated infections are unfortunately common, estimated to affect 1 in 25 patients at any given time in the United States.(2) In Canada, data shows approximately 1 in 9 admitted patients will develop a healthcare associated infection.(3) Besides the added suffering of patients and their families, healthcare associated infections add extra costs into the healthcare system and the wider economy. Each infection means extra time in hospital, added treatments, more lab tests, medications, let alone the additional time and resources of nurses, physicians, and allied healthcare staff.(4)
Canadian researchers estimate that healthcare associated infections are linked to thousands of deaths per year.(5) Other researchers have found that after adjusting for other factors that might influence length of stay, patients with a healthcare associated infection, compared to uninfected patients, stayed in hospital an average of 11 days longer, incurred 2.9 times greater hospital costs, and incurred 3.2 times greater post-discharge costs.(6)
When faced with this sort of data, it becomes clear why healthcare associated infections have been a major focus of patient safety practitioners over the world.
What can we do about it?
Healthcare has turned to the principles of High Reliability Organizations to build safer systems and improve patient care outcomes by: (1) having a heightened awareness of operations; (2) being preoccupied on failures (even near misses); (3) deferring to experts (e.g. front line staff); (4) practicing resilience; and (5) being reluctant to simplify.(7)
The UHN is on a journey to becoming a HRO. In 2017, UHN committed to making healthcare safer. One of UHN’s major organizational focuses between 2018 and 2021 was on reducing hospital acquired conditions, which included central line infections, c. difficile infections, and surgical site infections. UHN has been able to reduce the rates of these three preventable hospital-acquired infections by adopting High Reliability Organization principles. Specifically, for each healthcare associated infection, evidence based bundles were created and implemented with stakeholders and subject-matter experts. In this series of posts, we will explore various hospital acquired conditions and offer examples on how UHN applied HRO principles to reduce them.
As you can see, hospital acquired infections are linked with increased mortality and morbidity and increased healthcare utilization. High Reliability Organizations can help reduce the incidence of hospital acquired infections and improve patient care.
Unfortunately, it seems as if Ms. Jones has developed a number of conditions related to her stay in hospital. After assessing her, you decide that she has most likely had a fall, and also may be developing an infection. After ordering a CT scan of her head, adding on some bloodwork and starting a new course of antibiotics, you let her know that she will need to stay in hospital for the weekend. After updating the disappointed family, you wonder what, if anything, could have been done differently to get Ms. Jones home to her garden a little bit earlier.
That's it for the first instalment in our 4-part series on Patient Safety Fundamentals in partnership with the University Health Network. Let us know what you think on Twitter at @Hi_Qui_Ps. If there is anything specific you would like to learn about, e-mail us at hiquips@gmail.com. Stay tuned for Part 2 of our series on Patient Safety Fundamentals. Next post's topic: Reducing Central Line Associated Blood Infections!
Senior Editor: Dr. Lucas Chartier
Copyedited by: Daniel Dongjoo Lee
References
Provincial Infection Control Network - BC (PICNet). An Assessment of Infection Control ActivitiesAcross the Province of British Columbia (Corrected v1.0-2007). 2006. Accessed October 19, 2021 at http://picnetbc.ca//sites/picnetbc2/files/PICNet_Publications/PICNet_Needs_Assessment_Part_1_Corrected_final_2.pdf
Magill SS, Edwards JR, Bamberg W, Beldavs ZG, Dumyati G, Kainer MA, Lynfield R, Maloney M, McAllister-Hollod L, Nadle J, Ray SM, Thompson DL, Wilson LE, Fridkin SK; Emerging Infections Program Healthcare-Associated Infections and Antimicrobial Use Prevalence Survey Team. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014 Mar 27;370(13):1198-208. doi: 10.1056/NEJMoa1306801. PMID: 24670166; PMCID: PMC4648343.
Zoutman DE, Ford BD, Bryce E, Gourdeau M, Hébert G, Henderson E, Paton S; Canadian Hospital Epidemiology Committee; Canadian Nosocomial Infection Surveillance Program; Health Canada. The state of infection surveillance and control in Canadian acute care hospitals. Am J Infect Control. 2003 Aug;31(5):266-72; discussion 272-3. doi: 10.1067/mic.2003.88. PMID: 12888761.
Gould IM. Costs of hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) and its control. Int J Antimicrob Agents. 2006 Nov;28(5):379-84. doi: 10.1016/j.ijantimicag.2006.09.001. Epub 2006 Oct 11. PMID: 17045462.
Van Iersel, A.. Infection Control: Essential for a Healthy British Columbia. The Provincial Overview. Victoria BC: Office of the Auditor General of British Columbia. 2007 Accessed September 15, 2021 at http://www.bcauditor.com/PUBS/2006-07/Report11/ProvincialOverview.pdf
Plowman R, Graves N, Griffin MA, Roberts JA, Swan AV, Cookson B, Taylor L. The rate and cost of hospital-acquired infections occurring in patients admitted to selected specialties of a district general hospital in England and the national burden imposed. J Hosp Infect. 2001 Mar;47(3):198-209. doi: 10.1053/jhin.2000.0881. PMID: 11247680.
Weick KE, Sutcliffe KM, Obstfeld D: Organizing for high reliability: processes of collective mindfulness. In Research in Organizational Behavior. Volume 21. Edited by: Sutton RI, Staw BM. Greenwich, CT: JAI Press; 1999:81-124.