Issues Of The Environment: Fighting Superbugs And Hospital Infections

May 11, 2016

Dr. Lona Mody, Professor of Internal Medicine at the University of Michigan
Credit Courtesy Photo / University of Michigan

One out of every four senior citizens contract multi-drug resistant infections, or superbugs, after a hospital stay.  In this week's "Issues of the Environment," WEMU's David Fair speaks with Dr. Lona Mody, Professor of Internal Medicine at the University of Michigan, on ways to resist these powerful bugs.


Overview

  *   The hands of patients, rather than medical staff who practice systematic hand hygiene, are a significant source for multidrug-resistant bacteria that can lead to life threatening infections, particularly in the elderly.  A recent University of Michigan study found that 1 in 4 seniors have superbugs on their hands after a hospital stay.

  *   Hospitals in our listening area were recently given grades for safety, which for the first time included grades for health care-associated infections.  Michigan does not mandate reports on health care-associated infections.  Four times lawmakers rejected reforms.

Superbugs from Hospitals and Post-acute Care Facilities

Nurses are used to hearing about hand hygiene best practices for health care workers, but patients may need more help and training in this area. Findings from a recent University of Michigan study found that 1 in 4 seniors have superbugs on their hands after a hospital stay.  Moreover, seniors who go to a nursing home or other post-acute care (PAC) facility will continue to acquire new superbugs during their stay, according to the researchers’ findings, published in a JAMA Internal Medicine research letter.

The study focused on patients who have recently been admitted to the hospital for a medical or surgical issue and temporarily need extra medical care in a PAC facility before fully returning home.  Older people often need extra time in a post-acute care facility for rehabilitation after common procedures, such as hip and knee replacements.

The research team studied 357 such seniors who were admitted from the hospital to several PAC facilities in southeast Michigan.  One-quarter of these patients (24.1%) had at least one multidrug-resistant organism (MDRO), or superbug, on their hands when they checked in.

Researchers tested the same patients’ hands after two weeks and then monthly, for up to six months or until their discharge home from the post-acute care facility.  During the follow-up visits, they found not only did these organisms persist, but even more seniors acquired superbugs on their hands--up from one in four (24.1%) to more than one in three (34.2%).

“We’ve been educating health care workers for decades about hand hygiene, and these numbers show it’s time to include patients in their own hand hygiene performance and education,” says lead author Lona Mody, M.D., M.Sc. Mody is the associate chief for clinical and translational research at the U-M Geriatrics Center and a research scientist at the Ann Arbor VA Geriatrics Research Education and Clinical Center.

A high level of MDROs on patient hands increases the chance that these superbugs will be transmitted to other frail patients and health care workers. Frequent antibiotic use in post-acute care patients also increases the probability that MDROs introduced to a post-acute care facility will flourish.

Because of overuse of antibiotics in many healthcare settings, certain strains of several infectious bacteria have evolved to be resistant to treatment with the drugs--making them even more dangerous than other strains.  The Centers for Disease Control and Prevention issued a new report in March on hospital-acquired infections including those involving superbugs, and called for increased efforts to prevent them from spreading.

A Change in Culture

Mody notes that today’s aging patients want to be active, much more than in the past. They often choose to stay in facilities that offer group activities and social events. However, when people leave their room often, they’re more likely to touch areas of a care facility’s environment, healthcare workers and other patients--which puts them at risk for acquiring new MDROs.

Increasing numbers of seniors bringing hospital superbugs through the revolving door of the PAC facilities for short stays (as opposed to living long-term) means new policies and innovations are needed to stop the superbugs from spreading more deeply into the post-acute care facilities, Mody says.

Adapting Staff Lessons to Patients

“Patient hand washing is not a routine practice in hospitals,” says Mody, also U-M’s Amanda Sanford Hickey, Collegiate Professor of Internal Medicine and a member of U-M’s Institute for Healthcare Policy and Innovation.  "We need to build on the overarching principles we’ve already developed with adult learning theories and bring them to patients.”  One strategy includes physically showing the superbugs that grow on people’s hands, by growing them in the lab.

“People are always surprised when they see how much can grow on their hands--and how they can effectively clear these organisms by simply washing hands appropriately,” Mody says.

Mody and her team developed a toolkit for PACs to use in training employees to control infections, called the Targeted Infection Prevention (TIP) Study Toolkit.  It could also be adapted to a patient audience, including:

  • Educational posters about hand hygiene

  • Educational modules and trivia questions about hand hygiene

  • An infection preventionist on-site to ensure availability of hand hygiene products, including alcohol gel for personal use 

Proper Hand Hygiene to Prevent Superbugs

Because of the amount of antibiotics and cleaning agents used in medical settings, the germs that survive build up a resistance that makes them more likely to outlast a defensive attack by a person's immune system.  Since elderly patients are already more prone to infections, having these bacteria in their homes can be dangerous, especially during a recovery period.  The Centers for Disease Control and Prevention stated that about 2 million people become infected by antibiotic-resistant bacteria each year in America, and an average of 23,000 of them will die from the infection.  The elderly are the most likely demographic to have serious health consequences from these germs.

The best way to prevent infections from these superbugs is a simple one - the patients need to maintain a regular hand washing routine. "We've been educating healthcare workers for decades about hand hygiene, and these numbers show it's time to include patients in their own hand hygiene performance and education," said the lead author of the study, Dr. Lona Mody, associate chief for clinical and translational research at the U-M Geriatrics Center. "People are always surprised when they see how much can grow on their hands- and how they can effectively clear these organisms by simply washing hands appropriately."

According to the CDC, proper hand washing should be done

  *   Before preparing food, eating, or tending to any kind of open wound

  *   After preparing food, using the restroom, cleaning up, touching a pet, blowing their nose or sneezing.

Make sure that your elderly loved one knows the proper way to wash his hands. It may seem silly, but washing hands for the right amount of time is essential for making sure it is effective.

  1.  Wet the hands thoroughly with cool or warm water.

  2.  Thoroughly lather hands with soap, making sure to get the less obvious areas like between the fingers and under the fingernails.

  3.  Scrub the hands for at least 20 full seconds.

  4.  Rinse completely under running water.

  5.  Dry hands with a clean towel.

By following the CDC's steps carefully, your senior can help eliminate the harmful bacteria that he brings home with him from the hospital. 

2016 Hospital Safety Score Ratings

When it comes to prevention of avoidable errors, accidents and patient infections, five Michigan hospitals are receiving consistently high marks from a biannual study ranking patient safety across the United States.  University of Michigan Hospitals in Ann Arbor was one of five Michigan hospitals that received "straight 'As' in the latest Hospital Safety Score ratings; published each spring and fall since 2012 by the Leapfrog Group, a national watchdog nonprofit that uses surveys and government data to assign letter grades for patient safety.  Straight 'As' means an 'A' grade was given in each iteration of the report, which calculates a numerical safety score for more than 2,500 U.S. hospitals.

Local Hospital Grades

  *University of Michigan Hospitals in Ann Arbor - As

  *Chelsea - St. Joseph Mercy Hospital - As and one B

  *Ypsilanti - St. Joseph Mercy Hospital - 3 As, 2 Bs, 2 Cs (Cs for 2016)

  *Livingston (Howell) -  St. Joseph Mercy Hospital - 2 Bs, 5 Cs

  *Oakland (Pontiac) -  St. Joseph Mercy Hospital - 5 As, 1 B, 1 C (B and C for 2016)

The grades are correlated with patient safety. Each hospital grade includes a full score breakdown that rates performance on factors like prevention of infections, bed sores, falls and embolisms; leaving of objects in a patient's body during surgery, broken stitching, computerized medication prescribing, staff handwashing, nurse-to-patient ratios and effectiveness of leadership in preventing such errors.

According to the Centers for Disease Control and Prevention, about 1 in 20 hospitalized patients daily across the U.S. catches an infection caused by receiving medical care. In total, the Leapfrog analysis showed an estimated 206,021 avoidable deaths occur in U.S. hospitals each year (not all from infection) and 33,439 of those lives could be saved annually if all hospitals had the same performance as those receiving an 'A.'

When it comes to an avoidable death after a patient checks into a hospital, the Leapfrog Group says the findings point to a 9 percent higher risk in 'B' grade hospitals over 'A' grade hospitals. That risk factor increases to 35 percent in 'C' grade hospitals and 50 percent in 'D' and 'F' grade hospitals. The 'C' grade is "where things start to get sketchy," said Bret Jackson, president of Economic Alliance for Michigan, a nonprofit business and labor union group which partnered with Leapfrog Group on the hospital ratings effort.

Underperformers included Hurley Medical Center in Flint, McLaren Macomb in Mt. Clemens, and U.P. Health in Marquette, each of which got a 'D' in the latest ratings.  The Michigan Health & Hospital Association called the Leapfrog ratings "one tool" among many for consumers to make hospital choices.

Beaumont received 'C' grades for its hospitals in Grosse Pointe, Farmington Hills, Royal Oak, and Wayne. The rest of the group's hospitals rated a 'B.' "The Leapfrog Group's safety grades do not provide an accurate picture of the quality efforts in many hospitals and favor hospitals that participate in their voluntary hospital survey," Beaumont said.

Jackson said the Leapfrog methodology was developed by a "blue ribbon patient safety expert panel" that includes experts from Johns Hopkins, Massachusetts General Hospital, and other leading U.S. medical centers.  It has been peer-reviewed and published in patient safety medical journals, he said.  "It's been validated and in use for many years," he said.  Scores are derived from government data from the Centers for Medicare and Medicaid Services (CMS), the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention, and the Leapfrog Hospital Survey.

Jackson said Leapfrog used the most recent data available and hospitals that didn't participate in the survey weren't penalized, but the government data was weighted differently to account for the lack of volunteered information when the nonprofit was analyzing data to produce a single composite score. Grades are not "on a curve" and every hospital has an equal chance at a good score. "It's a pretty accurate representation of how safe that hospital is," he said.

Jackson said that top-performing hospitals have demonstrated an institutional culture of safety that comes, mainly, from safety-oriented leadership.  Administrators make rounds, talk to patients and staff and empower employees to be observant instead of focusing on assigning blame for mistakes.  "They're asking for suggestions and taking responsibility, but yet working on how they can correct mistakes so they don't happen in the future," he said.

Grading for ‘Superbugs’ in Michigan for the First Time

Although many states require hospitals to report rates of infections like MRSA (Methicillin-resistant Staphylococcus aureus), C. diff (Clostridium difficile), CAUTI (catheter-associated urinary tract infection), CLABSI (central line-associated bloodstream infections), or other surgical site infections, Michigan does not. Leapfrog said the spring 2016 safety scoring measures MRSA and C. diff for the first time.

Michigan is the nation's second-most populous state that does not mandate reports on health care-associated infections. Talks between the industry and state health officials about requiring greater transparency stalled in 2014. 

Michigan is Less Transparent than Other States Regarding Hospital Infection Rates

  • Michigan is the nation’s second-most populous state that does not mandate reports on health care-associated infections.  Four times lawmakers rejected reforms.  Thirty-one other states demand them.

  • Still, about half of Michigan’s 169 hospitals voluntarily supply information to the state – with a catch.  The hospitals demand, by contract, that the information be kept anonymous.

  • Regardless, the state is free to release the data, MLive discovered.  The secrecy protections are invalid - and have been for years, documents show. Still, the Michigan Department of Community Health will not release the information.  Nor will it even confirm which hospitals provide it. The department rejected a Freedom of Information Act request and requested hundreds of dollars to disclose internal emails generated by MLive’s questions. “Just because language may be in (state contracts allowing publication of individual hospital rates) does not mean we have to publish it anywhere else,” said Angela Minicuci, department spokeswoman.

An executive with the Michigan Health & Hospital Association – the state’s fifth-largest lobbyist last year – says concern about health care-associated infections ranks 10 on a scale of 10, the highest level.  But of the state’s largest hospital systems, few provide details on their websites, MLive found.

Unintended Consequences of Antibiotic Overuse

Antibiotics are considered the keystone of modern medicine, but their excessive use continues to generate unwanted side effects.  The U.S. Centers for Disease Control and Prevention (CDC) isn’t historically known for using pessimistic language, but lately they’ve been sounding the alarms about the consequences of overusing antibiotics.

CDC director Tom Frieden has warned of “nightmare bacteria,” those that have evolved defenses against modern antibiotics. This leads to to strains that can cause fatal infections. While specialists are making strides to preserve the effectiveness of antibiotics and to slow potential infections through better policy, the overuse of antibiotics continues to have severe health consequences for the U.S. and around the world.

1.  Antibiotics Help Teach Good Bacteria to Go Bad - Bacteria have evolved defenses against antibiotics through the process of horizontal gene transfer. Essentially, bacteria don’t need to reproduce to pass along their genetic protection from antibiotics. They can simply pass along these genes to fellow bacteria like students passing notes in a classroom. One study found that bacteria passing through the colon can transfer their resistance genes to other forms of bacteria. 

2.  Antibiotics Are Helping Drive Up Drug and Hospital Costs - The further antibiotic resistance spreads, the more often common antibiotics—including many available as generics—must be retired.  This means that ridding patients of infection requires longer, more expensive forms of therapy. The average patient facing an antibiotic-resistant infection can expect a medical bill of between $18,588 and $29,069 in 2009 dollars, totaling $20 billion in health care costs each year in the U.S., according to estimates from the Alliance for the Prudent Use of Antibiotics at Tufts University.

3.  Antibiotics Increase Fatal Diarrhea Cases in Children - a new CDC study found that children who are mistakenly given antibiotics for viral illnesses, like the common cold are more susceptible to aggressive antibiotic-resistant strains of the bacteria commonly known as C. diff.  The study found that 71% of children who suffered C. diff infections had been given courses of antibiotics for respiratory, ear, and nose illnesses 12 weeks before infection.  C. diff, a bacteria found in the human gut, can cause severe diarrhea and is responsible for 250,000 infections in hospitalized patients and 14,000 deaths every year among children and adults.

4.  Antibiotics Can Upset Sensitive Gut Flora - Your intestines contain around 100 trillion bacteria of various strains. While some can be deadly, there’s a natural balance in the gut that can be thrown out of whack by antibiotics. These helpful bacteria, known as gut flora, support immunity and proper digestion.

Aggressive antibiotics, while helpful if you have a serious infection, can wipe out many good gut bacteria while leaving those immune to antibiotics to flourish.  That’s the case with C. diff diarrheal infections. 

Dr. Lona Mody

Dr. Mody is one of very few internists in this country with an expertise in aging populations, epidemiology, an active research laboratory in microbiology and a translational research agenda focused on vulnerable aging population.  She has mentored several junior faculty, fellows, post-doctoral students and residents in conducting clinical, epidemiologic, as well as laboratory-based research projects and has had uninterrupted NIH funding since 2003.  In 2015, she received a 5-year NIH K24 Midcareer Investigator Award to mentor junior faculty in translational aging, infectious diseases and health outcomes research.

Her NIH and AHRQ funded work has created a thriving consortium of post-acute and long-term care facilities in southeast Michigan interested in developing interventions to enhance infection prevention in a traditionally resource poor setting.  In an NIH-R01 study (PI: Mody), her team evaluated a multi-modal targeted infection-prevention (TIP) intervention to prevent resistant organisms and infections in long-term care residents with indwelling devices.  This study has garnered national attention and spurred several subsequent pilot projects.  Our group (PIs: Saint, Mody) has been awarded an AHRQ contract to implement lessons learnt from this model to 500 federal and non-federal post-acute and long-term care facilities across 50 states in the US.  Funded by another concurrent NIH-R01 (PI: Mody), her team is defining the complex relationship between antimicrobial resistance, caregiver and environmental contamination, and functional disability in post-acute care facilities.  In order to understand transmission dynamics within post-acute and long-term care facilities, she is collaborating with other national leaders to evaluate spread of organisms from a resident to healthcare worker gown and gloves.  She is nationally active at several research methodology and career development activities at the American Geriatrics Society, Society for Healthcare Epidemiology of America, and the Infectious Diseases Society of America

Like 89.1 WEMU on Facebook and follow us on Twitter

— David Fair is the WEMU News Director and host of Morning Edition on WEMU.  You can contact David at 734.487.3363, on twitter @DavidFairWEMU, or email him at dfair@emich.edu