White blood cells ingest MRSA, (methicillin resistant Staphylococcus aureus). Image from National Institutes of Health.
Jimi Suwaiti doesn’t remember much of the first few months of 2017, but her mother, Sharon Blackwell, does.
Blackwell watched her 48-year-old daughter shake in her hospital bed in Virginia Beach because the pain from a bacterial infection was so terrible, and hallucinate, in her feverish state, that people were coming into her room.
Suwaiti was wrestling with antibiotic-resistant MRSA, a common health care-associated infection, those acquired in hospitals or other medical facilities. About 1 in 25 people nationwide develop a healthcare-associated infection every day, the Centers for Disease Control and Prevention estimates.
Virginia hospitals have policies to protect patients from infections, usually claiming that they take every possible precaution. And according to data compiled by the state and the Centers for Disease Control and Prevention, Virginia facilities are consistent with national averages in preventing infections.
But that baseline is just a starting point, said Sarah Lineberger, who coordinates the Virginia Department of Health’s health care-associated infections program. The goal is to have a lower number.
And federal inspectors still regularly find infection-control lapses at hospitals around the state, according to reports, which note that staff sometimes forget basics like washing hands or properly marking equipment as clean or dirty.
Every year, nationwide, 75,000 people with those infections die, the CDC estimates. That’s about double the number of people killed in car crashes annually. The state Department of Health does not track the number of Virginia deaths from health-care infections.
MRSA, or Methicillin-resistant Staphylococcus aureus, is one of several so-called “superbugs” that are resistant to antibiotics and can prove nightmarish to treat. In 2016, there were 177 cases of MRSA infection in Virginia health facilities. Another is C. diff, or Clostridium difficile, which infects more than 2,000 Virginia residents every year.
Among the goals in Virginia’s Plan for Well-Being, created by the health department to improve a number of health care measures by 2020, was for every hospital to cut its C. diff infection rate to .07 SIR, short for “standardized infection ratio,” calculated by comparing the actual number of infections to the predicted number.
When the plan launched in 2016, only 38.5 percent of Virginia’s hospitals had C. diff rates that low. But in 2017, when the plan was most recently updated, 38.3 percent did, even further from the 100 percent goal set for 2020.
Antibiotic-resistant infections can lead to life-threatening complications, as it did in Suwaiti’s case. Earlier this year, the World Health Organization called the superbugs one of the biggest threats to human health.
Blackwell slept on the couch beside Suwaiti during that month-long stay at Sentara Virginia Beach General Hospital. More than once, she thought her daughter was going to die.
“It was a horrible experience, for me and for her,” Blackwell said. “I’m not the same person I was.”
LEAVING THE HOSPITAL SICKER
About a decade ago, the CDC and health officials from many states stepped up surveillance of health care-associated infections, Lineberger said.
In 2016, the most recent year data is available, Virginia’s rates were about average compared to the national numbers. In some areas, the state’s hospitals did better than hospitals nationally, including for MRSA and central line-associated bloodstream infections, which can happen when doctors place tubes in veins to give medication or fluids or to collect blood for medical tests.
It’s difficult to compare the 2016 numbers to previous years because the CDC set up different baselines in 2015. But the state did seem to make improvements in some problem areas identified in the 2015 data, specifically for abdominal hysterectomy surgical-site infections and the antibiotic-resistant C. diff.
In 2015, Virginia saw more of both those infections than predicted, but in 2016 those numbers fell back down to a normal range compared to the national baseline. But some would argue that the national baseline is far from good enough.
Take C. diff, for example. Even having an “average” number of infections compared to the rest of the country still represents a fairly large number of patients. In 2016, there were 2,312 C. diff infections in Virginia.
Though that’s lower than the 2,542 that were infected in 2015, it is still largest sheer number of patients developing any of the tracked infections, Lineberger said.
“C. diff continues to be a priority for us,” she said.
Infections are always waiting to spread, and just one mistake — not tying a protective gown properly, or skipping one hand washing — can put a patient at risk.
“Probably the biggest concern regarding a healthcare-acquired infection is somebody leaving their hospitalization with a condition they did not enter our system with,” said Ellen Amalfitano, corporate director of quality with Bon Secours Health System. “That’s really the travesty around a healthcare-acquired infection.”
But in the hustle and bustle of the hospital environment, protocols can fall through the cracks.
Both Mary Washington Hospital in Fredericksburg and Bon Secours’ St. Mary’s Hospital generally have good track records when it comes to preventing infections, considered either average or above average. But since 2017, hospital inspectors have found problems.
In January, the staff at Mary Washington Hospital in Fredericksburg did not follow the proper policies when treating a patient diagnosed with MRSA, entering the hospital room without wearing the right protective equipment, according to a Centers for Medicare and Medicaid Services inspection report.
In October, MRSA broke out in the neonatal intensive care unit at Bon Secours’ St. Mary’s Hospital in Richmond, and an inspector determined that the hospital not only failed to report the case to the Department of Health, but that it did not test the staff members in the NICU to determine if they were the source of the transmission. Eventually, though, the state traced the cause of those outbreaks to the community, not the hospital itself.
Earlier in 2017, St. Mary’s had a more serious inspection, when everything from improper hand hygiene to a failure to identify equipment as clean or dirty resulted in an “immediate jeopardy” finding, the most severe penalty inspectors can impose and one that indicates the health and safety of at least one individual is at risk.
The immediate jeopardy determination was lifted that same day, though, after hospital staff developed a plan to correct the problems.
“One of the challenges is when we have so many people in hospitals who are touching and caring for patients, it becomes so important that we have reliable practices and that we are consistent in what we’re doing,” Amalfitano said. “We have to have our preventive techniques in place — every patient, every time.”
WHY DO INFECTIONS KEEP SPREADING IN HOSPITALS?
Health officials point to a variety of causes when explaining why reducing infection rates remains so difficult. The basic reason is simple: Patients are sicker than the average person, and therefore more vulnerable.
But health care-associated infections are also preventable, the CDC notes. Sometimes, they spread simply because there isn’t space to provide the best care.
If a patient has a drug-resistant infection, for example, ideally he or she would be placed in a private rooms, said Lineberger, the state health official. But for some hospitals, that simply isn’t possible, and patients must be placed with two or three others.
She said the state’s health care-associated infection advisory group is also working on improving communication at the time of patient transfer between facilities “because that’s a place where the ball often gets dropped.”
For example, Nursing Home A might know a patient has MRSA, but forgets to tell Hospital B, and then Hospital B doesn’t have the proper precautions in place.
But beyond communication and hospital design, one major cause of infection is far simpler, and seemingly easier to prevent: mistakes on the part of health care staff.
Hospital inspectors are often accompanied by senior staff members on visits. When there’s a mistake observed, like not wearing protective equipment or a nurse not washing hands at the right time, the inspector will ask why that happened, according to reports.
And the senior staff member will usually explain that the person isn’t following the hospital’s protocols. Often, to address the failings, the hospitals will retrain staff.
Another explanation for those mistakes is turnover. Not only are nurses cycling in and out of patients’ rooms, but so too are family members, physicians who may not be familiar with the patient, cleaning staff or even volunteers.
During one Mary Washington Hospital inspection, a staffer from the surgical department was visiting a patient who was isolated because of an infection but didn’t wear the right protective equipment, an inspection report notes.
“In the hospital, you have to make sure education is done with all groups, not just the nurses on the floor but with environment services cleaning staff, and contract agencies, and physicians who might be doing rounds at multiple facilities,” Lineberger said. “There’s so much movement around the hospital.”
That’s what Mary Washington Hospital and St. Mary’s Hospital point to: human errors. And they say they’re focused on preventing them.
“We try to look at every situation that is patient-related as that Swiss cheese model — we’re trying to eliminate as many holes in the Swiss cheese so that we’re not allowing errors to happen, we’re catching them,” said Tammy Tibbs, manager for infection control at Mary Washington Hospital.
Last year, Mary Washington launched an initiative to encourage peer coaching and staff members holding each other accountable, like reminding each other to wash hands.
St. Mary’s Hospital has a similar approach and constantly retrains staff on safety and infection prevention.
“Now what works against that is staff turnover, new providers, new departments,” Bon Secours’ Amalfitano said. “When we switch around a workflow, that’s when you have potential gaps in the process.”
Sentara Healthcare’s Dr. Dennis Szurkus, executive medical director of infection prevention, said Sentara’s hospitals also encourage staff members to keep each other accountable, calling, “All hands on deck,” to each other if someone forgets to wash their hands.
The health system also uses score cards to keep track of how well they are performing and, last year, Sentara began outfitting its inpatient rooms with copper-infused linens and patient gowns after conducting a clinical trial that showed copper products can prevent infections like MRSA and C. diff., among other measures.
Still, there will always be limits to what hospitals can do.
Tony Fiore, chief of the epidemiology research and innovations branch at the CDC’s Division of Healthcare Quality Promotion, noted that for some infections, like MRSA, a patient can arrive at a hospital already colonized with the bacteria and invasive surgical procedures can cause the infection to become more serious.
“I don’t think we can ever expect zero healthcare-associated infections,” he said.
‘I COULD HAVE DIED’
Suwaiti and Blackwell aren’t sure when Suwaiti developed MRSA. It could have been in the hospital during a joint aspiration, in which fluid around a joint is removed with a needle. It’s possible she could have had it before she was admitted.
A Sentara spokesperson said the hospital does not comment on specific patient cases. According to CDC data, the hospital performs about average for most infection types, though comes out better for C. diff and worse for abdominal hysterectomy surgical-site infections.
Suwaiti had gone to the emergency room a couple months before because of a spot on her stomach, but she doesn’t know if it was MRSA. Providers gave her antibiotics and sent her home, asking her to return in a couple of days. But Suwaiti didn’t have insurance and couldn’t afford so many visits, so she didn’t go back because she thought she was getting better.
Then she fell and injured her knee, and again didn’t want to go to the hospital because of the cost. She went to the emergency room and got pain pills, but after a few visits was eventually admitted and diagnosed with sepsis, a blood clot behind her knee and kidney failure.
She stayed at Sentara Virginia Beach General Hospital for a little over a month, until she was released in mid-March and her family drove her to University of Virginia Health System in Charlottesville, because they knew she was still sick.
Soon after she was admitted, she went into septic shock and was transferred to the intensive care unit, she said. There, her doctors discovered that her MRSA had infected two-thirds of her femur bone.
“I could have died,” she said.
This story has been updated to add additional information about Sentara’s infection-control measures.
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