Infection control in the US: 2016 year in review

2016 has been yet another busy year for infection control and hospital quality professionals, as new hospital rankings were released, the threat of superbugs continued to grow and drug diversion from hospitals increased.

The following is a breakdown of five of the major infection control, patient safety and quality occurrences that affected U.S. hospitals this year, presented in no particular order.

Antibiotic resistance threat grows

While this has been a perennial problem, there were several notable advancements in 2016 that warrant it a place on this list.

In April, a strain of E. coli resistant to colistin — the antibiotic of last resort — was discovered for the first time in the U.S. Previously, it had only shown up in pigs, raw pork and a small number of people in China and Europe. Since the first announcement, three more examples of the "untreatable" superbug have turned up in the U.S. as of September.

Regulatory and accreditation organizations have started taking steps to force hospitals to take responsibility for antibiotic stewardship. In May, the National Quality Forum, the CDC and Nashville, Tenn.-based Hospital Corporation of America released "Antibiotic Stewardship in Acute Care: A Practical Playbook," a guide for hospitals on how to implement an antibiotic stewardship program.

It escalated quickly after that, with the Joint Commission adding a medication management accreditation standard, which, among other elements, requires hospitals to make establishing antimicrobial stewardship an organization priority, and CMS proposing a rule change that would require hospitals to implement antibiotic stewardship programs to continue participating in Medicare and Medicaid programs.

Antibiotic resistance isn't just an issue in the U.S. — it affects people of all countries. The United Nations made a historic move this year, as the high-level meeting it held on Sept. 21 was just the fourth time the U.N. General Assembly had discussed a health issue. The meeting resulted in all 193 U.N. member states signing a declaration to address antibiotic resistance.

CMS overall hospital quality star ratings launch to chagrin of hospitals

CMS released its Overall Hospital Quality Star Rating Program in full on July 27 — three months behind schedule and in the face of unrest in the industry.

The program, which assigns a one- to five-star rating to hospitals based on quality data, outcomes data and patient satisfaction scores, was supposed to launch in April, but hospitals and legislators spent the first months of the year lobbying the agency to delay releasing the scores. Hospital associations and members of Congress argued the program used flawed metrics that put academic medical centers and safety-net hospitals at a disadvantage.

To handle the pushback, CMS delayed releasing the ratings until July, using the three months to further explain the methodology to stakeholders.

In the July release, 102 hospitals earned five stars. CMS plans to update the ratings each quarter, and did so in October, when 112 hospitals earned the top star rating.

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Devices put patients at risk

Medical devices continued to pose risks to patients this year, and in some instances, the device manufacturers played a role in the problem.

For instance, news broke in July that Olympus, the Japanese medical device manufacturer that sells duodenoscopes linked to several infection outbreaks, had warned European hospitals in 2013 that the scopes were difficult to clean and could spread infections, but decided not to warn U.S. hospitals of the same risk. Contaminated scopes were tied to 35 deaths and many more infections in the U.S.

In 2015, another type of device — heater-cooler machines used during open-heart surgery — was found to spread a serious bacterial infection. This year, the CDC announced in October the infections are linked to a specific brand of heater-coolers, the Stöckert 3T heater-cooler devices, made by LivaNova (formerly Sorin Group Deutschland), that are used in 60 percent of open-heart bypass procedures in the U.S. The devices were contaminated during Mycobacterium chimaera during manufacturing.

"Hospitals should check to see which type of heater-coolers are in use, ensure that they're maintained according to the latest manufacturer instructions, and alert affected patients and the clinicians who care for them," Michael Bell, MD, director of the CDC's Division of Healthcare Quality Promotion, said.

Lastly, a study in Infection Control & Hospital Epidemiology this fall found removing contamination from robotic surgical instruments, even after cleaning multiple times, is nearly impossible. The study's authors pushed for new cleaning standards.

"These instruments are wonderful tools that allow surgeons to operate with care; but completely decontaminating them has been a challenge for hospitals," Yuhei Saito, RN, lead author of the study and assistant professor at the University of Tokyo Hospital. "By implementing new cleaning procedures using repeated measurements of the level of contamination on an instrument more than once, we could potentially save many patients from future infections."

Zika in the U.S.

Zika mania started late in 2015, when the World Health Organization named Zika to its list of emerging diseases likely to cause major epidemics, and the first case of the mosquito-borne virus was reported in the U.S. in Texas in early 2016.

Since then, much has been discovered about the virus, including its confirmed link to microcephaly and that it can be transmitted sexually for months after symptoms subside. The virus has also been linked to the autoimmune disorder Guillain–Barre syndrome in adults. The condition incites paralysis and has been linked to two deaths in Puerto Rico.

On Feb. 8, President Barack Obama requested more than $1.8 billion in emergency funding to combat the virus in the U.S., and a month's-long partisan quarrel ensued. Emergency funding for Zika wouldn't garner congressional approval until the end of September, nearly two months after four Zika infections in the state of Florida borne of local mosquitoes were reported, marking the beginning of local transmission of the virus in the U.S.

On Oct. 25, Tom Frieden, MD, director of the CDC, delivered sobering news to a crowd gathered at The Atlantic's CityLab conference at the InterContinental Miami hotel, "Here's the plain truth: that Zika and other diseases spread by Aedes aegypti [mosquito species] are really not controllable with current technologies. So we will see this become endemic."

As of Nov. 17, the CDC has tallied more than 1,000 Zika infections among pregnant women in the U.S., as local transmission of the virus continues in Miami. Additionally, 28 infants have been born with congenital Zika-related birth defects and five pregnancies have been lost due to Zika-related stillbirth, miscarriage or terminations.

Drug diversion in hospitals

Multiple hospitals across the U.S. were forced this year to notify patients of potential infections from contaminated needles after hospital employees diverted opioid medications, possibly introducing contaminated needles to the patient population.

Arguably the highest profile case of such an occurrence involved the former surgical technician Rocky Allen, who is HIV positive. In January, Swedish Medical Center in Englewood, Colo., fired Mr. Allen after he was witnessed stealing a syringe filled with fentanyl and replacing it with one filled with saline solution. The needle-swapping incident spurred the hospital to offer nearly 3,000 patients free testing for HIV and hepatitis B and C. The incident also prompted several other hospitals in Arizona, California and Washington, all former employers of Mr. Allen, to warn patients of possible infection risk. No patient infections related to Mr. Allen have been detected. In July, Mr. Allen pled guilty to charges of tampering with a consumer product and obtaining a controlled substance by deceit.

As America's rampant rates of opioid abuse persist, drug diversion will continue to be an ongoing issue for hospitals. As the country is learning, and as hospitals must learn too, drug addicts can often be difficult to spot. The image of the archetypal drug addict has been subverted by the wide-reaching epidemic. Kimberly New, JD, BSN, RN, the founder of Diversion Specialists, spoke on the necessity of the implementation of drug diversion programs in hospitals at the AORN Surgical Conference & Expo in Anaheim, Calif., on April 3.

"You cannot look at someone and discount [that] they might be diverting," said Ms. New. "Everyone needs a diversion program… we need to recognize we're all at risk."

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