Tuesday, December 8, 2009

Hospital Error Rates - Still a Long Way to Go

To Err Is Human Blog Series Logo

This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.

"In hospitals, high error rates with serious consequences are most likely in intensive care units, operating rooms and emergency departments…" — To Err is Human, p.36

We'd all like to think that, 10 years after the publication of To Err is Human, the problems and conflicts it described have been examined and improved. But a new study published Dec. 2 in the Journal of the American Medical Association underlines how very far we have to go.

The study, informally named EPIC, was a prospective point-prevalence survey — essentially, an intense single-day snapshot — of infections in 1,265 ICUs in 75 countries on May 8, 2007. It found that 51% of the critically ill patients in those ICUs (7,087 of 13,796 adults) were experiencing infections on that day, and 71% (9,084 of 13,796) were receiving antibiotics.

Those percentages are dismaying enough. But here's the really bad news: This iteration was EPIC II; its predecessor study, EPIC I, was conducted 15 years earlier, on April 29, 1992. And over those 15 years, the ratios of infected patients and antibiotic therapy worsened: In 1992, they were respectively 45% and 62%.

Now, it is fair to say that the databases that lie behind both studies do not exactly match. EPIC I (the European Prevalence of Infection in Intensive Care study) comprised data on 10,038 patients in 1,417 ICUs in 17 Western European countries. EPIC II (for Extended Prevalence of Infection in the ICU) was designed to sample ICU infection rates across the entire world. It took in 152 fewer ICUs but extended across a much wider geographic swath, though many of the European hospitals that participated in EPIC I are present in EPIC II as well. The authors' comment on the geographic mix within EPIC II can serve as well as a caution for comparing the two studies: "Comparisons among geographic regions should be interpreted with caution, because clearly there are large differences in healthcare systems, ICU facilities, and regional policies for infectious disease management." And it is worth noting as well that EPIC II, unlike EPIC I, did not focus only on nosocomial infections — but that, say the authors, is because the behavior of some of the organisms infecting ICU patients, such as methicillin-resistant Staphylococcus aureus, has grown so complex: "We were concerned that it may be difficult to distinguish between community-acquired, hospital-acquired and ICU-acquired infections."

Nevertheless, the results of EPIC II are unsettling reading for anyone concerned about quality of care. The longer they had been in the ICU, the more likely patients were to be experiencing an infection. Infections were more likely to be Gram-negative than Gram-positive or fungal. Patients with infections were more likely to die during their hospital stay. And in a finding that should trouble anyone concerned with global inequities in healthcare, the lower a country's proportion of spending on health care relative to its gross domestic product, the higher its rate of ICU infection was likely to be.

An accompanying editorial emphasizes the relationship between ICU infections, ICU antibiotic therapy and the development of antibiotic-resistant organisms: "Early intervention with appropriate antibiotics is lifesaving in patients with severe infection, yet the profligate use of antimicrobial agents contributes to progressive antimicrobial resistance. Quality-of-care indicators now penalize physicians for delayed antibiotic use in specific situations; no such imperatives are used to limit extended and unnecessary antibiotic use."

The editorial's authors lay out some critical considerations going forward — increased antibiotic stewardship, excellent infection control — but they acknowledge the troubling trend embedded in the data from EPIC I and EPIC II: "A “postantibiotic era” is difficult to contemplate but might become a reality unless the threat of progressive antibiotic resistance is taken seriously."

-- Maryn McKenna is a journalist and blogger and author of the forthcoming book SUPERBUG: The Fatal Menace of MRSA (Free Press, March 2010).

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