Hospital factors bigger than patient severity of illness
Hospital factors bigger than patient severity of illness
HAIs 'not necessarily inevitable'
Infection control practices and other "hospital factors" specific to individual institutions appear to be a greater influence on infection risk than a patient's severity of illness, researchers found.
A study on surgical wound infections concluded that "the risk of infections for roughly comparable patients varies significantly across the hospitals. Although some of the increased risk may be due to unmeasured patient characteristics, it is likely that much of it is due to different hospital-specific practices and environments."1
Though the study did not assess such practices in the hospitals, they would include such variables as the method of hair removal, traffic through the operating room, and prolonged duration of surgery. They also include the attention given to hand washing throughout the hospital and the diligence with which antibiotics are given prior to surgery. Several patient-specific factors have been consistently associated with increased risk of surgical wound infection, including age, diabetes, obesity, smoking, immunosupressants, malnutrition, and duration of preoperative hospitalization.
"The study does not assess which specific hospital practices are most meaningful, [but it shows] that variation in infection rates occurs at the hospital level more so than at the patient level," explains lead author Christopher S. Hollenbeak, PhD, an economist at the department of health evaluation sciences in the Penn State College of Medicine in Hershey, PA. "The patient factors were important and they were significant. They do contribute to the risk of infection, but I think a larger part of the story is attributed to things that are going on at the hospital level, which means that these [infections] are not necessarily inevitable."
Using hospital data submitted to the Pennsylvania Health Care Cost Containment Council, the authors studied all discharges in the state from Oct. 1, 2004, through Sept. 30, 2005, in which a circulatory (65,940), neurological (6,706), or orthopedic (107,825) procedure was performed. They estimated the impact of patient-specific factors on risk of infection and compared the ability of these factors to predict infections relative to hospital effects. Although patient-specific factors had a statistically significant association with risk of infections, much of the risk of surgical wound infections is determined by hospital factors, the researchers determined.
"What this is suggesting is that there is a lot more in the variation in infection rates explained by variations between hospitals than by variations between patients," he says. "Even thinking about this on an intuitive level, a patient who comes in may be more susceptible than another to get an infection. But if they are not exposed, then even if they are susceptible they are less likely to get an infection. Thinking about it like that, I don't think that infections are inevitable. Getting them to a level that is much lower than current benchmarks is both practical and possible."
For circulatory procedures, patient severity, diabetes, chronic renal failure, and obesity were significant predictors of infection. Only age was a significant risk factor for neurological procedures. For orthopedic procedures, patient severity, COPD, diabetes, and obesity were associated with significant risk for infection.
"However, these patient characteristics did not provide the basis for a good predictive model for surgical wound infection. Adding hospital fixed effects improved predictions from 23% to 33%," Hollenbeak and colleagues concluded. "This suggests that the risk of infections for roughly comparable patients varies significantly across the hospitals. Although some of the increased risk may be due to unmeasured patient characteristics, it is likely that much of it is due to different hospital-specific practices and environments."
Reference
- Hollenbeak CS, Lave JR, Zeddies T, et al. Factors associated with risk of surgical wound infections. Am J Med Qual 2006; 21(suppl): 29S-34S.
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