Great expectations: ICPs must raise goals, reset’ endemic infection rates

APIC keynote mixes candor and encouragement

Beset with both complacency and "battle fatigue," too many infection control professionals have set their standards too low and accepted endemic infection rates too long, keynote speaker Victoria Fraser, MD, told some 3,000 attendees recently in Minneapolis at the 27th annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC).

"We have set our standards too low," said Fraser, medical director of infection control at BJC Health System in St. Louis. "We have not tried to achieve perfection. We have not demanded or expected excellence everywhere that we could. Our senses have been dulled by the volume and magnitude of the problem."

Rather than finding a 1% surgical-site infection (SSI) rate acceptable, for example, why not aim for a .01% SSI rate, she said. "We suffer from battle fatigue," Fraser added. "We’ve been worn out by antibiotic resistance [and] lack of compliance with hand washing. We have so few resources most of the time, we tread water just to keep from drowning, but we don’t really go anywhere."

In a pointed address that mixed frank assessments with words of encouragement, Fraser challenged ICPs to redefine the paradigm and set their goals higher, with the knowledge that some will fail.

"I believe that you all can tremendously decrease nosocomial infections if you set your goals high and you work successfully with teams," she said. "You need to set really high goals for yourself. Not all of your goals should succeed. If you are succeeding at everything you do, I would suggest that you are setting your goals too low."

ICPs may be too often satisfied with infection rates within national benchmark ranges, such as those in sentinel hospitals reporting to the Centers for Disease Control and Prevention, she noted. "I think we have to get beyond that," she said. "Our goal has to be as low as we can be."

Instead of the traditional focus on preventing and controlling outbreaks, Fraser urged ICPs to target endemic rates for reduction. "What about resetting the paradigm completely so that instead of just working on outbreaks, we set a goal that we are going to try to reset the endemic rates," she said.

This approach requires team-building by ICPs who focus on improving the process, not assigning blame for infections. For example, she advised that ICPs make the effort to go to other clinical staff meetings to share infection rate data, rather than simply calling their own meeting. "The biggest challenge here is that we are working with teams of people, very diverse groups of people," she said. "So we need to become excellent at teamwork and building teams. There is no limit to what can be accomplished if it doesn’t matter who gets the credit. This is not an infection control project; it is a team project."

Infection control efforts are clearly cost-effective, she said, emphasizing that preventing only 6% of nosocomial infections justifies the cost of a $60,000 infection control department. Indeed, research indicates that infection control programs cost only $2,000 to $7,000 per human life saved, which is considerably less expensive than widely accepted life-saving expenditures for mammograms and cholesterol reduction, she noted.

"It is not hard to demonstrate in almost any institution that the amount of money spent on infection control is usually a small fraction of what is lost on nosocomial infections," she said. The BJC system of 13 hospitals spends about $1 million annually on infection control efforts, but nosocomial infections still account for about $4 million in lost revenue.

"You have to make a commitment that you are going to lower infections by such a percent’ and thereby get [the institution’s] money back," Fraser said. "You need to align your infection control and your mission, vision, and goals with that of the institution and departments you are working with."

Despite her candor in assessing the state of the profession, Fraser’s message was ultimately motivating to many of the attendees. "It is a very exciting challenge she put out there for us," said APIC president Susan Slavish, BSN, MPH, CIC, an ICP at Queens Medical Center in Honolulu. "I think we should do the best we can. If we can reduce infections, we can have a significant impact on the cost of health care. Heath care is in a financial crisis; we need to contribute."

Amid discussions of infection control costs and justifying programs to administrators, Steven Miller, MD, vice president and chief medial officer at Barnes-Jewish Hospital in St. Louis, reminded ICPs of the ethical imperative to their mission.

"Don’t ever forget you have the moral prerogative," he told attendees. "Decreasing infections is the right thing to do."

In that simple assessment, Miller struck a chord with members of the audience. "That’s what really drives most of us to be working at the pace we work, at the hours we put in, and at the pay scale that we work at," said Susan Kraska, RN, CIC, an ICP at Memorial Hospital of South Bend, IN. "We all know and believe that it is the right thing to do. That is why there is that commitment, and why you find [career] longevity in infection control."