A study by the Columbia University School of Nursing found that while most hospitals have evidence-based policies on file for the control and prevention of health care-associated infections (“HAIs”), clinician compliance with these written policies, in practice at bedside, is lax, even in intensive care units (ICUs).

Entitled “State of infection prevention in US hospitals enrolled in the National Health and Safety Network,” this study by Patricia W. Stone, PhD, and colleagues appears in the February, 2014, issue of the American Journal of Infection Control click here to read it.

According to Stone et al. (2014), their study — which focused on three types of HAIs in 1,653 adult ICUs at 975 acute-care hospitals nationwide — is the most comprehensive review of infection control efforts at U.S. hospitals in more than three decades.

The three types of HAIs that these researchers studied were: (i) central line-associated bloodstream infections (or, “CLABSI”), (ii) ventilator-associated pneumonia (or, “VAP”), and (iii) catheter-associated urinary tract infections (or, “CAUTI”).  This study’s data were collected using a Web-based survey.


Click here to listen to Dr. Stone discuss this study’s findings.


Some of the evidence-based infection control policies to which Stone et al.’s (2014) study investigated clinician compliance were whether each surveyed hospital had instructions on file for clinicians: (i) to wash their hands before handling and inserting a central line catheter; and (ii) to elevate the head of the patient’s bed to 30-45 degrees to help prevent pneumonia.

Rules don’t keep patients from dying unless they’re enforced. — Patricia W. Stone, PhD, professor of health policy at Columbia University School of Nursing.(1)

MORE FINDINGS: In addition to finding that clinician compliance with written infection control policies in adult ICUs was relatively low, Stone et al. (2014) report that:

  • almost one third of the participating hospitals did not employ a certified infection preventionist (IP), which is inconsistent with published infection-control guidelines;
  • policies for the prevention of CLABSIs and VAPs were more prevalent than for CAUTIs, despite CAUTIs more frequently causing an HAI;
  • only one-third of the surveyed hospitals use an electronic surveillance system, even though these systems can provide important compliance data including “report cards” that monitor how well clinicians are complying with the hospital’s infection-control policies; and
  • while most of the surveyed hospitals have developed a checklist for the safe (and aseptic) insertion of central lines (on average, more than 90%), clinicians were found to comply with this checklist only about half of the time (on average, approximately 50%).

Every hospital should see this research as a call to action – it’s just unconscionable that we’re not doing every single thing we can, every day, for every patient, to avoid preventable infections. — Patricia W Stone, PhD.(1)

DISCUSSION: Stone et al.’s (2014) study raises a number of interesting points for discussion, including that:

    • as other research studies have confirmed, clinician compliance with checklists can reduce infection rates — but these reductions can only be achieved if clinical practices adhere to these checklists;
    • evidence-based clinical practices ensure patient safety — not merely having on file a codified set of written policies that dictates what clinical measures prevent HAIs;
    • behavioral changes, having in place a more robust system of accountability, and a healthcare program that provides incentives for practicing safe medical are crucial to the prevention of HAIs; and
    • accrediting surveys and inspections that focus as much on the completeness of a hospital’s documentation as (if not more so) on verification that the hospital’s clinical practices comply with its written infection-control policies are also important to the improvement of healthcare quality and the prevention of HAIs.

There is large evidence base supporting the use of audit and feedback interventions to improve professional practice and ultimately improve patient outcomes. — Stone et al. (2014)


Click here to read Dr. Muscarella’s related blog posting that, while it appreciates and acknowledges the importance of “feedback” to patient safety, discusses how this intervention can interfere with the scientific validity of a calculated percent reduction of CLABSIs in ICUs.


Stone et al.’s (2014) study also raises two additional points for discussion:

  • that infection control programs should feature the more widespread use of electronic monitoring systems to improve quality and reduce HAI rates; and
  • that crucial to the prevention of HAIs are greater regulation and control (for example, using electronic health records that prompt clinicians to provide a brief rationale for administrating an antibiotic in an atypical situation) of the administration of antibiotics.

Hospitals aren’t following the rules they put in place themselves to keep patients safe. — Patricia W Stone, PhD.(1)


Click here to read Dr. Muscarella’s series of articles about “superbug” outbreaks following gastrointestinal (GI) procedures. This is the most complete series of articles on this topic.


COMMENTARY:  Stone et al.’s (2014) findings are not entirely surprising.  HAIs are killing an estimated 100,000 patients in U.S. hospitals each year and create approximately $33 billion in excess medical costs.  According to Stone et al. (2014), the quality of some evidence-based practices designed to prevent infections is lacking.

Might Stone et al.’s (2014) findings of a lack of quality provide an explanation, at least in part, for the recent emergence of “superbugs,” which has been attributed to the over-prescribing of antibiotics?  Are antibiotics at times being overly administered to patients, possibly, to save money, instead of improving quality, and to compensate for the “gap” described by Stone et al. (2014) between a hospital’s documented infection control policies and its clinical practice of these policies at bedside? — Lawrence F Muscarella PhD

Change is indisputably needed, but how best to achieve the requisite improvements in quality and safety are debatable.

Indeed, having written infection control policies in place is important to the prevention of HAIs, but not more so — arguably, even less so — than hospitals routinely perfoming quality audits to verify a “zero gap,” namely that their infection control clinical practices, at bedside, are in strict compliance with these written, evidence-based policies.


Attention Healthcare Facilities: Could your GI endoscopy unit be harboring CRE?  Click here to read about a safety/auditing program specifically designed by Dr. Muscarella – this article’s author – to prevent infection-control breaches and disease transmission during ERCP and other GI endoscopic procedures.


Such audits may also be integral to controlling the emergence of antibiotic-resistant “superbug” bacteria, which reportedly are a result, in part, of the healthcare system’s current over-dependence on antibiotics.

What’s needed to treat these “superbugs,” as much as the development of more effective antibiotics, may be a more robust commitment to infection control, improved quality and enhanced cleanliness.


Attention Medical Device Manufacturers: Could your reusable medical device be harboring CRE?  Click here to read about a quality program designed by this article’s author – Dr. Muscarella – to improve the design of reusable medical instruments and to minimize the likelihood of their association with CRE transmission.


References: (1). Columbia study finds hospitals don’t follow infection prevention rules. Science Codex. February 6, 2014 (click here). Source: Columbia University Medical Center.

Article by: Lawrence F Muscarella, PhD; posted 2/20/2014, Rev A.

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