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By Megan Trucano and Dennis O. Kaldenberg, PhD

Rates of hospital-acquired infections (HAIs) in United States hospitals have steadily increased over the past several years and are approaching what some call epidemic proportions (Ecohard, 2006). With the rising number of HAIs in United States hospitals, healthcare providers are continually searching for ways to lower or eliminate high infection rates, with many striving to implement preventive strategies. Any effective safety-practice must necessarily begin with examining the relationship that exists between care provider and patient. Patients can provide unique insight into the care they receive, and care provider perceptions of safety-related practices have been linked to clinical outcomes in work done on organizational safety culture (Pronovost, et al., 2006). Understanding and utilizing both parties' unique perspectives can yield valuable data from which to begin lowering infection rates. We hypothesize that patients will observe some practices and their consequences while under care and reflect those observations in their ratings of hospital service quality collected on post-discharge surveys. We predict that facilities with lower patient ratings on specific service quality practices that could effect patient infections will also have higher rates of infections and infection mortality.

Method
The Pennsylvania Health Care Cost Containment Council (PHC4) recently released a report detailing each Pennsylvania hospital's overall hospital-acquired infection (HAI) and mortality rates for 2005. In 2005 alone, Pennsylvania reported 19,154 cases of HAIs, mostly consisting of urinary tract and surgical site infections — approximately 12.2 cases per 1,000 — leading to an average increase of 16.1 days in length of stay as well as an estimated additional $153,871 per patient, per visit (Burke, 2003). The published document reflects the outcomes of patients throughout the 168 general acute care hospitals across the state of Pennsylvania in 2005 (PHC4, 2006). During 2005, Press Ganey Associates surveyed 192,490 patients treated in 87 of the 168 Pennsylvania hospitals. These patient ratings of care were aggregated into facility scores and linked to the data released in the November 2006 PHC4 report.

Three questions from the patient survey were judged to measure practices that when poorly executed could create a more infection-prone environment. Included were patient ratings of 1) cleanliness, which speaks to creating a germ-free environment; 2) skill of the person who took the patient's blood, which speaks to blood draw protocols and practices; and 3) nurse response to the call button, which speaks to reducing the risk of self-soiling and other emergent problems with catheterization or intravenous equipment. To evaluate if relationships between the variables were uniform across all dimensions of service delivery, we also included a control group of three survey questions that were judged to be unrelated to infection-related safety practices: 1) room temperature; 2) helpfulness of the people at the information desk; and 3) speed of the admission process.

Results
After linking the hospital-specific data released by the PHC4 with the data from the Press Ganey survey, we found significant negative correlations between patient perceptions of the quality in the identified practices and facilities' infection rates (see Table). Facilities with higher scores on cleanliness, blood-draw skills, and nurse responsiveness items tend to have lower rates of infections and infection mortality. Correlations between the hypothesized unrelated safety practice items and infection rates were not significant. These results lead us to conclude that patient perceptions of the quality of care reflect external assessments of clinical quality.

Comments
Rising infection rates have been blamed on many and varied factors including antibiotic drug resistant strains of disease, understaffing, and insufficient training of health care staff (Gould, 2005). However, the PHC4 supports the opinion that HAI are not "inevitable, unavoidable by-products of health care" and that infection rates should be reduced to zero (PHC4, 2006).

The data in the present study suggest that patient ratings of certain hospital practices can serve as a parallel indicator of a facility's propensity toward patient infections. The World Health Organization (WHO) suggests that simple preventative measures should be taken regardless of the current rate of infection (Pittet & Donaldson, 2005), and recognizes that patients are aware when basic preventative practices are executed. The practices measured using the patient survey items mentioned above are ones that patients will observe and upon which every hospital can improve.

Survey Item	Infection Rate	Mortality Percent with Infection
Room Cleanliness	-.273(*)	-.333(**)
Skill of person who took your blood	-.247(*)	-.351(**)
Promptness in responding to the call button	-.231(*)	-.293(**)
Room temperature	-.134	-.142
Helpfulness of people at the information desk	-.134	-.177
Speed of admission process	-.152	-.146
* Correlation is significant at the 0.05 level (2-tailed). ** Correlation is significant at the 0.01 level (2-tailed)

Table: Correlations Between Survey Items and Infection and Mortality with Infection Rates

To improve the stability of the estimators, hospitals with fewer than 100 patient responses (N=3) were removed from the analysis, resulting in a final sample of 84 Pennsylvania hospitals.

References

Burke, J. P. (2003). Infection control — A problem for patient safety. The New England Journal of Medicine, 348, 651.

Gould, D. (2005). The fall and rise of cleanliness in British healthcare and the nursing contribution. Journal of Research in Nursing, 10, 495-509.

Pennsylvania Health Care Cost Containment Council (PHC4). (2006). Hospital-acquired infections in Pennsylvania. PHC4 Reports. Available at: http://www.phc4.org/reports/hai/05/default.htm.

Pittet, D., & Donaldson, L. (2005). Clean Care is Safer Care: The first global challenge of the WHO World Alliance for Patient Safety. American Journal of Infection Control, 33, 181-187.

Pronovost, P. J., Berenholtz, S. M., Goeschel, C. A., et al. (2006, August). Creating high reliability in health care organizations. Health Serv Res, 41(4 Pt 2), 1599-1617.

Volavka, M. (2006). In K. Ecohard, Hospital infections' climbing cost. United Press International.