HL20: Michael Edmond, MD—Ethics and Results in Infection Control

In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Michael Edmond, MD.

This profile was published in the December, 2011 issue of HealthLeaders magazine.

 "It really appears that you don't have to do active surveillance in order to reduce infections in your hospitals."

Back in 2003, Virginia Commonwealth University Medical Center epidemiologist Michael Edmond, MD, realized that the way hospitals try to prevent infections, with active surveillance, just didn't make any sense.

They were testing so many patients for just one type of infection, Methicillin-resistant Staphylococcus aureus. If the patients were found to be carriers, they would be isolated, with potential for adverse consequences.

"Isolation is not a benign procedure, because it increases patients' risk of falls, pressure sores, and electrolyte disturbances, and we know they get fewer visits from doctors and nurses," Edmond says. And from an ethical standpoint, he said, "Here's a group of isolated patients who don't get any benefit from that, but just bear the burden, because all the benefit accrues to the patients who are not colonized and not isolated."

It occurred to him that MRSA is only responsible for 10% of the nosocomial infections in a hospital, so controlling for it alone misses many other important organisms, "like some of the gram negative rods that are now essentially resistant to all the antibiotics we have."

So in 2004, he persuaded officials of the 779-bed hospital not to adopt active surveillance. He was, as he put it, "pushing the edge."

Instead of testing for MRSA, hospital staffers focus on central venous catheter insertion bundles, head of bed elevation for mechanically ventilated patients, and chlorhexidine baths for patients in the intensive care unit. 

Edmond and his teams also zero in on simple hand hygiene. They hire graduate students—three at a time—to walk the halls and observe healthcare providers washing their hands, a cost of only $25,000 a year.

"We collect more than 50,000 observations a year, and provide weekly feedback to providers on rates of compliance by each unit in the hospital, and by each type of provider—medical students, nurses, doctors, etc."

At first, hand hygiene compliance was just 40%, but now it is more than 90%, he says.

And the drop in all hospital-acquired infections for all organisms has been remarkable. "From 2003 to the first half of 2011, we've had an 86% reduction in infections in our ICUs, from 21 infections per 1,000 patient days to three. We've had an 84% reduction in central line-associated bloodstream infections and a 93% reduction in ventilator associated pneumonias. One of our ICUs has not had a single ventilator associated pneumonia case in over three years."

In all, he says, the hospital has saved $20 million in avoided cost of treating bloodstream infections, ventilator associated pneumonia, and urinary tract infections in the ICU.

Now, Edmond can say with confidence, "it really appears that you don't have to do active surveillance in order to reduce infections in your hospitals."

VCU is not the only healthcare system to throw out active surveillance for MRSA, but there aren't many other healthcare systems who have adopted this approach, Edmond says. In doing so, he admits to bucking a trend of what he calls "emotional zealotry" that has gotten out of hand.

Advocacy groups began to propel this practice in the mid 1990s, he says, in large part because of sad stories of MRSA tragedies. But what they advocate, and have been successful at achieving, Edmond says, is just not going to get the problem fixed; it doesn't serve the patients or their families and really, it makes matters worse.

"There are people who are really vocal advocates for doing this. I'm not sure that anything would make them change their mind," Edmond says.

Some hospitals even treat patients with antibiotics who simply test positive as carriers, even though they are not sick and risk further contributing to the problem of antibiotic overuse and the development of resistance organisms.

Some organizations have actively promoted the use of surveillance cultures with companies that manufacture MRSA testing kits, Edmond says. Companies have lobbied state legislators to try to get laws passed to require all these patients get tested for MRSA." He has argued this vociferously on a blog, "Controversies in Hospital Infection Prevention," which he writes with two other infectious disease specialists.

"You could easily say that this whole issue around active surveillance is the most polarizing issue in hospital epidemiology, maybe ever, but certainly in the last decade," he says.

Several states, such as Illinois, mandate that hospitals perform active surveillance testing on all patients admitted to the hospital.

During the past seven years that he's avoided active surveillance, Edmond says, new administrators or other hospital officials will come on board. And they will ask him "Why aren't we doing active surveillance, when other hospitals think it's so important?" 

And he tells them, not only do such programs not control hospital-acquired infections, they cost money. At VCU, for example, "it would cost more than $1 million a year in lab expenses. And administrators understand dollars," he said.

But as long as he keeps showing them success—in the most recent quarter there was only one MRSA infection in the entire hospital—persuading the C-suite isn't so tough to do, he says.

This article appears in the December 2011 issue of HealthLeaders magazine.