The impact of health care restructuring: DISCUSSION

20 Jan

The impact of health care restructuring: DISCUSSION

Health care restructuring in 1995 radically transformed our hospital, with a resultant impact on nosocomial blood stream infections. While there was a decrease in bed number, admissions and patient days at the hospital, patient popula­tions shifted from groups at lower nosocomial infection risk (eg, ophthalmology, psychiatry, internal medicine and paedi­atrics) to groups at higher risk (eg, surgical patients, nephrology). As a result, markers of nosocomial blood stream infection risk, such as ICU CVC days, TPN days and the use of hemodialysis, actually increased.

This increase in risk was associated with widespread in­creases in nosocomial blood stream infection including both ICU and non-ICU infections, primary and a range of secondary infections, and the increased frequency of wide spectrum of bacterial and fungal microbial causes of blood stream infections. The increase in absolute numbers of infections in­dicates that the increases were real and not simply a reflection of transfer of low risk patients, destined never to have an in­fection, to the community setting. This increase was likely a result of the transfer of high risk patient groups to the hospital that had been previously treated elsewhere in our region.

We only measured nosocomial infections resulting in blood stream infection, more than half of which were primary, ie, not attributable to another organ system infection. Neverthe­less, it is possible that an increase in nonbacteremic nosocomial infections may have also occurred, because blood stream infections secondary to a range of nosocomial infec­tions (pneumonia, urinary tract, surgical site) also increased measurably in frequency by an amount identical to that of pri­mary infections.

Of particular concern is that the greatest increases in infec­tion rates occurred for organisms that are difficult to treat (candida, pseudomonas) or increasingly antimicrobial resis­tant (Enterococcus species, Saureus). To date, we have not ex­perienced blood stream infection due to methicillin-resistant S aureus or vancomycin-resistant enterococcus. However, the spread of these resistant strains to our hospital and the dis­placement of the rapidly increasing numbers of their antimi­crobial sensitive counterparts would be a seriously negative development for our patient population.

What do our data say about the quality of hospital care de­livered? In previously published data, an increase in the risk-adjusted hemodialysis infection rate was shown during and following restructuring, attributable to an increased need to carry out hemodialysis via CVCs. Increases in dialysis- re­lated infections accounted for 29.5% of the total increase in in­fections between the two time periods. In the present study, using appropriate risk adjustment techniques, we have shown stable rates for ICU CVC infection and infections associ­ated with TPN, suggesting that the quality of care has not changed for these patient groups. These data suggest that the restructuring of health care delivery can be accomplished without a negative impact on the frequency of infectious com­plications, but that planning of change and monitoring of re­sults are necessary to ensure that this occurs.


Restructuring of the UAH was associated with measurable increases in the patient population risk of nosocomial blood stream infection, and resulted in a 31% increase in number and a 60% increase in rate of these infections. Because health care restructuring is occurring across Canada, it seems likely that our experience will be replicated elsewhere. As a result, the nature of hospital care has changed. Future hospital popu­lations will be more seriously ill, undergo more invasive pro­cedures and turn over more quickly than in the past. These changes have implications for health care planners. For exam­ple, nurse to patient ratios suitable for a mix of more and less seriously ill patients may be inadequate for patient groups who are all seriously ill. Finally, there are implications for hospital infection control programs (of proven value in reduc­ing rates of nosocomial infection); these program will need to be augmented to address the increasing infection risk of cur­rent hospitalized patient populations and to assess the impact of changing health care delivery. Previously recommended in­fection control staffing guidelines for acute care hospitals (one infection control practitioner to 250 beds) came from data col­lected in the 1970s, and this number is inadequate for the needs of current hospital patient populations.
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