Imagine you go to a hospital for a routine surgery. Everything seems fine with you until at some point you might have a surprise: an infection which the laboratory says was caused by something with a strange Latin name be it Klebsiella, Staphylococus aureus, Clostridium difficile and so on. This microorganism "befriended you" in the hospital. It could have come from other patients or from visitors, medical personnel or equipment. If you are lucky, proper treatment might save you. These infections, called nosocomial infections, can be lethal. In Slovakia 41 people died because of them last year.
"We have a list of, let's call them, already famous bacteria which are those that have evolved in such a way that they've acquired resistance to antibiotics and cause headaches when it comes to treatment because doctors run out of options. Hospitals are good environments for these pathogens because they can find suitable hosts there. The immune system of an ill patient is already busy dealing with an initial ailment and an additional infection is a burden for it as it needs to overstretch to fight it. In addition to this, many patients have some of their natural protective barriers under strain by intubation, catheter insertion, and so on," says doctor Adriana Liptaková, the Head of the Microbiology Institute of the Medical Faculty in Bratislava.
Now, the topic of increased resistance to antibiotics has been one of Slovakia's priorities during its stay at the helm of the European Union which will end in two weeks time. At a big conference on this topic in Bratislava in October Slovak Health Minister Tomáš Drucker summed up the situation in his country this way:"We are a country that has problems with antimicrobial resistance in hospitals, with the so called nosocomial infections, and the truth is that our system of reporting and dealing with them is not right."
Well, the minister did not offer more details but a quick look at a report of the Slovak Public Health Authority gives us some hints. In Slovakia, reporting cases of nosocomial infections is compulsory and the Public Health Authority is in charge with collecting such data. No less than 32 healthcare facilities reported that they recorded no nosocomial infections whatsoever last year. A regional hospital dealing with 18,000 hospitalized patients last year reported only one 1 case of nosocomial infection. Other regional ones reported 2. According to current legislation a figure calculated as the number of cases per total number of hospitalized patients is an indicator of quality of provided healthcare service which is to be taken into account by health insurance companies among others. But these official figures have been raising plenty of eyebrows as Darina Sedlaková, the head of the World Health Organisation's office in Slovakia explains. "If most renowned hospitals in Europe report that they have 6-10% nosocomial infections I don't believe it when Slovak hospitals report that they have 0.5% or 2%. It is something they artificially decide to report but it can't reflect reality."
According to Jaroslava Brňová from the Faculty of Public Health of Trnava University, a microbiologist by profession, who has been researching the issue of nosocomial infections in Slovakia with her students, the problem starts with the methodology itself. "This way of reporting as an overall percentage is weak and misleading. The reporting should be focused. For example the number of cases of blood infections should be reported not as percentage from all patients but from only those who had been exposed to a risk factor - in this case a central venous catheter. On the same principle, lung infections have to be calculated depending on their risk factor, which is mechanic ventilation, and the number of days they spent in this situation. The only type of nosocomial infection that can be mapped quite accurately using the current methodology is the one caused by microorganisms in the gastrointestinal tract with the exception of Clostridium difficile which is dependent on the prior use of antibiotics. Anyway, you need to actively follow all these cases day by day and not in a purely administrative way. It's estimated that 30-40% of nosocomial infections are preventable."
For this report I have contacted a wide range of hospitals of various sizes, both general and specialized, private and state run. Only about a third of them were willing to share their experience with dealing with nosocomial infections. The University Hospital "Louis Pasteur" in Košice, Slovakia's second largest city is one of them. Their chief-hygienist Ladislav Tomčo and deputy director L'uboslav Beňa explained why they think that nosocomial infections are a risk to patients' safety that in many cases can be prevented via better organisation: "Based on the current methodology we had 0.5% incidences of nosocomial infections last year but this type of figure does not say too much. It's a static indicator that does not encourage active surveillance and proper control and prevention. This is a problem at the national level. In our case we have been trying to do it differently. We have been performing active surveillance for patients with diarrhoea and signs of infection with Clostridium difficile bacteria. We have introduced a system of patient management in these cases and plan to extend our active surveillance programme next year. We hired new people in October, so we have three full-time employees specialized in public health."
Doctor Zuzana Fuchsbergerová, the chief hygiene-expert at the National Oncology Institute in Bratislava points to the fact that each hospital has its particularities and this has to be taken into account as the issue of nosocomial infections needs to be dealt with a high level of professional expertise, insight and resources. "We are a highly specialized facility that gathers a large numbers of patients with lowered immunity which means that we always have to count on the very high probability of a nosocomial infection. In their case, those microorganisms that live in, let's say, the gut, can find their way to the bloodstream which does not happen to other patients. These type of infections are very difficult to control in oncologic patients that's why our preventability rate is different. The high preventability rates can be applied to external factors, for example, contamination via hands. We have very strict rules when it comes to hygiene from wearing masks, protective clothes, and gloves to how we decontaminate the rooms. In some cases we need to keep the room empty for 24 hours before accommodating another patient there," says Fuchsbergerová.
So if you really want to have accurate and worthwhile data you need to allocate sufficient resources for active surveillance and this includes having the proper personnel to do it. Let's have a look at some recent numbers provided by the National Centre for Healthcare Information. In 2016 only 42 people have been working for healthcare facilities in Slovakia in the area of hygiene, epidemiology and public health. There were none in the Prešov Region and only one in the Nitra Region. So where do all those graduates from the public health schools go?" According to current legislation these graduates who want to work in hospitals are included in the category of "other healthcare personnel" which offers low salaries. As a consequence they go to work for pharmaceutical companies or private companies dealing with health and safety in workplaces,"says Jaroslava Brňová from the Faculty of Public Health at Trnava University, adding that epidemiology is not attractive anymore for medical school students either, so one solution that she and her colleagues want to propose is the possibility for their graduates to study some additional three years to specialize in epidemiology so they can get higher competencies and better pay in hospitals.
But even those hospitals which manage to be active in monitoring their risk of nosocomial infections still face hurdles ahead because it is not enough to teach your staff how to properly clean their hands. The situation in the area of sterilization has improved according to the the Public Health Authority which in its report from last year, it has found out that the percentage of contaminated samples from the sterilized material and equipment has lowered by almost a half year on year but some problem persist. Most of the equipment used for sterilization in Slovak hospitals is old. And so are many Slovak hospitals' buildings. Zuzana Drobová the spokesperson of the Public Health Office explains:"To minimize the risk of spread of communicable diseases it's important to ensure room for the isolation of the patient when the presence of a potential dangerous pathogen was detected. In terms of patient safety in healthcare facilities they need to eliminate the structural - technical defects. Leaking windows, damaged flooring and damaged sanitation can be a source of microorganisms. Supply hot water to sinks in the toilet is essential for proper hand hygiene. It is also necessary to ensure an adequate number of showers for patients in relation to the number of beds in nursing units. "
Listening to this I have, in front of my eyes, two buildings of the largest hospital in Slovakia, the University Hospital in Bratislava with their run down windows and balconies and the fact that during none of my five visits there I could not find either toilet paper nor soap at facilities for hundreds of patients waiting to see a doctor. Maybe the situation will be better once the new University Hospital in Bratislava will be built. Eliminating the structural-technical issues of a hospital is easier said than done as Zuzana Konyová from the Hospital with Policlinic in Brezno, Central Slovakia, explains: "'The underfunding of hospital leads to us being unable to find money for restoration work and for building enough rooms with private toilets and shower facilities which would enable the isolation of patients."
The hospital in Brezno is clearly not the only one in such a situation. According to a pan-European survey from 2012 less than 5% of all rooms in Slovakia's hospitals are single bed only and some of these are not necessarily suitable for patients' isolation but built for ordinary patients willing to pay for increased comfort. So, hospitals which don't have somewhere to isolate the patient have to improvise. Luckily, many Slovak hospitals still have wards for infectious diseases where patients can be placed to be taken care of. The same hospital in Brezno has raised another issue that has been affecting almost every regional and local hospital in Slovakia: the lack of qualified medical personnel, mainly nurses. The Slovak Chamber of Nurses and Midwives estimates that there is a shortage of about 12,000 nurses in this country's healthcare system. According to the 2016 Health at a Glance Report done by the Organisation for Economic Cooperation and Development (OECD) Slovakia is the only country in Europe where the total number of nurses as well as that per capita have been going down since 2000. If Denmark has 16.5 nurses per thousand inhabitants and the neighbouring Czech Republic 7.9, Slovakia has only 5.8 nurses and this figure includes those who work in administrative positions or education too. Chamber's president Iveta Lazorová says that this has become a profession which is not attractive for young people anymore. "The basic starting salary for a nurse is currently at 690 euro per month before taxes. With overtime and weekend shifts they can reach the average salary on economy, let's say, but this means a lot of time spent at work and far from their families. Then we have to bear in mind that this is hard work from both physical and emotional point of view and the lack of proper management in many hospitals adds extra stress to an already stressful profession," concludes Lazorová.
Someone does not have to hold a master of public health degree to realize that an overworked and stressed nurse taking care of more and more patients is at higher risk of making mistakes during, let's say, installing a catheter. Time will say if the current plan of the Health Ministry to give more competencies to the so called healthcare assistants will improve the situation.
Forced to improvise to cover for their shortcomings, some healthcare facilities cause troubles for others. According to the Faculty Hospital in Prešov one of the biggest problems they face when it comes to preventing nosocomial infections is the fact that they do not have enough information about the patients they receive from other facilities. A screening should be compulsory for such patients when they leave one facility. "Yes, this is a problem that we also face here at the National Oncological Institute. I think that the communication between hospitals is not always good. And then we have to bear in mind that not all facilities have the possibility to do all the required tests,"says doctor Zuzana Fuchsbergerová, the chief hygiene expert at the National Oncology Institute in Bratislava, adding that education of both healthcare personnel and patients, and investment in better materials and equipment are key for the proper management of nosocomial infections. Now if you remember at the beginning of this report I said that according to current legislation, the incidence of nosocomial infections is an indicator of quality for the provided healthcare service, which is to be taken into account by health insurance companies. Slovakia has a system of universal coverage based on mandatory contributions to the healthcare coffers which can reach 14% of somebody's monthly income for employed and self-employed. The state covers for pensioners, students, unemployed and mothers on maternity leave. These contributions are collected by three insurance companies which then re-distributes them to healthcare facilities. This is the main source of income for all hospitals in Slovakia regardless if public or private. How much attention do these health insurance companies pay to the incidence of nosocomial infections as an indicator of quality? "We do not have the possibility to check if the figure they report is real or not. Most probably they do not do it right and as a consequence this is not a relevant indicator for us. For this reason our clients do not have any possibility to evaluate a provider based on this indicator," says Matej Štepianský a spokesperson for Dôvera, the second largest health insurance company, adding that they do not have any analyses on how much money it costs the company a patient whose health has been affected by a nosocomial infection.
A similar reply came from Všeobecná zdravotná poisťovňa, the largest health insurance company, which added that its inspectors keep an eye on how hospitals deal with this issue. However, none of the hospitals to whom I talked for this report remember being questioned about this topic by any insurance company and as the deputy director of University Hospital "Louis Pasteur" in Košice said rather than looking at a number in a column the health insurance companies should check if there is real, proper system for monitoring and prevention of nosocomial infections in place. Maybe you have the feeling that patients are missing from this story, maybe you think they should put pressure on hospitals and as clients on their insurance companies too. Well, I thought so too. I checked how many complaints authorities received only to discover that it's unclear to whom you can complain in Slovakia to check whether the nosocomial infection you received in a hospital can be seen as you not being properly taken care of as a patient. Patients' organisations, which are not very strong in Slovakia, blame the system as a whole in quite general terms. To court only a few patients dared to go. In the database of the Justice Ministry I found only a handful of cases where nosocomial infection were involved, and so far all decided in favour of patients. As one of the lawyers involved in one of them explained, such a case can be lengthy and it's not cheap either.
If bacteria could read or hear I wonder what would they make of this report….
The enemy within
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