[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
TECHNOLOGY FOR PATIENT SAFETY
AT VETERANS HOSPITALS
=======================================================================
JOINT HEARING
BEFORE THE
SUBCOMMITTEE ON RESEARCH AND TECHNOLOGY &
SUBCOMMITTEE ON OVERSIGHT
COMMITTEE ON SCIENCE, SPACE, AND TECHNOLOGY
HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
SECOND SESSION
__________
JUNE 26, 2014
__________
Serial No. 113-83
__________
Printed for the use of the Committee on Science, Space, and Technology
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://science.house.gov
______
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COMMITTEE ON SCIENCE, SPACE, AND TECHNOLOGY
HON. LAMAR S. SMITH, Texas, Chair
DANA ROHRABACHER, California EDDIE BERNICE JOHNSON, Texas
RALPH M. HALL, Texas ZOE LOFGREN, California
F. JAMES SENSENBRENNER, JR., DANIEL LIPINSKI, Illinois
Wisconsin DONNA F. EDWARDS, Maryland
FRANK D. LUCAS, Oklahoma FREDERICA S. WILSON, Florida
RANDY NEUGEBAUER, Texas SUZANNE BONAMICI, Oregon
MICHAEL T. McCAUL, Texas ERIC SWALWELL, California
PAUL C. BROUN, Georgia DAN MAFFEI, New York
STEVEN M. PALAZZO, Mississippi ALAN GRAYSON, Florida
MO BROOKS, Alabama JOSEPH KENNEDY III, Massachusetts
RANDY HULTGREN, Illinois SCOTT PETERS, California
LARRY BUCSHON, Indiana DEREK KILMER, Washington
STEVE STOCKMAN, Texas AMI BERA, California
BILL POSEY, Florida ELIZABETH ESTY, Connecticut
CYNTHIA LUMMIS, Wyoming MARC VEASEY, Texas
DAVID SCHWEIKERT, Arizona JULIA BROWNLEY, California
THOMAS MASSIE, Kentucky ROBIN KELLY, Illinois
KEVIN CRAMER, North Dakota KATHERINE CLARK, Massachusetts
JIM BRIDENSTINE, Oklahoma
RANDY WEBER, Texas
CHRIS COLLINS, New York
BILL JOHNSON, Ohio
------
Subcommittee on Research and Technology
HON. LARRY BUCSHON, Indiana, Chair
STEVEN M. PALAZZO, Mississippi DANIEL LIPINSKI, Illinois
MO BROOKS, Alabama FEDERICA WILSON, Florida
RANDY HULTGREN, Illinois ZOE LOFGREN, California
STEVE STOCKMAN, Texas SCOTT PETERS, California
CYNTHIA LUMMIS, Wyoming AMI BERA, California
DAVID SCHWEIKERT, Arizona DEREK KILMER, Washington
THOMAS MASSIE, Kentucky ELIZABETH ESTY, Connecticut
JIM BRIDENSTINE, Oklahoma ROBIN KELLY, Illinois
CHRIS COLLINS, New York EDDIE BERNICE JOHNSON, Texas
BILL JOHNSON, Ohio
LAMAR S. SMITH, Texas
------
Subcommittee on Oversight
HON. PAUL C. BROUN, Georgia, Chair
F. JAMES SENSENBRENNER, JR., DAN MAFFEI, New York
Wisconsin ERIC SWALWELL, California
BILL POSEY, Florida SCOTT PETERS, California
KEVIN CRAMER, North Dakota EDDIE BERNICE JOHNSON, Texas
BILL JOHNSON, Ohio
LAMAR S. SMITH, Texas
C O N T E N T S
June 26, 2014
Page
Witness List..................................................... 2
Hearing Charter.................................................. 3
Opening Statements
Statement by Representative Larry Bucshon, Chairman, Subcommittee
on Research and Technology, Committee on Science, Space, and
Technology, U.S. House of Representatives...................... 6
Written Statement............................................ 7
Statement by Representative Dan Maffei, Ranking Minority Member,
Subcommittee on Research and Technology, Committee on Science,
Space, and Technology, U.S. House of Representatives........... 8
Written Statement............................................ 9
Statement by Representative Paul Broun, Chairman, Subcommittee on
Oversight, Committee on Science, Space, and Technology, U.S.
House of Representatives....................................... 11
Written Statement............................................ 13
Statement by Representative Lamar S. Smith, Chairman, Committee
on Science, Space, and Technology, U.S. House of
Representatives................................................ 13
Written Statement............................................ 14
Witnesses:
Dr. Chetan Jinadatha, Chief, Infectious Diseases, Central Texas
Veterans Health Care System
Oral Statement............................................... 17
Submitted Biography.......................................... 19
Dr. Elaine Cox, Professor of Clinical Pediatrics, Director of
Infection Prevention, Director of Pediatric Antimicrobial
Stewardship, Riley Hospital for Children
Oral Statement............................................... 20
Written Statement............................................ 22
Dr. Trish M. Perl, Professor of Medicine and Pathology, Johns
Hopkins School of Medicine; Professor of Epidemiology,
Bloomberg School of Public Health; Senior Epidemiologist, Johns
Hopkins Medicine
Oral Statement............................................... 25
Written Statement............................................ 27
Mr. Jeff Smith, President, Electro-spec, Inc.
Oral Statement............................................... 36
Written Statement............................................ 38
Mr. Morris Miller, Chief Executive Officer, Xenex Disinfection
Services
Oral Statement............................................... 54
Written Statement............................................ 56
Discussion....................................................... 100
Appendix I: Answers to Post-Hearing Questions
Dr. Chetan Jinadatha, Chief, Infectious Diseases, Central Texas
Veterans Health Care System.................................... 82
Dr. Elaine Cox , Professor of Clinical Pediatrics, Director of
Infection Prevention, Director of Pediatric Antimicrobial
Stewardship, Riley Hospital for Children....................... 98
Dr. Trish M . Perl, Professor of Medicine and Pathology, Johns
Hopkins School of Medicine; Professor of Epidemiology,
Bloomberg School of Public Health; Senior Epidemiologist, Johns
Hopkins Medicine............................................... 105
Mr. Jeff Smith, President, Electro-spec, Inc..................... 110
Mr. Morris Miller, Chief Executive Officer, Xenex Disinfection
Services....................................................... 119
Appendix II: Additional Material for the Record
Prepared statement by Representative Eddie Bernice Johnson,
Ranking Member, Committee on Science, Space, and Technology,
U.S. House of Representatives.................................. 128
Articles submitted by Subcommittee Representative Larry Bucshon,
Chairman, Subcommittee on Research and Technology, Committee on
Science, Space, and Technology, U.S. House of Representatives.. 130
Supporting documents submitted by Dr. Trish M . Perl, Professor
of Medicine and Pathology, Johns Hopkins School of Medicine;
Professor of Epidemiology, Bloomberg School of Public Health;
Senior Epidemiologist, Johns Hopkins Medicine.................. 150
TECHNOLOGY FOR PATIENT SAFETY AT VETERANS HOSPITALS
----------
THURSDAY, JUNE 26, 2014
House of Representatives,
Subcommittee on Research and Technology and
Subcommittee on Oversight,
Committee on Science, Space, and Technology,
Washington, D.C.
The Subcommittees met, pursuant to call, at 9:06 a.m., in
Room 2318 of the Rayburn House Office Building, Hon. Larry
Bucshon [Chairman of the Subcommittee on Research and
Technology] presiding.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman Bucshon. The joint hearing of the Subcommittee on
Research and Technology and the Subcommittee on Oversight will
come to order.
Good morning, everyone, and welcome to today's hearing
titled ``Technology for Patient Safety at Veterans Hospitals.''
In front of you are packets containing the written
testimony, biographies and Truth in Testimony disclosures for
today's witnesses.
Before we get started, since this is a joint hearing
involving two Subcommittees, I want to explain how we will
operate procedurally so all Members understand how the
question-and-answer period will be handled. We will recognize
those Members present at the gavel in order of seniority on the
full Committee and those coming after the gavel will be
recognized in order of arrival. I now recognize myself for five
minutes for an opening statement.
This morning's hearing will focus on an important public
health issue: the problem of patients contracting dangerous
infections while in the hospital. This problem has been in the
news lately due to disclosure of unfavorable information about
some Veterans Administration hospitals, including high rates of
hospital-acquired infections, or HAIs.
We want the highest quality of care and the highest
standards of patient safety in all VA hospitals. Big variations
among VA hospitals are a cause for concern.
However, as a former cardiothoracic surgeon, I am well
aware that HAIs are not a problem unique to the VA Health Care
System. Also, it is important to realize that hospital-acquired
infection rates will never be zero, but can and should be
aggressively minimized.
Rates of hospital-acquired infections appear to have
declined in recent years. During the 1990s, estimates hovered
around 2 million per year. The CDC's most recent estimate is
1.7 million hospital-acquired infections happen annually. The
CDC also calculates this works out to about a one in 25 chance
of contracting a serious infection while in the hospital.
The idea a hospital patient, on average, only has a one in
25 chance of getting an infection is certainly not a good
thing. Many infections that patients suffer from while
hospitalized originate from their own flora--their own
bacteria, for non-medical people--i.e., the skin, respiratory,
or intestinal bacteria for example, that comes to the hospital
with the patient.
That said, research has shown it is possible to prevent a
large fraction of hospital acquired infections. For example,
simple things like isolating patients who have serious
infections, and doctors and nurses washing their hands between
each patient, can go a long way toward controlling the spread
of potentially lethal infections. One hundred percent adherence
to all these best practices by health care personnel won't
solve the problem. Hand washing and hand sanitation is just as
important for family members and other hospital visitors, too,
as they often are unknowingly responsible for spreading
bacteria and viruses. Some types of viruses, for example, can
survive for months on a tray, a door frame or other surface.
Most people take for granted that antibiotics can
ultimately cure all but the most exotic types of infections.
Until a few decades ago, antibiotics were, for the most part,
an effective backstop against most hospital-acquired
infections. The evolution of antibiotic-resistant superbugs is
voiding the assumption that medicine can cure every infection.
More than one dozen types of pathogens have developed
resistance to most types of antibiotics. In some cases, just
one class of antibiotics is still effective, and in a few
instances, there are literally no antibiotics that are
effective against certain bacteria. Antibiotic overuse and
inappropriate use are significantly responsible for the growing
number of antibiotic resistant superbugs.
As a personal side note, I believe tort issues surrounding
the practice of medicine is partly responsible for this issue
and needs reform. Another problem is the slow pace at which new
antibiotics are being developed, due to the costly and lengthy
approval process.
According to the Infectious Disease Society of America,
just one organism, methicillin-resistant Staph aureus, better
known as MRSA, kills more Americans each year than the combined
total of emphysema, HIV/AIDS, Parkinson's disease, and
homicide.
The Food and Drug Administration recently approved a new
antibiotic for MRSA infections, but that is just one type of
bacteria, and the odds are that resistance to the new medicine
will develop.
The better news is that there are some promising new, non-
pharmaceutical innovations that can help to reduce hospital-
acquired infection rates significantly, innovations that don't
seem to carry the possibility of eventual antibiotic
resistance. These innovations have been developed from research
in several scientific fields, including nanotechnology,
robotics, computer science, and biology.
We are fortunate to have with us three physicians who are
national experts in infectious diseases and the prevention of
hospital-acquired infections and two witnesses will describe
the anti-infection innovations their companies have brought
forward. I look forward to this morning's testimony on this
important subject.
[The prepared statement of Mr. Bucshon follows:]
Prepared Statement of the Subcommittee on Research and Technology
Chairman Larry Bucshon
This morning's hearing will focus on an important public health
issue--the problem of patients contracting dangerous infections while
in the hospital. This problem has been in the news lately due to
disclosure of unfavorable information about some Veterans
Administration hospitals, including high rates of hospital acquired
infections, or HAI's.
We want the highest quality of care and highest standards of
patient safety in all VA hospitals. Big variations among VA hospitals
are a cause for concern. However, as a former cardio-thoracic surgeon,
I am well aware that HAIs are not a problem unique to the VA Health
Care System. Also, it is important to realize that HAI rates will never
be zero, but can and should be aggressively minimized.
Rates of hospital-acquired infections appear to have declined in
recent years. During the 1990's, estimates hovered around 2 million per
year. The CDC's most recent estimate is 1.7 million HAIs annually. The
CDC also calculates this works out to about a one in 25 chance of
contracting a seriousinfection while in a hospital.
The idea a hospital patient, on average, has ``only'' a one in 25
chance of getting an infection is certainly not a good thing. Many
infections that patients suffer from while hospitalized originate from
their own flora (ie skin, respiratory, or intestinal bacteria for
example.)
That said, research has shown it is possible to prevent a large
fraction of hospital infections. For example, simple things like
isolating patients who have serious infections, and doctors and nurses
washing their hands between each patient, can go a long way toward
controlling the spread ofpotentially lethal infections.
One hundred percent adherence to all best practices by health care
personnel won't solve the problem. Hand washing and hand sanitation is
just as important for family members and other hospital visitors, too,
as they often are unknowingly responsible for spreading bacteria and
viruses. Some types of viruses can survive for six months on a tray, a
door frame or other type of surface.
Most people take for granted that antibiotics can ultimately cure
all but the most exotic kinds of infections. Until a few decades ago,
antibiotics were an effective backstop against most hospitalacquired
infections.
The evolution of antibiotic-resistant superbugs is voiding the
assumption that medicine can cure infections. More than one dozen types
of pathogens have developed resistance to most types of antibiotics. In
some cases, just one class of antibiotics is still effective. And in a
few instances, there is literally no antibiotic that works. Antibiotic
overuse and inappropriate use are significantly responsible for the
growing number of antibiotic resistant superbugs. As a personal side
note, I believe tort issues surrounding the practice of medicine is
partly responsible for this issue and needs reform. Another problem is
the slow pace at which new antibiotics are being developed, due to a
costly and lengthy approval process.
According to the Infectious Disease Society of America (IDSA), just
one organism--methicillin-resistant Staphylococcus aureus, better known
as MRSA--kills more Americans each year than the combined total of
emphysema, HIV/AIDS, Parkinson's disease, and homicide.
The Food and Drug Administration recently approved a new antibiotic
for MRSA infections. But that's just one type of bacteria, and the odds
are that resistance to the new medicine will develop.
The better news is that there are some promising new, non-
pharmaceutical innovations that can help to reduce HAI rates
significantly, innovations that don't seem to carry the possibility of
eventual antibiotic resistance.
These innovations have been developed from research in several
scientific fields, including nanotechnology, robotics, computer
science, and biology.
We're fortunate to have with us three physicians who are national
experts in infectious diseases and the prevention of HAIs and two
witnesses will describe the anti-infection innovations their companies
have brought forward. I look forward to this morning's testimony on
this important subject.
Chairman Bucshon. I now yield to the Ranking Member, Mr.
Maffei.
Mr. Maffei. Thank you very much, Chairman Bucshon. I also
want to thank you for holding this hearing and I also want to
thank Chairman Broun, who is the Chairman of my Subcommittee,
the Subcommittee on Oversight, and I of course want to thank
Chairman Smith, the Chairman of the full Committee, and all the
Members for being here. This is an important hearing on the
technology for patient safety at Veterans Hospitals.
Health care-associated infections are a serious and
potentially deadly threat to anyone who spends time in a
hospital, any hospital. In fact, overall, not just the VA but
all hospitals, there is an average of 200 individuals who die
every day as a result of health care-associated infections.
This amounts to an estimated 75,000 people a year. Another
650,000 patients become infected each year during their
hospital stays, and it can cost as much as $45,000 per patient
to treat these infections. Health care-associated infections in
the United States alone cost as much as $45 billion a year.
I would stress that these infections are not unique to the
Veterans Administration's hospitals. I know that health care-
associated infections and medical mishaps do not stop at the
door of the VA, however. Unfortunately, they are prevalent in
all health care facilities, and the tools to combat these
infections and to prevent medical errors are the same
regardless of where the care is given.
I look forward to hearing from our witnesses today about
both proven methods and new technologies that can help play a
role in addressing this serious issue. I am particularly
interested in hearing from Dr. Trish Perl from Johns Hopkins
University, who brings a wealth of experience and expertise to
the area of infectious diseases and the role that technology
can play in their prevention. She has firsthand experience
implementing new technologies to combat hospital infections,
some that worked successfully and some that actually increased
the rate of infection. I look forward to hearing from her about
the possible benefits and potential downsides to implementing
unproven technologies in the hospital settings.
Mr. Chairman, I must confess, though, I do have concerns
about the testimony of one of our witnesses, however, and that
is simply that it wasn't submitted at all in a clear
contradiction of this Committee's rules and practices. It is
the standard practice of the House Committee on Science, Space,
and Technology to have advanced written testimony from
witnesses before they testify. Today, the Majority has taken
the opposite approach and is willing to sit a witness from the
Veterans Administration that has provided no written testimony
in advance of this hearing. I am concerned that Majority staff
knew about this problem and did not rectify it in a timely
manner and agreed to sit this witness without having written
testimony prior to the hearing several days ago rather than
postponing the hearing or moving forward without this witness.
My understanding is that the failure to have testimony is
not the failure of the witness, Dr. Jinadatha, so I apologize
to you. I am sorry you are caught in the middle of this. I know
that you have provided--you prepared your testimony and it was
an approval process that was the issue, but still, I did want
to voice these concerns because I do think it is very, very
important that we don't set a precedent in this Committee that
we do not want to set, that we will have--particularly with the
Oversight Subcommittee, that we will have witnesses testifying
without having submitted in advance for everybody on the
Committee to look at, peruse, develop questions on written
testimony.
So with those concerns stated, Mr. Chairman, I yield back.
[The prepared statement of Mr. Maffei follows:]
Prepared Statement of the Subcommittee on Research and Technology
Ranking Minority Member Dan Maffei
Chairman Bucshon, Chairman Broun thank you both for holding this
important hearing today on ``Technology for Patient Safety at Veterans
Hospitals.''
The recent disclosures of mismanagement at the VA are deeply
troubling. I represent nearly 50,000 veterans in Central New York and I
want to ensure they receive the best care possible. Last month, as a
result of these revelations about the VA, I personally called for the
Secretary of the VA, Eric Shinseki to step down so that the VA could
move forward with new management.
But nothing about the substance of this hearing, focused on the
threat of Healthcare Associated Infections (HAIs) and potential methods
to successfully address them, is isolated to the VA.
Healthcare Associated Infections are a serious and potentially
deadly threat to anyone who spends time in a hospital--any hospital. By
this time tomorrow 200 individuals at U.S. hospitals will have died as
a result of healthcare associated infections. This amounts to an
estimated 75,000 people per year. Another 650,000 patients become
infected each year during their hospital stay.
It can cost as much as $45,000 per patient to treat these
infections. Healthcare Associated Infections in the U.S. alone cost as
much as $45 billion per year.
I would stress that these infections are not unique to Veterans
Administration (VA) hospitals. My home District in Syracuse, New York
includes one VA hospital and six public and private hospitals. I know
that Healthcare Associated Infections and medical mishaps do not stop
at the door of the VA. Unfortunately, they are prevalent in all
healthcare facilities. And the tools to combat these infections and to
help prevent medical errors are the same regardless of where the care
is given.
The good news is that a recent report released by the Centers for
Disease Control and Prevention (CDC) shows steady progress at the
national level against Healthcare-Associated Infections. The report
found a 44 percent decrease in central line-associated bloodstream
infections between 2008 and 2012; a 20 percent decrease in infections
related to 10 major surgical procedures between 2008 and 2012; and a 4
percent decrease in hospital-onset MRSA (Methicillin-resistant
Staphylococcus aureus) bloodstream infections between 2011 and 2012.
But combatting healthcare associated infections is still difficult,
often deadly and very costly.
Technologies can help, but I doubt there is a single silver bullet
available in this fight to eradicate these troubling and pervasive
infections. Simple steps like proper hand-hygiene, appropriate training
and clear communication can also have a major impact on the spread of
these healthcare associated infections.
I am looking forward to hearing from our witnesses today about both
proven methods and new technologies that can help play a role in
addressing this serious issue. I am particularly interested in hearing
from Dr. Trish Perl from Johns Hopkins University, who brings a wealth
of experience and expertise in the area of infectious diseases and the
role that technology can play in their prevention. She has first-hand
experience implementing new technologies to combat hospital infections,
some that worked successfully and some that actually increased the rate
of infection. I look forward to hearing from her about the possible
benefits and potential downsides to implementing unproven technologies
in the hospital setting.
Chairman Bucshon. Thank you. I would also like to comment
on that. Rule 3, Section C says insofar as is practical, no
later than 48 hours in advance of his or her appearance, each
witness who is to appear before the Committee or any
Subcommittee shall file a printed copy in electronic form or
written statement of his or her proposed testimony and a
curriculum vitae. In this situation, we had some difficulty
with the process through the VA getting the written testimony
final approval and we felt that the testimony of this witness
was very valuable and it was not practical to get the testimony
in in time. The delay was unexpected due to the process needing
approval and therefore I feel that the witness's testimony is
valuable and in no way would prejudice the discussion at this
hearing and therefore should be allowed.
Mr. Maffei. Would the Chairman yield?
Chairman Bucshon. I will yield.
Mr. Maffei. Mr. Chairman, I appreciate those comments, and
I certainly--that is why I would not object to Mr. Jinadatha
being a witness here because I do believe that he has a lot of
important things to say, but my understanding is that the
Majority staff did know about this in enough advance notice to
have done something about it. So while I appreciate that at
this point of course it couldn't be avoided, there was a point
where it could have been, and that is my concern.
The Chairman of my Subcommittee, Mr. Broun, has pressured
the Administration many times about the----
Chairman Bucshon. I take back my time. Thanks for that
opinion. I appreciate it. We don't like the situation either
but again, feel that the testimony of the witness is very
valuable to the context of this hearing, and at this point we
will proceed ahead with the hearing.
Chairman Smith of Texas. Mr. Chairman, could I just add a
comment here?
Chairman Bucshon. I yield to the Chairman of the full
Committee, Mr. Smith.
Chairman Smith of Texas. Thank you. I do want to reassure
the Ranking Member, Mr. Maffei, that we actually did try to get
the written testimony and we share his sentiments completely. I
am as frustrated as anyone else, and I have been frustrated
both in this Committee and other Committees when we have had
witnesses who because of various governmental rules have not
been able to give us the written testimony that we all would
like to see ahead of time. So I think we made a good-faith
effort to try to get it over the last several days.
I also want to say to the Ranking Member, I very much
appreciate his measured remarks, measured comments, and because
they were measured, they even have a greater impact than he
might think, and we will try to make sure that, as he
suggested, this is very much the exception to the rule and not
the rule.
Mr. Maffei. Would the Chairman yield just so I can thank
the gentleman?
Chairman Bucshon. I will yield.
Mr. Maffei. I do want to thank the Chairman of the full
Committee and of course, you, Mr. Chairman, for hearing me out
on this, and I will just stick with, I just don't want this to
be the precedent of the Committee. But thank you very much for
hearing us out.
Mr. Broun. Mr. Chairman?
Chairman Bucshon. Mr. Broun, I yield.
Mr. Broun. Thank you, Mr. Chairman.
I just want to remark to my dear friend, good friend, my
coworker on our Oversight Committee, that as he stated in his
remarks, it has been something I have been very concerned about
and I am extremely concerned just like my friend, Mr. Maffei,
is about this very issue, and I would be objecting tremendously
except for I think this is an extremely important witness that
can give us some insight into the VA, and his testimony has
been approved by the VA, from my understanding. It is just some
other parts of the Administration that have delayed or dragged
their feet, and let me assure my friend, Mr. Maffei, that the
staff on this side have been very, very diligent in trying to
get this written testimony approved.
His oral testimony--in his oral testimony, he can read his
written testimony, and that is okay with the VA. And so what we
are trying to do is prevent deaths, and I think this is an
emergent situation or I would be objecting very vehemently
myself, I assure you, and I don't want this to be a precedent
any more than my friend wants it be a precedent. We must have
written testimony, but in this case, because of life-
threatening situations, I think it is prudent for us to go
ahead and hear from the witness, and I appreciate my friend's
comments and I agree with wholeheartedly and I appreciate us
being able to go forward, and I thank you very much. At this
point I will yield back.
Chairman Bucshon. I will reclaim my time and then with
that, I will now recognize the Chairman of the Subcommittee on
Oversight, the gentleman from Georgia, Mr. Broun, for his
opening statement.
Mr. Broun. Thank you, Dr. Bucshon. I thank all the
witnesses for being here today and going through this little
necessary dialogue between us, and I look forward to hearing
from you all today. For those of you all who are not from the
South ``you all'' is singular and plural, so I appreciate all
of you all being here.
As both a medical doctor as well as a U.S. Marine, it is
deeply troubling to me to hear reports of poor care given to
veterans in my home State of Georgia as well as across this
country. In January of this year, I returned to Augusta for an
oversight visit to the Charlie Norwood VA Medical Center with
some of my colleagues. During the trip, I was extremely
saddened to see the cavalier attitude expressed by the VA, and
the potential implication for hospital-associated infections,
or HAIs, and preventable deaths. A recent Wall Street Journal
article on VA hospitals cited specifically that, ``at Augusta,
the in-hospital death rate was 120 percent above that of the
best facilities.'' This kind of negligence is intolerable and I
won't stand for it.
The principal function of our federal government under the
Constitution is to provide for our national defense, and it is
imperative that we take care of the men and women who so
bravely served our country with dignity and pride. We made
promises to veterans, and we must fulfill those promises for
those who have sacrificed for all us to keep us free as a
nation. Our veterans should receive the best care available
anywhere in the country, and there is no question about that.
The Centers for Disease Control and Prevention states that
``approximately 1.7 million HAIs occur in United States
hospitals each year, resulting in up to 99,000 deaths and an
estimated $20 billion in healthcare costs.'' Contributing to
these numbers is a wide variation in medical care at VA
hospitals with substantially more HAIs and preventable deaths
at certain VA hospitals. However, since the VA does not
publicly disclose comprehensive details on each of their
facilities, it is hard for veterans and their families to
receive fair warning that they are walking into a potentially
life-threatening situation when they are requesting medical
care from those VA facilities.
What is additionally astounding is that the infection rates
at some VA hospitals exceed the rates at private sector
hospitals by ten times or more. On top of that, the Wall Street
Journal article I mentioned earlier notes that, ``VA senior
management suspended a long-standing program that had sent
teams of doctors and monitors to its worst-performing hospitals
to try to improve them.'' As the Chairman of the Oversight
Subcommittee, I consider this lack of oversight,
accountability, and due diligence to be totally inexcusable and
intolerable.
The treatment of veterans is not only a moral issue, but a
national security issue as well. If the federal government
fails to fulfill the promises it has made to our veterans, how
are we going to recruit the finest men and women to come into
the military and stay to be senior NCOs, senior officers, or
flag officers? It just will not happen.
I look forward to hearing from our witnesses about
technologies that can save veterans from preventable infections
and deaths. I also encourage everyone at the VA listening to
this hearing today to renew their commitment to our veterans by
doing everything in their power and as soon as possible to
ensure that our Nation's heroes are given the care that they
deserve and have earned.
I thank you, Chairman Bucshon, Dr. Bucshon, my good friend
and medical colleague, for holding this very important hearing,
and I yield back the balance of my time.
[The prepared statement of Mr. Broun follows:]
Prepared Statement of the Subcommittee on Oversight
Chairman Paul Broun
Thank you, Chairman Bucshon, and thank you to all of our witnesses
for being here today. I am looking forward to hearing from you all on
this very important matter.
As both a medical doctor and a U.S. Marine, it is deeply troubling
to hear reports of poor care given to veterans in my home state of
Georgia as well as across this country. In January, I returned to
Augusta for an oversight visit of the Charlie Norwood VA Medical Center
with some of my colleagues. During the trip, I was extremely saddened
to see the cavalier attitude expressed by the VA, and the potential
implication for hospital-associated-infections--or HAIs--and
preventable deaths. A recent Wall Street Journal article on VA
hospitals cited specifically that, ``at Augusta, the in-hospital death
rate was 120% above that of the best facilities.'' This kind of
negligence is intolerable.
The principle function of our federal government under the
Constitution is to provide for our national defense and take care of
the men and women who have so bravely served our country with dignity
and pride. We have made promises, and we must fulfill those promises
for those who have sacrificed for us. Our veterans should receive the
best care--there is no question about it.
The Centers for Disease Control and Prevention states that
``approximately 1.7 million HAIs occur in U.S. hospitals each year,
resulting in up to 99,000 deaths and an estimated $20 billion in
healthcare costs.'' Contributing to these numbers is the wide variation
in medical care at VA hospitals with substantially more HAIs and
preventable deaths at certain VA hospitals. However, since the VA does
not publicly disclose comprehensive details on each of their
facilities, it is hard for veterans to receive fair warning that they
are walking into a potentially life-threatening situation when
requesting medical care. What is additionally astounding is that the
infection rates at some VA hospitals exceed the rates at private sector
hospitals by ten times or more.
On top of that, the Wall Street Journal article I mentioned earlier
notes that, ``VA senior management suspended a long-standing program
that had sent teams of doctors and monitors to its worst-performing
hospitals to try to improve them.'' As the Chairman of the Oversight
Subcommittee, I consider this lack of oversight, accountability, and
due-diligence to be inexcusable.
The treatment of veterans is not only a moral issue, but a national
security issue as well. If the federal government fails to fulfill the
promises it has made to our veterans, how are we going to recruit the
finest men and women to come into the military and stay to be senior
NCOs, senior officers, or flag officers? It won't happen!
I look forward to hearing from our witnesses about technologies
that can save veterans from preventable infections and deaths. I also
encourage everyone at the VA listening to this hearing today to renew
their commitment to our veterans by doing everything in their power, as
soon as possible, to ensure our nation's heroes are given the care that
they deserve and have earned.
Thank you again Chairman Bucshon for holding this very important
hearing, and I yield back the balance of my time.
Chairman Bucshon. Thank you, Dr. Broun. I now recognize the
Chairman of the full Committee, Mr. Smith, for an opening
statement.
Chairman Smith of Texas. Thank you, Mr. Chairman.
The long delays and unacceptable quality of VA health care
for tens of thousands of our veterans has recently become
public. Following up on a series of letters to the VA Inspector
General and others, I recently met with Acting VA Secretary
Gibson at the Audie Murphy Memorial Hospital in my district in
San Antonio. I was reassured that he sincerely wants to fix the
problems facing our veterans but we need swift action and
strong resolve to fix such a broken system at the VA.
Veterans who live in the 21st Congressional District of
Texas and across our country should have the best health care
America can provide. American veterans have made tremendous
sacrifices to protect and defend our freedoms. They deserve the
best health care possible, as soon as possible.
Today's hearing will enable us to understand more about
patient safety and how scientific research and new technology
can boost efforts to prevent patients from contracting serious
infections while they are hospitalized.
A number of VA hospitals are among the worst in the United
States in terms of inflicting preventable infections on their
patients. Hospital-acquired infections are a serious public
health problem that affects patients in hospitals all across
the country. In the worst-performing hospitals, which includes
some VA hospitals, up to ten percent of patients are harmed by
such infections.
A few years ago, a state agency in Pennsylvania analyzed
millions of hospital records and found that the in-hospital
mortality rate among patients who contracted infections was
about five times higher than among patients who were not
infected. Research has shown that most of these infections are
preventable if hospitals and medical personnel adhere to
systematic prevention measures. This starts with essential
steps such as thorough, repeated hand-washing and isolation of
infected patients. However, hand hygiene and other commonsense
measures have been only partially successful.
We are fortunate to have with us this morning three
physicians who are experts in the field of preventing hospital-
acquired infections. As far as that goes, we have three doctors
who are Members of these two Subcommittees this morning, and
they are experts in their own right. We also have
representatives from two companies that have developed new
tools and technologies to prevent infections in hospitals. I
look forward to learning more about the science behind fighting
harmful hospital-acquired infections, and I am particularly
interested in how the VA health care system, the largest
integrated health care system in America, could deploy
scientifically proven technology and practices with the goal of
setting the highest standard of patient safety in all of its
hospitals.
Thank you, Mr. Chairman, and I will yield back.
[The prepared statement of Mr. Smith of Texas follows:]
Prepared Statement of Full Committeee
Chairman Lamar S. Smith
The long delays and unacceptable quality of VA health care for tens
of thousands of our veterans has recently become public.
Following up on a series of letters to the VA Inspector General and
others, I recently met with Acting VA Secretary Gibson at the Audie
Murphy Memorial Hospital in my district in San Antonio. I was reassured
that he sincerely wants to fix the problems facing our veterans. But we
need swift action and strong resolve to fix such a broken system at the
VA.
Veterans who live in the 21st Congressional District of Texas and
across our country should have the best health care America can
provide. American veterans have made tremendous sacrifices to protect
and defend our freedoms. They deserve the best health care possible, as
soon as possible.
Today's hearing will enable us to understand more about patient
safety and how scientific research and new technology can boost efforts
to prevent patients from contracting serious infections while they are
hospitalized.
A number of VA hospitals are among the worst in the United States
in terms of inflicting preventable infections on their patients.
Hospital-acquired infections are a serious public health problem
that affects patients in hospitals all across the country. In the
worst-performing hospitals, which includes some VA hospitals, up to 10%
of patients are harmed by such infections.
A few years ago, a state agency in Pennsylvania analyzed millions
of hospital records and found that the in-hospital mortality rate among
patients who contracted infections was about five times higher than
among patients who weren't infected.
Research has shown that most of these infections are preventable if
hospitals and medical personnel adhere to systematic prevention
measures. This starts with essential steps such as thorough, repeated
hand-washing and isolation of infected patients.
However, hand hygiene and other common-sense measures have been
only partially successful. We are fortunate to have with us this
morning three physicians who are experts in the field of preventing
hospital-acquired infections. We also have representatives from two
companies that have developed new tools and technologies to prevent
infections in hospitals. I look forward to learning more about the
science behind fighting harmful hospital-acquired infections.
I'm particularly interested in how the VA health care system, the
largest integrated health care system in America, could deploy
scientifically proven technology and practices, with the goal of
setting the highest standard of patient safety in all of its hospitals.
Chairman Bucshon. Thank you, Chairman Smith.
At this time I would like to introduce our witnesses. Our
first witness is Dr. Chetan Jinadatha--how did I do--very
well--the Chief of Infectious Disease Section at the Central
Texas Veterans Health Care System in Temple, Texas. Dr.
Jinadatha is also an Assistant Professor of Medicine at Texas
A&M University Health Science Center. He is the President of
the Texas Infectious Disease Society. Dr. Jinadatha is board-
certified in infectious disease. He is also an active
researcher in hospital-acquired infections, the role of
environment in hospital-acquired infections, and the evaluation
of no-touch disinfection technologies. Dr. Jinadatha completed
his medical degree in India and his master's in public health
at Texas A&M. Welcome.
Our second witness is Dr. Elaine Cox, Professor of Clinical
Pediatrics. Dr. Cox trained at Indiana University School of
Medicine and has been on the faculty in the section of
pediatric infectious disease since 1995. She is currently
serving as the Medical Director of Infection Prevention,
Medical Director of the Pediatric Antimicrobial Stewardship,
and a Safety Officer for Riley Hospital for Children at IU
Health. In addition to these and other clinical duties, Dr. Cox
has spent much time working on legislation that impacts
children's health in the State of Indiana. Dr. Cox earned her
undergraduate degree in biochemistry from Indiana University
and her medical degree from Indiana University School of
Medicine. Welcome.
Our third witness is Dr. Trish Peri. Did I get that right?
Dr. Perl. Perl.
Chairman Bucshon. Perl. My eyes. I should have put my
glasses on, I guess. Dr. Perl is a Professor at the Department
of Medicine and Infectious Diseases and Pathology at Johns
Hopkins University School of Medicine and in the Department of
Epidemiology at the Johns Hopkins Bloomberg School of Public
Health. She is a Senior Epidemiologist for the Johns Hopkins
Hospital--John Hopkins Medicine. Dr. Perl received her bachelor
of arts and medical degree from the University of North
Carolina at Chapel Hill and a master's of science degree from
McGill University in Montreal. She completed her residency in
internal medicine at McGill University and a fellowship in
infectious diseases and clinical epidemiology at the University
of Iowa in Iowa City.
I now recognize Representative Todd Young from Indiana to
introduce our fourth witness.
Mr. Young. Thank you, Mr. Chairman. It is an honor to be
here with you today. I would just like to say, you are a person
of professional competence, high personal integrity and a good
friend, so thank you so much for allowing me to introduce our
witness, Jeffrey D. Smith, a Hoosier, a resident of Indiana's
9th Congressional District and President and CEO of Electro-
spec, which is located in Franklin, Indiana.
Mr. Smith and I had an opportunity to visit briefly
yesterday, and it was clear during that brief visit that he
cares as deeply as I do about the health of our Nation's
veterans and preventing hospital-acquired infections in our
Nation's Veterans Hospitals.
He has been with Electro-spec since 1994 and held positions
of increasing responsibility beginning as Vice President in
1994. Mr. Smith is also President and CEO of Steriplate LLC, an
Indiana corporation he formed in 2013. It focuses on the
design, development and implementation of antimicrobial
finishes for medical and commercial applications. In May of
1997, Mr. Smith purchased the business from former owner David
Yates and assumed the position of CEO and President at that
time.
I want to thank you for your presence here today and your
testimony about your promising work on potential veteran-saving
technology. Thank you, sir.
I yield back.
Mr. Broun. Would the gentleman yield?
Mr. Young. Indeed.
Mr. Broun. As a fellow Marine, I would like to correct a
statement that you made. There is no such thing as a former
Marine. Once a Marine, always a Marine.
Mr. Young. I agree with the gentleman's comments. If the
gentleman will yield?
Mr. Broun. Certainly. Thank you.
Mr. Young. I am told the taxonomy is, there is no such
thing as an ex-Marine. There may be a couple of exceptions out
there. But whatever. I am proud to be a Marine with you, and
thank you. Duly corrected by the senior gentleman on the panel.
Mr. Broun. Semper fi.
Mr. Young. Semper fi. I yield back.
Chairman Bucshon. Thank you. I now recognize the Chairman
of the full Committee, Mr. Smith, to introduce our final
witness.
Chairman Smith of Texas. Thank you, Mr. Chairman.
Mr. Chairman, I am happy to welcome Morris Miller from San
Antonio, who is going to be testifying today.
As CEO of Xenex, Mr. Miller is responsible for the
company's business strategy and oversight of day-to-day
operations. Under his guidance, the company has grown and
established itself as the world leader in UV room disinfection.
After starting his career as an attorney, Mr. Morris served as
co-founder and President/CEO of Rackspace Hosting Inc., which
now has over $1 billion in annual revenue and a market cap in
excess of $5 billion. He is an alumnus of Phillips Exeter
Academy, the University of Texas at Austin, and the Dedman
School of Law at Southern Methodist University, as am I.
Mr. Chairman, I yield back, and we welcome Mr. Miller.
Chairman Bucshon. Thank you, Mr. Chairman.
As our witnesses should know, spoken testimony is limited
to five minutes each after which the Members of the Committee
have five minutes each to ask questions.
It is the practice of the Subcommittee on Oversight to
receive testimony under oath. Does anyone have a problem with
taking an oath? Then if you would please stand and raise your
right hand. Do you solemnly swear or affirm to tell the whole
truth and nothing but the truth, so help you God? Let the
record reflect that all the witnesses participating have taken
the oath.
And at this point I will now recognize Dr. Jinadatha for
five minutes for his testimony.
TESTIMONY OF DR. CHETAN JINADATHA,
CHIEF, INFECTIOUS DISEASES,
CENTRAL TEXAS VETERANS HEALTH CARE SYSTEM
Dr. Jinadatha. Good morning, Chairman Dr. Bucshon, Chairman
Dr. Broun, Chairman Smith, Ranking Member Maffei and Members of
the Subcommittee. I thank you for the opportunity to
participate in this important discussion today. My name is
Chetan Jinadatha, and I am the Chief of Infectious Diseases at
the Central Texas Veterans Health Care System and an Assistant
Professor in the Department of Medicine at Texas A&M University
Health Science Center.
I currently serve as the President of Texas Infectious
Disease Society. My area of research interest is reduction of
hospital-acquired infections using technology including the
effectiveness of ultraviolet disinfection.
It is reported that hospital-acquired infections cause 1.7
million infections and 100,000 deaths annually within the
United States, costing health care systems $30 billion to $40
billion. Methicillin-resistant Staph aureus-related hospital-
acquired infections alone cost $9.7 billion annually. It is
hard to predict the percentage of preventable hospital-acquired
infections but most facilities aim for zero hospital-acquired
infections.
Patients may harbor resistant organisms prior to admission
and not have any signs or symptoms. However, the same patient
may develop an infection from the organism that they came with
or acquire a new organism during their hospital stay, thus
resulting in a hospital-acquired infection.
The hospital environment includes surfaces in the patient
room, equipment or the hands of health care workers who acquire
it from touching other patients or surfaces. An estimated 20 to
40 percent of hospital-acquired infections in the United States
have been attributed to cross-contamination by a health care
personnel hands, either by direct patient or by touching
contaminated environmental surfaces.
Recent literature has indicated that supplementing manual
cleaning with disinfection technologies such as hydrogen
peroxide systems or UV light technology systems decreased
microbial burden on high-touch surfaces such as bed rails, call
buttons, toilet seats in patient rooms.
Although the systems add cost and time to the disinfection
process, the bacterial load reduction after using these systems
effectively complements manual cleaning. Preliminary evidence
suggests from a single center study showed a 52 percent
reduction of Clostridium difficile hospital-acquired infection
with the implementation of UV-based protocol. A federally
funded, multi-center study in private setting is currently
underway to evaluate the effectiveness of UV in reducing
hospital-acquired infections.
Similarly, several studies that have shown decreased multi-
drug-resistant organism acquisition and reduction in hospital-
acquired infection rates after implementation of hydrogen
peroxide system across hospitals. In comparing the hydrogen
peroxide system to that of an ultraviolet system, hydrogen
peroxide requires prolonged exposure time and ventilation
system modification for aeration but disinfects better than UV.
UV technology disinfection time is shorter than hydrogen
peroxide but it has lower bacterial reduction on surfaces.
Hence, technologies such as ultraviolet or hydrogen
peroxide have the potential to have an impact on transmission
of pathogens in the hospital environment and possibly prevent
life-threatening infections. A federally funded study is
currently underway to evaluate the effectiveness of UV on
hospital-acquired infection rates in four Veterans Affairs
Medical Centers, one of which is mine.
In 2013, the Central Texas Veterans Health Care System
initiated several patient safety initiatives to decrease the
risk of developing hospital-acquired infection including the
deployment of ultraviolet disinfection system after manual
cleaning.
Reducing hospital-acquired infection requires a multi-
prolonged approach. Interventions or technologies such as
ultraviolet or hydrogen peroxide do not decrease the importance
of rigorous hand-washing, isolation of appropriate patients,
and other measures to prevent the spread of pathogens in
hospitals. New technologies for prevention do not obviate the
need for manual cleaning or antimicrobial stewardship. Health
care professionals must work together with the patients to
prevent the spread of antibiotic-resistant organisms in health
care settings.
Meanwhile, further research is needed to ascertain the
generalized ability of our studies and define the specific role
of new technologies in hospital-acquired infection prevention.
Emergence and spread of antibiotic-resistant bacteria is a
significant public health threat. In addition to basic
infection prevention and control practices such as hand hygiene
and the use of isolation precautions, good antibiotic
stewardship and use of supplemental technologies may provide
effective and improved strategies to prevent the spread of
health care-associated infections and create a safer
environment for our patients.
Mr. Chairman, this concludes my testimony. I welcome any
questions from the Committee.
[The prepared statement of Dr. Jinadatha follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman Bucshon. Thank you, Doctor.
I now recognize our second witness, Dr. Cox, for five
minutes.
TESTIMONY OF DR. ELAINE COX,
PROFESSOR OF CLINICAL PEDIATRICS,
DIRECTOR OF INFECTION PREVENTION,
DIRECTOR OF PEDIATRIC ANTIMICROBIAL STEWARDSHIP,
RILEY HOSPITAL FOR CHILDREN
Dr. Cox. Good morning. On behalf of Riley Hospital for
Children at IU Health, I want to thank all of you here for your
continuing commitment to patient safety by focusing on
hospital-acquired infections in all patients. Riley Hospital is
a self-standing children's hospital with an 85-year history. We
see about a quarter of a million patients a year and we are
part Indiana University School of Medicine, which gives us a
lot of opportunity for research and development of
technologies.
So we have heard a lot of statistics this morning: nearly 2
million infections, 100,000 deaths, one in 25 of our
hospitalized patients every day having a hospital-acquired
infection. This results in about 7.5 million excess hospital
days in our country every year, increasing our length of stays
by about three to ten times over the expected.
When you look at cost, conservative cost measurements for
direct cost are about $5 billion to $6 billion, and when you
add in total costs, it is certainly upwards of $30 billion.
But I don't think that these statistics necessarily clarify
the entire picture of personal cost. So I work in a children's
hospital and I will share with you that recently we had a baby,
a newborn, in for heart surgery. Now, that takes two weeks to
get out of the ICU and 4 weeks to get out of the hospital,
minimum. This family had a 3-year-old at home that they were
away from all these weeks. They finally promised their son they
would be home for the weekend and they would spend time with
him when the baby acquired a central-line-associated
bloodstream infection, or a CLABSI. This set that baby's
recovery back 6 to 8 weeks and devastated a 3-year-old at home.
I think the personal costs suffered by these families that
encounter these infections go far beyond the event itself and
is not reflected in our statistics.
You know, fighting infection has always relied on
prevention, whether it is from vaccination or the development
of the bundle, which we now all use to prevent infections, as
the Chairman said. We have used it at Riley. We have cut our
CLABSI rate by 65 or 70 percent. But the question is, is that
enough? Is that enough for any of our patients, our veterans
all the way to our babies?
I think the other problem is that we have plateaued. What
are our other strategies? Well, certainly we have a reaction
position we can take. We can treat with antibiotics. That is
kind of the horse already being out of the barn. By then,
infection is already set up.
You know, antibiotics have changed the face of infectious-
disease treatment in America, which has been great, but it has
also led to the development of resistance. This is accelerating
in our time, and it is directly due to antibiotic overuse and
use, and there is no antibiotic we have currently that is
impervious to the development of resistance. These are
important players in HAIs. They occur in about 16 percent of
the events, and over infections that have susceptible organisms
they increase length of stay by an additional 20 percent and
cost by an additional 30 percent.
We use antimicrobial stewardship, we use isolation and we
have slowed the development and spread of resistance but we
haven't eradicated it, and CDC just recently came out and said
that infection with these multi-drug-resistant organisms is an
emerging threat to health care in the United States.
In light of all that, I think we do need to look at new
technologies. We have used some things in the environment. Can
we expand that? Can we get beyond 55 to 65 percent safe for our
patients? I think we have known the effects of metals for
years. Why can't we expand their use in the environment? And
can we look at the patient level? Can we coat things like
orthopedic rods and ventriculoperitoneal shunts and cardiac
implants so that we can prevent infections at the patient
level?
We have known about the germ theory since the mid-19th
century. We have the Institute of Medicine report, ``To Err Is
Human,'' on patient safety since 1999 and yet we are still
struggling. We are still only 55 to 65 percent safe for the
patients in our environment who trust us to care for them.
The impact financially on the health care budget is severe
and negative, and I think if we could whip this problem as much
as possible, we could turn those resources to other initiatives
for patient safety and patient quality of care and, above all,
do no harm, as is our oath.
I thank you for this hearing.
[The prepared statement of Dr. Cox follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman Bucshon. Thank you.
I now recognize Dr. Perl for your testimony.
TESTIMONY OF DR. TRISH M . PERL,
PROFESSOR OF MEDICINE AND PATHOLOGY,
JOHNS HOPKINS SCHOOL OF MEDICINE;
PROFESSOR OF EPIDEMIOLOGY,
BLOOMBERG SCHOOL OF PUBLIC HEALTH;
SENIOR EPIDEMIOLOGIST, JOHNS HOPKINS MEDICINE
Dr. Perl. I will start by turning on the microphone.
Chairmen Bucshon and Broun, Chairman Smith, Ranking Members
Maffei and Lipinski, and distinguished Members of this
Subcommittee, thank you for the opportunity to appear today.
I will share lessons learned from hospital attempts to
integrate technology into clinical care and highlight the
importance of using scientific assessment to ensure hospitals
make cost-effective and evidence-based decisions to improve
patient outcomes.
I am a Physician and a Professor at Johns Hopkins
University and their Senior Epidemiologist, and I am also the
former President of the Society of Health Care Epidemiology of
America, which is the professional society that works around
health care-associated infections and multi-drug-resistant
organisms.
That aside, my job has allowed me to study novel
technologies including no-touch technologies and to investigate
outbreaks associated with new products and devices, i.e., in
other words, the unintended consequences of using these devices
in the health care environment.
The Committee should be aware that I am doing a large
research study that is partially funded by the VA, and my
husband is employed by the University of Maryland and the VA.
Health care-associated infections, as everyone has
mentioned, are common and actually cause about half of the
untoward events that occur in health care affect approximately
four percent of all patients. As we have heard, they are costly
to patients and to the health care system, and to prevent these
health care-associated infections, we encourage hand hygiene,
vaccination, isolation, and more and more integrating
technology. Many novel technologies are introduced into the
market every year. It is commonly difficult to determine the
merit of each device or idea without independent, well-designed
studies that look at their efficacy.
I would actually like to review two personal experiences of
why we need to be thoughtful about using technology and how we
need to approach our efforts to protect patients. Approximately
eight years ago, we began a study at our institution and looked
at a technology that vaporized hydrogen peroxide, an excellent
disinfectant, into the environment. The goal is to disinfect
surfaces that were potentially contaminated with bacteria
despite terminal cleaning. The technology was intriguing and
expensive yet there were unknowns including around patient
safety and the impact on our other expensive equipment.
Ultimately, we developed a study, and after testing in our
intensive care units, we significantly decreased the risk of
acquiring a multi-drug-resistant organism in the patients in
those units. No risk to patients, damage to equipment or the
facility was identified. Hence, our recommendation to our
leadership was to continue using this technology, and it was
based on scientific evidence. We have subsequently showed that
we can use this technology to disinfect surfaces of supplies
that are in these rooms, they can be reused, and it leads to
cost savings that help pay for this technology.
Another story is in mid-October 2004, our institution
introduced a new mechanical valve needleless device, which is
used on IV tubing. These are devices that decrease needle
sticks among health care personnel. By April of 2005,
approximately six months later, the catheter-associated
bloodstream infection rate in our children's hospital had
increased by 60 percent. Using fluorescent dye, we determined
that these devices could not be cleaned using standard
techniques. When we removed the device from our institution,
our rate returned to normal. What seemed to be a very benign
introduction of a nursing product turned into significant
patient safety issue for our patients.
So in summary, health care-associated infections are a
significant challenge for health care despite strides to date,
there are huge opportunities to improve patient safety and we
should begin and insist upon the basic infection prevention.
However, there is a role for technology that can improve our
processes and protect patients. This technology, while often
tantalizing, can have unexpected consequences and we must be
vigilant in our approach to its introduction.
Congress should continue its long history of supporting
science, and this is an area where science needs to guide
decisions so we are thoughtful about how to introduce and use
technology. The health care community should develop standards
to measure the effectiveness of new technologies like this new
touch disinfection that are being discussed today so we can
measure their efficacy in a standard fashion. Congress should
consider funding learning labs or centers of excellence to
evaluate these exciting products in the context of patient care
using trained scientists. These labs consider the multiple
issues that impact patients to assure we do not do harm. There
is not a one-size-for-all solution, and this effort needs the
expertise that will translate science into effective patient
care.
Thank you.
[The prepared statement of Dr. Perl follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman Bucshon. Thank you, Dr. Perl.
I now recognize Mr. Smith for five minutes to present his
testimony.
TESTIMONY OF MR. JEFF SMITH,
PRESIDENT, ELECTRO-SPEC, INC.
Mr. Smith. Thank you, Chairmen Bucshon, Broun and Smith,
Members of the Committee, and Congressman Young for that nice
introduction. I am not nearly as eloquent as my doctors are on
the panel so I might sneak a ``y'all'' into my testimony. We
will see.
I am President of Electro-spec and Steriplate. What we do,
we specialize in high reliability and highly functional
electroplating of devices for the military, aerospace, medical
and automotive industries, and the reason I am here today is to
talk about a new technology that we have developed called
Steriplate. Steriplate was designed specifically for medical
applications, antimicrobial situations hopefully to make a
dramatic impact in the transmission of HAIs.
But first I want to draw kind of an analogy to what the
statistics that were shared with you previously. Imagine a
Boeing 737 crashing every single day in the United States with
200 people on board and there are no survivors. Can you imagine
what the general public would be? Can you imagine what the FAA
would be dealing with? That is what we are dealing with with
HAIs, just to put things in perspective. The Department of
Health and Human Services has made this an agency priority goal
for HAIs. They have new metrics in place with goals hopefully
to be achieved by the year 2020. So it is a big issue
obviously. Copper and copper alloy as well as antimicrobial
metal coatings are the one continuous, sustainable method for
reducing the bacterial burden that you have on surfaces,
whether they are in body or out of body. Our Steriplate
process, which I have some examples here for you, employs
copper as one of the metals as well as another antimicrobial
metal in the process, and it is designed specifically for again
antimicrobial functionality but also by alloying in other
metals, we designed a metal that has more tarnish resistance,
corrosion resistance and wear resistance than traditional
copper. The antimicrobial testing that we have done thus far
specifically on the traditional HAI bacteria, E. coli, for
example, we had a 99.9998 percent reduction. With MRSA, we had
a 99.998 percent reduction, and similar results against C. diff
and B. subtilis bacteria.
Another aspect of Steriplate that we have designed is using
nanotechnology in the process to impart hydrophobic or
hydrophilic surface. The hydrophilic surface is designed to
provide an antimicrobial that is on touch surfaces outside the
body. We are currently using this technology for surfaces that
typically can be contaminated by touch or translocation as
well. The hydrophobic aspect of Steriplate really was designed
for in body, and what we are trying to do is repel typical
solution in terms of blood, urine, cerebral fluid, whatever it
may be, and the applications that we are working on right now
in terms of implantable devices are everything from VP shunts
to Baclofen pumps for cerebral palsy, scoliosis rods, access
ports for dialysis, just to name a few, the traditional types
of devices that have a high rate of infection associated with
them.
Another aspect of this is also to potentially have a
surface that is antithrombotic to prevent clotting as well, so
an antimicrobial and antithrombotic surface.
But to summarize today for you, the time, cost and
complexity associated with developing this technology is huge.
You know, we are geared specifically to try to provide an
answer to not just the Veterans Hospitals but hospitals across
the United States. We are a small company. We have 85
employees. But we have reinvested about 30 percent of our net
profit back into developing this technology. So it is really
critical for us to be able to be here today to present our
technology to share with you our findings as well as hopefully
be able to solicit help from federal agencies like NIH, CDC,
National Science Foundation, Veterans Affairs as well or any
other federal agencies that might be able to help us continue
to develop the technology behind Steriplate and hopefully
antimicrobial surfaces in general.
Thank you very much.
[The prepared statement of Mr. Smith follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman Bucshon. Thank you very much, Mr. Smith.
I now recognize Mr. Miller for five minutes to present his
testimony.
TESTIMONY OF MR. MORRIS MILLER,
CHIEF EXECUTIVE OFFICER,
XENEX DISINFECTION SERVICES
Mr. Miller. Good morning. Thank you, Chairman Smith,
Chairmen Broun and Bucshon and other distinguished Committee
Members. It is an honor to be here today.
Every year, HAIs cost $20 billion and kill 100,000
Americans, more than breast cancer, auto accidents and HIV
combined. This is a devastating problem, so I wanted to share
some good news with the Committee. Hospitals that use our germ-
zapping robot kill pathogens and drug-resistant superbugs and
their infection rates have dropped more than 50 percent. I am
joined today by Dr. Mark Stibich, who along with his Xenex co-
founder, Julie Stachowiak, both hold Ph.D.'s in epidemiology
from Johns Hopkins. They founded Xenex to stop hospital-
associated infections.
Just two years ago, scientists were unsure the role of the
environment in the passage of the infections from patient to
patient. Over the past two years, we know without a doubt that
these pathogens and superbugs exist on bed rails, remote
controls, nurse call buttons, telephone handsets. These
superbugs are microscopic. We have spent--I have spent a lot of
time with housekeepers over the past two years. These are some
of the hardest-working Americans you have ever met. They cannot
do the task that is assigned to them in the time that they
have. They clean but they cannot disinfect every surface, and
they never know whether they have eliminated the microscopic
superbugs. Now in our hospitals, they clean and then they use
our Xenex robots. We call them housekeeping heroes.
My written testimony has every detail of our proven, peer-
reviewed outcome studies in journals like American Journal of
Infection Control. To summarize, we have seen a sustained 53
percent reduction in C. diff infections. We have seen a
sustained 56 percent reduction in MRSA, also known as staph
infections. Just this week, two VAs told us, Muskogee, 50
percent drop in overall infections, Iowa City, 30 percent drop
in C. diff. This is the only technology of its kind that has
shown this ability to impact rates.
Now, since 1901, we have known that we can use ultraviolet
light put out by low-intensity narrow-spectrum mercury bulbs to
disinfect things like water. In the hospital where room
turnover time is critical, they are too slow. The Xenex robot
uses full-spectrum, high-intensity pulsed xenon bulbs to create
UV light and destroy the DNA of bacteria in four ways. The
light is 25,000 times brighter than sunlight. Disinfection
takes about five minutes. The pathogens have no defense.
At the end of 2013, more than 200 hospitals including 26 VA
Hospitals now utilize the technology. How do we know the
results that have been peer-reviewed and published? Because our
customers purchase the devices, they achieve the results. They
were so excited that they decided to publish them.
Just recently, a new customer, an infection preventionist
from a California hospital, came to me. They had an outbreak in
their labor and delivery suites. Sixty mothers and their
newborns, didn't ask for it, all got MRSA. They were fighting
it. They were following all of the CDC guidelines. They
couldn't stop it. In desperation, they called us. We sent over
one of our employees. The employee began disinfecting the
rooms. Within three days, the outbreak stopped. There have been
no more infections since.
So the next logical question I would think is, well, what
is the cost of technology like this? It is about $1 per patient
day. And the return on the investments for a 36-month use of
the robot, the hospitals tell us it pays for itself in about
four months.
So one of the questions you asked was, what can Congress
do? On Hospital Compare, which is a Web site that you all
insisted on sharing data, insist on more data, specifics on
MRSA, C. diff, VRE and the other infection rates that we know
are preventable. To the extent that you can, don't pay for
preventable infections, and a little bit outside the box,
incentivize hospitals. If you gave them $1 to $1.50 per patient
day that they could bill through to use this advanced
disinfection, this would give patients the disinfection they
need and don't know to request.
In 1968, Congress mandated that automakers install
seatbelts. In 2012, seatbelts saved over 12,000 lives. If
Congress mandated the proper disinfection of these hospital
rooms, we could save that many lives in two months.
I feel pressure every day because 5,000 Americans are
infected and 273 die. We have the technology to save them. If
you or a loved one ever has to go to a hospital, you would like
to know that your hospital or procedure room would not make you
sick.
Let us work together to prevent millions of infections and
save 50,000 lives a year. Our veterans, their families and all
Americans deserve no less.
Thank you.
[The prepared statement of Mr. Miller follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman Bucshon. I would like to thank the witnesses for
their testimony, and reminding Members that the Committee rules
limit questioning to five minutes. At this point the Chair will
open the round of questions. I recognize myself for five
minutes.
I want to start with Dr. Perl because one of my areas--I
mean, I was a cardiovascular and thoracic surgeon, and other
than orthopedists, probably the most infection-averse people in
the hospital. It is obviously a disaster when it happens.
I have always been interested in when people come in how
to, you know--what the patient themselves are bringing into the
hospital and what the effect not just on hospital-based
antibiotic use but outpatient antibiotic use as on the
development of resistant bacteria, and I can say this because I
have four kids and they have all kinds of ear infections and
everything, and I have parents who are seniors who get
antibiotics for all kinds of things that they probably
shouldn't. Can you just discuss a little bit about maybe some
of the things we might do in training infectious-disease
professionals or internists about really how to manage that on
an outpatient basis because I do think that has a significant
impact on inpatient hospital infection.
Dr. Perl. Yes. Thank you for the question, and I think you
are absolutely correct. The reality is that we don't have all
the answers but what we can tell you is, even actually after
one dose of antibiotics, you can develop resistant organisms.
It has been best studied actually in the perioperative surgical
setting where they have looked at that. So the challenge really
is to really make sure that we use antibiotics appropriately,
and to do that, we really have to enhance diagnostics. When we
can differentiate whether somebody has a bacterial infection
versus a viral infection, you can direct your therapy much more
appropriately to limit the use of antibiotics, to define
duration, course durations, and also to make sure that we
simplify the antibiotic and really use one that we don't go
more broadly than we need to.
So in terms of what we can do in the outpatient setting, it
is almost like it is really common sense. Just make it simple.
Make sure it is for the right thing and----
Chairman Bucshon. And I think, don't you also think that it
is a public education process? I mean, how many--every
practicing physician has had a patient come in and they clearly
have a viral infection but it keeps going and they just have a
hard time believing that it is not something that needs to be
treated with antibiotics. It is probably a multipronged
approach, right? I mean, all of us that practice medicine know
that phenomenon, right? And what happens is, the patient will
ultimately get antibiotics from someone, and so how do we solve
that problem? Maybe we can--is there a way we can bring this
more to the public attention than we already are?
Dr. Perl. I don't have all of the answers but I would
certainly tell you that there have been very effective public
health campaigns that we could look to. I mean, we have been
able to reduce smoking. We have been able to get people to use
car seats. We have been able to get people to use seatbelts. So
I think that there are clearly examples out there but it
requires directed, concerted effort from multiple groups, as
you know, not only directed at health care professionals but
also, as you point out, the public.
Chairman Bucshon. Thank you. That is a big problem to
solve.
Dr. Cox, are there different or more significant risks
resulting from hospital-acquired infections at pediatric
hospitals, such as IU Health, comparing children to adult
hospitals? Is there a difference?
Dr. Cox. So there is a difference. Children are not just
short adults, certainly, but I think it is sort of interesting
if you look at the two ends of the spectrum, sort of what you
have at this end of the table, very young infants and very
elderly patients. Their immune systems do not function quite as
well as they do in the peak times of their life and so they are
both at risk. I also think when you look at self-standing
children's hospitals, there is a lot of referral patients, the
very complicated problems. They require a lot of
instrumentation. So you are a cardiovascular surgeon. All
cardiovascular open hearts who have been on the pumps require a
lot of instrumentation, no matter your age, and those are the
risks that occur everywhere, even beyond children.
Chairman Bucshon. Okay. Thank you.
And are there--at Riley, what is your review process you
identify a hospital-acquired infection and do you think--has
that morphed over time to change or improve the process to try
to retrospectively find out why exactly that happened? Do you
have information on that?
Dr. Cox. We do. So I think it is pretty typical, I think,
of what is becoming the norm across the country. So it used to
be nobody worried about this, it is just a little bit of extra
antibiotic, until that became clear that that is not
appropriate, and so now what hospitals do, including ours, is
we have a standardized work flow. Every single infection in our
hospital that is hospital-acquired is investigated. There is a
form. Our nursing staff, our clinical nurse specialists who are
advanced practitioners, sort of lead the information gathering.
We review the chart. We interview everybody who took care of
the patient in that 48 hours prior to the onset of the
infection. Then we sit down as a multidisciplinary group, RTs,
physical therapists, nurses, doctors, everybody, pharmacists,
that we can get and we look at every piece of that puzzle.
What has happened over time is initially we had all these
aha moments, right--oh, this shouldn't have happened, we should
have used this technique, we didn't do that. I think over time
as we have gotten better, we have sort of picked that low-
hanging fruit, if you will, and we have cleared up those things
that are easily done and so we have seen our infection rates go
down. What becomes the challenge then, right, as we review
these cases, the solutions get harder and harder and so we need
to come up with new strategies that don't replace what we have
always done but just augment them.
Chairman Bucshon. Thank you very much, and my time is
expired so I will recognize Mr. Swalwell for his questioning.
Mr. Swalwell. Thank you, Chair, and good morning to our
witnesses.
I wanted to start by first comparing our VA Hospitals to
non-VA Hospitals across the country, and I just want to go
witness by witness. Yes or no, to your knowledge, is there any
known difference in any studies that you are aware of or
anecdotally in hospital-acquired infections at VA Hospitals as
compared to non-VA Hospitals. I will start with Dr. Jinadatha.
Yes or no?
Dr. Jinadatha. No.
Mr. Swalwell. Dr. Cox?
Dr. Cox. No.
Mr. Swalwell. Dr. Perl?
Dr. Perl. No.
Mr. Swalwell. Mr. Smith?
Mr. Smith. No.
Mr. Swalwell. Mr. Miller?
Mr. Miller. Don't know.
Mr. Swalwell. And Dr. Jinadatha, are you aware of any
studies underway or in your own experience working with
patients in central Texas who are veterans with regard to HAIs?
Dr. Jinadatha. Yes, sir. As I mentioned in my testimony, we
have a multicenter study where we are looking at how does
implementation of UV technology affect outcomes such as
hospital-acquired infections so we have two intervention sites
and two control sites so we are comparing standard practice
versus enhanced cleaning to see if that makes a difference.
Mr. Swalwell. Great. And certainly in the last six months,
we have learned a lot about Veterans Hospitals. Over the last
four to five years, we have learned a lot about the veterans'
claims disability backlog and most on this panel, I assume,
would agree and most of my colleagues would agree that what we
promise our veterans and how we treat our veterans is not
matching up and that we promised them that we will take care of
them and right now we have unacceptable backlogs in the care in
some of these hospitals that have been highlighted like in
Phoenix, for example, is outrageous and not what they deserve.
However, I am concerned that by having this hearing, we may
be alluding to or implying that a problem exists that does not
exist, and we could further hurt confidence that our veterans
have in our health care system by implying that HAIs exist or
occur at a greater rate at VA Hospitals than they do elsewhere,
and so Dr. Jinadatha, is it your experience that you are not
seeing at least in the central Texas system anything that would
exceed your area, community or private hospitals?
Dr. Jinadatha. We are a very small facility, sir. We have
90 operating beds. So our infection rates when we compare it to
our hospitals of our similar size, we are at national average
or below national average on some of the measures.
Mr. Swalwell. And Mr. Smith called for to study this not
just for our Veterans Hospitals but for non-Veterans Hospitals
additional federal funding for the CDC, for the NIH, for the
National Science Foundation, and just going again across with
the witnesses, would you agree that when we are making our
budgeting priorities we should be increasing funding for those
programs or cutting funding? So would you say increase or cut,
Dr. Jinadatha?
Dr. Jinadatha. Since I am a researcher, increase.
Mr. Swalwell. Okay. And Dr. Cox?
Dr. Cox. Increase.
Mr. Swalwell. And Dr. Perl?
Dr. Perl. Increase.
Mr. Swalwell. Mr. Smith?
Mr. Smith. Yeah, definitely increase.
Mr. Swalwell. And Mr. Miller?
Mr. Miller. Increase with incentives.
Mr. Swalwell. And actually I am glad you brought up those
incentives because Dr. Perl, starting this fall Medicare is set
to impose penalties on hospitals that have poor infection
control rates as an incentive to improve quality of care. Do
you believe that this is a reasonable policy that will help
reduce hospital infection rates? And then Mr. Miller, if you
could follow up on that?
Dr. Perl. I am not a public policy researcher but I think
that if it does go ahead, and in your opinion, that is the way
the country should go, that we absolutely need to make sure
that we don't have untoward consequences as a result of that. I
mean, I think the risk is that we lose resources that may be
supporting some of the practices that all of us have been
talking about.
Mr. Swalwell. Great. And Mr. Miller, is that an incentive
you would support, and could you give us examples of others
that you might support?
Mr. Miller. So I think the--I am in support of including
more in Hospital Compare data and increasing the penalties on
value-based purchasing, making sure that things like MRSA, C.
diff, VRE, Gram-negative staph, that those are all included in
there so that the hospitals absolutely know they are not going
to make money by making the patients sick. Is that responsive?
And then the second thing is, the other idea is, that's the
stick, and then providing them with an incentive that enables
them to say okay, I have got 20,000 patient days coming up, I
can afford to buy the technology that is going to save you 20
to one on your spend, that is more direct.
Mr. Swalwell. Thank you, Mr. Miller, and Mr. Chair, I yield
back the balance of my time.
Chairman Bucshon. I want to take a personal privilege and
just comment briefly on what has happened at hospitals when
Medicare decides not to pay for infections, for example, in
cardiovascular surgery when you have a sternal wound infection.
They decide not to pay for it. Now the hospitals that I have
worked at now culture everybody when they come into the
hospital and it is flooding our microbiology labs with nasal
swab cultures and others to try to prove that indeed the
infection came to the hospital with the patient. So your
comment on unintended consequences of public policy is well
taken.
I now recognize Dr. Broun for five minutes.
Mr. Broun. Thank you, Dr. Bucshon.
By the way, Mr. Swalwell, there are some studies that show
that some VA hospitals have higher infection rates than others,
so there is data.
Back to my question. Dr. Jinadatha, as I alluded to in my
remarks, the Veterans Health Care Administration executives in
Washington apparently have access to detailed information about
quality care and patient safety at individual VA hospitals all
across the system but a lot of this information is not
available to the public. As the Chairman of the Oversight
Subcommittee, I am a huge proponent of transparency and
accountability. So when I hear that some VA hospitals exceed
the infection rates of private-sector hospitals by 10 times or
more, it seems especially important to alert veterans to the
kind of medical treatment that they should expect to receive.
So why isn't the VA more forthcoming in providing objective
information and data about individual patient outcomes in VA
hospitals?
Dr. Jinadatha. Mr. Chairman, I am a frontline clinician and
I usually focus on what I can do for the veteran that is at my
hospital. Unfortunately, I will have to take it for the record
and see what I can get back.
Mr. Broun. Well, if you would, please, because I think it
is imperative that patients know what the infection rates are,
et cetera, as well as all patient outcomes at various
hospitals.
I will ask all witnesses this. If the two technologies
represented here today were implemented properly at all VA
hospitals, how much would that improve current conditions? In
addition to highlighting technologies that can help improve vet
infections and death, what more can Members of this Committee,
Members of Congress do to improve care for our veterans? And
Mr. Miller, I know you offered some suggestions in your
testimony so let us start over here on the other side with Dr.
Jinadatha.
Dr. Jinadatha. Generalizing one center experience and
applying it across all VAs, I don't know whether it will
decrease or not because I believe every hospital is different.
The patient population is different. The procedure done is
different. The culture is different. So I don't know whether
that will solve the problem. It might help some institutions
and it may hurt some institutions, depending on the local
conditions.
Dr. Cox. You know, it is a difficult thing. I think first
and foremost, people should know the kind of care they are
entitled to get and what they should expect. I think
accountability comes from knowledge, and I think educating the
consumer as well to the role that they pay is critically
important. We don't need an antibiotic for everything, and you
know, you don't need a line in longer just because it is more
convenient, and we need to consider how we prepare the entire
care team, which includes not only the hospital-based personnel
but the patient and family themselves, and I think that can go
a long way. I think all of these strategies can augment it. The
question is, are we ever going to get to zero, and I think that
is a question we think probably not but can we be closer.
Mr. Broun. Dr. Perl, if you would answer quickly, I have
got some more questions and I want to go forward so I am about
to run out of time in another minute and a half.
Dr. Perl. Well, just to sort of add to what has been said,
we actually don't know. There have been not been any head-to-
head studies, and I think this Committee needs to really
recognize that there are incremental potential benefits or
incremental potential detriments with any of these
technologies, and they must be studied in a very rigorous way
so that we make good choices.
Mr. Broun. Thank you. And I will just--Mr. Smith, if you
don't mind, I have got another question that I would like to
ask Dr. Cox and Dr. Perl.
Both of you referred to the concept of the bundle and you
referenced that in your testimony. It is an approach that
appears to have helped in you all's own hospitals to decrease
infection rates significantly. So what specifically does the
bundle entail, and do you see this is something that can be
implemented in the VA Hospitals? Dr. Cox?
Dr. Cox. Yes. So the bundle is just a series of very easy
things--wash your hands, scrub the hub, let it dry, access with
aseptic technique, review every day if you need this device in
place, and it is tweaked a little from device to device but
that is the basic premise, and the beauty of it is, it is very
inexpensive and it is very quick and it is very easy to do, and
it should be able to be done not only in all hospitals and VA
hospitals but in resource-limited countries as well.
Mr. Broun. Dr. Perl, any addition to that?
Dr. Perl. No, I would agree with what the witness said. I
would just add that actually there have been some data in VA
hospitals looking at implementation of these bundles that have
actually shown they are effective. So they are device-specific
but they can actually give people very structured processes
that facilitate good care.
Mr. Broun. Thank you all.
Mr. Chairman, if I may take a point of personal privilege?
Chairman Bucshon. Sure.
Mr. Broun. As a family-care doctor, I just want to state
that something I fought my whole medical career is
overutilization of antibiotics in patients, and I have had
patients come to my office, as all primary-care physicians do,
for every earache, for every child or every sore throat, every
cough, even bronchitis, most of these are due to viral
illnesses or allergies, and antibiotics are not appropriate in
that treatment modality for taking care of those patients.
Patients have to be responsible too.
I have spent a career trying to educate my patients and my
patients' moms and dads that antibiotics are not the solution
to every fever, and whatever we can do, whatever you can do,
whatever the medical community can do to try to help stop this
overutilization of antibiotics is something that I focused upon
my whole medical career and it is absolutely imperative that we
continue to do that.
And one other final comment, Mr. Chairman, is that these
hospital-acquired infections just--they are a whole plethora of
things, whether it is a nosocomial pneumonia, as you very well
know, whether it is Legionella that develops from a faulty air
conditioning system, whether it is a catheter or an IV set or
anything else or whether it is a heart valve, the problem has a
whole wide variety of potential causes and so it is not a very
simple thing to say the bundle is going to protect our patients
from infections, and it is just absolutely--I thank you or
helping us put together this hearing, and I yield back. I thank
you for the leeway.
Chairman Bucshon. Thank you, Mr. Broun. I now recognize the
Chairman of the full Committee, Mr. Smith.
Chairman Smith of Texas. Thank you, Mr. Chairman, and let
me direct my initial questions to Mr. Miller.
Mr. Miller, in your oral testimony today, you gave us the
good news that on the whole, you felt like your device, your
technology has reduced infections by about 50 percent,
sometimes a little bit more, sometimes a little bit less. That
is a phenomenal drop and has incredible consequences if you can
reduce the infections by half. To take it to the next step,
that means you are saving a lot of lives as well.
My question is merely--I would like for you to expand a
little bit more on how effective your technology is in creating
a bacteria-free environment, particularly compared to other
methods that are used.
Mr. Miller. Thank you. So I think this also responds to Dr.
Broun as well. Before we ever released the product, we did
testing at M.D. Anderson, and at M.D. Anderson, comparing post-
cleaning rooms versus rooms that were cleaned with Xenex, we
found that the cleaning didn't make a statistically significant
difference. In other words, whether you clean the room or
didn't clean the room, if you ran the robot, there ended up
being 20 times less bacteria. This is on a colony-per-square-
inch count at the end of the day, and where manual cleaning
could never get rid of VRE in the environment, the robot was
able to basically because it doesn't miss surfaces. It is
always hitting it with its high-intensity UV light, and as a
result of having a less bacterial count in the room, then the
patient isn't subject to getting infection even if perhaps
somebody forgets to wash their hands, maybe they won't infect
the patient anyway. So getting that bacterial load way down, 20
times lower, is part of the key of the success of the device.
Chairman Smith of Texas. And Mr. Miller, also, what
impediments have you encountered in trying to persuade others
to use your technology and have a wider spread use of your
technology?
Mr. Miller. Overwhelmingly, the primary objection is, they
say well, we just don't have enough budget to do that, we
understand the benefit to the patients but we just can't afford
it.
Chairman Smith of Texas. You said it paid for itself, I
believe, in four months. How did you calculate that?
Mr. Miller. That is what the hospitals report back to us,
so our very--one of our very first hospitals said they got a 50
to 1 payback on the investment. They saved almost 1,100 patient
days just after starting to use it in their ICUs.
Chairman Smith of Texas. What is the typical cost of this
device?
Mr. Miller. It costs about $104,000 for the device and then
it can treat somewhere between 30 and we have hospitals
treating as many as 65 patient rooms per day, so on a per-room
basis, it ends up being somewhere between $2 and $3.50 on the
discharge of that patient.
Chairman Smith of Texas. That is amazing, and I appreciate
your putting that in the record.
My next question is, what kind of obstacles have you
encountered in developing even new processes or new technology?
Mr. Miller. We are working as fast as we can. Dr. Stibich
spends the Majority of his time thinking about what is the next
iteration.
Chairman Smith of Texas. Have there been any regulatory
problems that you have encountered?
Mr. Miller. Not so far.
Chairman Smith of Texas. Okay. I am glad to hear that. I
thought maybe you had. Okay.
The other question I have is, are there any other similar
products like yours available on the market?
Mr. Miller. As Dr. Perl referred to, there is hydrogen
peroxide gas. It can absolutely work. It takes about three and
a half to four hours including sealing the room, disinfecting
it, but it does a good job. There is also the--there is devices
that are built on mercury bulbs, and if you had two and a half
hours, approximately two hours and fifteen minutes to disinfect
a hospital room, those work as well. So basically it is a time
difference, four hours, two hours and fifteen minutes, or about
ten minutes.
Chairman Smith of Texas. Okay. Thank you.
And let me ask whatever panelist might be the best one to
answer this question, and that is, is there any danger that
bacteria will develop a resistance to these types of methods
that are trying to create a bacteria-free environment? Mr.
Miller, if you want to respond first, it looks like you are
eager to.
Mr. Miller. Yeah. We know of a--there is a recent study
that showed that the bacteria do not develop a resistance to
this kind of treatment.
Chairman Smith of Texas. Let me just see if any of the
doctors on the panel have a comment on that as well. Is there
any danger that bacteria would develop a resistance to this
type of technology?
Dr. Jinadatha. We in central Texas evaluated the risk of
developing resistance to mercury-based and xenon-based
technologies, and in our preliminary report--and I want to
disclose that it is not peer-reviewed yet. We did present this
data at the APIC meeting that there was no development of
resistance in our experiment.
Chairman Smith of Texas. That sounds to me like more good
news, not only for you all but, more importantly, for patients
in the hospitals themselves.
Thank you, Mr. Miller. Thank you all for your expert
testimony today, and Mr. Chairman, I will yield back.
Chairman Bucshon. Thank you, Mr. Smith. At this point I
will ask unanimous consent to introduce the Wall Street Journal
investigative articles about VA health care into the record,
and note that in those articles, within the VA system itself,
there does appear to be a wide variance on the incidence of
hospital-acquired infections.
[The information appears in Appendix II]
Chairman Bucshon. At this point I will recognize Mr.
Lipinski for five minutes.
Mr. Lipinski. Thank you Mr. Chairman. I want to thank you
and all the chairmen for holding this hearing. Although the
issues we are talking about today are not unique to VA
hospitals, we do owe it to our veterans to do all we can to
take care of them for what they have given to us, for us, the
sacrifices they have made. So I want to thank of our witnesses
for coming to testify today.
The first thing I wanted to ask is, I wanted to ask Dr.
Perl, I just wanted to get your thoughts--I know you are not an
expert on the specific technology but the Xenex's pulse xenon
ultraviolet technology, do you believe this technology has been
proven or do you believe more research is needed to test its
potential benefits for reducing the rate for infections?
Dr. Perl. So I would actually say that there is preliminary
evidence suggesting that it does decrease the microbial
contamination in the environment. There is limited evidence
that is not as rigorous as we would like looking at the impacts
in the clinical setting--does it actually decrease infections--
and that is really that translation that is needed.
Mr. Lipinski. Okay. I just wanted to get clarification
there.
Something else I wanted to bring up. I know it has been
discussed a little bit, and it was also in written testimony.
Dr. Perl, I think many of us would like to think that there is
a single solution for this problem; if only we adopted the
right technology, health care-associated infections would be
eliminated, and I am not talking just specifically on this
issue but on all issues that we get here, that we discuss here
in Committee. We are looking for that one breakthrough that is
going to solve everything, and we know it is more complicated
than that, especially an issue that I talk about very often
here on this Committee is the aspect of human behavior. We
could have the best technology in the world, if it not being
used correctly or may be not used at all or we are just doing
things that are bad, that human behavior can undermine the best
technology that we have in place.
So Dr. Perl, can you speak of the importance of low-tech
applications or processes such as training, clear communication
and proper hand hygiene that would help in efforts to eliminate
infections? Before you go, I just want to say everyone on the
Committee knows I am always talking about the importance of
having research in behavioral sciences, and behavior--we need
to understand people's behavior or else the best technology is
not going to do us any good. So what can you add on that?
Dr. Perl. I think you have actually really stated the big
challenge. Human factors, which is really this behavior is a
huge challenge for us in health care. We are asking people to
do multiple tasks with critically ill patients commonly, and
including a lot of different things simultaneously, and so what
you are always challenged with is making sure that people are
doing everything that they need to do and that you facilitate
those kinds of behaviors. So we could have all of the
technology in the world but if people don't know how to use it
or how to integrate it into their work flow or they don't have
time to integrate it, then we are back to square one. So this
whole issue of not only bringing in the technology but actually
figuring out how to operationalize it once we know what works
is going to be critical, and having done clinical trials in
this arena, I can just tell you, it is much more difficult than
it looks at face value. So it is a huge challenge as well as
issue to think through.
Mr. Lipinski. Would you like to add something, Mr. Miller?
Mr. Miller. Just two things. We agree with that. As part of
a bundle, we never just deliver a robot. There is always robust
training that goes to the people. That is number one. And then
number two, three of the studies out of the six that I have
shown you are actually outcome studies showing the reduction
peer-reviewed in the published journal so not just showing
reductions in pathogens in the environment.
Mr. Lipinski. Thank you. I will yield back.
Mr. Johnson. [Presiding] I thank the gentleman for yielding
back. The Chairman has stepped out for a minute, and I have
taken his place, so I will yield myself five minutes,
Representative Bill Johnson from Ohio, and first of all, Dr.
Jinadatha, thank you for being here today, and the entire
panel. I recognize that you specifically did not have--you are
not the reason why we didn't get written testimony. It was the
bureaucracy, and quite honestly, I must state for the record
that that is exactly what is causing so many Members here and
so many Americans across the country concern is the bureaucracy
in the VA that is not looking out for the best interest of our
veterans, and I am not speaking about you specifically. But
clearly, we have some major issues, and this attitude of, we
will get to you when we get to you, and a lack of sense of
urgency in addressing the concerns of the voice of the American
people, which is the United States Congress, that is very, very
concerning to me, but I do want to thank you for being here
today.
And with that, let me ask just a few basic questions. What
suggestions do you--and this is for the entire panel and we
will just go left to right if that is okay. What suggestions do
you have to prevent the outbreaks and the spread of diseases,
for example, such as Legionnaire's?
Dr. Jinadatha. My belief is, it is about people, process
and products, and I think if we master all the three, we
probably could prevent a lot of our infections including
Legionella.
Mr. Johnson. Okay. Dr. Cox?
Dr. Cox. I think you have to go both from an environmental
approach, particularly for things like Legionella. I think you
have to take what Dr. Perl said and get rapid diagnostics so
that you can intervene earlier because outcomes will be better,
and then I think you have to keep looking at the individual
patient level, what can you do there as well.
Mr. Johnson. Okay. Thank you. Dr. Perl?
Dr. Perl. You have asked actually a very loaded question,
and it really requires a comprehensive approach, and I think we
have identified the people issues. There are technologic
solutions but there is also implementation that is critical in
all of this, and it has got to be multidisciplinary and really
involve everyone from frontline staff to leadership to really
be effective.
Mr. Johnson. Thank you. Mr. Smith?
Mr. Smith. Yeah, my belief is really, is it kind of two
things. It is mindset, getting people to understand that HAIs
are not inevitable, they are preventable. That is the big thing
initially. The second thing, as Dr. Perl said, implementation
or practice, and it is a collaborative effort. There is no one
specific solution. It is going to take a collaborative effort
of multiple technologies to be able to make the impact that we
all want.
Mr. Johnson. Okay. Mr. Miller?
Mr. Miller. And what we have seen is when the hospital
administration makes a concrete commitment to patient safety,
it is amazing what you can see.
Mr. Johnson. It kind of starts at the top, doesn't it?
Mr. Miller. Absolutely.
Mr. Johnson. And we see that in many instances. That seems
to be the key.
Dr. Jinadatha, do you know if the VA has specifically
implemented any procedures to prevent Legionnaire's outbreaks
like the one that happened in Pittsburgh? Has Legionnaire's
been addressed specifically within the VA?
Dr. Jinadatha. I will start with my facility. We have a
water safety Committee, and the chair is led by the top leaders
from the front office, and we take every precaution to do
whatever we can within our powers to make sure our veterans are
safe from the Legionnaire's perspective at our facility.
As to the VA, I am not sure. I probably can get back to
you. But I know it is a concentrated effort that is going on to
do whatever we can to take care of that.
Mr. Johnson. Shifting gears just a little bit, kind of a
different subject. You know, we have read stories about
millions of dollars in performance bonuses paid to VA hospital
managers even as patient wait times for appointments and other
problems including HAIs festered. Should the VA explicitly and
primarily base performance pay to health care managers on
objective measures of care that our veterans receive? I would
just like your opinions, and we will go left to right again.
Dr. Jinadatha, do you have an opinion?
Dr. Jinadatha. No, sir.
Mr. Johnson. You don't have an opinion, or your answer is
``no''?
Dr. Jinadatha. I don't have an opinion.
Mr. Johnson. Okay. Dr. Cox?
Dr. Cox. I think with all the benchmarking data that we
have now and accountability, I think that performance measures
can be instituted in a lot of varieties including for bonuses.
Mr. Johnson. Okay. Dr. Perl?
Dr. Perl. I think there is a risk, and you have to really
actually decide what you are looking for. The risk is that if
it is a performance-related measure, that there is strategy to
game the system, and so perhaps if you include those, you also
want to have process measures that are a little bit harder to
game, so I think that is the risk, and there are people who are
much smarter than I that are thinking about those things.
Mr. Johnson. Got you. Mr. Smith?
Mr. Smith. As a small-business owner, my life revolves
around risk-reward and accountability, and so while I can't
specifically comment to your question, in any situation, reward
and accountability, I think, is a good thing.
Mr. Johnson. Mr. Miller?
Mr. Miller. And I am cognizant of what Chairman Bucshon
said earlier about unintended consequences. On the other hand,
in all the companies that I have grown, we have 6,000
employees, there is nothing like incentives that are properly
put in place to get them focused on what the administration of
that entity wants to see happen, and then you measure it and
then you re-measure it and then you adjust the incentives
constantly.
Mr. Johnson. Well, thank you all, and as a 26-1/2-year
veteran, I can tell you that I am concerned about the care that
our veterans get. I appreciate the edification on this
particularly interesting and critical subject that you brought
to us today, and I agree, there is no such thing as a former
Marine. Semper fi. I am Air Force, but thank you for your
service. I yield back to the Chairman.
Chairman Bucshon. I yield now to Ms. Esty for five minutes.
Ms. Esty. Thank you, and I want to thank the Chairman again
for holding this important hearing today, and I want to thank
all our witnesses. We certainly all have a shared commitment to
serving those who have served us, and some of the issues we
have seen are a microcosm of what we see more broadly in
hospitals. As one whose father sat in a prominent university
hospital in 2005 where he had a staph infection induced in the
hospital that greatly accelerated his demise, this is of
particular concern to me and something I am aware of the
consequences that happens.
A couple of things just at the outset. I think we have
heard over and over again, and as I serve on the Transportation
and Infrastructure Committee as well and on the Rail
Subcommittee and I live in Connecticut, the importance is a
safety culture because this has to do with human element of any
of these technologies, any of these procedures are ultimately
going to depend on human beings to implement them and so we are
going to need to create a safety culture at each and every
institution and we also need to frankly make it easy for people
to do the right thing, and that is to be able to use the
technology well for everybody involved in the situation to be
able to do the right thing most easily and not force them to
adapt to what we think they ought to do but actually recognize
the reality of human behavior. So that being said, I think the
best technology in the world, as we would all agree, is not
going to do any good if people won't use it properly.
So to that end, I wanted to turn to you, Dr. Perl, to talk
about how we do currently test technologies because in order to
have appropriate testing, you want to reduce the number of
variables but at the end of the day, we also have to look at
human behaviors. Could you talk a little bit about that?
Dr. Perl. So I probably recognize one end of that spectrum,
but in general, there are different kinds of technologies and
what happens for drugs, for example, may be different than what
happens for devices and could be different than some of the
disinfectants that are being talked about and actually the
current technology that has been discussed today as far as I
understand is somewhat unregulated and there are no standards.
So in general, there is a process that is usually run at the
government level where the device or the drug is regulated.
What happens in the FDA is a little different than what will
happen in, say, the EPA for disinfectants. Once that goes
through that process, then products are generally brought into
the marketplace and commonly people will approach you and say I
have this new device, I would like you to look at it, or I have
this new product I would like you to look at it, and then how
you approach it will be very different. What I do may be
different a little bit than what Dr. Cox does, and we try and
look at the technology not only from a safety point of view but
from an infectious risk point of view, from an engineering
point of view, and if we think it is interesting, you can
either pilot it or commonly you may say look, there are some
risks and benefits and we would actually like you to go ahead--
we would like to do a study, and then you try and determine
sources of funding to go ahead and do these kinds of studies.
Sometimes these are done under the rubric with IRBs, or
institutional review boards, and sometimes they are actually
done as quality projects. So that is in general the process.
It has been relatively difficult for us to get funding to
test this kind of technology in a much more what I would call
rigorous scientific way.
Ms. Esty. And I can follow up on exactly that point, who
currently is funding the research on these technologies, and if
you have thoughts about who ought to be, whether we need a
dedicated federal funding stream to deal with technologies.
Obviously we do in the drug category. We have separate ones for
medical devices. Is this something, given the importance of
HAIs, that we ought to be looking at a funding stream dedicated
to that in and of itself?
Dr. Perl. So I think that funding for HAIs has actually
been--it has been greatly underfunded, given its importance,
and we really do not have a good home. The NIH will say this is
really not our area. They might fund resistance at a very basic
science level. The CDC really does not have that much research
funding, and what they have is minimal. Traditionally, we
haven't gone a lot to the EPA, et cetera, and AHRQ has not been
necessarily quite as interested in technologies but more
implementation science. So there is not a good home, and I
think that--I am not sure that another infrastructure needs to
be created but certainly there needs to be an infusion into
this arena to assure that we are studying things appropriately.
Ms. Esty. And if I may, could I ask all five you if I can
follow up afterwards, if you have thoughts about just deciding
a home. I agree with you, it makes no sense to create a new
agency. That would be foolish. But someone needs to take
ownership of this issue clearly. It makes no sense to have no
dedicated stream, given the expense, the mortality, the human
expense, as well as the cost to our system. Someone needs to
wrap their arms around this, take ownership, start developing
metrics and have a funding stream that it gets the respect and
resources it deserves.
Thank you all very much.
Chairman Bucshon. I would agree with that.
I now recognize Mr. Collins for five minutes.
Mr. Collins. Thank you, Mr. Chairman.
Dr. Jinadatha, as Chief of Infectious Diseases, do you run
your own blood testing lab and so forth in your hospital?
Dr. Jinadatha. We have our own pathology, microbiology and
hematology lab, and of course, I have my own research lab.
Mr. Collins. So using PCR and molecular diagnostic
equipment? If a patient comes in, you will do your own blood
tests?
Dr. Jinadatha. Yes, we have.
Mr. Collins. Now, one thing I have been concerned about
is--and I know you are not in Buffalo, but in Buffalo, our VA
hospital was--it was discovered by the IG a year and a half
ago. They were reusing insulin pens. A very basic, you can't
make this stuff up, reusing insulin pens. We had to test many
thousands of patients to see if they had contracted HIV or
hepatitis through the refuse of these insulin pens. We just
discovered through a whistleblower that they were not properly
sterilizing their instrumentation, I mean, not just by a little
bit, and so the whistleblower contacted the Office of Special
Counsel and now it just came out two days ago about
instrumentation within the hospital not being sterilized,
almost, again, something you can't imagine.
So what I really discovered is, coming out of the private
sector, best practices are the heart and soul of quality, but
in many cases, that means benchmarking. We have three great
hospital systems in western New York: the Kaleida Health
System, Catholic Health System and Erie County Medical Center.
The VA was not benchmarking with any of them, and I can only
use the word ``arrogance.'' The arrogance of the VA system was,
we are the best, we are the biggest. Well, they are anything
but, and if you don't benchmark, how do you know what others
are doing? Because, you know, not to say for sure but I can
assure you, the other systems weren't reusing insulin pens on
several patients. They were sterilizing their instrumentation.
So a real quick question. Do you do and do you have someone
that does proficiency programs testing out your technicians on
your molecular diagnostic equipment?
Dr. Jinadatha. We have a certification process, the CAP,
which is the----
Mr. Collins. College of American Pathology?
Dr. Jinadatha. Yes.
Mr. Collins. So CAP is running your program?
Dr. Jinadatha. They come and inspect us, so does, I
believe, IG and----
Mr. Collins. So with CAP, they are sending you the samples
two or three times a year, influenza, whatever, and then they
are scoring you?
Dr. Jinadatha. Yes. I believe we undergo CAP certification.
Mr. Collins. How is your score?
Dr. Jinadatha. Since that is not something I run, I don't
know but----
Mr. Collins. Well, I am glad because that is an outside
agency. CAP does a very good job.
Dr. Jinadatha. They kept us working, so I believe we are
good on their benchmarks.
Mr. Collins. So does your system benchmark? I mean, are you
making sure you have got best practices?
Dr. Jinadatha. We have a national infectious disease office
that is located in Cincinnati, and we get directives, we get
handed down best practices that we should be implementing, some
of the examples that have been alluded by the panelists are
MRSA bundle, the MDRO program. We have a CLABSI reduction
program and an antimicrobial stewardship program.
Mr. Collins. But is that coming down from on high to you or
is your hospital reaching out to the others even in your area
just to share information?
Dr. Jinadatha. Absolutely, sir. One of that would have been
an example of how we instituted UV disinfection technology at
our facility. So in our facility, which I can speak for, we do
both. We take some of the best practices that are given to us
from the national office. We also initiate on our own some best
practices that I follow the literature and bring it into--try
to bring it into practice.
Mr. Collins. Again, in Buffalo, I just don't--I wonder if
any other panelist has a comment, not as a physician, but how
could you reuse insulin pens? How could they be doing that? Or
in the case of instrumentation, not sterilizing it. And it was
really--the technicians didn't seem to care. They were going
through the motions. I mean, does anyone else--it is almost
rhetorical. Mr. Smith?
Mr. Smith. Just a quick comment. You know, one of the
questions before was practice, implementation, training people
and so forth, and again, it is going to take a collaborative
effort to have the favorable impact that we all want.
With our technology, it is not--it does not require
training people. It is just simple implementation, whether it
is in the touch surfaces outside the body or potentially inside
the body. So this is a continuous type of technology that does
not require training. And so thankfully, you take the human
element out of that, the decision making--the poor decision
making out of that aspect.
Mr. Collins. Thank you. I just would conclude by saying it
is obvious our veterans deserve the best care. It has been very
disappointing in the Buffalo area with a very large hospital,
we have not delivered the best care, and I go back to--you
know, I have sensed a level of arrogance within the VA that
they just know best, and then when you show them they don't,
they still say they know best.
So anyway, thank you, Mr. Chairman.
Chairman Bucshon. Thank you. We need to bring this more to
the public's attention. It does get out there some into the
mass media. When we discuss funding for a lot of medical
research, obviously there is a disparity between different
disease processes within the funding stream, many of which is
related to, in my view, for political reasons and for the fact
that some things are on the front page and some things are not.
This is one area that we have heard today that the dramatic
impact on the people that we take care of in health care and
how it most likely is very clear that we need more research and
more public awareness of this problem because the impact, I
think, can be dramatic.
So I would like to at this point thank all the witnesses
for their valuable testimony and the Members for their
questions. The Members of the Committee may have additional
questions for you, and we will ask you to respond in writing.
The record will remain open for two weeks for additional
comments and written questions from the Members.
At this point the witnesses are excused and this hearing is
adjourned. Thank you.
[Whereupon, at 10:49 a.m., the Subcommittees were
adjourned.]
Appendix I
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Answers to Post-Hearing Questions
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Appendix II
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Additional Material for the Record
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