Fighting Invisible Killers: How the Lack of Infection Prevention & Control (IPC) in Hospitals Harms and Kills Patients
- EvaluCare
- May 26
- 5 min read
“The Centers for Disease Control and Prevention (CDC) reports that 1.7 million infections annually are healthcare‐related, and as a result, 99,000 people will die each year.” PubMed
Healthcare‐associated infections (HAIs) remain one of the most serious, and preventable, threats to patient safety in U.S. hospitals. Despite decades of emphasis on hand hygiene, antimicrobial stewardship, and environmental cleaning, nearly 1 in 31 hospitalized patients suffers an HAI on any given day, and tens of thousands of lives are lost annually PMC.
To turn the tide, hospitals must invest in truly effective Infection Prevention and Control (IPC) programs, backed by leadership support, adequate resources, and rigorous evaluation. they must see these programs as essential components to a robust quality program, fully integrated into patient safety, regulatory readiness, continuous quality improvement activities and support it with performance based surveillance systems to respond quickly to evolving threats.
In this deep‑dive, we’ll:
Examine the scope and human toll of HAIs
Outline the components of an effective IPC department using The Joint Commission’s IC‑1 and IC‑2 standards
Detail the major types of HAIs patients face
Show how expert review, such as by EvaluCare, can identify IPC failures that contributed to patient harm
1. The Scope and Consequences of HAIs
1.1 National Burden
1.2 Why HAIs Persist
High patient acuity and invasive devices (central lines, ventilators, catheters)
Antimicrobial resistance, which complicates treatment
Environmental reservoirs (e.g., contaminated sinks, surfaces, equipment)
Human factors, including lapses in hand hygiene and staffing shortages
1.3 Patient Impact
Increased morbidity: prolonged ICU stays, additional procedures
Psychological trauma: anxiety, loss of trust in healthcare
Financial hardship: copays, deductibles, lost wages
Building an Effective IPC Department
The Joint Commission’s IC‑1 Standard (Infection Prevention and Control) provides a roadmap for planning and implementing an IPC program. Below, we break down each element, at a cursory level, and why it matters.
IC‑1: Planning
1A. Responsibility
Designated leadership: A board‐level leader must oversee IPC, ensuring it’s not siloed under “quality” but integrated into organizational strategy.
Infection Preventionist (IP): At least one certified IP (e.g., CIC credential) per 100 beds.
1B. Resources
Staffing: Sufficient IPs, data analysts, educators, and support personnel.
Budget: Dedicated funds for surveillance software, staff education, and supplies (e.g., personal protective equipment).
1C. Risks
Risk assessment: Ongoing identification of high‑risk procedures (e.g., central line insertions, surgical services).
Gap analysis: Comparing current practices to national guidelines (CDC, SHEA, APIC).
1D. Goals
SMART Objectives: Specific, Measurable, Achievable, Relevant, Time‑bound targets (e.g., “Reduce central line–associated bloodstream infections [CLABSI] by 25% in 12 months”).
1E. Activities
Surveillance: Active monitoring of device‐associated infections and MDRO (multidrug‐resistant organisms).
Education: Annual competency assessments for hand hygiene, sterile technique, and environmental cleaning.
1F. Implementation
Operational planning: Roll‑out schedules, multidisciplinary committees (nursing, pharmacy, environmental services).
Policies & procedures: Written protocols for sterilization, isolation precautions, and outbreak management.
IC‑2: Implementation
2A. Activities
Hand hygiene program: Alcohol‑based rubs at point of care, compliance audits with direct observation.
Environmental cleaning: Use of EPA‑registered disinfectants, UV‐C or hydrogen peroxide vaporizers for terminal cleaning.
2B. Medical Equipment, Devices, and Supplies
Sterilization & reprocessing: Validated sterilizers, high‑level disinfection for semi‑critical items.
Single‐use policies: Clear disposal procedures to prevent cross contamination.
2C. Transmission & Infection
Isolation precautions: Contact, droplet, and airborne protocols with signage, dedicated equipment, and PPE stations.
Cohorting: Grouping patients with the same pathogen in dedicated areas.
2D. Influenza Vaccination
Annual staff vaccination: Mandatory or strongly encouraged, with declination tracking.
Patient & visitor education: Signage and vaccine clinics during flu season.
2E. Health Care–Associated Infections
Device‐associated infections: CLABSI, catheter‐associated urinary tract infections (CAUTI), ventilator‐associated pneumonia (VAP).
Surgical site infections (SSI): Preoperative chlorhexidine showers, perioperative antibiotic timing.
IC‑3: Evaluation & Improvement
Monthly data review: CLABSI rates, CAUTI rates, hand hygiene compliance.
Root Cause Analyses (RCA): For each HAI event, multidisciplinary investigation.
Performance improvement projects: PDSA cycles targeting high‐risk units, interventions tested and scaled.
Common Healthcare‑Associated Infections
Below is a list of HAIs patients may acquire—and each carries a measurable risk of severe complications or death:
Central Line–Associated Bloodstream Infection (CLABSI)
Catheter‑Associated Urinary Tract Infection (CAUTI)
Ventilator‑Associated Pneumonia (VAP)
Surgical Site Infection (SSI)
Clostridioides difficile Infection (C. difficile)
Methicillin‑Resistant Staphylococcus aureus (MRSA)
Vancomycin‑Resistant Enterococci (VRE)
Multidrug‑Resistant Gram‑Negatives (e.g., CRE)
Hospital‑Acquired Pneumonia (HAP)
Other Device‑ or Procedure‑Related Infections
Mortality Risks:
CLABSI: up to 25% attributable mortality
VAP: 20–50% mortality
C. difficile: ~5% mortality in hospitalized patients
Case Examples of IPC Failures
CLABSI Outbreak in ICU: A 15‐bed ICU experienced six CLABSIs in one quarter. Investigation revealed lapses in maximal sterile barrier precautions. After retraining and bundle implementation, CLABSI rates dropped by 70%.
MRSA Transmission on Surgical Ward: Patients colonized with MRSA were not flagged in the EHR due to data entry backlog. Lack of contact precautions led to four postoperative SSIs, prompting an RCA and overhaul of admission screening processes.
Influenza in Long‑Term Care: An outbreak among nursing home residents hospitalizes 20% of residents; staff vaccination rate was only 40%. Leadership instituted mandatory vaccination with medical exemptions, reducing influenza‐related admissions by 80%.
Why Hospitals Fail at IPC
Despite clear standards, many hospitals struggle due to:
Leadership Disconnect: Administrators unaware of IPC’s technical demands. Organizationl structures may not reflect the overall need or awareness of the importance of IPC as a core quality function.
Insufficient Staffing: Too few Infection Preventionist (IPs), environmental services staff, and bedside nurses.
Staffing Coordination: Critical collaboration between staff and departments not a part of core programing.
Budget Cuts: IPC supplies and technologies viewed as “optional.”
Data Silos: Poor integration between microbiology labs, EHR, and surveillance systems, including poor data dash-boarding and analytics at the service or unit level for system performance feedback.
Culture Gaps: Frontline staff not empowered to halt unsafe practices
Awareness, Stewardship, Vigilance: The lack of frontline awareness, stewardship of programing and vigilance in holding each other accountable to defined practices, such as sterile gowning, hand hygiene, CSR practices, care and maintenance, etc.
The Role of EvaluCare in Uncovering IPC Failures
When patients or families suspect an HAI contributed to harm, or death, and they need expert, objective analysis of the medical record and IPC practices. EvaluCare’s Services Include:
Clinical Record Review: Detailed correlation of care timelines with staffing logs, generally accepted antibiotic adminstration timelines for surgical cases, etc..
IPC Expertise: Evaluation by certified Infection Preventionists, epidemiologists, and infectious disease physicians. In medical malpractice cases, guide discovery of policy, and gaps, against generally accepted practices.
Gap Analysis: Benchmarking against CDC guidelines and The Joint Commission standards (IC‑1, IC‑2, IC‑3).
Root Cause Assessment: Identifying where planning, implementation, or evaluation failed.
Actionable Reports: Clear findings to support legal claims, regulatory follow‑up, or institutional causation.
By illuminating where IPC broke down, whether due to inadequate resources, training lapses, or policy gaps, EvaluCare empowers accountability by educating patients, families, and attorneys to drive meaningful improvements through accountability.
Conclusion: Turning Data Into Action
Healthcare‐associated infections are a leading, yet largely preventable, cause of death and suffering in hospitals. Building and sustaining an effective IPC program demands:
Strong leadership commitment to IC‑1 planning and IC‑2 implementation
Sufficient resources—people, budget, and technology
Continuous evaluation (IC‑3) to close gaps and celebrate success
A culture of safety where everyone—from the CEO to the housekeeper—owns infection prevention
When IPC systems falter, the consequences are devastating. But with a rigorous, standards‐based approach—and the investigative support of experts like EvaluCare—hospitals can reduce HAIs, save lives, and honor the trust patients place in them every day.
If you believe that an infection contributed to your loved one’s harm, EvaluCare is here to help. Our experienced team will perform a detail medical care review. We have proprietary ways of evaluating hospital infection prevention and control practices even without formal malpractice cases to determine whether if hospital care contributioned to an HAI. Remember that all HAIs are preventable.
Our team of experts will guide you toward the answers and a direct resolution you deserve.
Learn more: EvaluCare Medical Care Review Services
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