Wednesday, February 02, 2011

Our patients are sicker

What more do we need to know? The British Medical Journal published a study showing that Peter Pronovost's program to reduce central line infections in Michigan saved lives.

A new study finds that a safety checklist program developed by a Johns Hopkins doctor has reduced patient deaths in Michigan hospitals by 10 percent, in addition to nearly eliminating bloodstream infections in health care facilities that embraced the prevention effort.

The research, published in the British Medical Journal, is the first to show a drop in patient mortality in hospitals using the Hopkins program. Previous studies have found major reductions in bloodstream infections from using the checklist when inserting catheters or central lines to give patients medication, fluids or nourishment.

Well, duh. But I guess it is important to have scientific verification. But I can almost hear the comments from some places: "That wouldn't work here. Our patients are sicker."

So, how long will it take for this approach to be used across the country? This study is based on work from nine years ago. If this is like other innovations in medical care, it will take a decade and a half more to spread.

Here's my proposal to jump-start it. Publish the monthly rate of central line infections for all hospitals on a public website. CMS, IHI, the Dartmouth Atlas group or some other organization could do this in a nano-second, creating a voluntary website, giving each hospital a password through which it could enter its own data. There is no need to audit the figures. We can trust people to be honest.

And, at the bottom of the website, the host could list the hospitals that have chosen NOT to publish.

Then, you would see the power of transparency.


Mary Ellen said...

From Facebook:

And make sure to publish the rates of pediatric hospitals too - none of which are published yet on any site - as far as my little blonde head has yet found...would love to be shown wrong on this.

Ken Farbstein said...

I agree.

Paul, thanks for your past early leadership in this, both in halving your hospital's rate of central line infections, and in reporting your rate, as mentioned in my 2007 blog post at

Anonymous said...

Paul, we need a massive jump-start indeed. The article says:

"Pronovost said that hospitals in 47 states have signed up for the Hopkins-developed infection prevention program. So far, about 38 have actually begun the two-year training regimen that goes along with using the checklist."

So, just say 38 hospitals per year begin training - with about 5700 hospitals in the U.S., at that rate it would take about 150 years for all hospitals to be trained.

Now, we might say the training rate will accelerate, but you math whizzes calculate what it would take to get all hospitals trained in 5 years.

Jump-start, yes. By all means.


Lisa McGiffert said...

Certainly the CLABSI checklist has saved lives and prevented many infections, but we, the public have no idea, which hospitals are getting the most out of this excellent program -- that is why Consumers Union's Safe Patient Project has pushed for hospital-specific reporting since 2003. I like the idea to have CLABSI rates updated more frequently than once a year as the data we are seeing now is not timely. But a voluntary reporting system is not the answer. First, not everyone will participate - most likely those hospitals with the worst record will not volunteer. Second, collecting and entering the data needs to be standardized for comparability. Last - "trust them"? No, we cannot leave this to trust. While auditing infection rates is not yet widespread, the states that are auditing have found everything from administrative errors to failure to follow protocol in identifying infections to outright withholding information. Those who are harmed and the public deserve real accountability.

Paul Levy said...


Reporting on this matter is highly standardized. There is a commonly accepted CDC definition.

If you want to get into auditing people's submissions, you enter a bureaucratic "black whole" that will add months of delays to any reporting.

Self-reporting is self-correcting since it occurs every month. No one is good enough to fake numbers month to month, over an extended period of time!

So, don't let the perfect be the enemy of the good.

Lori Nerbonne said...


Yes, there are commonly held definitions and standardization by NHSN (via the CDC), but those of us who work on state infection reporting laws know the realities of public reporting, and sadly what they've revealed is that 'voluntary' and non-validated data means many hospitals will not participate (the outliers especially) and hospitals will report what makes them look best (they cherry-pick which units/infection rates to report).

If you go ask the states who've been doing public reporting for years they will confirm these realities. That's why the ARRA funds distributed to states by the CDC last year allowed for funds to go toward validation of the data.

One last note: at a recent CDC stakeholders meeting, I listened to a leading expert in data reporting explain that there are many ways that hospitals figure out ways to fudge the data to make themselves look good.

We need every hospital in the country reporting validated, hospital-specific, standardized HAI/CLABSI rates. Even better; forget the rates and report them in raw numbers so consumers can understand them.

Paul Levy said...

I am afraid you miss the point. I have seen that hospitals that voluntarily report do so accurately. They know you can't fudge things when you have to post numbers month after month.

But, how's this as a compromise? To allow numbers to be current, hospitals would post them unaudited in one type of font (e.g., italic). Later, when they are verified, the font could be changed (e.g., standard).

I suggest this because if you do as you suggest and insist on only validated numbers to be published, they will never be current. They will be months old.

Under the system I suggest, if someone is systematically "cheating", it will be come evident soon enough. Knowing the numbers will be validated will eliminate potential cheating, in any event.

Anonymous said...

I am afraid I find this discussion very sad. Cheating, fudging, cherry picking, finding ways to make themselves look good. Are those the kinds of places we want taking care of us when we are deathly ill?

When you step back and really look at this as say, my 20 year old would, it's just very disheartening. We need to not let our cynicism skew our vision of what is really happening here.


Suzan Shinazy RN said...

Our healthcare system is where it is today because everyone 'trusted' physicians and hospitals to do the right thing.

I agree with Paul that it takes the industry a decade and a half to make improvements shown to save lives. That is the only thing we can 'trust' them to do.

Frances said...

Couldn't agree more on the value of public reporting and transparency around CLABSI rates, plus the value of calling out hospitals that are not willing to report. Leapfrog does just that, at least with our targeted hospitals. Our site lets anyone see the standardized rates, using the same methods as CDC, for hospitals in their community.

Kerry O'Connell said...

"Our Patients are Sicker" is an excuse that I hear a thousand times a year,I often wonder who truly has the sickest patients? I have fought hard for the public reporting you propose for the past 5 years. Yet many days I feel that public reporting has about as much impact as posting pictures of my teenage son's filthy room on his facebook page. Central Line checklists are a wonderful tool but every month I listen to ICP's describe how when they audit the the paper lists 99.9% of the time every box is checked but when they actually watch the procedures compliance is at best 75%-80%. Motivating thousands of HCW's to do it perfect every time is a monumental task. My solution for jump starting is even simpler than yours. Write legislation that if a Patient aquires a Central line infection the hospital must reimburse the insurer the cost of treatment and the installing HCW must reimburse the patient their out of pocket expenses. Shared pain might generate some intense focus on the issue.

Kevin Shea said...

I come from the automotive industry, in which, if there is a defect in your vehicle, it is covered by warranty, and often managed by a Fed agency.

An infection is a defect in the process that "does harm" to the customer.

When patients reenter a hospital after getting an infection there, why does that patient have to pay again?

My experience: 2 friends, 2 back surgeries, 2 infections. Personally I WANT the information!

Anonymous said...

Ooh, Kerry is edging closer to my wild idea that Medicare might someday declare every patient death a never event until proven otherwise - and not pay for the hospitalization. I like Kerry's idea even better. Hmm, maybe this thing has legs.


Anonymous said...

Ooh, Kerry is edging closer to my wild idea that Medicare might someday declare every patient death a never event until proven otherwise - and not pay for the hospitalization. I like Kerry's idea even better. Hmm, maybe this thing has legs.


Yeast Infection said...

First, not everyone will participate - most likely those hospitals with the worst record will not volunteer. Those who are harmed and the public deserve real accountability.