tag:blogger.com,1999:blog-32053362.post8462519983295756770..comments2024-03-26T00:25:34.026-04:00Comments on Not Running a Hospital: Good and bad news about infection controlPaul Levyhttp://www.blogger.com/profile/17065446378970179507noreply@blogger.comBlogger32125tag:blogger.com,1999:blog-32053362.post-39806629605604457212009-11-22T19:55:08.049-05:002009-11-22T19:55:08.049-05:00Huh?Huh?Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-69339284448153387832009-11-22T16:13:22.920-05:002009-11-22T16:13:22.920-05:00Thanks for the openness Paul-
Has your hosptial i...Thanks for the openness Paul-<br /><br />Has your hosptial investigated the use of nanotechnology in infection control?<br /><br />How about the use of ATP monitoring to quantify cleanliness?<br /><br />Billbillhttp://www.24x7infectioncontrol.comnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-76411239119985576732009-02-20T08:19:00.000-05:002009-02-20T08:19:00.000-05:00Sir,We physicians are trained as master craftsmen,...Sir,<BR/>We physicians are trained as master craftsmen, not as members of a team. As students, we go on attending rounds and try to outperform our peers with our exhibitions of knowledge. As residents in training, we learn that we have the power to speak and it will happen, that is, the intern will write the order, the unit clerk will take it off, and other folks will follow the order. The only teaching about how to deliver care was, "Stay until it's done." We go into practice trapped in a cultural crevice where we know more than any of the support staff, we do everything, we make all the decisions, we don't trust anyone else to do the right thing, even our peers and we live under the tremendous pressure that comes with trying to accomplish an impossible task given the methods we are trained with.<BR/><BR/>Given all that, I am still optimistic. The level of pain has risen to the point where even change looks good to some. You are part of that group. If you then follow Everett Rogers work on the Diffusion of Innovations, the next step is to make the benefits of the early adopters visible to others to influence the next wave of adopters. I do this in the rural counties of PA, where early adopters are geographically distant and functionally isolated. They light up and glow when they learn about others who are making the same change to empowered teams. They feel validated and they are willing to share and learn from each other.<BR/><BR/>Rather than challenging all the leaders in Boston to follow your lead, you might search out those who are ready to change and let the rest stay the way they are for now. Since only 13% of any population are early adopters, you won't get them all at once. However, driving along the adoption curve will bring them along and you won't have to wait for incremental change.<BR/><BR/>I am very glad I found your blog. Thanks for making your own efforts visible.Lonnie E. Fuller Jr., MDhttps://www.blogger.com/profile/01526395617629892453noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-48927852106418715122009-02-14T00:24:00.000-05:002009-02-14T00:24:00.000-05:00My 84 year old mother, and many like her, refuse t...My 84 year old mother, and many like her, refuse to go to the hospital, in fact live in deathly fear of going to the hospital becuase she and they know that once in, they are likely to die of infections contracted while there, if not for whatever acute condition brought them there. If BIDMC can succeed in publicizing it success at infection control, it would go a long way to easing the anxiety of potential patients who need early treatment but currently refuse it to their detriment.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-38783695683262050432009-02-13T10:39:00.000-05:002009-02-13T10:39:00.000-05:00I think most people will tell you that such an app...I think most people will tell you that such an approach is at variance with how hospitals function, i.e., with MDs and others insisting on retaining control of the relationship with the patients.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-49803357642566161532009-02-13T10:36:00.000-05:002009-02-13T10:36:00.000-05:00Paul,The current situation will change, it has to....Paul,<BR/><BR/>The current situation will change, it has to. I think the entire health care industry is headed for serious change, which will hopefully benefit all of us.<BR/><BR/>Regarding the idea of implementing QC for hospitals, to reduce infections and provide better care, I think the only serious way to bring about this change is to emulate the QC processes of other industries. There should be an entire department at every large provider to deal with QC issues, and the QC management should control all operations. Procurement, surgery, clinics, engineering, etc. should all have to answer to QC. Annual meetings with the heads of all depts would be necessary, at which time revisions to the current processes would be proposed.<BR/><BR/>I'm sure you are familiar with this sort of operations structure, but I'm not sure if it is implemented at all in the hospital setting.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-92001851920208858322009-02-13T08:10:00.000-05:002009-02-13T08:10:00.000-05:00Anon 8:24;Well, in this case the people that didn'...Anon 8:24;<BR/><BR/>Well, in this case the people that didn't "buy in" were the new administration, so the converted were the ones to eventually "bye out". (Other members of the medical staff were essentially passive.) Nonbelievers are not limited to members of the medical profession by any means. My bottom up idea was predicated on the notion that if every doctor in a hospital is trained in the tenets of patient safety, it would become necessary and normal practice, not an evangelist's dream.<BR/><BR/>nonlocal MDAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-90941894543443216362009-02-13T02:08:00.000-05:002009-02-13T02:08:00.000-05:00My partner (Tucson Dunn, a former hospital CEO) an...My partner (Tucson Dunn, a former hospital CEO) and I were just discussing transparency issues in hospital billing system and how this is making American hospitals less competitive internationally when going head to head like Apollo Hospital Group facilities in India, or Bumungrad International in Thailand (to just mention two of the better known examples) which make publicly available their billing codexes.<BR/><BR/>The key point that Tucson made is that when a vigilant patient finds a suprise on their hospital bill (like a 1000 dollar toothbrush) it is tremendously difficult to get such a mistake (intentional or not) refunded, because, as you well know, the bill has to make it up to management level in the hospital. And this doesn't usually happen until 90 days have passed from the initial billing (that's when the clerks office sends the bill upstairs), at which point, the patient, through no mistake of his, sees his/her credit rating drop (the clerks office has been alerting the credit company at regular intervals for three months about not having yet recieved payment on a 1000 dollar bill and the credit company could care less if it was a toothbrush or an engagement ring)...at which point patients will take their complaints public and litigation and/or public embarassment for the hospital ensues. Meanwhile, all this could have been avoided if the bill was written so that a lay person could understand it, instead of being an endless list of letters and numbers worthy of a Dan Brown best seller.<BR/><BR/>This logic holds for the transparency issue you talk about. And, while I understand where much of hospital administrator's fears about transparency comes from at a time in our history when even good samaritans can get sued by those they save (see December 18 California Supreme Court Ruling allowing good samaritans to be sued for non-medical care) it is amazing to me that in this age of constant information flow, and of ever more prominent Health 2.0 philosophies perforating academic discussion, how hospital administrators can still be turning a deaf ear to the pleads of consumers for greater transparency. Mr. Levy, you are absolutely right about it being a life or death choice.<BR/><BR/>//Damjan<BR/><BR/>p.s. - long time reader, would love to link blogs - blog.hanovera.comAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-10021065178350793602009-02-13T01:13:00.000-05:002009-02-13T01:13:00.000-05:00OMD, I think you are correct, in that almost all ...OMD,<BR/> I think you are correct, in that almost all of the quality indicator measures that are currently in place have problems. Some have poor evidence of benefits in mortality, some lead to unintended consequences (over use of antibiotics, or overly aggressive rush to Cath lab for possible MIs). I think it is important to thoroughly review the evidence behind these quality indicators.<BR/> Speaking of... the National Quality Measure Clearinghouse (www.qualitymeasures.ahrq.gov) publishes overviews of thousands of different suggested quality measures. Some of these do list the evidence behind the measure, though it is rarely randomized controlled trial data. I recently reviewed a number of these indicators as they relate to emergency medicine, and the evidence behind them. It was eye opening. I think the key is to use a package of multiple quality indicators which are difficulty to "game" and to carefully watch out for the unintended consequences that these measures may lead to.<BR/><BR/> A number of organizations support the use of central Line infection rates as a quality measure, including our friends the Joint Commision. The Veterans Health Administration also use this measure. I've stolen part of their description for the evidence in favor:<BR/>"The CDC's National Healthcare Safety Network (NHSN) reported in July 2007 the median rate of CLAB infections per 1,000 central line days in NHSN participating hospitals ranged from 1.9 in Major Teaching Medical Surgical ICUs to 2.2 in Medical ICUs. The attributed mortality for these CLAB infections is mixed in the literature. The documented studies range from no increase in mortality when controlled for severity of illness, to a 35% increase in mortality in prospective studies that did not control for severity of illness. Further research to clarify the mortality associated with CLAB infections is needed, but the available data are consistent with an attributable mortality of CLAB infections, ranging between 4% and 20%. These infections are associated with 2,400 to 20,000 deaths per year."*<BR/><BR/>So, the data isn't perfect, but it trends towards lowering death rate. The second question is are we harming patients in a way these studies don't capture? For example, are we taking central lines out of patients too early? Is the full package of sterile techniques harmful in some way? I don't think so, but it deserves consideration. <BR/><BR/>On the topic of education, I put in two of these lines at work tonight, and was happy to teach one of my more junior colleagues the full sterile technique. It probably only took an additional minute to get the patient fully draped and the physician in a sterile gown. It took about 40 seconds to fill out the proper paperwork out to document our technique. In this particular case, the time/effort expenditure is certainly worth it, even in a busy practice environment. <BR/><BR/><BR/><BR/><BR/><BR/>*Full document @ http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?ss=1&doc_id=12122&string=VHA+AND+central+AND+lineJonhttps://www.blogger.com/profile/04715761776674144257noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-42305402611491583582009-02-12T22:18:00.000-05:002009-02-12T22:18:00.000-05:00PaulYour indefatigable efforts to promote transpar...Paul<BR/>Your indefatigable efforts to promote transparency are admired by many, including us at the Kenneth B. Schwartz Center, where we know that opening up the lines of communication with patients and their loved ones is ultimately good for everyone.<BR/><BR/>Studies show that effective patient-caregiver communication is <BR/>associated with stronger relationships, enhanced patient satisfaction, and reduced malpractice claims. Patients want their caregivers to talk <BR/>to them honestly, frankly and clearly. And they want their <BR/>institutions to do the same. Keep pounding away at that wall of <BR/>recalcitrance Paul. The wall will eventually fall.<BR/><BR/>Julie Rosen<BR/>Executive Director<BR/>The Kenneth B. Schwartz CenterUnknownhttps://www.blogger.com/profile/13659609130355264556noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-19403624064947467492009-02-12T21:49:00.000-05:002009-02-12T21:49:00.000-05:00Local dental schools' clinics need to be looked at...Local dental schools' clinics need to be looked at with respect to infection control...Tufts University School of Dental Medicine Clinics <A HREF="http://dental.tufts.edu" REL="nofollow">http://dental.tufts.edu</A> Boston University School of Dental Medicine Clinics <A HREF="http://www.bu.edu/dental/" REL="nofollow">http://www.bu.edu/dental/</A> Harvard University School of Dental Medicine Clinics <A HREF="http://www.hsdm.harvard.edu" REL="nofollow">http://www.hsdm.harvard.edu</A> Forsyth Dental Clinics <A HREF="http://www.mcphs.edu/about_mcphs/mcphs_in_the_community/forsyth_dental_clinic.html" REL="nofollow">http://www.mcphs.edu/about_mcphs/mcphs_in_the_community/forsyth_dental_clinic.html</A>theszakhttps://www.blogger.com/profile/02671109875431805540noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-3706190605152391082009-02-12T20:24:00.000-05:002009-02-12T20:24:00.000-05:00" . . . I was "converted" by an anesthesiologist -..." . . . I was "converted" by an anesthesiologist - then all the advances we made with our Performance Improvement Council were lost when he went to another institution......gotta change culture from the bottom up. . . ."<BR/><BR/>It is hard to change culture if the people on the front line don't buy into the process change. It is sometimes necessary to give them the option to "Buy in or bye out".Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-20656835231706694882009-02-12T20:02:00.000-05:002009-02-12T20:02:00.000-05:00Google is promoting the idea that making home ener...Google is promoting the idea that making home energy usage easily visible <A HREF="http://www.google.org/powermeter/smarterpower.html" REL="nofollow">leads to improvements</A>. It's a compelling argument, just as with software bug counts and hospital infection rates. What's needed is a commitment to improvement that outweighs complacency, inertia, and fear.Michaelhttps://www.blogger.com/profile/16985892327107710890noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-10110875135479673432009-02-12T16:26:00.000-05:002009-02-12T16:26:00.000-05:00Children's Hospital is Boston does show informatio...Children's Hospital is Boston does show information about CLI, albeit in a roundabout way.<BR/><BR/>I was waiting in a pre-surgery area with my son last week and noticed various Windows laptops displaying a series of pages. I went to look at them and one said something like "106 days and counting since last Central Line Infection. Congratulations to (some department)."<BR/><BR/>I think it's important to make this information as visible as possible. In software we've found displaying measured values (bug counts, for example) generally causes the value to improve.Bernardhttps://www.blogger.com/profile/14936264471078732019noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-91684023878619783562009-02-12T14:25:00.000-05:002009-02-12T14:25:00.000-05:00Paul, congratulations on the great progress BIDMC ...Paul, congratulations on the great progress BIDMC has made. If you are looking for allies in quality improvement and patient safety, what about students? Students who have not yet been indoctrinated in the current health care culture are just as outraged as you are by inaction and failure. So many of these previous comments have referred to resistance in the current culture. Well, here's your chance to transform the culture. Teach us about how to function in a culture of transparency. Teach us how to share results of progress and success across institutions. Teach us how to prevent avoidable deaths. We are listening and are ready to take action. How can we help?<BR/><BR/>- Eva<BR/>future med student, IHI, Special Assistant to CEO<BR/><A HREF="http://www.ihiopenschool.blogspot.com/" REL="nofollow">www.ihiopenschool.blogspot.com</A>Eva Luohttps://www.blogger.com/profile/03422162956290956079noreply@blogger.comtag:blogger.com,1999:blog-32053362.post-60798344617251542212009-02-12T12:01:00.000-05:002009-02-12T12:01:00.000-05:00Carl,I think this has less to do with the number o...Carl,<BR/><BR/>I think this has less to do with the number of staff than with how work is organized among the staff you have. See Steve Spear's comment above and other things he has written.<BR/><BR/>OMD,<BR/><BR/>Dunno. Beyond my knowledge. Others can comment.<BR/><BR/>Anon,<BR/><BR/>Well stated!Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-6419981486685184032009-02-12T11:59:00.000-05:002009-02-12T11:59:00.000-05:00I'm glad to see such spirited and open discussion....I'm glad to see such spirited and open discussion. As a vascular surgeon at a large community hospital which refers many patients to BIDMC, I appreciate Mr. Levy's proactive style.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-64982873477788074182009-02-12T11:55:00.000-05:002009-02-12T11:55:00.000-05:00Accelerated movement in quality improvement at BID...Accelerated movement in quality improvement at BIDMC includes full support by the governance culture. The Board strongly supports an environment where attention is driven toward positive variation, where innovation is rewarded, and challenges are on the table to be discussed collaboratively. Trust is driven by transparency, and visa versa.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-4903286796421352122009-02-12T11:21:00.000-05:002009-02-12T11:21:00.000-05:00I am just doubting this metric in particular. How ...I am just doubting this metric in particular. How about disease specific mortality - like that for sepsis corrected for apache?Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-64666648855828467542009-02-12T11:01:00.000-05:002009-02-12T11:01:00.000-05:00Paul,First off, I look forward to hearing you spea...Paul,<BR/><BR/>First off, I look forward to hearing you speack at ACHE's Congress. <BR/><BR/>Second,I am very impressed by your low rate of central line infections at your hospital. I do wonder, however, if this topic has anything to do with staffing resources. I have worked in a hospital setting for many years and have seen staff, very competent staff perform procedures quickly and sometime maybe not as careful as they should have. This was only because they needed to care for other patients, chart, etc. With healthcare cost above skyrocketing already and no end in site, at least for the near future, is this an unrealistic expectation of hospitals? Are we putting to much work load on great staff that we are causing burn out, shortages of nureses, doctors, tech, etc. Could this all be related in a big picture way of looking at healthcare today?Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-10439847853250499682009-02-12T10:58:00.000-05:002009-02-12T10:58:00.000-05:00Right, a blame-free environment is a prerequisite ...Right, a blame-free environment is a prerequisite to real success.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-25285093011893135962009-02-12T10:55:00.000-05:002009-02-12T10:55:00.000-05:00From someone on the tip of the spear, the change h...From someone on the tip of the spear, the change has to start in education and training. The culture has been, you make a mistake you get the rod from your superior because they know they will get it from theirs etc, etc. I'm speaking from a nursing viewpoint but have also seen it on the medical side.<BR/>I think this is why the whole Journey to Zero (or whatever your institution calls it)scares me; the stakes are high, the pressure is on-will the data be clean?<BR/>To make real improvements in healthcare we must remove the punitive response to reporting the truth.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-50699629183759526722009-02-12T10:35:00.000-05:002009-02-12T10:35:00.000-05:00Please! If you think another metric or set of met...Please! If you think another metric or set of metrics is better, propose it. Don't use the excuse of some amount of imprecision for a failure to track problems and success. That is a recipe for failure to act.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-19526652699726984222009-02-12T10:12:00.000-05:002009-02-12T10:12:00.000-05:00The problem is that these issues are much more com...The problem is that these issues are much more complex. Its hard to say that a certain mortality is attributable to central line infections as sicker patients get these infections and the mortality of not having a central line at the appropriate time because it are removed too soon for fear of line infections is also unclear. Just to post rate of line infections is simple but unclear if lower line infections is necessarily a good thing. Because JCAHO or medicare has chosen to follow these things is the "scientific" reason they have been followed. No one is tracking incidence of pneumothoraxes or other complications for lines that are removed too soon and then have to be replaced. By the same measure posting overall in-hospital mortality would also be a misleading fiure.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-32053362.post-18427752142341944652009-02-12T09:32:00.000-05:002009-02-12T09:32:00.000-05:00So is this world expert working with medical schoo...So is this world expert working with medical school deans to ensure such training becomes embedded in medical school curricula? This is the only way you are going to ultimately change culture and attitudes in the medical profession. Believe me, I was one of the ignorant ones, till I was "converted" by an anesthesiologist - then all the advances we made with our Performance Improvement Council were lost when he went to another institution......gotta change culture from the bottom up.<BR/><BR/>nonlocalAnonymousnoreply@blogger.com