Tuesday, March 13, 2012

Stop smiling. It is not good enough.

Ok, call me a sourpuss, or call me a contrarian, but I am put off by the self-satisfaction evident in this graphic in the Boston Globe.  To be fair to the newspaper, its coverage reflects how the story about a reduction in the rate of central line infections was reported by the state Department of Public Health's Bureau of Health Care Quality and Safety.  That report presents data for the period July 1, 2009 through June 30, 2011.

The good news is that the rate of such infections dropped by 24% during that period.  The bad news is inherent in this description:

Central Line Associated Blood Stream Infections (CLABSIs): A central venous catheter (CVC), sometimes known as a central line, is a special type of flexible tube that is placed through the skin into a large vein in a patient’s chest, arm, neck or groin and ends in or close to the heart or one of the major blood vessels. . . . While central venous catheters are considered an essential part of providing critical care, their use also places patients at increased risk for infection. Central line associated blood stream infections (CLABSIs) are serious, costly, and most can be prevented by following accepted practices for inserting and caring for central lines (my emphasis).

A rate of one infection per thousand patient days, while a reduction from the previous period, is not equivalent to "most can be prevented."  According to the story, that rate of infection still represents about 200 cases annually in the state. This article from the Centers for Disease Control attributes a mortality rate of 12 to 25 percent for each infection.  So 200 cases of infections means that somewhere between 24 and 50 people died unnecessarily.  These people are anonymous in the state's report, but every one is someone's mother, father, sister, or brother.

The infuriating aspect of the Globe's chart is the inclusion of a so-called national baseline rate based on data from 2006-2008.  This was clearly prompted by the DPH report saying things like:

All ICU types has standardized infection ratios (SIRs) that were statistically significantly the same or lower than predicted when compared with both state baseline and national rates.

That kind of analysis has no probative value with regard to anything.  We might as well have said that a child's ability to do calculus increases by 100% between 3rd grade and high school -- such was the state of national medical attention to central line infections during the period in which the baseline rates were calculated.

There were a very few exceptions back in the early years of this century.  In January of 2011, it was reported that Peter Pronovost and his colleagues:

developed the checklist nine years ago (my emphasis), along with a training program that attempts to change the culture in hospitals so staff will speak up if patient-safety rules aren't being followed. The checklist ticks off five basic precautions, such as washing hands, to prevent the spread of germs.

The program got its first widespread tryout in Michigan, where Pronovost said 70 percent of the state's hospitals put it into practice starting in 2004.

"Prior to our study, the mortality rates in Michigan and surrounding states were quite similar," the researcher said. Those death rates diverged once Michigan hospitals began using the prevention program.

"It's breathtaking," Pronovost said. "With our program, patients are alive who wouldn't be if they were outside Michigan."

While Peter and his colleagues worked, most hospitals slept easily with the thought that these things happen.  Perhaps they were motivated by the complacency of  knowing that deaths from central line infections were not even considered reportable adverse events.  More likely, they were just doing things by habit.  A doctor once told me, "As residents, we didn't even bother putting on gloves during those procedures.  We did as we were taught by the previous class of residents."

As I have noted, too, such benchmarks are useless as tools in encouraging process improvement.   Catherine Carson, Director, Quality & Patient Safety at Daughters of Charity Health System put it well:

When the goal is zero – as in zero hospital-acquired infections, or falls – why seek a benchmark? A benchmark would then send the message  - that in comparison to X, our current performance level is okay, which is a false message when the goal of harm is zero.  So be careful when reporting benchmarks, because you are sending a message of acceptable performance.

I know that I should praise the Massachusetts hospitals for their progress in this arena.  After all, less is better, and they do deserve credit for making the effort.  But, don't give kudos for beating a standard that is not a standard.   Let's not forget that the only intellectually defensible target in this arena is zero.


Anonymous said...

Pronovost's work is the standard now, and not anything else. Until others can meet that standard, which was proven in a real-life environment in multiple different hospitals, no one should be smiling. Thanks for continuing to hold people's feet to the fire on this, Paul. Until others are radicalized by these deaths as you are, their smiles are hollow and self-congratulatory.

Anonymous said...

I work at a mid-sized hospital. Those of us who work in the ICUs internally agreed to set the goal for our central line infection rate to zero even though our board/CEO set it at 20% lower each year once we got below the "national benchmark." And we have been at zero for over 2 years in one of our units, and over 1 year in the other.

But it did take even me a while to believe zero was possible. Before Pronovost published his Michigan work I figured those hospitals with no infections were gaming the numbers. That's why that paper was so important. Michigan showed us that real hospitals can really do this. Not single sites, not just fancy AMCs, not small centers that refer out sick people before an infection could be counted.

Susan Shaw said...

Frustration is warranted.  Zero is the only acceptable target, especially once you grasp the fact that any rate above zero equals real patients suffering real deaths.  (That's a downside of using rates. Numbers and ratios disconnect us from the reality that these are real live people who we harm).

We also set our only acceptable goal for cental line associated infectios at zero. Once this was our target, we shifted from being compliant with our central line bundle to being fully committed to the goal of zero. And I am extremely proud that our results demonstrate our commitment: no central line infections within our three ICUs for a year (over two years in two of them!)

What is more important than the implementation of the bundle and checklist is the culture within the ICUs. You need to create an ICU environment where nurses truly felt empowered, safe and comfortable stopping a doctor to remind them to scrub their hands or interrupt the doctor if a break in sterile technique occurred. A big part of this work needs to focus on the behaviours and responses of the doctors! Thats where the coaching and leadership comes in.

Success in this work requires commitment and leadership from all levels. We all need to stop saying that most infections can be prevented, ALL these infections can be prevented.

So keep being a sourpuss. Push us to be better than we already are. D