Wednesday, February 13, 2013

Not so fast

I have been flooded with emails from people sending me the link to the newest report from the Centers for Disease Control about the "dramatic" reductions in CLABSIs:  "A 41 percent reduction in central line-associated bloodstream infections since 2008, up from the 32 percent reduction reported in 2010."

The CDC reminds us:

A central line is a tube that is placed in a large vein of a patient's neck or chest to give important medical treatment. When not put in correctly or kept clean, central lines can become a freeway for germs to enter the body and cause serious bloodstream infections. CDC estimates that 12,400 central line-associated bloodstream infections occurred in 2011, costing one payer, the Centers for Medicare & Medicaid Services (CMS), approximately $26,000 per infection.

Not to mention killing people unnecessarily.

I say without hesitation that this is not good enough. First, the CDC insists on using flawed standardized infection ratiosPer the CDC, "the SIR is a summary measure used to track healthcare-associated infections over time. It adjusts for the fact that each healthcare facility treats different types of patients. The SIR compares the number of infections reported to NHSN in 2011 to the number of infections that would be predicted based on national, historical baseline data."

"The predicted number is an estimated number of HAIs based on infections reported to NHSN during January 2006–December 2008."

In other words, a period of time during which most hospitals were doing very, very little to prevent infections.

There is no virtue in benchmarking yourself to a substandard norm. As noted by Catherine Carson, Director, Quality & Patient Safety at Daughters of Charity Health System: 

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.

Second, whatever metric you choose, the overall progress is just too slow.  In terms of protocols and training and auditing, we know what it takes to avoid CLABSIs.  For details, call Peter Pronovost.  This is not a technical problem:  It is a problem of leadership. It takes clinical leadership, administrative leadership, and supportive governance to make it happen.  At least one of these ingredients is missing in too many hospitals.

1 comment:

Unknown said...

Our experience dates back 37 years. I put ALL our central lines in myself, often 5-6 per week. We had a specific procedure for removing lines, and culturing all potential sites of infection in the event of fever.

Our infection rate for central catheters was 3%. The only deaths were attributed to prolonged neutropenia and disease progression (Usually AML and aggressive lymphoma.)

As I review the CDC numbers, I see extensive "lumping" of patient categories, potentially biased separation of hospital size and academic affiliation, and no identification of underlying disorder or ongoing disease state. Who put the lines in? Who cared for them? Was care appropriate?

It seems inadequate to suggest that all these variables will simply "come out in the wash."

The parallel with air safety is interesting in that precipitating events in 1945 were totally unknown. Consequently, a comparison to events in 2011 is no comparison at all. Ditto central lines.