One-Two-Many: A new way to count HAIs?

I’m reading a fascinating book by Daniel Everett, entitled, “Don’t Sleep, There are Snakes: Life and Language in the Amazonian Jungle”. I’m no linguist, but I enjoy his observations about how the development of language is informed by the needs of the culture—based upon his time living and working with the Pirahã people in the Amazon. One of his observations, also described by his colleague Peter Gordon in this Science article, has to do with the way the Pirahã “count” (or describe an amount) by using a “one-two-many” system. How is this relevant to hospital infection prevention, you ask? Well, as we adopt a new goal of zero HAIs, and as infection rates (and denominators) become much less important than whether an infection occurred or not, I wonder if we should simplify our surveillance by using a “zero-one-two-many” system to count HAIs….it sure would save a lot of time.

From those who brought you “getting to zero”

Here’s a comment that has received an unusually robust response on the Emerging Infections Network:

My hospital system plans to do blood cultures on all patients who are admitted with a central line in place (decision not yet final, but momentum is great). Such cultures would prevent mis-labeling of community-acquired infections as hospital-acquired, if infection actually happened to be present on admission and was not clinically suspected. This would allow upgrade of DRGs, to increase reimbursement, and would prevent a CLABSI from being labeled wrongly as hospital acquired. Our state has mandatory reporting and comparison of CLABSI for all hospitals and there is great pressure to reduce rates. I have great reservations about this practice, having seen this done before when blood contaminants stalled the entire purpose of the admission, adding to antibiotic use and length of stay. Does anyone else have opinions or experience with this practice?

So just to be clear: as a result of pressure to get their publicly reported rates of CLABSI to zero (and to maximize reimbursement), this hospital plans to obtain admission blood cultures on every patient with a central venous catheter. Not only will these non-indicated cultures drive up healthcare costs, they will result in untold days of unnecessary antibiotic use (for the blood culture contaminants that will greatly outnumber true pathogens), increase pressure for antimicrobial resistance, prolong hospital stays, and could result in potentially lethal adverse effects (drug reactions, C. difficile, etc.).

Happy Monday!

Bundle the baby

There's a new paper in Pediatrics that evaluates implementation of central line insertion and maintenance bundles across all referral NICUs (n=18) in New York state. Surveillance for infections followed NHSN methodology and evaluated a 12-month period prior to implementation of the bundles to a 10-month period after the bundles were implemented. Overall, there was a 40% reduction in CLABSI. Higher volume NICUs demonstrated lower infection rates and less variation in performance. For each standard deviation increase in maintenance checklist usage, there was a 16.5% decrease in CLABSI rate. However, the authors point out that "in light of some agencies’ considering CLABSIs to be “never events,” it is important to note that no NICU achieved an overall CLABSI rate of 0."

Targeting zero credibility?

I have written before about the unintended adverse consequences of an inability to be honest about HAI prevention, and Mike recently blogged about “aspirational goals” and reality. At the end of his post, Mike linked to an inspiring news story about the success being achieved at the City of Hope, among the sickest of patients. A telling quote from this piece demonstrates how “zero talk” can not only motivate, but also demoralize those who are on the front lines of infection prevention:

"It's tough, especially when there is a lot of literature out there that talks about zero infections….I think there should be zero infections. But not all health care-associated infections are preventable.”

As if on cue, I got an e-mail today from Bard Access Systems APIC, announcing the roll-out of a new website entitled, “I Believe in Zero CLABSIs”. Zero is no longer an “aspirational goal” for Bard Access Systems APIC, but a very concrete one:

“We not only believe in Zero CLABSIs — we know it is possible, and we are confident that the tools and resources contained on this website will provide you with the framework you need to help your facility BELIEVE and ACHIEVE ZERO CLABSIs.”

If APIC is unwilling or unable to speak honestly about HAIs, they will eventually lose credibility with their members who fight daily to prevent them. Furthermore, insisting that zero is already achievable weakens the rationale to perform the kind of groundbreaking translational research that is needed to push CLABSI rates ever closer to an irreducible minimum. Why investigate novel approaches to prevention if we already know how to eliminate every CLABSI?

Aspirational goals

There's a paper in the February issue of Infection Control and Hospital Epidemiology by a group of investigators at the University of Pennsylvania. They set out to perform a systematic review of the literature to determine the proportion of healthcare associated infections that are reasonably preventable. Their determination was that 65-70% of central line associated bloodstream infections and catheter-associated urinary tract infections were reasonably preventable, and that 55% of ventilator-associated pneumonia cases and surgical site infections were reasonably preventable. Quick, someone call APIC--they're still targeting zero! I know, I know: zero is an aspirational goal. And I'm still aspiring to be a professional football player.

Addendum, 1/23, 9:55 AM:  I just ran across this article published yesterday in a California newspaper. Now here's a piece that's apropos, and one that tries to tell the other side of the story.

DHHS releases 2010 Adverse Events in Hospitals report

The Department of Health and Human services just released an 81-page report titled: Adverse Events in Hospitals: National Incidence among Medicare Beneficiaries. Using a nationally representative random sample of 780 Medicare beneficiaries discharged in October 2008, physicians determined (1) whether an adverse event occurred, (2) whether the event was an NQF Serious Reportable Event or a Medicare hospital-acquired conditions, (3) what the level of harm was to the patient, and (4) whether the event was preventable.  Using this sample, they estimated that 13.5% of all hospitalized Medicare patients experienced an adverse event and in 1.5% the AE contributed to their deaths.  These extrapolate to 134,000 adverse events and 15,000 deaths in a single month. Multiply by 11.7498 (or 365.2425/31) if you want yearly estimates for an average year.  Yes, I'm being a smart a**, but multiplying by 12 is incorrect.

One thing we're always concerned about on this blog is the percent of HAIs that are actually preventable in the current 'get to zero' world that we live in.  In the DHHS report, physicians estimated that 44% of the AEs were preventable, 51% were not preventable and in 5% they were unsure.  The costs were $324 million in October 2008 or 3.5% of all hospitalization costs. They suggest that the FY2009 attributable costs of AEs were $4.4 billion, with two-thirds of the costs being associated with extended hospital stays.

So what about HAIs?  Table 3 in the report classifies the 128 AEs into categories and 19 or 15% of the AEs were HAIs.  Thus, 2.5% of all hospitalized Medicare patients had an HAI. There were 5 UTIs, 4 CLABSI, 4 other BSI, 4 RTIs and 2 SSIs.  The physicians classified only 60% of the infections as preventable.  I wonder if this will help Mike achieve one of his wishes for the 2010 New Year? I could probably dig deeper but I've got work to do and I don't want to ruin all of your fun.

Link: November 2010 DHHS Adverse Events in Hospitals report.

h/t: Megan McKenna

In it to win it

Good news going into the weekend: the CDC just declared Healthcare Associated Infections (HAIs) to be one of their first six “Winnable Battles”. They have coined this term to describe “public health priorities with large-scale impact on health and with known, effective strategies to intervene.”

I hope this leads to more resources—not just for implementation but for novel prevention research. As we’ve pointed out before, there is more than one view of what it means to “win” the war on HAIs. By one assessment, we already know how to prevent HAIs. All we need to do is implement this knowledge and such infections will drop to zero (and if they don’t, we can finesse the definitions until they do!). A more nuanced view is that our current prevention strategies are effective, but only against the subset of infections those strategies target. That is, there are still infections that cause harm and for which we do not currently have effective prevention strategies. These differences in perspective are also well illustrated by Mike’s earlier post on hospital epidemiology and quality improvement.

Where you fall on this continuum makes a big difference in terms of where you’d like to see more resources. Should they be devoted primarily to implementation of existing strategies (and to “implementation science”), or to research addressing novel approaches to infection prevention? (I realize that the correct answer is "both". But resources, sadly, are not infinite)

*motivational poster image courtesy of Despair, Inc.

The CDC has a brand new blog

And I like it! I especially enjoyed the post by our own Phil Polgreen, which features his iScrub application. Alex Kallen also has a nice recent post on prevention of CLABSI outside the ICU, which is a topic overdue for attention.

However, I did wince when I read about this event:

“I believe in zero CLABSIs!” shouted a group of 3,400 APIC Annual Conference attendees at the conclusion of patient-safety leader Dr. Peter Pronovost’s opening session.

Why does this make me uncomfortable? It isn’t because I haven’t bought into the power of CLABSI prevention efforts—we have units whose efforts have pushed CLABSI rates to zero for months at a time, and we celebrate that. I also think that most infection preventionists (IPs) understand the difference between a rah-rah, go-get-‘em, “aspirational” BHAG on one hand, and a realistic assessment of what is preventable on the other.

The problem is that many people don’t understand this difference. Among them are fellow healthcare workers, hospital administrators, reporters, the general public, third-party payers, and malpractice attorneys. To them, 3400 infection control experts witnessing to their belief in zero CLABSIs means that every CLABSI must be preventable, and therefore that every CLABSI represents an unconscionable breach of practice. We’ve blogged before about some of the potential unintended consequences of the “zero” paradigm. Fudged definitions, antibiotic overuse, pitched battles between unit personnel and IPs over every device-associated infection, and an atmosphere of blame and punishment, just to name a few.

The fact is that not every CLABSI is preventable. Most are, but not all. Even Peter Pronovost’s hospital's ICUs, though they have wonderfully low rates, still experience CLABSIs. If we follow perfect processes of care, we should be able to prevent those infections that arise from around the catheter insertion site, and those that are introduced exogenously. But what about those arising from gut translocation of bacteria in a critically ill patient? Even the most aggressive gut decontamination regimen (which will inevitably accelerate antimicrobial resistance rates) won’t be able to prevent organisms from gaining access to the catheter in this way.

We should be able to mobilize the troops to drive CLABSI rates to their irreducible minimum without setting unachievable goals. I do admit that “getting to zero” is a catchy phrase, though, and very well-suited to campaigning for lower infection rates. The theme I proposed for our latest CLABSI prevention campaign was roundly rejected….and I still don’t understand what was so wrong with: “Zero Is Great, But One Every Few Months Is Pretty Darn Good, Too”.

Pronovost on accountability

Peter Pronovost has a commentary in JAMA this week that is worth a read. Check out the whole thing, I'll post only one small paragraph here:

So who is accountable for reducing CLABSIs? Clinicians inserting and maintaining catheters must be accountable for performance, complying with evidence-based practices. Hospital leaders must be accountable for infection rates, monitoring rates, and supporting prevention initiatives. These mechanisms must be supplemented with the public reporting of valid infection rates, financial incentives from insurers, and when needed, sanctions from regulators. This pandemic of infections can be remedied and prevention of other types of preventable harm can be attempted if clinicians—physicians and nurses—work as a team.

My only comment: public reporting of valid infection rates...is much easier said than done, as we've discussed at length in prior blog posts. Meanwhile, the overzealous pursuit of zero perpetuates the daily battles being waged in some centers between infection preventionists (who are "calling" CLABSIs) and ICU clinicians and administrators (who are challenging these calls).

Did someone get fired for using NHSN or NNIS definitions to count CLABSIs?

Wow. I just read the second article that Mike posted Saturday out of the Chicago Tribune and I kinda wish I didn't. I'll paste the section that scared me a bit below, but it appears that someone might have been fired for "over-reporting HAIs", which is a bit scary to me. There is tremendous pressure to not call a BSI , a CLABSI, which I think is now part of the getting to zero culture. I wonder what percent of the way towards zero will be paved with these sorts of statements:

"Thorek's infection rate was the highest of all medical centers in Illinois. Frank Solare, Thorek's president and chief executive officer, said hospital officials have collected medical charts for the 22 infected patients and have "started an independent review … to try and understand this."

Asked why the Lakeview hospital didn't take action last year, Thorek's compliance officer Morgan Murphy said a former employee didn't alert senior management to the problem. "It wasn't making its way up the chain, unfortunately," he said.

Senior management also suspects that the employee may have counted central line infections incorrectly, inflating the hospital's numbers. "There may have been over-reporting," Murphy said."