BY MICHAEL MILLENSON
There’s an infection that afflicts thousands of Americans yearly, killing an estimated one in five of those who contract it, and costs tens of thousands of dollars per person to treat. Though there’s a proven way to dramatically reduce or even eliminate it, the Centers for Disease Control and Prevention (CDC) inexplicably seems in no hurry to do so.
Unlike Ebola, this infection isn’t transmitted from person to person, with the health care system desperately racing to keep up. Instead, it’s caused by the health care system when clinicians don’t follow established anti-infection protocols – very much like what happened when Texas Health Presbyterian Hospital encountered its first Ebola patient. That hospital’s failure flashes a warning sign to all of us.
The culprit in this case is called CLABSI, short for “central-line associated bloodstream infection.” A central line is a catheter placed into a patient’s torso to make it easier to infuse critical medications or draw blood. Because the lines are inserted deep into patients already weakened by illness, an infection can be catastrophic.
CLABSIs are deadlier than typhoid fever or malaria. Last year alone they affected more than 10,000 adults, according to hospital reports to the CDC, and nearly 1,700 children, according to an analysis of hospital discharge records. The infections also cost an average of nearly $46,000 per patient to treat, adding up to billions of dollars yearly.
At one time, CLABSIs were thought to be largely unavoidable. But in 2001, Dr. Peter Pronovost, a critical care medicine specialist at Johns Hopkins, simplified existing guidelines into an easy five-step checklist with items like “wash hands” and “clean patient’s skin with an antibacterial agent.” Hopkins’ CLABSI rate plunged.
In a pilot project testing this approach with 103 Michigan hospitals, the average hospital intensive care unit (ICU) decreased its bloodstream infection rate to zero within 18 months, saving more than 1,500 lives and nearly $200 million. The results appeared in the New England Journal of Medicine in 2006 and were later celebrated by Dr. Atul Gawande in The New Yorker and in his best-seller, The Checklist Manifesto. In 2008, the Agency for Healthcare Research and Quality (AHRQ) funded an ambitious partnership with state hospital associations to eliminate CLABSIs altogether.
So why are thousands still being infected?
The best explanation, albeit an uncomfortable one, is “out of sight, out of mind.” Unlike Ebola, bloodstream infections don’t threaten anyone in the grocery store, office or next seat on the airplane. Nor, unlike HIV, is there a risk that a doctor or nurse coming in contact with the patient’s bodily fluids could sicken or die. As a result, it’s easy for clinicians to convince themselves they’re doing a good job of infection control. That can lead to relaxed standards and a slow reaction to evidence of harm.
Look again at Texas Health Presbyterian Hospital. In 2011, the hospital noticed a spike in its bloodstream infections. Correcting the problem came down to ensuring a few simple actions, according to a research paper the hospital presented at an infection-control meeting earlier this year. That’s the good news. The bad news is that like with many other hospitals, the process took a very long time to implement. Even so, the hospital was still in the CDC’s good graces, because its infection rate was below the national benchmark.
In 2009, the CDC gave hospitals until 2015 to reduce their “standardized infection ratio” by 60 percent from a national baseline period of 2006-2008. Despite the swift decline in infections shown by hospitals that were part of the AHRQ effort over a matter of months, the CDC gave hospitals years to improve and even then refused to set zero patient harm as a goal.
Earlier this year, the agency raised the bar, asking hospitals to reduce bloodstream infections to half the January 2015 level. But it extended the timeline all the way to 2020, or 14 years after Pronovost’s New England Journal article.
An analysis I and colleagues did of the CDC’s own data emphasizes how generous that timeline is. During fiscal 2013, nearly 1,200 hospitals, or 42 percent of facilities treating adults and reporting to the CDC, had no CLABSIs at all.
Unfortunately, it’s difficult for patients to tell which hospitals are the most rigorous about preventing what are euphemistically called “hospital-acquired conditions.” Though many hospitals report bloodstream infections monthly to the CDC, public information is available only yearly – and the number of patients dying isn’t reported at all!
Doctors Without Borders may be better at infection control than high-tech U.S. hospitals (Photo credit: Wikipedia)
There are valid clinical reasons why standard prevention measures can sometimes fail, and maintaining a zero CLABSI rate can be difficult. Still, a physician at a neonatal ICU recently related to me how she’d kept her unit free of CLABSIs for two years and they’re aiming for three.
Did laxity by the CDC in fighting an infection that is caused by hospitals leave the door open to hospital infection-control lapses that have hurt the Ebola fight? The fact is that protecting the sickest and most vulnerable patients requires hospital staff to exhibit the discipline of a high-reliability organization. It requires culture change and consistency. The same behavior is needed to stop the spread of Ebola. As a BBC commentary recently pointed out,Médecins Sans Frontières (Doctors Without Borders) has treated thousands of Ebola patients in Africa with just 16 medical workers contracting the disease, while Texas Presbyterian treated one patient and already has two sick nurses and 80 workers under observation.
By failing for years to demand that hospitals adopt high-reliability behaviors when it comes to hospital-caused infections, the CDC may have inadvertently left all of us vulnerable.
Michael Millenson is a contributing editor with THCB and a principal with Health Quality Advisors.
As for the demand, note that I said a voluntary goal should be zero. That’s different than a government mandate. Having said that, government has a role to play when industry (any industry) fails to take action to protect the public. So, for instance, it’s why there are regulations on how long truckers can drive and airline pilots can fly.
In this case, I think transparency of infection data to the public and private payers being more aggressive would work wonders without regulatory action.
Everyone has two doctors: his own and his own body. The bod is fightibg stuff every day that we don’t see. It is constantly beating back infections that accordongly never take off. It is taking on neoplastic mutations and eliminating these cells by cytotoxic T cells and complement. It is down-regulating autoimmunity situations and upregulating immune cytokines and T cells. It is pouring out iron containing molecules that bind with oxygen and CO2. It is reabsorbing and excreting and secreting a bunch of electrolytes and waste products that keep us in balance with the proper chemistry of life.
It is not exactly what we do that keeps folks healthy. It is what both of the above doctors are doing.
As an example, I have noticed that many seniors on admission to the hospial have low pre-albumon and albumin, suggesting that they have protein malnutrition. Proteins make all the tools we need: the enzymes, the membranes, the organelles….the pliers and screwdrivers and wrenches of life. You are not going to help a CLABSI by attacking it in this theater of war.
Every doc has a partner in this business and his partner needs to be as fit as he is.
Best comment I have read in weeks on THCB. Thanks, WP.
“By failing for years to demand that hospitals adopt high-reliability behaviors when it comes to hospital-caused infections, the CDC may have inadvertently left all of us vulnerable.”
Just wondering where that “demand” power would come from? Too aggressive regulations will bring out the government overstep police and the cries of big government is ruining our lives.
Since Booby put up that hearsay article, I guess it is fair game. There are many missteps. Is it not shocking that something as simple and cheap as good technique and maintenance of central lines would trump the $$$ billions going to the HIT vendors whose devices serve as impediments to safety.
I can easily fathom the scenario of doctors who have to click in the order for a central line in order to obtain it and then be so time pressured that they cut corners on CVP line implant technique.
The problems in hospital safety are not isolated to the specific event, but are commonly due to infrastructure dysfunction and its adverse impact on the health care professionals.
The number one culprit nowadays is the EHR, and that Sittig et al paper fails in its attempt to exonerate the EHR and the industry that built it.
“Did laxity by the CDC in fighting an infection that is caused by hospitals leave the door open to hospital infection-control lapses that have hurt the Ebola fight? The fact is that protecting the sickest and most vulnerable patients requires hospital staff to exhibit the discipline of a high-reliability organization. It requires culture change and consistency. The same behavior is needed to stop the spread of Ebola.”
My Adobe Acrobat highlighter review of a new open paper on the Dallas “pt zero” mis-dx: