January 10, 2011
A Magic Bullet To Reduce Hospital-Acquired Infections–Or Is It?
By Michael D. Shaw
Despite constant improvements in health care technology, between five and ten percent of all patients contract at least one hospital-acquired infection (HAI) during their stay in an acute care hospital. HAIs are also known as health care-associated infections and nosocomial infections. The media is full of stories describing patients entering the hospital for a “routine” procedure, only to die of an HAI.
The most frequently cited report on HAIs, entitled “Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002” was published in 2007. It pegged the estimated number of HAIs in U.S. hospitals—adjusted to include federal facilities—at approximately 1.7 million, with deaths estimated at 98,987.
In light of these staggering figures, many consumer groups, including the venerable Consumers Union, have advocated some sort of mandatory reporting system, whereby hospitals would divulge their infection rates. Provisions requiring such reporting are now part of the new Patient Protection and Affordable Care Act (Obamacare).
This sounds great until you realize that the lion’s share of reporting is generated by the hospitals themselves, and is neither audited nor verified by an independent third party. Critics have compared this to a student writing out his own school report card, and handing it over to his parents. Moreover, such reporting does not include, nor is it required to include, all HAIs. Rather, it focuses mainly on those infections that tend to occur in intensive care units.
The bellwether type of infection chosen for reporting is the so-called Central Line-Associated Bloodstream Infection (CLABSI). As infection control guru Lawrence Muscarella, PhD explains:
Central venous catheters, or simply central lines, are long, narrow intravascular catheters (tubes) that are inserted into one of the patient’s large peripheral veins, typically terminating at or near the heart, or in one of the body’s great vessels (e.g., the superior vena cava). They are used to deliver medications, fluids, and nutrition to critically ill patients.
Inasmuch as CLABSIs will occur in very sick patients, they are far more likely to be quite serious, and if prevented, there is an immediate positive benefit. The theory—largely untested—is that the way a hospital handles CLABSIs is indicative of how it would handle all types of HAIs.
The magic bullet promised in the title of this piece is a remarkably simple checklist introduced by Peter J. Pronovost, MD, PhD—an intensive care specialist physician at Johns Hopkins Hospital in Baltimore, Maryland. His five-item checklist protocol applies to the insertion of central venous catheters…
- Wash their hands with soap.
- Clean the patient’s skin with chlorhexidine antiseptic.
- Put sterile drapes over the entire patient.
- Wear a sterile mask, hat, gown and gloves.
- Put a sterile dressing over the catheter site.
Phenomenal improvement in infection rates has been reported in virtually all facilities that have instituted Pronovost’s protocol, and numerous honors have been bestowed on him, including being named one of the world’s most influential people in 2008 by Time magazine. Certainly, the title of his book, published in February, 2010 betrays no false modesty: Safe Patients, Smart Hospitals—How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out.
Much of the hospital industry—and the media—is all too willing to accept Pronovost’s magic bullet. Allow me to raise a few questions.
As stated earlier, nearly all the infection data is unvalidated, unaudited, and is reported by the hospitals themselves. In addition, the reported improvement in infection rates is subject to a host of confounding factors.
Consider that when a drug is being evaluated, a double-blind study is always used, whereby neither the patient nor the person dispensing the medication knows if it is the test drug or a placebo. If this were not done, the well-known “placebo effect” could occur whereby the patient thinks he is getting the therapeutic drug, and therefore will automatically feel better, or at least claim to feel better.
Apparently, in all cases when Pronovost’s magic bullet is being evaluated, everyone involved already knows that a highly-touted program is underway, which is sure to dramatically reduce the infection rates.
Perhaps, the hospital will endeavor to assign more experienced personnel to deal with the central lines. Perhaps doctors will overly prescribe prophylactic antibiotics, to help ensure a lower infection rate. Perhaps the hospital will be more “judicious” in reporting infections, so that one that might properly be associated with the central line, is now described as occurring because of skin contamination, for example.
Notwithstanding these confounding factors, if Pronovost’s checklist works and causes great improvement in infection rates, clearly, the hospital has been deficient in one or more of the five items he stresses. Yet, each and every one of those items is nothing less than basic standard of care. Are these “improved” hospitals admitting that previously they were drastically substandard? Would that not open them up to lawsuits?
Finally, the mere existence of the checklist does not prove that it is actually being adhered to. Thus, only a controlled and third-party validated blinded study, which also audits adherence to Pronovost’s checklist, would prove that it works.
Until such a study appears, his magic bullet is little more than voodoo, and its widespread acceptance is troubling, to say the least.