Just before the long weekend, health providers heard some upbeat news, a fine respite from all the gloom about the sustainable growth rate and healthcare reform politics. In fact, infection control officials who attended a briefing almost sounded like they were attending a pep rally and not a press conference.
That's because it isn't every day that a federal agency can boast an 18% cut in dreaded CLABSI, or central line associated bloodstream infections, which occur an estimated 248,000 times each year in U.S. hospitals. These usually preventable infections cost the healthcare system $2.7 billion annually, and are said to be the cause of between 31,000 and 60,000 hospital deaths a year.
The good cheer was presented in the form of a document from the Centers for Disease Control and Prevention entitled the "First State-Specific Healthcare-Associated Infections Summary Data Report," an 18-page summary that examined the occurrence of these types of infections in hospitals during the first six months of 2009. What the project found was that there was a dramatic drop in CLABSI compared with the previous three years. The findings paralleled earlier reports, but included a much larger and more diverse sample of hospitals.
"We believe this decrease reflects broader implementation of CDC guidelines, enhanced tracking and measurement, and improved practices at the local level by thousands of dedicated healthcare professionals," said Arjun Srinivasan, MD, the CDC's associate director for Healthcare-Associated Infection Programs.
If there was a caveat about their sense of accomplishment, it was that the results were from a collection of data from just 17 states, which as of June 30, 2007 were the ones with laws requiring CLABSI reporting to the CDC's National Health Care Safety Network. About 10 more states have since enacted reporting mandates for these infections, but clearly what infection control leaders want is for all 50 states to have them in place. That's so they can have all the data to serve as a benchmark for future improvement.
This report included information from 1,538 facilities in those 17 states: Colorado, Connecticut, Delaware, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Oklahoma, Oregon, Pennsylvania, South Carolina, Tennessee, Vermont, Virginia and Washington. Only Tennessee and Maryland had infection ratios above expectations. Of the 15 states, 13 had fewer than expected instances and two had rates as expected. All rates were calculated based on a rate per 1,000 line days.
According to a table in the report, states that did not have reporting requirements had some hospitals that did report to the network, but in none of those non-reporting states was the number of reporting hospitals more than half. That will have to rapidly change, the researchers say.
One of the speakers at the briefing was Peter Pronovost, MD, an intensivist at Johns Hopkins University whose simple infection control "checklist" has been credited with getting many of those states' infection rates to drop. In fact, surgeon Atul Gawande reportedly credited Pronovost with "saving more lives than that of any laboratory scientist in the past decade."
The report "marks a turning point in transparency and accountability for healthcare," Pronovost said. "We now must begin to be responsible for our outcomes and no doubt these data will make some uncomfortable. We need to learn how to be accountable; to make progress we will need to collaborate and (be) coordinated."
"Central line associated bloodstream infections are the polio campaign for the 21st century," he added.
Pronovost, director of the division of adult critical care medicine at Johns Hopkins and medical director of the Center for Innovations in Quality Patient Care, pointed to the tremendous success he and infection control officials at Johns Hopkins University and at 100 intensive care units in Michigan were able to achieve by following these five steps.
- Remove unnecessary lines.
- Wash hands prior to procedure.
- Use maximal barrier precautions.
- Clean skin with chlorhexidine.
- Avoid femoral lines.
He added that a key element to make that checklist work is that hospitals must "empower nurses to sop the placement of a catheter if the physicians don't comply with the checklist.
"Working together, following this checklist, we can substantially reduce these infections. We've seen what is possible. We have prevented infections and we've saved lives," Pronovost said. "Now we must spread it across our great country and now we must begin to be accountable for our outcomes."
That may seem uncharacteristically cheerleader-like for a physician scientist, but CDC officials said that hospitals are going to have to get used to this kind of reporting. In future reports, CLABSI statistics will be augmented by detailed reports that include surgical site infections and catheter-associated urinary tract infections.
But while the report was touted as a turning point for transparency and accountability, it does not list hospital-specific infection rates, an omission that a reporter for the Associated Press put in the form of a question. "I'm thinking many readers would think of transparent as naming the hospital so they can hospital shop, so to speak," the reporter said.
Another speaker at the press conference, Rachel Stricof, director of the New York State's Bureau of Healthcare Associated Infections, which does publish hospital-specific infection rates, replied, "I believe only a handful of the states thus far have published their rates, but you will see more and more doing so as we collect a sufficient amount of data to make the information reliable."
In an e-mail to me yesterday, Pronovost wrote, "There is legitimate uncertainty about how to measure many types of harm and the extent to which they can be prevented. (But) a notable exception is CLABSI. It can be accurately measured and almost always prevented. As such it has become the test case for learning how to be accountable for outcomes."
Pronovost wrote that healthcare right now "needs a success story for quality and safety. And I believe CLABSI will be that story. Once we reduce these rates nationally, we can take what we learned about how to collaborate and apply it to the next type of preventable harm, such as ventilator associated pneumonia."
That sounds like a challenge that's worthy of a pep rally any day.
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