Getting to Zero...
I’m in Minneapolis today to give a talk to the North Central Chapter of the Infectious Diseases Society of America on Getting to Zero. I spoke on the topic at SHEA’s annual meeting last year, and although the talk was well received it was deemed controversial. After all, how could anyone be against Getting to Zero healthcare associated infections?
Well, having practiced as an infectious diseases physician for nearly 20 years, it seems obvious to me that the elimination of healthcare associated infections is not in the realm of possibility. As I make rounds in an academic medical center, the patients I see are ever more critically ill. For many of the patients in the ICU, we have bypassed nearly every natural barrier to infection for prolonged periods of time. More of our therapies involve high levels of immunosuppression. Despite our best efforts at reducing environmental contamination, any space where humans are found will be inhabited with the organisms that live on and in us. Thus, my biggest problem with the GTZ concept is that I believe that it’s inherently dishonest, and the dishonesty is unfair to patients and their families. It implies that HAIs can be completely eliminated (doesn’t zero mean no infections?).
APIC is now developing a series of HAI elimination guides. This sets up its members in hospitals across the country for failure and places them under enormous pressure from administrators when zero remains elusive. The end result is that when an infection occurs, there is the implication that someone must be at fault. It creates a culture of blame. And it sets the stage for more legislation. I think APIC's perseveration on the zero concept demonstrates what I have suspected for quite some time based on my feedback from many APIC members—there’s a real disconnect between frontline ICPs and APIC leadership. Just this week I was invited to give my GTZ talk at another regional APIC chapter and we have received many positive comments about this blog from APIC members.
I am not arguing that we can’t improve our infection rates. Peter Pronovost’s group shattered the glass floor, showing us how low bloodstream infection rates could be driven when the process of central line insertion is highly standardized. I used to believe that only a minority of HAIs were preventable; now I believe that most can be prevented. But there’s a big difference between most and all. Importantly, Pronovost’s group did it the right way—they conducted good studies and published their results in the peer reviewed literature. They didn’t view their work as a product to market and sell.
The medical ICU in my hospital has not had a case of ventilator associated pneumonia for the past 15 months. I’m enormously proud of that unit and the wonderful people who work there, but we’re not having a zero celebration and believe me, we haven’t eliminated VAP. Zero is ephemeral because in the race between man and microbes, the bugs usually win. They were here long before us, and no doubt will be here after we're long gone.
Well, having practiced as an infectious diseases physician for nearly 20 years, it seems obvious to me that the elimination of healthcare associated infections is not in the realm of possibility. As I make rounds in an academic medical center, the patients I see are ever more critically ill. For many of the patients in the ICU, we have bypassed nearly every natural barrier to infection for prolonged periods of time. More of our therapies involve high levels of immunosuppression. Despite our best efforts at reducing environmental contamination, any space where humans are found will be inhabited with the organisms that live on and in us. Thus, my biggest problem with the GTZ concept is that I believe that it’s inherently dishonest, and the dishonesty is unfair to patients and their families. It implies that HAIs can be completely eliminated (doesn’t zero mean no infections?).
APIC is now developing a series of HAI elimination guides. This sets up its members in hospitals across the country for failure and places them under enormous pressure from administrators when zero remains elusive. The end result is that when an infection occurs, there is the implication that someone must be at fault. It creates a culture of blame. And it sets the stage for more legislation. I think APIC's perseveration on the zero concept demonstrates what I have suspected for quite some time based on my feedback from many APIC members—there’s a real disconnect between frontline ICPs and APIC leadership. Just this week I was invited to give my GTZ talk at another regional APIC chapter and we have received many positive comments about this blog from APIC members.
I am not arguing that we can’t improve our infection rates. Peter Pronovost’s group shattered the glass floor, showing us how low bloodstream infection rates could be driven when the process of central line insertion is highly standardized. I used to believe that only a minority of HAIs were preventable; now I believe that most can be prevented. But there’s a big difference between most and all. Importantly, Pronovost’s group did it the right way—they conducted good studies and published their results in the peer reviewed literature. They didn’t view their work as a product to market and sell.
The medical ICU in my hospital has not had a case of ventilator associated pneumonia for the past 15 months. I’m enormously proud of that unit and the wonderful people who work there, but we’re not having a zero celebration and believe me, we haven’t eliminated VAP. Zero is ephemeral because in the race between man and microbes, the bugs usually win. They were here long before us, and no doubt will be here after we're long gone.
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