Tuesday, January 25, 2011

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?


  1. What I would tell people when I worked on the VA's "Ensuring Correct Surgery" Directive 8 years ago or so, which was a sort of precursor to the JC's policy, was that a wrong surgery should be like a plane crash. It should be a sort of a one in a million thing, not a one in 20 or 30,000 thing. For VA this would be on average every 2-3 years instead of on average every month. For CLABSI, one in a million is obviously impossible but it seems that the VA rate has gone from around 5 per 1000 line days to 1.25 per 1000. Maybe 0.5 per 1000 systemwide is possible? Have you guys commented yet on all the data that VA has recently put on-line yet? It's amazing: http://www.hospitalcompare.va.gov/aspire/index.asp.
    It even includes staff satisfaction with leadership at the VAMC level. Pretty gutsy to post it all...

  2. Thanks! I agree that we should post more about the VA--maybe as Eli becomes more ensconced, he will! I was our VA hospital epidemiologist for 10 years, and have been impressed for some time with their commitment to patient safety.

    Regarding your first point, I think there are some important differences between wrong site surgery and CLABSI (because I agree that wrong site surgery should be a "never event"). For one thing, the definitions for CLABSI are flawed, ensuring that even those centers that are "perfect" in their application of the CLABSI bundle will see patients who meet the definition. Second, there are some mechanisms for CLABSI that are not preventable at this time, a major one being translocation of gut bacteria to the bloodstream, seeding the catheter. No amount of attention to the CLABSI bundle will prevent that from happening.

  3. I agree that the notion that "Getting to Zero" is an achievable and reasonable goal has unintended consequences--included those cited in your blog. Unintended consequences not cited include:
    1)--Motivation for overt "cheating" by some individual and institutions (ie failing to report cases of CLABSI. I am not pointing fingers at any one person or institution but I suspect that cheating is occurring to some degree in some institutions
    2) Motivation to NOT get cultures from patients with central lines and catheters because a positive culture would have adverse consequences to unit leadership/physicians. Lack of a positive culture may mean that it is impossible to prove a CLABSI occurred but it could obviously adversely affect treatment decisions and outcomes
    3) Presuming that a bacteremic patient had a CLABSI simply because it met an administrative/bureacratically derived definition may lull some doctors from considering or recognizing that the real source of the blood stream infection was elsewhere. This recently occurred at one of our hospitals. The source of this patient's MRSA bacteremia was correctly assessed as an infected defibrillator months after the case was reported to NHSN as a CLABSI.
    4) Wise and practical clinicians know that Getting to Zero as a concept is pure folly. As a result some of them may be tempted to think that hospital epidemiologists (even those who don't subscribe to this theory) are hopeless impractical dreamers. Specifically, the more widespread the notion of getting to zero becomes, the more likely that all hospital epidemiologists will be considered to be foolish..
    5) God only knows how many lawsuits have or eventually will be filed against hospitals until this concept is officially put out to pasture.

  4. I agree on all counts! Thanks for adding to our ever-expanding list of unintended adverse consequences of the zero obsession.

  5. Did you guys see what the American Hospital Association is endorsing. Stepwise progress to a goal that is low but not zero. Seems to make sense?
    "The AHA commits to helping hospitals reduce central line-associated bloodstream infections, with the long-term goal of zero, by reducing infections to less than 1.5 per 1,000 in 2011; less than 1 per 1,000 in 2012; and less than 0.5 per 1,000 in 2013 (2010 baseline is 2 per 1,000 central line days)."
    See full text at: http://www.ahanews.com/ahanews_app/jsp/display.jsp?dcrpath=AHANEWS/AHANewsArticle/data/AHA_News_012411_strategic&domain=AHANEWS