Sunday, April 22, 2012

CDC "shameful and unethical"???

I'm heading to Delaware in a few weeks to speak at an Infectious Diseases symposium. My assignment is to talk about myths and controversies in infection prevention. It's a juicy topic, and one that I find fascinating. So once again I'll be speaking on "Getting to Zero," a myth so big it rivals the Tooth Fairy. We've blogged about it many times, with Eli recently attributing the death of Facts to be partly due to this big lie.

There are a couple of interesting recent developments on the GTZ front. First, one of the biggest promoters of the concept, APIC, appears to have expunged it from its website. Good thing I made screenshots of the old website for posterity's sake! Secondly, Paul Levy, a former hospital administrator, who writes the blog Not Running a Hospital, devoted a posting to GTZ yesterday. The title of the post is "Unethical and Shameful Behavior at the CDC." He blasts CDC and its director, Tom Frieden, for the use of the standardized infection ratio (a "meaningless methodology"), risk adjustment (he questions why medical school affiliation should impact infection rates), and the use of benchmarks (since zero is the goal). Unethical and shameful? Really?

The concept of Getting to Zero HAIs is at least 5 years old, and I find it amazing that I have yet to meet an infectious diseases physician (you know, those people that every day actually take care of patients with infections) who believes that HAI rates can be reduced to zero. Those of us in the reality-based community understand that when you immunosuppress patients as profoundly as we do, and use ever more invasive devices for ever longer durations of time, believing in Getting to Zero requires ingesting an awful lot of kool-aid. We certainly have to keep trying our best to reduce infections, but we also have to recognize that the advances in medicine are double-edged swords, and honesty requires that we acknowledge that infections will continue to occur despite our best efforts.

So kudos to APIC for moving on, and to CDC for the great work it does with not nearly enough resources. 

Graphic: Jeffrey Sumber


  1. "Getting Zero" is a nice wish, but I'll have to agree that currently it doesn't seem within the realm of possibilities.

  2. I see no problem with zero as an aspirational goal. What else are you going to use - 10% reduction? 20%? Any number would be just a wild guess, wouldn't it. And, oddly, there are a number of places who have actually achieved zero for a substantial length of time. What are you going to say to them? Quibble with their numbers? Deride them for trying? Tell them it won't last! To what end?
    What is the obsession with proving zero can't be reached, anyway? Have you actually tried to reach zero in your hospital, with what results? These posts sound more like someone defending the status quo than someone trying to improve.

  3. Thanks for your comments. Neither Dan nor I are currently practicing hospital epidemiologists (so have nothing to hide). Having seen Mike's annual report from his hospital, I can honestly say that he has the most impressive infection prevention program in existence. That's one of the main reasons why I joined this blog. The problem with the "zero" aspiration goal is that it has become a mandate and is associated with significant unintended consequences. Also, it's unclear if we should be setting goals based on unattainable benchmarks. It's not enough to reference anecdotal reports and claim that they are generalizable; at least not in an epidemiological sense.

  4. Eli,

    I have never seen zero used as a mandate. I have only seen it used by the clinical leaders at hospitals as an inspirational goal.

    I think you confuse epidemiological science with management and leadership. As Beverly notes above, if the concern in a hospital is elimination of preventable harm, there is no intellectually defensible target other than zero. In my former hospital and others (check the work of Peter Pronovost and others), the medical staff viewed zero as an aspirational target. They faced no incentives or penalties, other than a professional desire to reduce harm to their patients and hold themselves accountablity to the standard of care in which they believed. The redesign of work was done with good will, humor, and humility.

  5. Paul,
    I hope Mike responds further since it was his post.

    My comment was directed at Beverly's assertion: "Have you actually tried to reach zero in your hospital, with what results? These posts sound more like someone defending the status quo than someone trying to improve", which in some way highlights the blaming associated with the zero goal.

    Yes, zero can be a target but it is one that leads to blame and negative 'side-effects' like overuse of antibiotics. We have posted previously on an IP that was fired for "over-calling" CLABSIs and leading to a hospital having "high" rates. These "high" rates are likely targets for improvement that are now swept under the rug in the quest for zero. Another aspect of zero is the constant fight over definitions for device infections - this has nothing to do with patient safety and has everything to do with targeting zero and not actually targeting patient safety. I think the negative externalities of "zero" outweigh the positive ones and that's why I feel it is not intellectually defensible.

    Even in the Keystone NEJM paper, the mean CLABSI rate was greater than zero. At my previous hospital, for CLABSI, we set a 100% target for checklist completion among a few other process measures and had great success. We did it without zero.

    My point: zero is not a patient and if you target zero, you frequently miss the patient.