Saturday, May 26, 2012

Postmodern infection prevention

My bad! A few weeks ago I was handing out kudos to APIC for removing all the "getting to zero" propaganda from their website. Was I an idiot or what?! Now zero has become APIC's new vision--Healthcare without infection. All of us would like healthcare without infection. All of us would like automobiles without vehicular accidents, too. But most intelligent human beings who have ever driven a car know that we'll never eliminate automobile accidents no matter how many safety features the auto industry designs. Importantly, we've learned that there are many things we can do to make driving safer. The same holds for healthcare.

I think the zero kool-aid that APIC keeps drinking is really part of post-modernism, the philosophical paradigm that holds there is no absolute truth. Postmodernism is inherently anti-science. David Gorski, a physician who blogs at Science-based Medicine, writes:

"To the post-modernist “scientific medicine is no more valid a construct to describe reality than that of the shaman who invokes incantations and prayers to heal, the homeopath who postulates “healing mechanisms” that blatantly contradict everything we know about multiple areas of science, or reiki practitioners who think they can redirect “life energy” for therapeutic effect. In the postmodernist realm all are equally valid, as there is no solid reason to make distinctions between these competing “narratives” and the “narrative” of scientific or evidence-based medicine."
Stephen Colbert talks about truthiness,"truths that a person claims to know intuitively "from the gut" in that it "feels right" without regard to evidence, logic, intellectual examination, or facts." According to Colbert, “It used to be, everyone was entitled to their own opinion, but not their own facts. But that's not the case anymore. Facts matter not at all. Perception is everything. It's certainty.”

A few years ago, a colleague, also a hospital epidemiologist at an academic medical center, sent me an email that encapsulates the effect of postmoderism on our field. He wrote:
“I used to think that the increased attention on HAIs would be a really good thing, despite the hassles. But I sense that the tide has turned strongly and decisively against the academic, ID-trained hospital epidemiologist. No one defers to that training or expertise anymore–they bow down instead to Toyota models and non-ID trained, self-styled patient safety gurus who preach buzzwords. At my hospital we now report to hospital administration only through someone who spent most of his career in the automotive industry. He's a nice guy and all, but come on, nobody at the table when the “hospital leadership group” discusses infection data has any ID or infection control training!”
If we could be magically transported back a half century with the corpus of evidence about healthcare associated infections that exists today, it might be possible to come close to eliminating HAIs in the hospital of 1962. But advances in medicine continue to make patients more immunosuppressed and devices have become increasingly more invasive. We continue to bypass every one of the body's natural barriers to infection. This is why, as I have said previously, I have yet to meet an infectious diseases physician who believes that HAIs can be eliminated. During my travels I have found that most infection preventionists agree. This leads me to believe that there is some disconnect between APIC leadership and the IPs in the trenches. And it's a good thing I'm not a cynical person! If I were, I might think that APIC's vision would be a great way for the organization to "partner" with industry to prevent infections through some good old fashioned quid pro quo.

I decided when I was a fourth-year medical student that I wanted to be a hospital epidemiologist. I very much wanted to spend my career studying the problem of HAIs and designing ways to reduce them. I still find it fascinating over two decades later. I would love to see the day when there are no HAIs. But I live in the reality-based community that embraces modernism, a place where science is the tool to explain what we observe in the world. So I'll freely admit that I believe in microbiology, epidemiology, vaccines, climate change, and anything else that valid evidence reveals to be true. I also believe that APIC is unfortunately spinning ever further into a parallel, postmodern, anti-science, truthy universe.  

Photos: Institute for Science in Medicine;  BWOG


  1. Of course HAIs can't be eliminated. They can only be made much less frequent than they are or have been.

    The sad thing is that programs to reduce them have been extremely unpopular among "the academic, ID-trained hospital epidemiologist". This has allowed people like Peter Pronovost and Rajiv Jain (both docs but not ID docs and not epidemiologists) to eat the lunch of the academic, ID-trained hospital epidemiologists. These guys (and some ladies like Marta Render and Chris Goeschel) developed and implemented, along with some few cooperative and open-minded academic, ID-trained hospital epidemiologists, programs that dropped a bomb on CLABSI in Michigan (and then many other places) and MRSA (and then many other bugs) in the Veterans Health Administration. Ask yourself, would the world be better off if Pronovost and Jain had stayed in their own domains and not encroached on that of the the academic, ID-trained hospital epidemiologist? Can you say yes to that question? I don't think you can.

  2. neldridge202, I read Mike's post a bit differently than you did, and based upon your first sentence I think you agree with him (seems you mostly take issue with the writer of the e-mail from which he quoted). And I disagree with a few things in your comment above. First, I don't think any of the bundled approaches (e.g. CLABSI, VAP, with the possible exception of active MRSA surveillance) are at all unpopular with ID-trained epidemiologists. On the contrary, it was this group that developed the evidence base for them, and most of this group had implemented such bundled approaches long in advance of the Keystone study or the VA initiative (I know that we did so long before the IHI campaign, and saw ~60% reduction in CLABSI in our adult ICUs). I use the Keystone study and the 36 month follow up BMJ paper in every HAI talk I give, and discuss how game-changing these data are. And I also think most ID-trained epis are very appreciated of those who have taken these evidence-based approaches and scaled them up so successfully. Bravo to them, and I hope we see more such charismatic and energetic proponents of infection prevention, from all backgrounds.

    The challenge now, of course, is to move infection rates ever lower. There are many implications and unintended consequences of believing that zero is truly possible and that every single HAI is preventable, but to me the most concerning is the inherent assumption that we already know how to prevent each HAI. Our investigative work is done, in other words, and all we need now is good implementation. It's very hard to see how we can make the additional progress we need if this becomes the new paradigm.

  3. Getting to zero infections acquired in hospitals is about as possible as getting to zero car-crash injuries. Both are impossible, based on what we know now about how they happen and how they can be prevented.

    But let's not rewrite history. At the time, in 2007 and prior, there was a lot of disdain among ID docs and hospital epidemiologists for the kinds of one-size-fits-all approaches associated with many programs based on "bundles" and other selected sets of required practices and procedures that were grouped together and packaged as programs that would be done simultaneously at dozens or more hospitals, instead of one at a time based on local perceptions of what was necessary at that hospital.

    This took about 5 minutes to find on-line: (Unfortunately I didn't save the letter signed by a non-trivial number of VA's top ID docs and sent to the Under Secretary for Health around the same time saying the MRSA Prevention program was a bad idea.) As we know the program worked out pretty well. See: Could it have worked without the testing? Maybe. Maybe not. Maybe the testing convinced staff that this was a real program, and not a flavor of the week. And testing promised to identify patients who came in MRSA negative but developed infection on colonization while in the hospital; staff knew that this could be now measured and tracked, this might have been a motivator for actually doing any number of evidence-based practices... No one knows exactly how these programs have worked, but it's clear that they have. This is not unlike other types of safety improvements that have happened, for example auto and aviation - so many things have been done to make them safer that we can't be sure which of the interventions and changes made a difference. But this is a good problem to have instead of a bad problem to have.

    See slides 6 to 16 on this set...

    This 2007 article mentions another early non-ID doc pioneer in this area: Rick Shannon.

    One last thing: I'm a huge fan of this blog and learn a lot from it. The one that pointed to this slide set by Mike (I don't know him and feel funny calling him Mike) was especially valuable: It provides a great summary of what's known and unknown and what can and can't be done about C diff.

  4. Thanks--we appreciate you following the blog, and I'm glad it has been useful. I think some who are very vested in a particular orthodoxy within infection prevention or quality improvement may find an occasional post to be jarring, but that is precisely because we aim to discuss controversial areas in infection prevention (hence the title of the blog) and aim to make people think. You are one of just a few who regularly comment and challenge, and we do appreciate it.

    I will also politely note that in my first comment above I excepted those bundles that included mandatory universal MRSA active surveillance (many, if not most, hospital epidemiologists were not enthused, and many remain unenthused). But we've blogged aplenty about that. However, I don't think I'm rewriting history when I say that ID-trained academic hospital epidemiologists embraced the CLABSI and VAP bundles. Can you find examples of resistance to the widespread adoption of those bundled prevention measures? I don't know of anyone in my circles who didn't think they were (and remain) excellent approaches to preventing life-threatening infections. There is acute interest in which individual aspects of each bundle are most important, and when we ought to re-think bundles (to add new elements, as we added CHG oral care to the VAP bundle, or to drop elements if additional evidence finds them to be of little benefit or even harmful). That's just part of the ongoing inquiry that should (and too often doesn't) happen as part of a prevention research agenda.

  5. I really like this thread of discussion. I just want to add that I also think most ID-hospital epi folks embraced the CLABSI bundle (which I think was developed at Wash U by the ID-hospital-epi group there). However, "we" couldn't get critical care and other MDs interested. It took one of their own to do the convincing and even then it remains a hard sell to many folks.

  6. Agree with Eli that this is a great thread. neldridge202 raises an interesting question about whether interventions that may work should be mandated (e.g., MRSA active surveillance). I think we need to allow hospitals to have some choice in their interventions, otherwise we'll be forever stuck with what at the moment may appear to be effective. With regards to MRSA active surveillance, I have resisted, and the MRSA rates at my hospital are lower than at most hospitals that have done active surveillance (data have been submitted to ID Week). Along the way, I've saved my hospital $10-20 million in lab costs, and kept a lot of patients out of contact precautions. Frederick Taylor, among others, developed the concept of scientific management--a theory that there was one best way to do everything. It seems as though some would like to apply that to healthcare, even though the idea was discredited in industry decades ago. There have been many mandates in healthcare that have failed, even though the interventions were thought to be the one best way. Some examples include smallpox vaccination of healthcare workers, first dose of antibiotics for CAP patients within 4 hours, and currently some of the antibiotic choices for CAP patients. While some would disagree, I'd add MRSA active surveillance to the list, not because it may not work but because they may be cheaper, more patient friendly ways to achieve MRSA control. And we may ultimately learn that SCIP will join the list.

  7. There are many countries in the world which are still struggling to get FROM zero (rates). Some just because they simply don’t have infection control programmes yet, and some because of externally regulated, essentially punitive approach to infection control that prevented them from reporting HAI. Tempting the regulators there with the slogans like “getting to zero” or “zero tolerance” (and this already went far beyond just the US context) would simply jeopardize any attempts to implement modern infection control. And, in any case, these countries cannot (and, probably, should not) afford e.g. mandatory MRSA total active surveillance or any other expensive practices that are still to be properly evaluated...

  8. Very good point, Sergey. We have failed to consider the impact of getting to zero on other countries. Thanks for pointing this out.