Why are we so terrible...

...at hand hygiene? Atul Gawande has a piece in the New Yorker entitled "Slow Ideas", that asks why some innovations (and yes, the act of cleaning hands was once an innovation) are so slow to catch on. He starts the piece by comparing two mid-1800s innovations, anesthesia and surgical antisepsis, and outlining reasons why the former spread so much more readily than the latter.

"So what were the key differences? First, one combatted a visible and immediate problem (pain); the other combatted an invisible problem (germs) whose effects wouldn’t be manifest until well after the operation. Second, although both made life better for patients, only one made life better for doctors. Anesthesia changed surgery from a brutal, time-pressured assault on a shrieking patient to a quiet, considered procedure. Listerism, by contrast, required the operator to work in a shower of carbolic acid. Even low dilutions burned the surgeons’ hands. You can imagine why Lister’s crusade might have been a tough sell."

These simple observations are highly relevant to hand hygiene, an innovation that still hasn't completely taken hold after 150 years. Mike was recently in Iowa City to give an excellent talk on hand hygiene and made similar points. Microorganisms are invisible to the naked eye, the diseases they cause have incubation periods that separate cause (poor or absent hand hygiene) from effect (infection, sepsis, death), and an individual failure of performance is almost never linked directly to the adverse outcome. I should let Mike take it from here, but the alternatives to what we've been doing (constantly-evolving campaigns that have impacts which extinguish over time) involve long-term, multi-faceted approaches that have the goal of eventually "hard-wiring" the behavior.

Why surgical complications may actually hurt profits despite what you've just read.

If there is no financial incentive to reduce excess length of stay, why has every hospital spent the past 20 years trying to reduce it?

There's a high-profile and important paper in JAMA this week by Sunil Eappen and colleagues. The study looked at surgical discharges during 2010 from a single 12-hospital system and determined that admissions that included a surgical complication were associated with a higher profit (defined as the contribution margin) than admissions without complications. The authors concluded that this creates a disincentive for hospitals to prevent surgical complications since they might see reduced profits as a result.  This is a very provocative finding and it's getting a lot of well-placed media attention, as you might expect. However, there is an important caveat with the study that I would like to highlight.

In the study the authors report that admissions with surgical complications result in $39,000 higher "profits" if the care is reimbursed via a private payer and $1800 if Medicare is the payer. However, as Dr. Reinhardt correctly noted in the editorial, "Allocating profit and loss is exquisitely sensitive to the many assumptions made in economic modeling and must be performed carefully to provide useful evidence about the financial ramifications of surgical complications and other services." His concern dealt mostly with how the authors allocated fixed costs in their calculations. My concern has to do with what the authors assumed happens to an empty bed once a patient is discharged in a US hospital.

This is what the authors assumed (and mentioned as a limitation): "We did not estimate the effect of 3 potential factors that could affect the hospital economics of surgical complications. First, the shorter lengths of stay of procedures without complications could benefit the small percentage of hospitals operating at full capacity because they might be able to admit additional patients with favorable insurance who were “crowded out.”" What this means is that they didn't include any profits that might be generated by an empty bed filled with a second (or third or fourth) patient. In the study, around 5% of patients developed a complication and stayed an excess of 11 days (at the median) - the mean would be higher.

Note: Based on recommendations of Johns Hopkins professor and retired CFO, Bill Ward, we focused on estimating the costs of HAI using return-on-investment calculations from filling empty beds that manifest through HAIs avoided in the Business-Case SHEA Guideline. In discussions he suggested that excess bed capacity is quickly taken off line and therefore doesn't impact economic evaluation to a large degree. If there is no financial incentive to reduce excess length of stay, why has every hospital spent the past 20 years trying to reduce length of stay?

The big question: Do you believe that 5% of beds in hospitals with high surgical volumes sit completely empty for almost two weeks? Of course, there is excess capacity in the US system, but the amount of excess capacity is most important here, not that it exists. You can't completely ignore profits from increased admissions. For example, if only one patient was admitted into a bed vacated by a "healthy" patient discharged at day three that would would have otherwise been occupied by a patient with a surgical complication discharged at day 14, the results of the study would be have been negated - i.e., it would have been a negative study. If more than one patient was admitted into an empty bed over 11 days, which seems likely at most high-volume hospitals, admissions with surgical patients with complications would result in reduced profits compared with admissions without complications. It would have been nice to see estimates of the excess capacity at the 12 hospitals under study.

A provocative study and wonderful analysis. However, as Dr. Reinhardt states, the study "provides important data on a pressing clinical and financial problem affecting hospitals" yet "much of this represents a shell game of how costs are allocated." I would add, and which profits are included or excluded.

Image source: wikipedia

Rethinking the System: Atul Gawande's HMS commencement address

JR Hildebrand and his pit crew

"A structure that prioritizes the independence of all those specialists will have enormous difficulty achieving great care...We don’t have to look far for evidence. Two million patients pick up infections in American hospitals, most because someone didn’t follow basic antiseptic precautions."

You can read the full speech in the New Yorker (here)

Being Deb Yokoe - Atul Gawande's APIC keynote

I just sat through Atul Gawande's APIC keynote speech. I was expecting to be inspired and amazed. What I wasn't expecting was Deb Yokoe. Dr Gawande spent the first 30 minutes pacing the stage and discussing the day he followed Dr. Yokoe and her team around the Brigham. He described her as a smiling, occasionally giggling with dimples and tennis shoe wearing hospital epidemiologist. It must have been a very busy day as I think he mentioned 7-8 outbreaks she was dealing with at the time including tularemia and a frozen strawberry foodborne outbreak. Having worked with Dr Yokoe as a fellow in a research capacity, I have always appreciated her work and felt she never got enough credit for her contributions. It is very nice to see that changing.

A particularly touching part of the hospital tour with Dr Yokoe was when Gawande described the staff flowing in and out of the ICU rooms and realizing that this was far different than the controlled OR environment and then he realized one of the MRSA isolated patients was his own and that he might have given MRSA to the patient. He got his biggest applause when he quoted Deb as saying "I don't want to be an infection control cop.". Gawande agreed with her and spent some time discussing the importance of team work and getting infection control out of the police business. Well, he has every right to be hopeful. An important effort made at the Brigham that others should consider copying is that infection control is now a rotation for medical students. I suspect it isn't mandatory, but it is a start.

My favorite part of the talk, apart from his discussions of the surgical checklists that were highlighted in his latest book, was when he was asked a question about mandates. He described that in any advance there are early adopters, medium adopters and late adopters. He then added in a class of people called exceptionalists, people who say they are different or their hospitals are too different to do things like clabsi checklists. His point was that there is a time when mandates are needed but the key variable is the timing. One must wait to mandate until after the early adopters are on board and worked out all of the implementation details. Any mandate that comes too early, alienates these early adopters and hurts implementation. Food for thought.

Gawande's Velluvial Matrix

The New Yorker's website has posted Atul Gawande's recent commencement address to the graduates of Stanford Medical School. In his talk he describes great medicine as "work with a different set of values from the ones that medicine traditionally has had: values of teamwork instead of individual autonomy, ambition for the right process rather than the right technology, and, perhaps above all, humility—for we need the humility to recognize that, under conditions of complexity, no technology will be infallible. No individual will be, either." It seems to me that this encapsulates the essence of our daily work in healthcare epidemiology.

Atul Gawande - Interview

Recently, Atul Gawande sat down with Rahul Parikh, MD in Salon.com to discuss healthcare reform, checklists and music. It's an interesting discussion on changing the healthcare system and improving quality including the need for better data. The interview occurred before the Massachusetts Senate election, so it seems at times like it was written decades ago when there actually was hope for healthcare reform. Final note: I agree that Radiohead ruled at some point, but as far as ruling the day, perhaps Spoon or Super Furry Animals should have been mentioned. (Thanks John Cole)

Atul Gawande - The Checklist Manifesto

Dan has commented several times on Atul Gawande's New Yorker articles (here and here). As he stated, his writing is highly influential both politically in Washington and in driving patient safety. Those who like his articles and books will be excited to know that he has a new book coming out next week titled "The Checklist Manifesto." You'll be even more excited that you can hear him now on APIC's website and see him July 12th at the New Orleans APIC conference where there will be an "exclusive book signing at the premier conference for infection prevention education." I was going to comment on the fact that SHEA might be considered the premier conference by some, but then I realized SHEA's meeting will be going away in a few years, so it's probably not worth mentioning...

I'm sure we'll write more about his newest book when we've had a chance to read it. In the meantime, I will be sitting next to my fireplace hoping Santa finds it in his heart to place a copy in my stocking.

Healthcare reform and cost containment

Back in May I flagged an article by Atul Gawande. That piece, which put McAllen, Texas on the map (but not in a good way), illustrated nicely the consequences of the perverse incentives built into the fragmented U.S. healthcare system. The article became required reading in the White House during the debate over healthcare reform.

Dr. Gawande has another article in the New Yorker this week, this one addressing strategies for cost containment. Although failure to more aggressively curb costs has been a common criticism of the current reform bills, Gawande argues that pilot programs such as those included in the bill (including one that would penalize hospitals with high infection rates) are the most promising long-term approach to cost containment and quality improvement.

He uses the history of U.S. agricultural practices as an analogy, arguing for a form of positive deviance writ large--establish small-scale pilots around the country, and expand or replicate those that are successful. The process would be guided by government but not with big comprehensive mandates.

I agree with that general approach to quality improvement and infection prevention, and I think we are already seeing how certain interventions that clearly work (e.g. the central-line associated bloodstream infection prevention bundle) are being more widely adopted. What we desperately need is more funding to quickly study competing approaches and determine what works best.

Getting Less for More

There’s an excellent piece in this week’s New Yorker, by the surgeon-author Atul Gawande….must reading during the ongoing debate about healthcare reform. Gawande uses real life examples from a Texas community to illustrate just how broken our healthcare system is. The larger points of the article aren't exactly new, but the way he addresses them makes them very accessible. Go read it for yourself.