Pronovost weighs in on the white coat

Peter Pronovost, arguably the nation's leading expert in patient safety, gave us his thoughts on the white coat debate yesterday on The Armstrong Institute's blog Voices for Safer Care. His conclusion: there's enough evidence to ditch the white coat.

Here is the core of his argument (in his words):

We could voluntarily ditch the white coats without needing a clinical trial to tell us it’s OK. We know that white coats can carry pathogens, and it is logical to think that germs could be transmitted from physician to patient. Given that confirming this theory could be prohibitively expensive, we can look at the implications of acting and not acting. While the risks of maintaining the white coat tradition are clear — potentially more infections and preventable deaths — the risks of removing this potent symbol of professionalism would be less significant, though certainly real for some clinicians. How would patients react? Studies disagree on whether they prefer the white coats — some may find them reassuring, but others may see them as elitist. 

Some experts may argue that we should instead focus on proven infection control practices, such as hand hygiene. Yet it's hard to see how voluntarily giving up your white coat would distract from that. It may even raise awareness in general about the importance of hand hygiene once clinicians consider the pervasiveness of germs on their attire, stethoscopes and keyboards. The risks of doing nothing seem much greater than of making the change.

As we have said for several years, mandates should be reserved for interventions with the highest level of evidence to support them. Neither banning the white coat nor mandating flu vaccine for healthcare workers are backed by evidence at that level. But there's enough evidence to suggest that hanging up your white coat and getting a flu shot are probably the right things to do. And to get a flu shot you have to take your white coat off anyway. So do both and leave the coat behind!

Healthcare quality: Running from science

We've blogged before about our hang-ups with QI. So I was pleased to see a thoughtful perspective in this month's Health Affairs by Peter Pronovost and Richard Lilford entitled "A Road Map for Improving the Performance of Performance Measures." As you might guess, this piece focuses on the validity of quality metrics, and Pronovost deserves credit for trying to push the hospital quality community to clean up its act.

The conclusion of the essay is also the money quote: "For the past decade, health care quality has largely sought quick fixes and run from science; the results are evident. Let us hope that efforts in the next decade embrace science instead."

Pronovost on HAIs

Photo: Johns Hopkins Medicine

There's an interview with Peter Pronovost on reducing healthcare associated infections in tomorrow's Wall Street Journal. You can view it here.

Pronovost on accountability

Peter Pronovost has a commentary in JAMA this week that is worth a read. Check out the whole thing, I'll post only one small paragraph here:

So who is accountable for reducing CLABSIs? Clinicians inserting and maintaining catheters must be accountable for performance, complying with evidence-based practices. Hospital leaders must be accountable for infection rates, monitoring rates, and supporting prevention initiatives. These mechanisms must be supplemented with the public reporting of valid infection rates, financial incentives from insurers, and when needed, sanctions from regulators. This pandemic of infections can be remedied and prevention of other types of preventable harm can be attempted if clinicians—physicians and nurses—work as a team.

My only comment: public reporting of valid infection rates...is much easier said than done, as we've discussed at length in prior blog posts. Meanwhile, the overzealous pursuit of zero perpetuates the daily battles being waged in some centers between infection preventionists (who are "calling" CLABSIs) and ICU clinicians and administrators (who are challenging these calls).

Safe Patients, Smart Hospitals

I had some beach time last week so I read Peter Pronovost's new book, Safe Patient, Smart Hospitals. It's the story of his journey in patient safety, which starts with his father's death, likely hastened by a medical error. Parts of the story are probably familiar to those who work in infection prevention, but I think it's worth reading.

One of the major points he makes is that the checklist, while important, can really only work when the hospital unit embraces a culture of safety. An aspect of the book that I particularly liked is his criticism of some of the work in quality improvement because measurements lack validity. Like Pronovost, I've been accused of trying to do research by QI folks, when all I was asking was to measure a process or outcome accurately and precisely. He also points out how often ego gets in the way of doing the right thing. Over and over, I kept wondering why change is so difficult in  hospitals even when the data for a new intervention are compelling. And he reinforced my belief that infection prevention, like many other aspects of patient safety, is all about high levels of compliance with simple practices.

Unfortunately, I suspect that Dr. Pronovost is preaching to the choir. Those who might benefit most from his words are least likely to turn the pages of this book.