Lessons from a 1944 CIA manual

The now declassified CIA Simple Sabotage Field Manual was created in the 1940s to help CIA agents “harass and demoralize the enemy”. It came to my attention via Atlas Obscura, and I thought some of the tactics might be familiar to those who work to implement change within hospitals and healthcare systems.

Here is the list of 8 methods for “General Interference with Organizations and Production” (page 28):

• Insist on doing everything through “channels”. Never permit short-cuts to be taken in order to expedite decisions. 
• Make speeches. Talk as frequently as possible and at great length. 
• When possible, refer all matters to committees, for “further study and consideration”. Attempt to make the committees as large of possible—never less than five. 
• Bring up irrelevant issues as frequently as possible. 
• Haggle over precise wordings of communications, minutes, resolutions. 
• Refer back to matters decided upon at the last meeting and attempt to re-open the question of the advisability of that decision. 
• Advocate “caution”. Be “reasonable” and urge your fellow-conferees to be “reasonable” and avoid haste which might result in embarrassments or difficulties later on. 
• Be worried about the propriety of any decision—raise the question of whether such action as is contemplated lies within the jurisdiction of the group or whether it might conflict with the policy of some higher echelon. 

Other key advice to managers and supervisors includes: 

• Hold conferences when there is more critical work to be done. 
• Multiply paperwork in plausible ways. Start duplicate files. 
• Apply all regulations to the last letter.

Now go forth and do the opposite!

CAUTI SCHMAUTI ! (part 3)

I've blogged before about the waste of time, effort and resources being utilized to prevent CAUTI (see here and here), and a new paper in Infection Control and Hospital Epidemiology adds fuel to my fire. This two-year study was performed in the adult ICUs at the Mayo Clinic and analyzed 105 CAUTI episodes. In 97% of cases fever was the primary indication for obtaining the urine culture, but on analysis 2/3 of the patients with CAUTI had alternative diagnoses to explain the fever. Thus it appears that CAUTI is highly over diagnosed. Moreover, preventability is relatively low and secondary bacteremias are uncommon. The authors "question the utility of surveillance for this low-frequency, low-morbidity HAI, which does not serve as a valuable patient-centered outcome." And they conclude: "CAUTIs, as currently defined by NHSN (even with the 2015 definition changes), are not clinically relevant, and efforts to reduce CAUTI may be better directed at other more serious healthcare infections."

  

The paper is accompanied by an excellent editorial by Dan Livorsi and Eli Perencevich. They thoughtfully dissect all the problems with the CAUTI metric and offer some alternatives. They note that it is debatable whether a NHSN-defined CAUTI represents an episode of preventable harm. And they remind us that the opportunity cost is significant.

It's time to end the war on CAUTI.

Graphic: Living with a Catheter

Dollars, denominators, and risk adjustment

Because not everyone who reads this blog reads the comments, I wanted to highlight these particularly insightful observations about Mike’s post on denominators for CLABSI (emphasis mine):

"The thought experiment works with the assumption these two ICUs are indistinguishable except for the frequency of CVC use. Historically, I think the justification for comparative rates using CVC denominators was a no-brainer. These devices were critical to saving lives, and the variations in device utilization probably reflected differences in patient populations, even within similar types of locations. Accounting for the overwhelming primary risk (the CVC) made sense, since these devices were critical to care. The problem you’re outlining now is very real -- as the clinical environment has proven that a lot of the variations in CVC use may in fact be personal preference. Just like the argument with CAUTIs (where foley use is deemed less critical to care) to use a patient-day denominator is strong, we may be at a time where the CLABSI argument is as strong. Improving the classification of ICU types, by more objective criteria than currently used in NHSN (i.e. the 80% rule), would really advance the comparative metric substantially, and likely provide more valid risk adjustment with patient-day denominators than we currently have with these archaic classification schemes (e.g., "med-surg icu"). Advancing the use of composite administrative data to classify patient locations to a more objective, reliable, and granular level, based on fractions of patient-days that have key underlying diagnosis, procedures, etc. is greatly needed."

Given the millions of dollars that are now at stake based upon a hospital’s performance on healthcare-associated infection (HAI) metrics, it’s hard to overemphasize the pressure that is now being placed on the NHSN definitions, and the importance of ensuring that the definitions keep pace with evolving approaches to patient care. When I was a medical resident (yes, way back then), the presence of a CVC was a good indicator of severity of illness and likely served well as built-in risk adjustment for the broad categories of ICU. The same cannot be said now; the device utilization ratios (and percentile ranks compared across NHSN units) vary markedly between different ICU types in our hospital, and do not correlate well with illness severity. And as we’ve learned with CAUTI, the device days that are most amenable to reduction (the “low hanging fruit”) are always the lowest risk device days.

Denominators matter

Let's perform a thought experiment. At St. Eligius Hospital there are two ICUs. These two ICUs have the same number of beds, the same number of patient days (12,000/year), and the same case mix index. In fact, they're essentially identical, except that ICU A has an annual CLABSI rate of 2.7/1,000 central line days and ICU B has a CLABSI rate of 5.0/1,000 central line days. Which ICU is better performing with regards to CLABSI? Well, without any other data to consider, we'd be greatly tempted to conclude that ICU A is the better performer since it's CLABSI rate is nearly one-half that of ICU B. Now, let's add another piece of information: ICU B focused on reducing central line placement as a safety intervention--so at year's end, ICU A had 7,500 central line days and ICU B had 3,000 central line days. This means that ICU A finished the year with 20 CLABSIs, and ICU B had 15. Now it's clear that ICU B is the better performer despite having the higher rate.

This is not just a theoretical problem. During my first rotation on the Infectious Diseases Consultation Service at the University of Iowa last year, I was struck by the low prevalence of central lines in the medical ICU. Turns out my perception was spot on--when I looked at our NHSN data, I saw that 3 of our 5 adult ICUs have central line utilization ratios less than the 15th percentile nationally. This is not an accidental occurrence; clinicians in those ICUs have worked hard to avoid placement of devices that are associated with infection. The problem is that the central lines that do get placed in these units are concentrated in a group of patients that are sicker and more likely to develop CLABSI, since the less sick patients will be managed without a central line. Moreover, the denominator is reduced. And the result is higher CLABSI rates. Here, no good deed goes unpunished.

But there's an easy fix. Instead of using device days as the denominator, use patient days. In our thought experiment, we would see that ICU A would have a CLABSI rate of 1.7/1,000 patient days and ICU B would have a rate of 1.2/1,000 patient days. The better performer (ICU B) will now have the lower rate, as expected. Makes sense, no? CDC should move to address this given the financial penalties hospitals now face based on CLABSI rates. Changing the denominator would provide an incentive for hospitals to aggressively reduce device insertion. And since NHSN has collected patient days for decades, there would be no loss of long-term trending. Lastly, use of patient-days as a denominator produces a patient-centered metric. Think about it: do we really care at what rate catheters become infected? No! Our focus should be on what rate of and how many patients become infected, which is also more intuitive for providers at the sharp edge of patient care.

It's time to kill MRSA exceptionalism

For nearly two decades, we've lived in a delusional state where many in the field of infection prevention somehow believed that MRSA was so much worse than MSSA that it needed to be treated in a special way. We needed to find all those who are colonized and isolate them (aka search and destroy). We needed to wrap ourselves in plastic before entering their room. We needed to destroy any unused disposable products that remained in the room at the time of hospital discharge. We needed to terminally clean the room in a special way. And on and on and on.... All because MRSA was special. We didn't need to do any of those special things for plain old MSSA.

Some of us have been baffled by this magical thinking from the start. After all, MRSA and MSSA are transmitted in exactly the same ways. We're even more baffled after we see the evidence that in the endemic setting search and destroy doesn't work and contact precautions don't work either. And can anyone honestly say that MSSA invasive infections are benign?

A new multicenter study of invasive S. aureus infections in hospitalized infants published in JAMA Pediatrics should drive another nail in the coffin of MRSA exceptionalism (free full text here). Nearly 4,000 infected babies were studied and outcomes were compared between MSSA and MRSA infections. MSSA infections were nearly three times more common. Although there was no difference in mortality rates between the two groups, twice as many babies died of MSSA infections.

We need to quit chasing pathogen-based approaches (vertical strategies) to infection prevention and focus on horizontal strategies that reduce infections from all pathogens (e.g., hand hygiene, stethoscope disinfection, bare below the elbows, chlorhexidine bathing). Because all pathogens are important. I often joke that I've never had a patient tell me that they don't want a MRSA infection, but they'll take an MSSA. And that is definitive proof that patients figured out that MRSA exceptionalism was a bad idea long before most hospital epidemiologists.

Photo:  CDC.

Reader Survey: White coats contribute to the unsafe hierarchical culture in healthcare

Following on the heels of Mike's bare-below the elbows debate at IDWeek, I posted a quick survey to gauge your impression of the level of acceptable harm associated with white coats. I'm still working on the power calculations that will be informed by the survey, but wanted to say thank you to the many who answered the questions. In the meantime, I also wanted to post the comments left by you, our readers. I've posted almost all of the comments thus far apart from those with swearing or those that mention their answers to question #1 of the survey.

One thing that struck me when reading the comments is that the white coat is a symbol that perpetuates hierarchy and is part of an unsafe culture. We need to create healthcare systems without hierarchy and it seems that the white coat contributes to a system where 58% of nurses that see harm are afraid to speak up "and people need to be able to speak up." Thus, even if you are in the minority who believes that white coats are not involved in pathogen transmission, your white coat might be harming patients by contributing to an unsafe hierarchal culture.

An interesting patient-centered quote that seems to run counter to the current thinking associating white coats with professionalism: "If there are better options that would reduce transmission of infection then burn the white coats. As a patient I dislike them - intensely. Reminds me of a butcher shop or auto mechanic- not reassuring at all."

Pro White Coat:

"Not an issue as long as changed daily and sleeves rolled up above the elbow and they don't carry medical equipment in the pockets"

"The white coat continues to be an important identifier of the profession, and symbols are important"

"It is certainly useful to carry things but also represents antiquated power hierarchy. Although there is no evidence, it plausible that they could transmit infections. Then again so could stethoscopes which have more direct patient contact."

"Can't prove it is causing resistance-- and I think patients like it"

"Needs an RCT. Anything else is nonsense ... unless we say all healthcare providers put on and remove scrubs at work"

"We have white coats with short sleeves. This is no problem in my opinion. BUt bare below the elbows has become the standard in most Dutch hospitals. Probably the turning point was a documentary with a hidden camera showing that healthcare workers knew that handhygiene was important that they should not wear jewelry, but they just didn't take the rules serious. Sometimes we don't need science but a good mirror and public response"

"Fashion item"

Pro Bare Below Elbow (OK with eliminating White Coats):

"It's merely a badge of authority and seniority masquerading as cleanliness and something "sciencey"

"A disease-ridden, antiquated symbol. They project the same professional and scientific insecurity as when doctors started wearing them to appropriate the public legitimacy of science."

"I appreciate that for many, the white coat is a status symbol and helps create an instant first impression on patients. That being said, times are changing. The physician is not the most important person in the room. The healthcare team is what should be the focus now. Tear off the coat and tear down the hierarchy"

"I understand white coats as a part of PPE when you don't want to get something on yourself or to prevent things on you from spreading. But when the white coat goes EVERYWHERE you go, it doesn't maintain it's protective qualities. Also, as a pharmacist, I'd much rather have normal, professional or consulting coversations as a professionally dressed human than a white coat."

"If it's a vector for microorganisms, eliminate it. Simple"

"Not necessary. Wear scrubs like everyone else. If your ego needs the coat, get therapy"

"I hate it. Adds to elitism and difference. Separates us from our humanness"

"White gets filthy too quickly"

"In the past, it was a status symbol for physicians; this is now translated to our students, ancillary staff and physician extenders. It is not represent amount of fundamental knowledge or the ability to care for patients. It was an extension of the laboratory part of our profession transitioned from black coats earlier in the last century. Currently, it is nothing more than a status symbol or accessory"

"White coats offer no benefit. We should try to prevent infections by any means necessary"

"I don't think white coats are necessary, but then I'm also not American!"

"Don't wear them in Australia. If you're worried about getting dirty, wear scrubs"

"It's part of a bygone age"

"Given the association with pathogenic transmissions, I am appalled we are still handing them out to our medical trainees!"

"I work at a pediatric hospital where most physicians do not wear white coats. Anecdotally, pediatricians seem to eschew white coats in order to be more friendly and approachable. Don't know what impact this has on HAI at our hospital"

"Doctors don't walk around with head mirrors anymore; the white coat makes about as much sense to me. Why do we still have this thing that exists for no other reason than a vector for disease?!"

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image source: NYT

The White Coat Debate Needs Your Opinion!

The white coat debate continues. If you'd like to see the latest and greatest discussion concerning the doctors white coat, head over to Phil Lederer's blog and read his White Coat FAQs. In the meantime, I have a couple quick questions for you. Thanks for taking our survey!