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bloodstream infections

Hospital-acquired infections: How do we reach zero?

This week, the U.S. Centers for Disease Control and Prevention issued two reports that are simultaneously scary and encouraging.

First, the scary news: A national survey conducted in 2011 found that one in every 25 U.S. hospital patients experienced a healthcare-associated infection. That’s 648,000 patients with a combined 722,000 infections. About 75,000 of those patients died during their hospitalizations, although it’s unknown how many of those deaths resulted from the infections, the CDC researchers reported in the New England Journal of Medicine.

On the bright side, those numbers are less than half the number of hospital-acquired infections that a national survey estimated in 2007. And a second report issued this week found significant decreases in several infection types that have seen the most focused prevention efforts on a national scale. Noteworthy was a 44 percent decrease in central line-associated bloodstream infections (CLABSI) between 2008 and 2012, as well as a 20 percent reduction in infections related to 10 surgical procedures over the same time period.

These infections were once thought to be inevitable, resulting from patients who were too old, too sick or just plain unlucky. We now know that we can put a significant dent in these events, and even achieve zero infections among the most vulnerable patients. At Johns Hopkins, we created a program that combated CLABSI in intensive care units through a multi-pronged approach—implementing a simple checklist of evidence-based measures while changing culture and caregivers' attitudes through an approach called the Comprehensive Unit-based Safety Program (CUSP). The success was replicated on a larger scale across 103 Michigan ICUs and then later across most U.S. states, with impressive results.

These and similar successes have changed caregivers’ beliefs about what is possible, and inspired more efforts to reach zero infections.

What will it take to attain this goal—or at least get much closer?

We need policymakers to continue providing support so that we can mature the science of improving patient safety. We need their help to create valid and widely accepted performance measures, as well as advance implementation science so that we can learn how best to translate medical evidence into everyday bedside practice.

Hospitals have a big role, of course. As organizations, they must focus on the safety and quality of care with the same rigor and accountability that they bring to their financial performance. Almost without fail, hospital CEOs can tell you if their organization is meeting its budget goals. There are financial specialists at various levels of the organization, and there are consequences for poor performance. When it comes to patient safety, however, those structures rarely exist, even when the desire to reduce harm is strong. Some hospital CEOs I've met didn't know the infection rates at their facilities. Sometimes those rates are known only by the infection prevention department.

What we need are chains of accountability that link everyone in a hospital—from the board to the frontline staff—so that everyone has a shared understanding of their organizational goals, knows their role in meeting them, and gets feedback (such as dashboards) on how they are performing. Those organizations also need the internal capacity—health care professionals with the appropriate training—to carry out their roles in this chain. It sounds simple, but clearly it’s not. Over the past year, Armstrong Institute researchers worked with the VHA hospital engagement network on a demonstration project that sought to create those accountability structures at 10 U.S. hospitals. The initial results are encouraging, with 92 percent of participants reporting that they felt their organization has made improvements in targeted areas, such as surgical site infections (SSIs). It’s breathtaking what we can accomplish when everyone is working toward the same goal.Read More »Hospital-acquired infections: How do we reach zero?

A safety checklist for patients

checklistFar too many patients are harmed rather than helped from their interactions with the health care system. While reducing this harm has proven to be devilishly difficult, we have found that checklists help. Checklists help to reduce ambiguity about what to do, to prioritize what is most important, and to clarify the behaviors that are most helpful.

The use of checklists helped to reduce central-line associated bloodstream infections at The Johns Hopkins Hospital, in hospitals throughout Michigan, and now across the United States. Clinicians have begun to develop, implement and evaluate checklists for a variety of other diagnoses and procedures.

Patients can also use checklists to defend themselves against the major causes of preventable harm. Here are a few you can use:

Health care-associated infections

  • Ask about your hospital’s rates of central-line associated bloodstream infections in the intensive care unit. The best hospitals use the definitions provided by the Centers for Disease Control and Prevention and have rates less than one infection per 1,000 catheter days. A rate above three should cause concern.
  • Whenever clinicians enter your room, ask if they have washed their hands. Request that visitors also wash their hands often. Washing can be with alcohol gel or soap and water.
  • If you have any type of catheter, ask every day if that catheter can be removed.

Identification errors

  • If you are admitted to the hospital, check your ID bracelet to make sure all information is correct. Staff should use this bracelet to confirm your name before any treatments or tests.
  • If you are making an outpatient visit, staff should ask you to confirm your name and another unique identifier, such as your date of birth, before treatments or tests.
  • Verify that blood and other specimens taken from your body are labeled in front of you.

Read More »A safety checklist for patients

Health care needs greater accountability, not excuses

Hand washing

I recently spoke to an executive in the energy industry who had a joint replacement at a hospital in New York. His wound developed an infection, which required four additional hospital admissions and several operations. He asked me about hand hygiene in hospitals. Proudly, I told him that, at Johns Hopkins Hospital, we are at 80 percent compliance with hand hygiene, up from 30 percent not that long ago. I focused on the improvement. He focused on the failures. "So," he said pointedly, "one in five times you do not comply with basic hand washing rules, potentially causing infections—or even death." He asked what we are doing about it.

I told him how we try to learn from the high performers and to improve the poor performers, how we train staff on the importance of hand hygiene, how we report compliance rates to unit teams, how we put pictures of patients with the words “please wash” outside their rooms.

The executive said, "All that is great, but where is the accountability?" In any other industry, there is accountability to ensure staff comply with safety standards, standards that are often much less consequential than hand washing. Other industries help staff improve compliance; they also hold local managers accountable for poor performance. To get results, you must both support staff and hold them responsible.

Read More »Health care needs greater accountability, not excuses

Counting our patient safety blessings

My daughter just asked me what I was thankful for this Thanksgiving. As I reflected on the blessings in my family and personal life, I also thought about what I was grateful for in patient safety. While progress has been slower than any of us would want, we certainly have many things to count:

Patient- and family-centered care is getting long-overdue attention. About two years ago, nurses on one unit at the Johns Hopkins Children’s Center began conducting  shift-change reports in patients’ rooms, rather than in the hallway, so that patients and family members have the chance to ask questions and get the most up-to-date information. More hospitals are including patients on committees. These are small changes, but they represent a larger acknowledgement of the importance of building care around patients’ needs and to seek their wisdom.

Clinicians are increasingly engaged in the work of patient safety. In the past they have largely stayed on the sidelines or have pushed back—often appropriately—against regulatory mandates, interventions or measures that are not informed by science. Yet clinicians did not step forward to take the lead. Now they are. Professional societies, physicians, researchers, nurses, want the science to be good, the measures to be wise, and the interventions flexible enough to fit into their local context. Over the last two weeks, I had calls with several professional societies planning safety programs. At Hopkins, more than 100 faculty members recently showed up at a meeting for those interested in conducting patient safety research.

Read More »Counting our patient safety blessings