Hospital infections and processes

I have written in the past about attempts to increase the standardization of practices in hospitals. A recurring example in this area is inserting (and maintaining) a central line (also called a central venous catheter). This example is appealing for two reasons.  First, it is both commonly used and a frequent source of infection. Basically, a patient only gets a central line if they are not in good shape but a large number of patient in critical condition end up with one.  Hence, a number of sick patients are at risk of becoming sicker.  How many? According to the Chicago Tribune (Tracking hospital infections, May 16), quite a few.

About 80,000 hospital patients are infected annually in the U.S. when pathogens invade the bloodstream through the catheters, and upwards of 30,000 die. The germs can come from a patient’s skin, doctors’ ties, nurses’ coats, the catheter itself and various other sources. …

Such improvements save not only lives but money. Patients who survive central line infections spend an extra week in the hospital, on average, and incur up to $30,000 in additional medical expenses, according to the Institute for Healthcare Improvement.

The Trib also had this spiffy graphic explaining just what a central line does:

The second reason central line infections are such a big deal is that they arguably represent a solved problem.

A turning point came when Dr. Peter Pronovost, a critical care specialist from Johns Hopkins Hospital, published research in 2006 in the New England Journal of Medicine demonstrating that more than 100 intensive care units in Michigan nearly eliminated CLABSIs by following a checklist of simple procedures.

When medical staff focused vigilantly on patient safety; worked closely together; washed their hands; used gloves, masks and gowns; draped patients with coverings, and rigorously cleaned sites where catheters were inserted, among other measures, infection rates in Michigan dropped to an average rate of 1.4 for every 1,000 catheter days, from 7.7 previously.

The article also reports how sticking with this approach has paid off for one Chicagoland hospital:

One facility that took Pronovost’s strategies to heart was Central DuPage Hospital in Winfield, which last year had one infection in its two medical/surgical ICUs, down from 19 in 2008. After reviewing its performance, Central DuPage discovered that many central line infections occurred days after the catheter was inserted. When hospital staff instituted a dozen steps designed to maintain the sterility of the line, infections plummeted, according to Dr. David Cooke, the hospital’s vice president of quality and safety.

What’s remarkable then is that some hospitals have made fairly little progress on reducing the number of central line infections. As the graphic above shows, some hospitals had infections  5 or more times higher than expected.  A related Tribune article has a hospital by hospital reaction to these numbers (Illinois hospitals address high infection rates, May 16). The responses are a little disheartening.  They range from complaints that problems were not be escalated up the chain of command to questioning the reported data.

It will be interesting to see how well these hospitals do in future years. This is how many people would like to see the system work: Identify best practice and make data available so the public can judge how a hospital performs.  For central lines, we have an unambiguous idea of what good practice is.  Further, the Pronovost checklist approach is simple.  It does not require expensive capital or new personnel.  It just requires that care givers understand the process and be disciplined enough to stick to it. There are no excuses not to do it. The question is whether the public shaming part will matter.  I can’t imagine that administrators at Thorek Memorial or Roseland Community were overly happy with there 15 minutes of fame in the Trib. That said, I doubt that this article or this data will make that much of a difference in hospital choice. I am not sure how many people know what a central line is or whether they are a candidate for one. Convenience and familiarity will likely be the deciding factor in choosing a hospital.