Journal Review: New CDC director advises striving for zero infections
New CDC director advises striving for zero infections
Gerberding JL. Hospital-onset infections: A patient safety issue. Ann Intern Med 2002; 137:665-670.
The director of the Centers for Disease Control and Prevention (CDC) has well-established roots in health care epidemiology, as underscored by this article warning that a "culture of complacency" may set in unless institutions continuously strive to reduce their infection rates.
The former chief of the CDC division of healthcare quality improvement, Julie Gerberding, MD, MPH, was named CDC director earlier this year. In this grand-rounds review, she analyzes what she once called "the n of one": a hospital-acquired infection in a single patient. The case is that of a 78-year-old man with lung cancer who died after developing hospital-onset pneumonia and urinary catheter- related infection during hospitalization for elective removal of a cerebellar metastasis.
Even with flawless care, the patient was prone to developing serious infectious complications as a consequence of both endogenous and exogenous risk factors. But there was a flaw in reviewing that case that raises the issue of whether the patient’s death could have been prevented or delayed, Gerberding found. "[The patient] developed clinical, microbiological, and radiographic evidence of infection on the sixth day of hospitalization but did not begin receiving antimicrobial therapy for 24 hours. Given his increased risk for pneumonia and urinary tract infection, the failure to start antimicrobial therapy when fever was first noted seems to be an error of omission, especially because he was receiving dexamethasone therapy. The team caring for [the patient] probably underestimated the importance of low-grade fever in a patient receiving systemic corticosteroids."
All institutions could benefit from a careful internal review of how hospital-onset infections are managed, she said. If treatment delays are common, the institution should seek to improve the systems of care, not simply individual clinicians’ responses to suspected infection.
But that said, Gerberding asked the $64,000 rhetorical question: Are nosocomial infections medical errors? "Did these infections and their outcome reflect deficiencies in the quality of health care [the patient] received?" she asked. "Were they a consequence of medical errors (and therefore preventable), or were they unfortunate but unavoidable complications of tertiary care for this severely ill patient? The answers to these questions are far from clear. Although some interventions may have reduced [the patient’s] risk for infection, it is also possible that his course would not have been substantially altered despite the initiation of evidence-based guidelines."
The patient safety movement has shifted the perception of medical errors, adverse events, and infection prevention. "Altering the premise that many infections are inevitable, although some can be prevented’ to each infection is potentially preventable unless proven otherwise’ is consistent with the expectations of patients and the Institute of Medicine," she wrote. "Perhaps hospital-onset infections that cause or contribute to death or other serious adverse consequences should serve as red flags that trigger close scrutiny of the safety and appropriateness of medical treatment, regardless of the institution’s overall infection rates."
When preventable causes are suspected, a root-cause analysis to identify factors inherent in the system or processes of care that contributed to the errors should be considered. The analysis starts with an event (for example, urinary catheter-associated sepsis) and progressively moves the focus of evaluation from special causes in clinical processes (for example, use of aseptic technique during catheter insertion) to common causes in organizational processes (for example, reduced staffing ratios) to identify potential interventions for prevention, she stated.
"Unless all institutions continuously strive to reduce their infection rates, there may be little motivation for better-than-average performers to improve, a situation that could lead to a culture of complacency,’" the CDC director warns. "A mindset that the current error rate can always be decreased almost certainly explains the fact that other complex industries routinely achieve error rates far below equivalent benchmarks in health care."