Don't shoot the messenger: Downside of "zero-tolerance' approach to infections
Don't shoot the messenger: Downside of "zero-tolerance' approach to infections
SHEA meeting reveals CDC moving away from concept
A fascinating, philosophical exchange among some of the nation's leading health care epidemiologists recently came down to the value of zero. Here we mean zero as in the popular catchphrases such as "zero tolerance" for infections, expressions meant to crystallize a complex idea and convey the resolution of infection control professionals in the national effort to eliminate the scourge of health care-associated infections (HAIs).
However, a growing concern that the effort is backfiring was expressed recently in Orlando at the annual meeting of the Society for Healthcare Epidemiology of America (SHEA). What was supposed to instill a sense of a field afire with action and determination has somehow morphed into unrealistic patient expectations and a shoot-the-messenger mentality, SHEA speakers and audience members noted.
"I personally find the "zero-tolerance' concept pretty toxic," said Victoria Fraser, MD, a health care epidemiologist at the Washington University School of Medicine in St. Louis. "I think it is associated with blame. It seems punitive. I don't think it is really helping us, and that is a term I would like to avoid. What we need is more tolerance, not less tolerance in our culture and in our world. We need more collaboration and less blame."
Indeed, there are anecdotal reports of internal pressures not to report infections and assigning blame to infection control professionals when they do. "The "zero approach' to health care-associated infections, I believe is rigid, dishonest, anti-intellectual, punitive, and drives a culture of blame," said Michael Edmond, MD, a health care epidemiologist at Virginia Commonwealth University (VCU) Medical Center in Richmond.
HAIs have traditionally been viewed with a certain air of epidemiological inevitability, seen in many cases as the unpreventable result of keeping very sick patients alive via invasive devices and other medical interventions. But that view has fallen out of favor in large part because consumer activists and patient safety advocates have taken the debate to the public square, where benchmark ranges and inevitable infections are difficult concepts to defend. The Centers for Disease Control and Prevention and infection control leaders have responded with "zero tolerance," "getting-to-zero" or "targeting-zero" campaigns, which imply that no infection is acceptable even if it is inevitable. It also suggests lax infection control compliance with cardinal principles such as hand hygiene and needle safety is unacceptable. The "zero-tolerance" concept was originally supported by Denise Cardo, MD, director of the CDC division of health care quality promotion (DHQP). However, at SHEA she clarified that the CDC is changing its message on the elimination of HAIs. "The concept of zero tolerance for infections — while I think initially people had good intentions when they came up with the idea, looking at [positive results] in other industries — is really becoming a big problem for everybody," she said.
Blaming the ICP
The CDC is hearing reports that even successful programs blame ICPs after the "zero" is shattered and an HAI occurs. "If there is one infection, the infection control program is blamed instead of focusing on the success," Cardo said. "While zero tolerance was an effective way to get everybody to pay attention, now we are paying more for the unintended consequences than the benefits. I think it is something we really to need to think of as we move forward — [expressing the goal] in a more positive way."
A related concern is that ICPs may be reticent to "call" a condition an infection, meaning zero tolerance may have a chilling effect on surveillance. "In terms of getting to zero, ICPs are really feeling intense pressure not to [report conditions] as infections," said Loreen Herwaldt, MD, health care epidemiologist at the University of Iowa Hospitals and Clinics in Iowa City. "Particularly when you have had a period of time — like we had in our medical ICU — of eight months with no VAP [ventilator-associated pneumonia]. Then all of a sudden, you find a patient who you think has VAP. I think [ICPs] start questioning themselves."
The CDC traditionally has adopted "elimination" goals for diseases such as tuberculosis, polio, and measles, added Chesley Richards, MD, MPH, DHQP deputy director. "I don't really like the "getting-to-zero' nomenclature so I talk more about elimination," he says. "I'm not sure that they are that much different. We have a plan for TB elimination, syphilis elimination, eradication of smallpox, international efforts with polio. I realize there are some dangers in trying to translate that framework to hospital-associated infections."
Regardless, there is little sentiment for going back to acceptable benchmark ranges, and the concept of an "irreducible minimum" may be too arcane for public consumption. Richards argued that the "elimination" language could convey the sense of a mission and common goal when explaining HAIs to the public and state and federal legislators. "That's what people pay attention to," he said. "From my perspective we have got to get our arms around an aggressive goal that really protects patients and really gets us all on the same page in a serious effort to reduce infections. . . . I don't want to be overly simplistic. Does this mean we can eliminate all infections? Maybe not. But I don't think it means we can't have a goal to do that."
Indeed, it's not like the quest for zero has been without success. One of the paradoxical problems in terms of public perception is the staggering success that some programs are reporting by using checklists, infection prevention "bundles" and empowering all care members to stop procedures. Though conceding that recent studies have dramatically shown that infection rates can be reduced much lower than traditional wisdom envisioned, Edmond said the "zero" mentality has given patients the idea that every infection is preventable. "The problem of course is that we don't yet know the proportion of HAIs that is preventable," he said. "Recent studies suggest that the majority is indeed preventable, but an important message, particularly for the public, is that not all HAIs are preventable. I don't think we have done a good job articulating the distinction between preventable and nonpreventable infections."
Because of the widespread perception that infections are more the result of lapses or errors that can be prevented, regulatory powers are turning recommendations into steadfast law. "This transforms thoughtful nuanced recommendations into black-and-white, all-or-none prescriptions that may be associated with unintended consequences," he said. "Interacting external influences have arisen in response to the increasing perception held by Americans that health care is a commodity and the patient role is one of a consumer. Thus the key stakeholders are pushing hospitals to higher levels of accountability, increased transparency, and rapid solutions to highly complex problems."
Patient anger well above zero
As a result, patient expectations may have been elevated to the point that any infection perceived as resulting from care makes the providers culpable. Edmond reported receiving angrily worded e-mails from a relative of a patient who died with a MRSA infection at another facility, but had previously been admitted to VCU. "I ask you, is it difficult to imagine where such [anger] arises in this "getting-to-zero' world?" he said. "After receiving the e-mail, I investigated the case and found that the patient was admitted to our hospital with a MRSA infection."
Rooted in the criminal justice system and often used at schools regarding drugs and weapons, the zero-tolerance philosophy has sparked recurrent protests of inappropriate punishment in other areas. For example, an 11-year-old Georgia girl was suspended from school for two weeks in 1990 under a zero-tolerance weapons policy because a Tweety Bird emblem was connected to her purse by a small chain. "The problem with the zero-tolerance approach is the rigid response," Edmond said. "It's unreasonably harsh, it ignores context and it creates a punitive culture. An example of that occurred in my hospital last summer following the transmission of community-acquired MRSA in our neonatal intensive care unit."
A zero-tolerance approach to hand hygiene compliance was adopted in the NICU, which included placing observers in the unit to watch nursing care, he said. "This greatly stressed the staff and ultimately led experienced nurses to question good practice," Edmond noted. For example, one nurse asked if she had to act quickly in an emergency would the hand hygiene mandate be waived. "This is an example of zero tolerance," he said, citing another case where the approach became a wedge between infection prevention and patient safety. "[In] our NICU, when a single neonate was colonized with MRSA, that baby was given a one-to-one nursing assignment, which resulted in multiple other babies receiving suboptimal care by higher patient-to-nurse ratios," he told SHEA attendees. "I would argue that an infection-free hospital stay is not the be-all and end-all. Infection control must be balanced against other competing safety and quality issues."
Has this drive to simplify and standardize infection prevention collapsed the complex science of health care epidemiology into bumper sticker slogans? Edmond seemed to say so, but the recent success of checklists and bundles argues that simple is indeed, sometimes better. Still, he warned that infection control risks abandoning its scientific roots to appease a growing number of stakeholders in the field. "All of us in infection control are well aware of the complexity surrounding health care associated infections," he said. "A Medline search on the term "nosocomial infections' yields nearly 35,000 published papers and there are currently at least four textbooks on the topic. . . . "[G]etting to zero' simply fails to capture the complexity of health care-associated infections and seems to jettison over three decades of research in health care epidemiology."
As a practical matter regarding surveillance, it may make more sense to extend the parameters of measurement, Fraser added. "If you have increasingly rare events, then it makes more sense to expand the size of the denominator; so you go from counting infections per 100 admissions to counting infections per 1,000 patient days or 1,000 device days," she told SHEA attendees. "It is not unreasonable to think about using 10,000 device days or 100,000 device days. If you think about setting rates over time, then having one infection should not ruin your day or your life when you have infection rates that are excruciatingly low. What you want to do is avoid blame and punishment . . . . [while] trying to advance the science and the field. [Also], if we had better risk stratification, then it would help people understand what is potentially preventable vs. what is not."
A public education effort about HAIs may help convey the complicated origins of some infections and disabuse patients from the thought that they are all preventable. "I think we need to do a much better job educating the public about definitions, causes, risk factors, and about what's preventable while still engaging them with our enthusiastic commitment to eliminate hospital-acquired infections," Fraser said. "We could do a much better job of educating the public, politicians and other agencies."
For example, a common perception may be that reduced infection rates inevitably mean attendant declines in patient mortality, but such data are not easy to get at, Fraser added. "My concern is that even if we can reduce hospital-acquired infections — because of the nature of health care — there will be new procedures and higher risk to patients," she said. Philosophically speaking, Fraser added that American culture — as opposed to some other countries — has a general view that life must be preserved even if a patient is beyond expectation of recovery. Preventing infections in such patients will remain a challenge made all the more difficult by the burgeoning epidemics of diabetes and obesity in this country. While changing public perception will be difficult enough, the health care landscape itself is undergoing dramatic changes that will increase pressure to eliminate infections. In that sense, some aspect of the zero-tolerance approach may be here to stay.
"The reality is that people respond to their incentives," said Patrick J. Brennan, MD, chief of healthcare quality and patient safety for the University of Pennsylvania Health System in Philadelphia. "Five years ago, there were very few incentives except the moral [imperative] of needing to deliver the best and highest-quality care. Now organizations are under the gun financially for nonpayment, threats of increasing liability as a result of transparency, and being stigmatized through public exposure. That has created a different set of incentives."A fascinating, philosophical exchange among some of the nation's leading health care epidemiologists recently came down to the value of zero.
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