Call to action: ICPs must take leadership role in patient safety movement

Epidemiology approach can reduce medical errors

Infection control professionals must seize a critical but fleeting opportunity to take leadership in the nation’s growing patient safety movement or risk getting swept aside by an issue that has captured both public imagination and political capital, a leading epidemiologist urges.

"This is a big change — a watershed event. Infection control practitioners and all health care epidemiologists need to see what is going on. The river is about to change and they need to jump on and ride it around the corner. Otherwise they’ll drown," Robert Haley, MD, a professor in the department of internal medicine at the University of Texas Southwestern Medical Center in Dallas, tells Hospital Infection Control.

A former director of the Centers for Disease Control and Prevention’s hospital infections program, Haley described the patient safety movement as a call to action at the CDC’s 4th Decennial Inter na tional Conference on Nosocomial and Healthcare- Associated Infections, held in March in Atlanta. The patient safety issue has rapidly gathered momentum since the Institute of Medicine (IOM) reported that tens of thousands of patients die annually as the result of medication mistakes and other preventable medical "errors."1 (See Hospital Infection Control, February 2000, pp. 17-21.)

The Clinton administration recently earmarked $20 million to support a Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality (AHRQ) in Rockville, MD. In addition, the president cited the IOM report in calling for the establishment of medical error reporting systems in all 50 states. It remains an open question whether nosocomial infections will be included in those reporting systems, which will collect data on medical errors that lead to death or serious injury.

Haley was initially skeptical of the IOM report, noting that it could be criticized for extrapolating from old data, not sufficiently accounting for attributable mortality in its estimates, and attempting to solve a problem by forming another government agency. But the bottom line is that it addresses an important issue that immediately captured the imagination of both the public and politicians, he said.

It would be a mistake to view the report as an obstacle rather than an opportunity, he told conference attendees. "This is an election year, with both Houses potentially at risk," he said. "[That] produced a match, and the IOM report came out like a can of gas. . . . One thing I’ve learned in my fifty-x’ years of life is about politics. Politics in America is the broad movement of opinion of the average citizens. When that bubbles up something big like this, you’re crazy to stand in the way of it."

Indeed, the regulatory nature of the patient safety movement has raised concerns among health care leaders and clinicians alike, creating the opportunity for ICPs to show increased value, he emphasized. "Let me tell you, this dwarfs anything I have seen in this field in over 25 years of working in it. This is a big deal," he told conference attendees. "It is a great opportunity. It is going to change hospitals for good, better or worse. It is an opportunity for us to get involved."

ICPs were slow to react when quality improvement movements really began to take hold some 15 years ago, Haley noted, adding that, "We have been ruing that ever since. [Now] most of us work for those people. Here comes another opportunity. The whole playing field is level again. Enlarge the scope of health care epidemiology to include medical error epidemiology and reduction."

Patient safety and health care quality issues became a predominant theme at the conference, with the CDC hospital infections program announcing research initiatives in the area as part of a previously planned name change and expansion of its mission. While emphasizing that infection control and health care epidemiology will remain its core focus, the CDC program wants to project a broader quality image. Though it may be a year before the name change is finalized at the government agency, the proposed new name is the Division of Healthcare Quality Promotion & Infection Prevention. "We are the premier experts in promoting health care quality, and we should acknowledge that, build on that tradition of excellence, and take ownership of that domain in the health care settings," Julie Gerberding, MD, MPH, director of the program, told conference attendees.

While the program was reassessing its mission long before the patient safety movement took center stage, Haley’s assessment of the importance of the issue is on target, added Steve Solomon, MD, chief of special studies activity in the CDC hospital infections program.

"You don’t need a weather man to see which way the wind blows," Solomon told attendees, quoting the classic Bob Dylan song lyric. "Bob Haley told us very eloquently which way the wind is blowing, and I certainly subscribe to his view. . . . It is time for us to move a little more aggressively into noninfectious areas because we already have the ability to collect that data. There is a tremendous amount of data available, and in the process of gathering data on complications [we can] get the data on noninfectious complications. . . . We need to understand the outcomes and make a cost-effective case for whatever we are doing, whether it is medical errors [or] whether it is infection control."

In that regard, the CDC program is stepping up research on patient safety issues and nosocomial infections, including whether and to what degree infections are the result of preventable errors, Solomon tells HIC. "It is a very important issue for us, and it is our intention in the hospital infections program to devote a significant amount of our resources over the next few years to this whole issue of defining the relationship between health-care associated infections and patient safety," he says. "Whether or not there is an error’ component to this is something we need to look at very carefully."

Haley directed the landmark CDC Study on the Efficacy of Nosocomial Infection Control (SENIC), which produced the much-cited estimate that only about one-third of infections are preventable.2 Whether that proportion is still accurate across a changed health care landscape is questionable, but there is little sense in getting mired in a debate about fractions of preventability, Haley noted. When the SENIC project was being conducted 20 years ago, only about half of hospitals even had a trained ICP, he said. "Now we have an army of nurse and physician epidemiologists in these hospitals," he tells HIC. "We have quality and risk management people. We have a huge force of people who know about this problem now, and it is a matter of synthesizing all this into a better direction."

Error issue will scare’ up funding

Health care epidemiologists and other quality improvement professionals may well have the skills to track and prevent medical errors, but will funding be forthcoming to develop such programs? Individual health care systems and third-party payers like the Health Care Financ ing Administration (HCFA) are going to have to provide resources if the programs are mandated, conference speakers noted.

"Who pays ultimately are the purchasers," Gerberding said. "HCFA is currently the largest purchaser of health care in the world, and they are the ones that are going to have to step up to the plate if they feel the program is worth investing in."

Moreover, health care providers are taking the issue seriously because the thought of reports of medical errors is "embarrassing" from a public relations standpoint and also raises liability issues, Haley added. "It is really up to us to conceive what the program is," he said. "What is going to be valuable to the institution [and] cost-effective to reduce these problems and improve quality? I think they’ll buy it because they are scared of this [issue]. This should be very frightening to these health care systems."

A long-time proponent of "surveillance by objective," rather than general tracking of a wide variety of infections, Haley urged use of such epidemiological models to report errors to clinicians. To do so, ICPs will have to establish specific case definitions and use risk-adjusted data for comparison with a control group. Measurements must be fed back to the hospital personnel who are in charge of the risk factors in order to truly change the situation, he emphasized.

"The infection control movement has demonstrated the power of feedback of risk-adjusted rates to reduce risks," Haley said. ". . . The epidemiologic model in quality improvement is, what is measured is controlled.’ If it is not measured, it is up to every [individual] doctor to fix it or not. Measure specific outcomes. Don’t measure medical errors in general, measure [specific] medical errors. If you measure specific ones, they will come under control."

Enhance safety with evidence-based’ model

As patient safety and reporting systems are set up, Haley urged ICPs to lobby the state agencies collecting the data to model the CDC’s National Nosocomial Infections Surveillance (NNIS) system. "Bring pressure on these agencies to provide research and leadership rather than fodder for the lawyers," he said.

Indeed, dramatic decreases in infection rates at CDC NNIS hospitals underscore that well-run infection control programs can provide an "evidence-based" model for the patient safety movement, John Eisenberg, MD, MBA, director of the AHRQ, said in the conference’s keynote address. In addition to declines in respiratory and urinary tract infections, the CDC reported a 44% decline in these hospitals’ bloodstream infection rates in medical intensive care units during 1990-1999.3

Eisenberg said the system is a particularly good model for reporting medical errors and other adverse outcomes because it uses evidence-based, clinically sensitive case definitions and a well-trained cadre of ICPs to implement interventions. "Let’s build on NNIS, learn from it, and make it a model for the other reporting systems that we have in this country," Eisenberg told attendees.

NNIS is emerging as a "benchmark network" model for confidential error-reporting systems in CDC discussions with AHRQ and other quality groups, Gerberding added. "Behind the scenes, there are things going on that we hope will be constructive and contributory," she said. "The concept of a benchmark network of facilities that contribute data about medical error rates or other medical problems . . . is an idea that we very much support, in part as it relates to the medical error reporting issue, but also as it relates to our core business."

But while NNIS is a state-of-the art benchmark network for compiling and comparing rates, the individual patient with a nosocomial infection will find little comfort in being a statistic in a top-flight data system, Gerberding reminded.

An n’ of one

"Does the patient with the infection say, Well, thank goodness the facility is lower than the 25th percentile [in NNIS] so it is not a problem that I am bacteremic?’ I don’t think that is the way the patient looks at it," she told conference attendees. "When we look at that patient, we need to keep in mind that from the individual patient’s perspective that maybe that infection was preventable, and we missed the boat. We have something to learn by looking at that infection and trying to figure out what went wrong here. What happened? What was the cause of this problem? Was the catheter left in too long? Or was the patient just simply very sick and really needed that catheter? . . . There is an individual here, and is there anything we could have done with this n’ of one to [solve] the problem?"

(Editor’s note: The IOM report is available on the Internet at http://books.nap.edu/html/to_err_is_ human/.)

References

1. Institute of Medicine Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

2. Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in U.S. hospitals. Am J Epidemiol 1985; 121:159-167.

3. Centers for Disease Control and Prevention. Monitoring hospital-acquired infections to promote patient safety — United States, 1990-1999. MMWR 2000; 49:149-153.