Point-Counterpoint: Hospital-acquired infections: Is getting to zero the right medicine?
Dr. Srinivasan is associate director for health care–associated infection prevention programs, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention. He disclosed no relevant conflicts of interest.
NO – Eliminating HAIs is unrealistic and has unintended negative consequences.
There are a variety of reasons why getting to zero HAIs is not the right medicine. First and probably most important is that it is dishonest. Patients today are sicker and more immunosuppressed, and the devices we use are ever more invasive. When we have patients in our hospitals who, for example, have total artificial hearts in place for more than a year, can we realistically imagine that there would not be any HAIs? I don’t think so.
Extensive medical literature documenting infection prevention initiatives attests to this. For example, a recent analysis suggests that even if all U.S. hospitals implemented all of the measures known to prevent HAIs, at best 55%-70% of common HAIs would reasonably be preventable (Infect. Control Hosp. Epidemiol. 2011;32:101-14). None were found to be 100% preventable.
If one looks closely at the Hawaii experience showing a median rate of zero HAIs, you actually see a 61% reduction in the rate of CLABSIs over 1.5 years, but it never reaches zero (Am. J. Med. Qual. 2012;27:124-9). That translates to up to 10 infections per quarter. So we can use words in loose ways and talk about zero median infections, but there were not zero infections in that study. If the final rate of 0.6/1,000 catheter-days were applied to my hospital, it would translate to 11 CLABSIs annually – hardly a number that would allow me to say I had eliminated these infections.
Efforts to achieve zero HAIs may be a manifestation of postmodernism, a philosophical paradigm in which there is no absolute truth, and one that puts evidence-based medicine on par with practices such as homeopathy and the notion that the measles, mumps, and rubella vaccine causes autism.
Aiming for zero HAIs drives a punitive culture. If we accept the concept of getting to zero, it then means that zero is actually attainable, and if that is true, then all HAIs are preventable. And if that is true, logic tells us then that the occurrence of an HAI must be someone’s fault.
The zero goal places enormous pressure on infection preventionists and their programs, and it creates adversarial relationships between infection prevention services and clinicians as they argue about whether an event is an infection. Hospital administrators ask why programs are not reaching zero. And the infection prevention people are caught in the middle of all this. They are in a terrible position: In some cases, they are deciding – in a way – whether people will get a pay raise or will be fired from their jobs.
Trying to eliminate HAIs fosters problems with surveillance, such as outright cheating, making subtle changes to case definitions that reduce infection rates, and underfunding infection prevention programs to reduce their sensitivity for case ascertainment.
It also leads to inappropriate medical practices. For example, many hospitals now check urine cultures on admission in patients with urinary catheters, or obtain blood cultures on asymptomatic patients simply because they have a central line. We know what those kinds of practices lead to nonindicated treatment and overuse of antibiotics.
Aiming for zero separates infection prevention from quality and safety because now, the "be all, end all" becomes an infection-free hospital stay, when maybe that is not the main goal from a patient perspective.
The zero goal also fosters expedient solutions over the hard work of behavior change. A report predicts that, in 2016, the market for infection-control devices and products will be $18 billion – triple that of the market for antibiotics to treat those infections. So there’s a lot of industry out there waiting to get into the market. That in turn contributes to a conflict of interest. Some leading infectious disease associations now have strong sponsorship from these industries that is likely not serving us well.
Aiming for zero also punishes hospitals that care for poor and sicker patients. As an example, in public reporting of hospitals’ infection rates, academic medical centers may appear to have comparatively worse performance.
Finally, if we already know how to get to zero, why would we ever invest any more in research to reduce infections? It really weakens the rationale for funding in the whole field of HAI prevention.
In sum, getting to zero HAIs is not a realistic or beneficial goal and may actually produce many unintended negative consequences. Clinicians and patients alike would be better served by a focus on achieving realistic reductions.
