A Skeptic Becomes A True Believer

By Manoj Jain
Special to The Washington Post
Tuesday, February 10, 2009

I was skeptical when my hospital embarked several years ago on an initiative to reduce the number of hospital-acquired infections in our intensive care unit.

These are infections that originate from the tubes and catheters inserted into the body -- for example, ventilator-associated pneumonia, related to a tube lodged in the windpipe to assist in breathing; urinary tract infection, related to a catheter inserted into the bladder to drain the urine; and bloodstream infection, related to a catheter threaded in the veins reaching the upper chamber of the heart.

Mind you, the tubes are critical for life-sustaining functions (breathing, nourishing, medicating and eliminating waste) during a serious illness when the body's organs are failing. The problem is that during the recovery period, some of the trillions of bacteria that live on a normal person's skin and in the alimentary, urinary and respiratory tracts begin to tunnel alongside the tubes into places they don't belong. Here they can cause life-threatening infections.

Before our initiative, for every 1,000 "device days" (for example, 100 ICU patients using one of those devices for 10 days), seven patients would get pneumonia, six would get blood infections and four would get a urine infection. That was the norm. In fact, for years I thought that hospital-acquired infections were the price we had to pay for intensive care. "You stay two weeks in the ICU and you get an infection -- that's not unusual," we would tell families.

And, honestly, it seemed to be a fair price. Patients with severe congestive heart failure and fluid in the lung are kept breathing by a ventilator until the heart recovers, the lung fluid clears and they are breathing on their own. Within a week they're back at home. So what if 10 percent of patients develop infections? We have powerful antibiotics to combat them. And so what if the treatment is expensive? (A ventilator-associated pneumonia or a bloodstream infection typically adds nearly $25,000 to the patient's hospital bill.) Medicare or an insurance company is paying.

Most important, without the devices, many of these patients would surely have died.

So as I said, I was skeptical when my hospital joined the quality improvement initiative led by the Institute for Healthcare Improvement, a nonprofit founded by Harvard pediatrician Donald Berwick.

Berwick is in the vanguard of nationwide efforts to reduce medical errors, standardize treatments, cut waste and bring patient-centered medical care to the bedside. Some 4,000 hospitals, including ours, participate in his institute's programs. In the case of our staff, Berwick insisted that we could reduce and even eliminate hospital-acquired infections.

Within a week after our first collaborative meeting (this was in the fall of 2002), the IHI team suggested that the ICU doctors and nurses at our hospital begin to use a checklist for every patient. For a patient on a ventilator, for example, it would include raising the head of the patient's bed to 30 degrees to prevent gastric secretions from going into the lung; seeing if ventilated patients could handle reduced sedation, so they could be extubated earlier; giving peptic ulcer prevention medicine to prevent gastric bleeding; and giving blood thinners to prevent clots in the leg that could potentially travel to the lung and cause a fatal pulmonary embolus.

Those sets of orders became known as an IHI "ventilator bundle." Similarly we had a "UTI bundle" for people with urinary catheters and a "central line bundle" for those getting catheters into the deep vessels close to the heart.

That last bundle required doctors to wear a sterile gown, mask and gloves before placing a central line -- a fairly obvious idea. I questioned how repeating such routine injunctions could have much effect on our infection rates.

But the truth is, at most hospitals in America, we have been far from 100 percent consistent on routine procedures. Berwick and the IHI realized that following those orders every time without a written guide was unrealistic. Airline pilots are not expected to do pre-flight checklists based on memory.

The quality improvement initiative forced us to look at the process, measure the results, provide feedback to key people and develop strategies to improve the care of our patients. Yet it all started with those checklists.

In fact, checklists may be one of the great medical innovations of recent years. Take the work of Peter Pronovost, an anesthesiologist at Johns Hopkins Hospital, rated one of the top 100 most influential people in the world last year by Time magazine. By implementing a checklist on the insertion and management of central venous lines with the help of Pronovost and his team, ICUs in Michigan hospitals reduced bloodstream infections to nearly zero.

Last month the New England Journal of Medicine published an international study led by Atul Gawande, a surgeon at Harvard, on implementing a checklist for surgical patients. It included common-sense things such as confirming the correct surgical site (left leg, not the right, for amputation) as well as technical checks, such as making sure antibiotic prophylaxis is given zero to 60 minutes before surgery, when it is most effective.

One item on the list is "Confirm all team members have introduced themselves by name and role." Studies have shown that a member of a health-care team is more likely to speak up when something is wrong if the members know each other by name.

That team concept has been key to the initiative at our hospital. Each morning, the ICU physician leads multidisciplinary rounds with the patients' nurses, ICU charge nurse, pharmacist, dietician, respiratory therapist and many others. That was a major change in our behavior, and its benefits were quickly apparent. With everybody on the team feeling responsible for reducing the number of infections, nurses became more vigilant, criticisms were welcomed rather than resented, and administrators began tracking infection rates like they tracked the budget and hospital census.

What was the result of all that effort?

After two years, we saw a 50 percent decline in our ICU infection rate, with a 21 percent (or $702) reduction in cost per ICU discharge. I was no longer skeptical; in fact, I often joked, "If this trend continues, I'll be out of a job as an infectious-disease consultant." Our hospital team, along with Berwick, went on to publish the results in the journal Quality and Safety in Health Care.

An interesting footnote: There were some resisters at our hospital -- often, unsurprisingly, the traditionally autonomous physicians. One afternoon in our infection-control meeting, an ICU nurse complained about a surgeon who refused to fully drape and wear a mask when placing a central line. He argued there was "no need." The nurse asked me what she should do.

With the firmness of a convert, I told the nurse: "Be a Rosa Parks. If it is not an emergency, and the surgeon refuses to follow the protocol, do not assist the surgeon in placing the line. I will back you up."

Thereafter, the surgeon complied. The hospital's culture of patient safety and quality had changed. And our efforts continue.

Manoj Jain is the medical director at Medicare's quality improvement organization in Tennessee and an adjunct assistant professor at the Rollins School of Public Health at Emory University in Atlanta. Comments: health@washpost.com.