YES – Eliminating HAIs is feasible and may help better focus prevention efforts.
For many years, research suggested that reducing hospital-acquired infections (HAIs) by one-third was the best we could do. But recent landmark efforts, such as the Pittsburgh Regional Healthcare Initiative (Morb. Mortal. Wkly. Rep. 2005;54:1013-16) and the Michigan Keystone Project (N. Engl. J. Med. 2006;355:2725-32), have shattered our notions of how many HAIs might be preventable, achieving reductions of nearly 70% in central line–associated bloodstream infections (CLABSIs). Similarly, a national campaign in England has achieved a 68% reduction in Clostridium difficile infections (Health Prot. Rep. 2012;6:38).
Dr. Arjun Srinivasan
These new data suggest that possibly all HAIs are preventable, and there are now many published reports in which institutions have reached zero. For example, the Hawaii experience has shown that a prevention initiative achieved a median rate of zero catheter-related bloodstream infections (Am. J. Med. Qual. 2012;27:124-9).
The advances in HAI prevention are coming in the context of an ever increasingly sick patient population, with patients who are more complicated than ever before. In fact, many of the greatest gains in CLABSI prevention have been among the very sickest patients in our hospitals – in the intensive care unit – as at the Johns Hopkins Hospital in Baltimore (Crit. Care Med. 2004;32:2014-20). So the rationale that we cannot get to zero because our patients are too sick simply is not relevant anymore.
We won’t know how many HAIs are preventable until we hit the bottom. But if our goal is not zero, we will likely end up accepting some infections that might be preventable. Therefore, we must set the goal at zero infections.
What if we don’t get there? That would suggest that some of these infections might not be related to health care delivery but rather to patient risk factors. And these are the infections that we can target. New research could end up preventing some of them. Modifications in definitions might be necessary to account for some of these infections.
One might then argue that we are just defining our way to zero. I would counter that plenty of places have, in fact, hit zero CLABSIs without any changes in our current definitions. But I will also argue that rational changes in our definitions will be needed to help us differentiate truly preventable HAIs and allow us to better focus our prevention efforts.
An excellent example is the new definition of the mucosal barrier injury–related bloodstream infections, which was discussed during the recent IDWeek. Making such an evidence-based change to a definition to focus prevention efforts is neither gaming nor cheating—it’s called good science and good policy.
The zero goal will also improve medical care through the wider adoption of best practices. Published reports of HAI prevention efforts show the successes have been obtained through the implementation of best practices, not through gaming, not through cheating. Zero HAIs as a goal is already driving real improvements in patient safety and quality.
Pushing for zero HAIs will also further research. How much can we argue for pushing the prevention research envelope if we decide that some of these infections are simply okay? How are we going to argue for funding for more prevention research if we tell them the infections aren’t really preventable? We will be much more successful if it’s clear that we need it to get to zero HAIs.
Getting to zero has been put forth as a goal that we should aim for, not as a standard that people should be punished for in the event it is not attained. In fact, value-based purchasing rules are based on relative infection rates – not on zero infection rates.
Moreover, it’s a long-range goal. This is not something that anyone is advocating for overnight. Evidence of that can be seen in the National Action Plan to Prevent HAIs, which calls for 30%-50% reductions, not zero, as the target for the first 5 years.
It must be acknowledged that sometimes an HAI is someone’s fault. Many U.S. institutions have yet to implement best practices for preventing CLABSIs, for example. How long can we hold these hospitals blameless for failing to do this?
In sum, getting to zero HAIs is not the right medicine, but the only medicine. It is our successes, published in our own medical literature, that have prompted the push to get to zero. We shouldn’t run away from the success that we have had; we should embrace it and build on it. Patients will no longer accept a goal of preventing some HAIs, and neither should we.