May 21 2010
The Institute of Medicine report is a frequent ‘rebuttal’ to science based/real medicine. The argument is usually phrased something to the effect that since medicine can be dangerous, SCAM’s are legitimate. Of course, one does not follow the other. It is the equivalent of saying since you are old, bald and pudgy, I am young, have a full head of hair, and are thin. If every doctor and hospital were to vanish tomorrow like an episode of the Outer Limits, SCAM’s would be just a ineffective.
Despite the flawed logic of the comparison, I have always had an affinity for the estimates that 44,000 to 98,000 were (note the deliberate use of the past tense) killed each year in hospitals. There may be methodological flaws in the estimate but the ballpark figure is probably correct.
In 1999 there were 5000 hospitals in the US. Just one death a quarter would bring the number of deaths to 20,000, and one death a quarter is not that many deaths. Lest I sound hardhearted, everyone dies, 2.5 million a year, and often death occurs in the hospital. Against the background of the mortality of existence, a few ‘extra’ deaths would be lost in the background.
For an individual doctor, it would be indistinguishable against the background death rate in the hospital. What makes it even more difficult to track and recognize excess mortality is that each death may be due to a different breakdown in medical practice.
Amongst my many jobs is Infection Control. For twenty years I have chaired Infection Control for both the Legacy Health, a collection of 5 hospitals in the Portland-Vancouver area, as well as for Portland Adventist Medical Center. As Chair I get the joy of sitting on many other committees such as Quality Council and Pharmacy. I know all the way hospitals could kill and the endless efforts to try and improve and perfect medical practice to avoid these complications.
In 20 years of investigating outbreaks, hospital acquired infections, and deaths, I have yet to see two infection related deaths that are due to same cause. Every infection was reviewed and evaluated as a potential for improvement, and I think we practiced the best medicine we knew of at the time.
With one exception, the universal horse shit compliance with hand washing that was the norm 20 years ago. It always boggled my mind that it was difficult back in the day to get people to wash their hands. The information on efficacy was only 150 years old, after all. But otherwise we practiced state of the art medicine. With the perfect vision of hindsight, I can see that state of the art left much to desired. We didn’t have the studies to guide practice that we have now, and I anticipate that 20 years from now I will be rolling my eyes at how we practiced in 2010. I will sound just like Bones McCoy wandering throughout a 1980′s San Francisco hospital grumping about the butchers of the past and hoping I do not run into T.J. Hooker.
Unlike the hodgepodge of practices that comprise SCAM, medicine changes and mostly for the better. Change is always slow, and always painful, and more difficult to implement than one could ever anticipate, but if you read the medical literature, you have to change.
Hospital based medicine is mind bogglingly complex and difficult, and humans are limited in their ability to always function perfectly. The Institute of Medicine knew what it was doing when they entitled their report “To Err is Human.” And all too often we were not able to pinpoint a breakdown that lead to a complication or death
When I started practice back in the last century, I would have thought that hospital acquired infections were part of the price of taking care of ill and compromised patients. Sure, we can minimize infections, but wound infections, ventilator pneumonias, and line infections are going to happen. You can’t do the things we do to people and NOT get an infection.
What both administrations at my hospital systems have in common is a commitment to patient safety and over the last decade they have committed considerable time and money to the application of proven procedures to decrease infections and other complications of hospital care.
You cannot know best practice based on individual experience. I like to tell the residents that the three most dangerous words in medicine are “In my experience.” You need large numbers of patients and studies to guide practice. The last 15 years have seen a large number of clinical trials aimed at discovering what is the best practice to prevent everything from line related infections to deep venous thrombosis. Dozens of science based investigations whose goal was to improve patient care in the hospital, and my hospitals aggressively applied them.
The first intervention was the use of alcohol foam instead of hand washing. I have in my mind, and cannot find the reference, that if a nurse would wash her hands appropriately after every contact, he would spend 80% of their shift washing hands. Soap and water, it turned out, was not a practical solution to keeping hands clean. It is too time consuming in a busy work day, despite it’s proven efficacy in preventing infections.
Alcohol foam can be used in a fraction of the time with superior results since it is much easier to foam frequently. And once I discovered it was not to be used orally like cheese whiz, the results were even better.
The foam is now ubiquitous in the hospitals. Even when the use of the foam was 20%, the overall infection rate in the hospitals fell by half when compared to rates with hand washing. Then, over the next decade, the hand hygiene compliance rate has steady increased to around 90% and there was a corresponding steady decrease in infections. It took over a decade of consistent work and a lot of trial and error to get the rates to 90%.
At one hospital the limiting problem was no foam outside the rooms. No one would walk an extra few feet to get to the foam. But at another hospital the fire Marshall said alcohol foam in the halls was a fire hazard and we could not put alcohol in the halls. He was eventually overruled, but what are you going to do in the meantime?
And I could go on for paragraphs about the issue of finding product that minimized the number of HCW’s whose hands where turned raw by the alcohol.
Ninety percent seems to be the best we can consistently achieve with the current program for hand hygiene, and we are puzzling over how to get the rates to 100%. One approach is the “It’s ok to ask” program, where patients are encouraged to ask their provider if they washed their hands. I asked a series of patients if they would ask, and they uniformly said no, they did not want to risk angering their health care provider. I agree. It is important not to piss off the person providing your morphine. Besides, would you fly on an airline if their motto was “It’s ok to ask if the landing gear is down.”
Last year I ran a red light. It was 7 am, I was taking the kids to school and I have to make a right then an immediate left across four lanes of traffic. I make this turn everyday. I am talking to the kids and I look several times, no traffic, and make the turns.
What I did not see was that the light was red nor did I see the cop stopped on my left. I was so intent on the traffic I missed two key features in my environment.
It is the main reason, I suspect, that we cannot get hand hygiene to 100% every time, every where. The hospital has too many opportunities to focus our attention elsewhere that, for the short term, allows us to forget to foam.
Somehow, and I do not know how, I suspect we need to make foaming the default rather than optional; then our rates will get to 100%.
But foam is not the only intervention my hospitals have implemented.
Surgical check lists, best practice bundles (collections of proven interventions gathered together) to prevent ventilatory pneumonias, to prevent intravenous catheter related infections, to prevent urinary tract infections, to prevent deep venous thrombosis. Innumerable checks and balances with pharmacy to prevent medication errors.
Simple things to prevent surgical wound infections but logistically difficult to get to 100%: timing of antibiotics to within an hour of cut time, no shaving the surgical site, not letting the patent get cold post op, and tight glucose control were are associated with decreased wound infections. Next up may be no staples with orthopedic cases as a recent meta-analysis demonstrated fewer infections with sutures. That will be fun, getting surgeons to alter practice.
Over the last year my hospitals have implemented dozens of practice improvements based on the medical literature to improve outcomes and the results have been amazing. Practices that were not effective were abandoned or modified, sometimes going through multiple iterations until were discovered was worked and was practical.
As a result, at Legacy we have prevented over 200 deaths (12.5% reduction in non-risk-adjusted mortality rate, which is now 1.47% for our system that includes a regional trauma center and regional burn center as well as two NICUs, oncology program, and multiple other high-risk programs) and over 570 prevented infections (39.5% reduction in whole-house infection count) above historical data. And that is over the most recent 24 months. At Legacy it is estimated we have also saved 8 million dollars in associated costs.
A few of the hospitals have gone a year without a ventilator associated pneumonia or a catheter related infection. Every year has seen a decrease in the healthcare associated infections and other complications.
That is 100 deaths prevented a year for 5 hospitals. Multiply that for the remaining 4,995 hospitals in the US and the IOM estimates for last century seem reasonable. But not for this century and not for the decades to come.
I used to think that infections were inevitable, but no longer. There is the occasional patient who will get an infection: the badly burned, the multiple trauma. But even the trauma ICU had a marked decrease in all infections with increased infection control compliance. We had a wound infection in a 400 lib patient who literally had dirt tattooed in the palms and soles and a Hemoglobin A1c of 15 who required emergency surgery. I was not surprised that patient developed an post-op infection. We did everything correctly and still had a complication. Sometimes the barriers we have to overcome to prevent infection may be too great, but it does not stop us from trying.
But the experience of Legacy and Adventist demonstrates that aggressive adherence to proven infection control works and that the majority of health care associated infections and deaths need not happen.
I have three epiphanies in my life: my first great meal (at a restaurant called St. Estephe’s), my first great Bordeaux (oddly enough, a St. Estephe’s), and when I realized that most infections in the hospital need not happen.
This has been a real decrease in infections and death, not just playing with numbers to look better. These hospitals look at every healthcare associated infection (HAI) as an improvement opportunity and do not sweep data under the rug.
I also know personally that the numbers are real. I used to derive a significant portion of my income from hospital acquired infections. There are many reasons why my income has declined by 60% over the last decade, not the least of which being large numbers of patients that used to make up my practice (HAI’s, AIDS) have disappeared. The majority of those 570 prevented infections would have been consults. I feel like Phillip Morris making stop smoking ads.
It was not easy making these changes; it took years of committed work. People are like oil tankers and change course slowly. And some are filled with toxic waste. An interesting aspect of instituting the policies and procedures has been who fought against the changes the hardest. Docs. Not all of them, just a small subset. There is a curious subset of MD’s who feel that the data does not apply to them. They do not need to follow infection control procedures, use full barriers when placing a line, or even wash their hands. And I do not get it. I cannot figure out why some docs are so recalcitrant about doing the right thing, the proven thing. Eventually everyone complied, but some people made it more painful than it needed to be.
My hospitals made a serious commitment to providing the best care as determined by the science. It was not simple and required a surprising amount of creativity and time to apply the evidence to the real world. But the nice thing is that when you apply science to problems, you get results. Science works. Quality initiatives work. Next time you point out the deaths caused by modern medicine, leave my hospitals out of it.
It makes me wonder. There are numerous naturopathic, chiropractic, and other alternative schools and clinics involved in patient care. I am sure that they too have numerous quality improvement studies to brag about that have improved patient care and outcomes.
Think of all the practices in medicine that, eventually, have been demonstrated to be worthless, or dangerous, or flawed and that were improved or abandoned for the betterment of patient care.
So let’s start a list, shall we. The following is the top 10 list of alternative medical practices that have been modified or abandoned because of studies that demonstrated they were ineffective or dangerous and the quality initiatives that have improved patient care:
1) Disposable acupuncture needles (thanks to wales)
Sorry. I found nothin’.
Perhaps it is a reflection of the perfection that is alternative medicine. Alternative medicine practices change based on evidence? No need.
Of course, I may well be wrong. As the board president of the Oregon Association of Naturopathic Physicians states, “Both MDs and NDs are trained to work from the evidence-based model of medicine, using best practices and standards of care.” I suppose my inability to find examples is due my inadequate Google and Pubmed skills to find the readily available information. I would have my 13 year old do it for me, but he is on a trip. Even if only 25% of medicine is science based, that is still 25% more than alternative practices.
Please, please, please, someone show me up. Hell, just give me some hand hygiene improvement data and let me know that, if nothing else, there is an understanding of germ theory in the alt med world. Ever since my local paper, the Oregonian, printed a picture of the local Natural Medicine School teaching acupuncture without gloves, I am not so sanguine about that understanding. It still gives me the willies to see that photograph and it looks for all the world that there are two boxes of gloves in the background, so I know they have them. It may be that all the gloves are left handed or right handed and so cannot be worn. Sometimes I pull out a glove for the right hand and it is a lefty glove and then I pull out a glove for the left hand and it is a righty, so I cannot find a pair to wear. It’s a problem.
Medicine slowly improves, too slowly sometimes. I know that 20 years ago we did not have the information to inform our practice that we do now. We did the best we could with what we knew at the time, and we do the best we can now with the information we have today. Still, despite the impressive improvements, it is a bittersweet victory. I can’t help but think what could have been, if only we had known.
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