Thursday, March 27, 2014

A fictional hospital story: Is it really fictitious?

File:Guantanamo captive's hospital beds -c.jpgThis vignette is an amalgam of conversations with several colleagues over the last couple years. It is completely fictitious.

Surgical site infections (SSIs) had increased in the last year at Generic General Hospital (GGH) and the president of the hospital wanted action. The infection control staff met and decided upon a set of interventions for SSIs that they then implemented in their surgical step down unit. The interventions included a campaign to raise awareness of SSI risks, an increased emphasis on hand hygiene, and the implementation of a new wound care protocol. During a 60 day trial period, intensified surveillance in the unit suggested that these interventions had reduced SSIs by 50 percent.

While it might appear to be a success story, the CEO of Generic Medical System (GMS), the owner of GGH and several sister facilities, including Generic Rehabilitation, Generic Skilled Nursing Care, and Generic Community Oncology, was curious. When briefed on the success, she wanted to know if the intervention was sustainable in the step down unit and whether it was generalizable to infection control in other GMS institutions, which also had moderate infection rates. She further asked if the resources taken from the small infection control budget at GGH for this pilot had resulted in increased incidence of HAI in other hospital wards and units. And of course she needed to know if the interventions would save money in the short and longer terms.

At a meeting called to address these questions, GGH staff decided that only continued surveillance would answer the issue of sustainability. They believed the intervention was generalizable to sister facilities (but when challenged later, they couldn't explain why, other than offering “expert opinion”). The staff didn’t have data on potential changes in the incidence of infection in other parts of GGH because the money and resources dedicated to the step down unit pilot program had resulted in decreased surveillance in other wards. One of the three infection control nurses covering the entire hospital was dedicated to the pilot, leaving a 33% reduction in person-power needed to collect and chart the statistics in the rest of GGH. Nobody had any idea of cost savings.

The CEO wasn't pleased. She explained to her leadership team the importance of sustainability, generalizability, avoidance of unintended consequences, and improving the bottom line. She noted that hospitals are zero sum enterprises: they have finite budgets, and in the absence of grants or donations to support trial patient safety interventions, what is focused on one activity must be taken away from other activities. In the example of the SSI interventions, she noted that the intensified surveillance dedicated to assessing that program diverted surveillance resources and left “blind spots” elsewhere in the institution.

She illustrated the point in the following way. Of the $10K GGH annual budget for HAI prevention, $2K was spent on posters and buttons promoting hand hygiene in the step down unit. Normally, that $10K was evenly distributed amongst wards across the hospital, but with this special project only $8K was left for routine prevention activities in other units. It wasn’t unreasonable to expect that there might be increases in HAIs in those wards, assuming the yearly $10K investment was having an effect in the first place.

To illustrate, she asked them to suppose that had been an increase in HAI in the transplant unit following the decreased prevention investment there. During the study SSI evaluation period -- the period of intensified surveillance in the step down unit -- it probably would have gone unnoticed, as part of the infection control staff were assessing the interventions in the surgical step down unit, instead of collecting routine HAI surveillance data in the rest of the hospital. In that case, the negative impact in the transplant ward would have been an unobserved and unintended consequence of the otherwise successful interventions in the surgical step down unit.

The CEO lectured her staff on the phenomenon of unintended consequences, cautioning them that the degree to which changes in standard operating procedures (e.g., hospital infection control or other patient safety interventions) result in unintentional consequences is unknown and requires additional research. She lamented the lack of a research group to address these and related issues. Perhaps one day, she thought, someone would do the research and develop evidence-based guidelines on the relevant issues. Until then, the leaders of GMS had limited options for reducing HAI throughout their network of facilities.

There are several key points illustrated in the vignette. First, unintended consequences of seemingly good ideas can occur. Second, existing programs can be impacted when new initiatives are launched if additional resources aren't provided. Third, because generalizable approaches are desirable, it is critical that researchers anticipate questions such as those the CEO asked her staff.

(image source: Wikipedia)