Grime and Punishment: Why Best Practices Matter (Part I)


We’ve had a lot of discussions on this Blog about metrics and best practices. Because they’re very important. Whenever I talk to colleagues who haven’t adopted a policy of best practices, they assume that A) It’s very difficult to identify best practices that will have a big impact and B) Putting these best practices in place will require tremendous effort. While I can’t deny that this can sometimes be true, a lot of best practices are a lot easier to deal with. That includes practices that can save huge amounts of money and even save lives. To demonstrate this, today we are going to look at best practices in health care. Specifically, we are going to look at the growing number of Central Line Infections that occur in hospitals.

A Central Line Infection (CLI) results when a “central line”, the needle and flexible tube, is inserted into a patient to connect an Intravenous feed to deliver drugs or other materials directly into the blood stream. A CLI is extremely serious, dangerous and expensive to the individual and the hospital. Let put a few numbers to this. Studies on the cost of a stay in a hospital, especially a stay in Intensive Care (your likely destination if you have a serious infection), and studies on the number of CLI’s each year, vary tremendously. However, we can do a quick estimate on the minimum cost. There is general agreement that at least 100,000 CLI’s occur annually in the US with 30,000 becoming fatal. To put that in context, in 2009 15,000 American’s were murdered. CLI’s are twice as deadly as all homicides. That’s pretty huge. The cost? In 2005 RTI International released a study of Michigan hospitals that estimated that a day in ICU cost $2,400. Let’s assume that a survivable CLI costs two days in ICU and a fatality costs four days, plus additional death costs of $10,000 (administration, autopsy, burial, etc.). The literature tells us that our estimate is low, because the first day or two in ICU is usually much more expensive, and the costs tails off in later days. But let’s stick with this very conservative estimate. Which doesn’t address other costs, such as law suits from the surviving members of the family.

That’s an annual cost of $336 million for survivors and $588 million for fatalities, just short of a billion dollars and 30,000 dead Americans! If you think that your operation is under pressure to improve performance and reduce costs, imagine the situation in health care today (just watch the battles over the Federal budget). How difficult would it be to reduce CLI’s? It turns out that comprehensive reports were developed at least as early as 1996…. 15 years ago, or  450,000 deaths ago. The literature outlines a laundry list of changes to procedures, which would reduce CLI’s by 66%. Some hospitals have followed these guidelines and completely eliminated CLI’s. How complex are these procedures? Well, we are talking about the complex world of modern medicine, so these procedures may be too technical for some of you but please bear with me. Here are the top recommendations:

  1. Clean your hands, before sticking a needle into a patient: Your mother may have introduced you to the best practice of cleaning your hands some years ago. Apparently, it’s still a best practice.  
  2. Clean the insertion site on the patient, before sticking a needle into the patient: OK this is more complex. If you grandmother ever cleaned some dirt off your face with her saliva, this is NOT a best practice. Training to “use a recommended disinfectant” may raise the cost of training.
  3. Use gloves, a mask and a hairnet, before sticking a needle into a patient: OK, grandma didn’t have anything to say about this. But it’s still a good idea.
  4. Don’t use a LCI if you don’t need to: No central line, no CLI. Perhaps a pill will do.
  5. Remove central lines when they are not needed: For example, you were to receive a one-time medication and no other drips are needed. TAKE OUT THE NEEDLE! 
  6. If the items above are too complex to implement, focus on just the first 2, which may deliver 80-90% of the benefits.

I think this deservs a “WOW”. If that much improvement can result form these changes, shouldn’t this already be solved? What’s wrong, and what can we learn from the problems with CLI’s? Tomorrow, I’ll finish this case study and see if we can apply what we’ve learned to your organization. But for today, that’s my Niccolls worth!

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