Special Edition on Infection Prevention & Control | Page 36

APIC’s efforts to create a culture of zero tolerance for noncompliance
with measures proven to prevent HAIs, as well as
demonstrates to healthcare administrators and clinicians how
they can implement effective strategies and simpler systems
for protecting patients from HAIs.
The concept of zero tolerance emerged in 2000 when
then-director of the CDC Julie Gerberding, MD, MPH, noted
that the goal of elimination had been applied to other public
health imperatives, according to Warye and Murphy (2008). A
few years later, the idea of getting to zero surfaced when APIC
published APIC Vision 2012, a strategic plan for the future.
According to Warye and Murphy (2008), Goal 1 of the plan
stated that APIC will “promote prevention and zero tolerance for
healthcare-associated infections.” They
add, “Since that time, APIC’s approach
has evolved and focused instead on
promoting a culture where targeting
The ‘getting to
zero’ movement
is the product
of three forces:
the expansion
of external
pressures
on infection
control
programs, the
intrusion of
suboptimal
evidence,
and the
convergence
of quality
improvement
and infection
control.”
zero healthcare-associated infections is
fully embraced.”
As Edmond (2008) observed, “The
‘getting to zero’ movement is the product
of three forces: the expansion of external
pressures on infection control programs,
the intrusion of suboptimal evidence, and
the convergence of quality improvement
and infection control.” Edmond (2008)
explains that consumers and consumer
watchdog groups have priorities that
may not be fully aligned with those
of infection prevention experts, and
that professional organizations may be
allowing other stakeholders to dominate
the agenda. He notes, “These external
influences have arisen in response to
the increasingly common perception
that healthcare is a commodity and
patients are consumers. Thus, the key
stakeholders are demanding higher
levels of accountability, increased transparency,
and rapid solutions to highly
complex problems.”
Edmond (2008) argued that getting
to zero is a product of the convergence
of quality improvement with infection control programs: “Until
recently, infection control and quality improvement operated in
different spheres, with quality improvement focused on noninfectious
adverse events. Today, that separation no longer exists,
and, in some cases, infection control interventions are managed
partially or entirely by quality improvement personnel. These
groups have different strengths, perspectives, and approaches
that, sometimes, lead to conflict ... Getting to zero is a concept
that was introduced by the quality improvement community
and embraced avidly by stakeholders, but it is a sound bite that
represents suboptimal evidence. It is commonly interpreted to
mean that the goal of reducing the number of HAIs to zero
is attainable, and, therefore, all HAIs are preventable; this
ultimately leads to the belief that the occurrence of an HAI
must be someone’s fault.”
He adds, “The ‘zero’ obsession has a number of worrisome,
unintended consequences. It sets up unrealistic expectations on
the part of the public and healthcare administrators, leading
to unreasonable demands on infection control programs. It
fosters a punitive culture, since someone must be at fault for
causing infections. It separates infection control from safety and
quality, when infection control concerns trump other important
safety issues. It has shifted the development of interventions
away from an approach based on local risk assessment to the
promotion of a one-size-fits-all approach. Healthcare workers
and hospital epidemiologists have become demoralized when
the expectations for getting to zero persist but the elusive zero
has not been attained. From a societal perspective, we continue
to divert ever-increasing resources to marginal improvements in
inpatient healthcare quality, while more people in the United
States lose access to care.”
As Fraser (2008) noted, “The concept of targeting zero HAIs
is controversial because many people believe it sets unrealistic
or impossible expectations that all HAIs are preventable and
that any HAI that may occur was due to an error or a broken
process. To me, targeting zero is problematic because it does
not address the variation in the risk of HAIs in different patient
populations or settings, it does not address the denominator or
time frame that is necessary to understand rates of infection,
and it inherently seems scientifically unrealistic. Although
I believe now that many more HAIs are preventable than I
thought even a few years ago, I do not believe our science is
yet robust enough to prevent all HAIs. When taken as a ‘big,
hairy, audacious goal,’ trying to eliminate HAIs seems quite
laudable, however.”
Edmond (2008) had argued that, “Getting to zero simply
fails to capture the complexity of HAIs, seems to jettison more
than three decades of research in healthcare epidemiology,
and does not convey the important message that, although
the majority of HAIs are preventable, some are not.” He adds
that suboptimal evidence is driving the process of getting to
zero. “The consequences of suboptimal evidence in infection
control include the use of administrative data to define and
publicly report HAIs, smallpox vaccination of healthcare workers,
annual fit-testing of N95 masks, attempts to quantify hand
hygiene compliance, and perseverating on methicillin-resistant
Staphylococcus aureus while other important pathogens
become increasingly prevalent.”
The STRIVE program hit similar bumps on the road to zero.
As Bhatt and Collier (2019) report, “Results showed some
hospitals realized some improvements in outcome and process
measures, and some maintained or achieved zero infections
during the intervention period. However, in aggregate, there
was no statistically significant change over time during the
program intervention period compared with the baseline
period for any of the HAIs. So, we asked, ‘Why not?’ Various
explanations, including limitations of data collection and
analysis as well as inconsistent engagement due to competing
priorities and high staff turnover, are possible. Also, because
some hospitals began with low HAI rates, the ability to see
a statistically significant change over time may have been
reduced. Qualitative findings did show stronger stakeholder
relationships had been established that could align and sustain
HAI prevention across the entire patient continuum of care.”
Bhatt and Collier (2019) found that state-based alliances
aimed at prevention are forming and behavioral changes
are happening, and some hospitals actually achieved zero
36 IP&C Special Edition June 2020 • www.healthcarehygienemagazine.com