Annals of Internal Medicine
Editorial
Whose Line Is It Anyway?
T
“
he show where everything is made up, and the points don’t matter.” That is how Drew Carey used to introduce the improvisational comedy television show Whose Line Is It Anyway? Players made everything up as they went along, and no one really kept score. If only medicine could be that way, but it is not. Our notes are scripted, our actions increasingly regimented according to clinical protocols and evidence-based guidelines, and you bet that everyone is keeping score: payers, administrators, patients, and physicians. That medical practice is less the “art” it used to be has been commonly, and perhaps appropriately, bemoaned for fear that we are becoming the deliverers of a prepackaged, off-theshelf service and less the professionals skilled at providing care to each patient uniquely. But scripted and rigidly ordered care has benefits, too—perhaps nowhere as evident as in the prevention of nosocomial complications. Standardizing hospital care has promoted adherence to practices associated with increased safety. Programmatic interventions aimed at promoting a culture of safetymindedness, including the use of safety checklists and regimented daily assessments of whether a central venous catheter (CVC) is still necessary, are associated with marked reductions in central line–associated bloodstream infections (CLABSIs) (1, 2). The relative contribution of each of the several changes involved in the reports of reductions in CLABSIs cannot be determined, but each change aims in part to standardize the approach to care and eliminate a “do-it-however-you-like” approach. Although study designs that more definitively determine which precise actions are responsible for the improvements would be ideal, they are probably not practical and the patients who avoid life-threatening CLABSIs likely do not mind. Similar lessons have been learned with the introduction of standardized “care bundles” to prevent mechanical ventilator– associated complications (3). But, CVC-related complications, including infection and thrombosis, remain (4, 5). Why? Certain patient-related factors are beyond our control, but others are completely within it. Removing a CVC the moment that it is no longer needed is one factor (6). To do so obviously requires being aware that it is there. Are we? In this issue, Chopra and coworkers (7) conclude that we are not—at least not often enough. Immediately after their morning assessments, clinicians responsible for orchestrating a hospitalized patient’s care (predominantly housestaff and attending physicians) were asked whether their patient had a CVC. Although more than 20% of the patients evaluated at the 3 academic medical centers involved had CVCs, over 20% of their clinicians were unaware of their presence. Some services were better than others, and although the study could not tell how many clinicians were surveyed more than once, did not deter-
mine whether the CVCs were still indicated, and did not survey nurses, at face value the rate of unawareness is troubling. Perhaps nothing is wrong here, as the most important limitation of this study is the lack of data on outcomes: Did patients whose clinicians were unaware of their CVCs have more complications? However, because we know that reducing indwelling time by removing CVCs is one of the most effective means of reducing their complications (6, 8), I suspect that the unawareness identified by Chopra and coworkers does matter. Furthermore, what else was missed on morning rounds? A developing pressure ulcer that might be addressed and healed? A drug rash? No, this is not another yearning for the “days of giants,” when, among other things, interns were expected to do a rectal examination on every patient. After all, CLABSI rates were higher in those bygone days (9). But I still believe that we need to examine our patients in a rational and purposefully directed manner. Even if, in theory, infection rates do not differ when the physician responsible for orchestrating care is unaware of the presence of a CVC (perhaps because of nursingbased programs or other systems designed to track and remove CVCs promptly), it irks me that we would be comfortable being unaware that a dangerous implement we inserted into our patient’s body remains and might no longer be needed. We have sworn to do no harm, and eliminating unneeded and threatening interventions is part of keeping that promise. Can our dreaded forms, electronic health records, and other aspects of increasingly standardized hospital care help? Formulated and electronic progress notes often have check boxes to indicate whether a CVC is present and still needed. Forms should not carry forward yesterday’s checkmarks, so that we might consider each item daily and be reminded when we have forgotten whether a CVC is present or still needed. Hospitals meticulously track device days, even electronically, as was done at one of the hospitals in Chopra and coworkers’ study. These data are typically monitored only by the hospital’s infection control practitioners. Why should they be siloed and not pushed to all clinicians responsible for coordinating a patient’s care? Certain aspects of daily work rounds essential to preventing avoidable harms should be scripted so that they are heard at each “performance” of patient care. Ultimately, however, we know that reminders and alarms frequently go unheeded or ignored. We have all seen forms nicely completed by clinicians who lack mindfulness of many or even all of the pertinent positives and negatives needed to understand and care for a patient. Providing a script here will not be enough. But, neither will © 2014 American College of Physicians 607
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/930970/ by a University of California San Diego User on 04/27/2017
Editorial
Whose Line Is It Anyway?
total improvisation where each of us gets to decide what to do or when and how to respond. To torture this analogy a bit further, I believe that we should “memorize our lines” and then be mindful as we deliver them. If we ignore our lines completely, however, I would argue that we should get off of the stage. Darren B. Taichman, MD, PhD Executive Deputy Editor Disclosures: The author has disclosed no conflicts of interest. The form
can be viewed at www.acponline.org/authors/icmje/ConflictOfInterest Forms.do?msNum⫽M14-2005. Requests for Single Reprints: Darren B. Taichman, MD, PhD, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, [email protected].
Ann Intern Med. 2014;161:607-608. doi:10.7326/M14-2005
References 1. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-32. [PMID: 17192537] 2. Berenholtz SM, Lubomski LH, Weeks K, Goeschel CA, Marsteller JA, Pham JC, et al; On the CUSP: Stop BSI program. Eliminating central line-associated
INFORMATION
bloodstream infections: a national patient safety imperative. Infect Control Hosp Epidemiol. 2014;35:56-62. [PMID: 24334799] doi:10.1086/674384 3. Berenholtz SM, Pham JC, Thompson DA, Needham DM, Lubomski LH, Hyzy RC, et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol. 2011;32:305-14. [PMID: 21460481] doi:10.1086/658938 4. Chopra V, O’Horo JC, Rogers MA, Maki DG, Safdar N. The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta-analysis. Infect Control Hosp Epidemiol. 2013;34:908-18. [PMID: 23917904] doi: 10.1086/671737 5. Chopra V, Anand S, Hickner A, Buist M, Rogers MA, Saint S, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. Lancet. 2013;382:311-25. [PMID: 23697825] doi:10.1016/S0140-6736(13)60592-9 6. O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al; Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011;52:e162-93. [PMID: 21460264] doi:10.1093/cid/cir257 7. Chopra V, Govindan S, Kuhn L, Ratz D, Sweis RF, Melin N, et al. Do clinicians know which of their patients have central venous catheters? A multicenter observational study. Ann Intern Med. 2014;161:562-7. doi:10.7326 /M14-0703 8. Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004;32:2014-20. [PMID: 15483409] 9. Centers for Disease Control and Prevention (CDC). Vital signs: central line-associated blood stream infections—United States, 2001, 2008, and 2009. MMWR Morb Mortal Wkly Rep. 2011;60:243-8. [PMID: 21368740]
FOR
AUTHORS
The Annals Information for Authors section is available at www.annals .org/public/authorsinfo.aspx. All manuscripts must be submitted electronically using the manuscript submission option at www.annals.org.
608 21 October 2014 Annals of Internal Medicine Volume 161 • Number 8
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/930970/ by a University of California San Diego User on 04/27/2017
www.annals.org
Editorial
Whose Line Is It Anyway?
T
“
he show where everything is made up, and the points don’t matter.” That is how Drew Carey used to introduce the improvisational comedy television show Whose Line Is It Anyway? Players made everything up as they went along, and no one really kept score. If only medicine could be that way, but it is not. Our notes are scripted, our actions increasingly regimented according to clinical protocols and evidence-based guidelines, and you bet that everyone is keeping score: payers, administrators, patients, and physicians. That medical practice is less the “art” it used to be has been commonly, and perhaps appropriately, bemoaned for fear that we are becoming the deliverers of a prepackaged, off-theshelf service and less the professionals skilled at providing care to each patient uniquely. But scripted and rigidly ordered care has benefits, too—perhaps nowhere as evident as in the prevention of nosocomial complications. Standardizing hospital care has promoted adherence to practices associated with increased safety. Programmatic interventions aimed at promoting a culture of safetymindedness, including the use of safety checklists and regimented daily assessments of whether a central venous catheter (CVC) is still necessary, are associated with marked reductions in central line–associated bloodstream infections (CLABSIs) (1, 2). The relative contribution of each of the several changes involved in the reports of reductions in CLABSIs cannot be determined, but each change aims in part to standardize the approach to care and eliminate a “do-it-however-you-like” approach. Although study designs that more definitively determine which precise actions are responsible for the improvements would be ideal, they are probably not practical and the patients who avoid life-threatening CLABSIs likely do not mind. Similar lessons have been learned with the introduction of standardized “care bundles” to prevent mechanical ventilator– associated complications (3). But, CVC-related complications, including infection and thrombosis, remain (4, 5). Why? Certain patient-related factors are beyond our control, but others are completely within it. Removing a CVC the moment that it is no longer needed is one factor (6). To do so obviously requires being aware that it is there. Are we? In this issue, Chopra and coworkers (7) conclude that we are not—at least not often enough. Immediately after their morning assessments, clinicians responsible for orchestrating a hospitalized patient’s care (predominantly housestaff and attending physicians) were asked whether their patient had a CVC. Although more than 20% of the patients evaluated at the 3 academic medical centers involved had CVCs, over 20% of their clinicians were unaware of their presence. Some services were better than others, and although the study could not tell how many clinicians were surveyed more than once, did not deter-
mine whether the CVCs were still indicated, and did not survey nurses, at face value the rate of unawareness is troubling. Perhaps nothing is wrong here, as the most important limitation of this study is the lack of data on outcomes: Did patients whose clinicians were unaware of their CVCs have more complications? However, because we know that reducing indwelling time by removing CVCs is one of the most effective means of reducing their complications (6, 8), I suspect that the unawareness identified by Chopra and coworkers does matter. Furthermore, what else was missed on morning rounds? A developing pressure ulcer that might be addressed and healed? A drug rash? No, this is not another yearning for the “days of giants,” when, among other things, interns were expected to do a rectal examination on every patient. After all, CLABSI rates were higher in those bygone days (9). But I still believe that we need to examine our patients in a rational and purposefully directed manner. Even if, in theory, infection rates do not differ when the physician responsible for orchestrating care is unaware of the presence of a CVC (perhaps because of nursingbased programs or other systems designed to track and remove CVCs promptly), it irks me that we would be comfortable being unaware that a dangerous implement we inserted into our patient’s body remains and might no longer be needed. We have sworn to do no harm, and eliminating unneeded and threatening interventions is part of keeping that promise. Can our dreaded forms, electronic health records, and other aspects of increasingly standardized hospital care help? Formulated and electronic progress notes often have check boxes to indicate whether a CVC is present and still needed. Forms should not carry forward yesterday’s checkmarks, so that we might consider each item daily and be reminded when we have forgotten whether a CVC is present or still needed. Hospitals meticulously track device days, even electronically, as was done at one of the hospitals in Chopra and coworkers’ study. These data are typically monitored only by the hospital’s infection control practitioners. Why should they be siloed and not pushed to all clinicians responsible for coordinating a patient’s care? Certain aspects of daily work rounds essential to preventing avoidable harms should be scripted so that they are heard at each “performance” of patient care. Ultimately, however, we know that reminders and alarms frequently go unheeded or ignored. We have all seen forms nicely completed by clinicians who lack mindfulness of many or even all of the pertinent positives and negatives needed to understand and care for a patient. Providing a script here will not be enough. But, neither will © 2014 American College of Physicians 607
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/930970/ by a University of California San Diego User on 04/27/2017
Editorial
Whose Line Is It Anyway?
total improvisation where each of us gets to decide what to do or when and how to respond. To torture this analogy a bit further, I believe that we should “memorize our lines” and then be mindful as we deliver them. If we ignore our lines completely, however, I would argue that we should get off of the stage. Darren B. Taichman, MD, PhD Executive Deputy Editor Disclosures: The author has disclosed no conflicts of interest. The form
can be viewed at www.acponline.org/authors/icmje/ConflictOfInterest Forms.do?msNum⫽M14-2005. Requests for Single Reprints: Darren B. Taichman, MD, PhD, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, [email protected].
Ann Intern Med. 2014;161:607-608. doi:10.7326/M14-2005
References 1. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-32. [PMID: 17192537] 2. Berenholtz SM, Lubomski LH, Weeks K, Goeschel CA, Marsteller JA, Pham JC, et al; On the CUSP: Stop BSI program. Eliminating central line-associated
INFORMATION
bloodstream infections: a national patient safety imperative. Infect Control Hosp Epidemiol. 2014;35:56-62. [PMID: 24334799] doi:10.1086/674384 3. Berenholtz SM, Pham JC, Thompson DA, Needham DM, Lubomski LH, Hyzy RC, et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol. 2011;32:305-14. [PMID: 21460481] doi:10.1086/658938 4. Chopra V, O’Horo JC, Rogers MA, Maki DG, Safdar N. The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta-analysis. Infect Control Hosp Epidemiol. 2013;34:908-18. [PMID: 23917904] doi: 10.1086/671737 5. Chopra V, Anand S, Hickner A, Buist M, Rogers MA, Saint S, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. Lancet. 2013;382:311-25. [PMID: 23697825] doi:10.1016/S0140-6736(13)60592-9 6. O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al; Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011;52:e162-93. [PMID: 21460264] doi:10.1093/cid/cir257 7. Chopra V, Govindan S, Kuhn L, Ratz D, Sweis RF, Melin N, et al. Do clinicians know which of their patients have central venous catheters? A multicenter observational study. Ann Intern Med. 2014;161:562-7. doi:10.7326 /M14-0703 8. Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004;32:2014-20. [PMID: 15483409] 9. Centers for Disease Control and Prevention (CDC). Vital signs: central line-associated blood stream infections—United States, 2001, 2008, and 2009. MMWR Morb Mortal Wkly Rep. 2011;60:243-8. [PMID: 21368740]
FOR
AUTHORS
The Annals Information for Authors section is available at www.annals .org/public/authorsinfo.aspx. All manuscripts must be submitted electronically using the manuscript submission option at www.annals.org.
608 21 October 2014 Annals of Internal Medicine Volume 161 • Number 8
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