'Best practices' . . . not always best

Dr. Jerome Groopman, whom I have mentioned before, has a fascinating article in the current New York Review of Books about the government's role in setting and requiring "best practices" in health care.

"Best practices" is in quotes because, as Dr. Groopman points out, such standards may not always be "best."

The government requires hospitals to adhere to its standards, and it reports on how well hospitals comply with them. Increasingly, Medicare, Medicaid, and non-government payers penalize hospitals with reduced or recouped payments for failing to comply with expert-defined best practices.

Yet, as Dr. Groopman writes: "[D]octors and other experts acting for the government and making use of research on comparative effectiveness. . . have repeatedly identified 'best practices,' only to have them shown to be ineffective or deleterious."

He ticks off a number of examples of "best practices" gone wrong, including:

- Medicare's tightly controlled blood sugar levels for intensive care patients "resulted in a higher likelihood of death."

- Medicare's recommendations for hip and knee replacements had "no effect" on complications.

- Federally-approved measures for congestive heart failure patients had "no major impact."

- Medicare's requirement for the speedy administration of antibiotics for pneumonia patients in emergency departments made things "worse."

Dr. Groopman even discusses a "best practice" that he helped develop that turned out to be in error. He also talks about common errors a researcher can make leading to a bogus "best practice."

This is not to say that research-based "best practices" are wrong. Adherence to such standards has improved hospital care, and I note Community General's success in such areas a low infection rates and low ventilator-acquired pneumonia.

It turns out, however, there is a difference between standards that are applicable in the same way for all patients (such as infection control practices) and standards as applied to an individual, given the complexity of the patient's illness (such a blood sugar management).

"[O]nce we depart from. . . mechanical procedures and impose a single 'best practice' on a complex malady," according to Dr. Groopman, "our treatment is too often inadequate."

VHA honors ICU for having no VAP cases

Congratulations to the staff and leadership of the Intensive Care Unit (ICU) at Community General Hospital. Because of their accomplishment, our hospital will receive an award for excellence at the VHA Leadership Conference, May 4, in Philadelphia, PA.

The award recognizes Community for having no cases of ventilator-associated pneumonia (VAP) for 12 consecutive months.

I’d like to acknowledge and thank Dr. Russ Acevedo, [1] ICU Medical Director, and the intensivist physicians who practice with him in the ICU. Appreciation also goes to Sue Kompf, RN, Staff Educator and Acting Manager of the ICU, and her staff. My thanks as well to Dr. Mitchell Brodey, Infectious Disease Officer, and to Sue Chamberlain, RN, Director of the Infection Control Program.

According to the Institute of Health Care Improvement (IHI):

VAP is the leading cause of death amongst hospital-acquired infections, exceeding the rate of death due to central line infections, severe sepsis, and respiratory tract infections in the non-intubated patient. Perhaps the most concerning aspect of VAP is the high associated mortality.

An article in Chest, published by the American College of Chest Surgeons, reports that VAP increases the time an ICU patient spends on a mechanical ventilator, as well as adding to the length of a hospital stay even after a patient is discharged from an ICU.

The Society of Critical Care Medicine among others, has identified a “bundle” of activities that “achieve significantly better outcomes when used together,” including elevating the head of the ICU bed, daily “sedation vacations” and assessments of a patient’s readiness for extubation, as well as prophylactic treatment[2] for peptic ulcer disease and deep venous thrombosis (DVT).

Community was notified of the honor by Curt Nonomaque, President and CEO of VHA, Inc., who said, “This award honors organizations that have differentiated themselves around national performance standards by achieving exceptionally high levels of performance.”

It is our second VHA award. In 2006 Community was honored for excellence in the clinical care of patients with heart failure (at left)

Congratulations on this milestone in quality patient care!

[1] Dr. Acevedo also directs the ICU at Crouse Hospital, and he is the chair of the Respiratory Care Network Steering Committee of the American College of Chest Physicians. Congratulations to Crouse Hospital, which will also be honored by the VHA for having no VAP cases in 12 months.
[2] “Prophylaxis” comes from a Greek word that means guarding against or preventing something. In medicine, a prophylactic treatment is a medical or public health procedure that helps prevent disease or injury.