Q&A: CDC’s Anti-Infection Program a Good ‘First Step’

November 12, 2020
Frank Diamond

Michael Millenson: “When you dig a little deeper, you end up though with some questions. We’re a big country, and this is an enormous crisis. Well, $180 million? You can barely buy a couple of US senators with that.”

Recently, the US Centers for Disease Control and Prevention launched Project Firstline. It’s a $180 million program that aims to educate healthcare workers about the proper way to keep themselves safe from infection, not just COVID-19 infection, but all infection. Michael Millenson is an internationally known healthcare expert who specializes in patient safety. Millenson, an adjunct associate professor of medicine at Northwestern University's Feinberg School of Medicine, has taken the healthcare system to task for its lack of attention to infection prevention. Recently, Infection Control Today® asked Millenson what he thought about Project Firstline. It’s a good first step, Millenson thinks. “The other groups that are joining here, the American Medical Association, the American Nurses Association, various hospitals, various public health groups: These are the people who are really the backbone of keeping Americans safe,” Millenson tells ICT®. “And the fact that they’re partnering with the infection preventionists is a good signal that this is a profession that’s important. This is not something that’s sort of back in the byways here.”

Infection Control Today®: What’s your take on Project Firstline?

Michael Millenson: It’s good. It’s good. I’m not sure whether it’s enough, but it’s good. If you look at it, what they’re trying to do, the way they’re trying to educate, the way they’re trying to partner with people, the way they’re trying to disseminate information quickly. All those are good things. The quality of information that they’re trying to disseminate: good things. They’re looking at hospitals, they’re looking at nursing homes, they’re looking at dialysis centers. All very good things. When you dig a little deeper, you end up though with some questions. We’re a big country, and this is an enormous crisis. Well, $180 million? You can barely buy a couple of US senators with that. And so, you know, is that really enough money for this crisis for hospitals and nursing homes and dialysis centers for a multiple hundred-billion dollar industry? Tens and thousands of employees, hundreds of millions of employees, however many it is? It’s just a little bit sort of like, OK, we’re working with the partners [so that’s] good enough. Maybe you’re working with partners, and it’s something that I want to applaud, but I don’t know how vigorously to applaud.

ICT®: It’s a first step. I guess.

Millenson: That’s a good way of putting it. It is a first step. But I think that, you know, part of the issue is when organizations like this put out their website and press releases. They’re selling the program, right? Participate, come be with us. And so, they don’t like to say things like, first step. I would agree with you. I think it is a good first step. But it needs to be something that people say, Well, now, they talk a little bit about how what we’re doing is intended to be something that lasts. That people continue to do. I think they’re aware of these issues. But, you know, hopefully they’ll continue to get financial support for this effort.

ICT®: My readership comprises infection preventionists, many with a nursing background, who other healthcare professionals sometimes view as hall monitors or the hand hygiene police. The ones I’ve talked to seem to welcome this CDC effort. I guess it could be an aid to them and what they have to do in terms of infection prevention. If it, again, as you say, goes far enough.

Millenson: Well, it is an aid. And I think, unfortunately, as you very well put it, there is this tendency to see infection preventionists as the hall monitors of healthcare. Maybe on a good day, you stay after school, and you’re banging erasers with them. But what’s helpful by having the

CDC do this, with the partners that they’re doing it with? These are sort of the elite of medicine, right? I mean, even though the CDC has gone through some reputational rough waters recently, the fact is that Americans have appropriately enormous respect for the CDC. The other groups that are joining here, the American Medical Association, the American Nurses Association, various hospitals, various public health groups: These are the people who are really the backbone of keeping Americans safe. And the fact that they’re partnering with the infection preventionists is a good signal that this is a profession that’s important. This is not something that’s sort of back in the byways here. This is something that’s important. And frankly, what they talk about, interestingly, is right. They say this is keeping our nation safe. So, all of a sudden, you’re elevated from, “Yeah, yeah, yeah. You’re watching to see whether I wash my hands” to something that’s vital. And that’s good. That’s part of the implicit message of this effort that’s really good for infection preventionists.

ICT®: When we talked in April, I remember that you got downright irked, we’ll say, about how infection has been ignored by the healthcare system in general. Do you think that the healthcare system has learned its lesson after COVID-19?

Millenson: No. I mean, this is to keep healthcare workers safe in the face of a pandemic that’s been killing them. It is not something that was launched to keep patients safe in the face of a problem that’s been killing 200,000 of them, more or less. And roughly, that’s the most accurate figure every single year for many years. And so, what this is, is a gateway for the healthcare system as a whole to understand the importance of infection prevention, not only for workers, but for patients as well throughout the system. I think that the healthcare system has not learned its lesson, but it is starting to learn this lesson. I think that the fact that we have a coordinated effort like this is a way of elevating the problem to national prominence. Just like many years ago, 20 years ago now, when the Institute of Medicine came out with the report To Err Is Human about patient safety. It wasn’t that what they said was that new. It wasn’t that new. But they put it together in a way that captured political attention, public attention, industry attention, and it came from the Institute of Medicine, which is an enormously respected place. And so, the CDC getting re-involved with infection prevention in a way that has not been a priority before, frankly, is good. It’s a good first step. It sends a signal. I hope that the industry takes it seriously. But it’s a good first step. I’m happy to go from critic to cheerleader once we have more to cheerlead about.

ICT®: And the 200,000 figure that you mentioned. That’s roughly how many people die from healthcare-acquired infections.

Millenson: Preventable healthcare-acquired adverse events. Not just infection. It could be an adverse drug reaction, essentially a medical error. And there are estimates that go from 100,000 to 400,000. I use the 200,000 number, because when I look at the medical literature, and I look at numbers that are actually used by the Department of Health and Human Services, in its strategic plan, they go with around 200,000 or 225,000. I think it’s a conservative estimate, as opposed to one that you can have a lot of arguments about. And again, that’s not negligence, but it is deaths that we can prevent. And so, to me one of the positive side effects of COVID is that good people doing their jobs who have become a little bit desensitized to the patient safety issue, because it’s not always obvious. You can’t always tell that something’s happening. It’s not negligence, it’s not malpractice, but it is preventable errors. [Those good people] have now seen some of the human toll a little more closely. And I think this is a good chance for an ethical reset, right? There’s a lot of respect for the danger that healthcare workers go through. There’s a lot of respect for how hard they work. But at the same time, there’s an acknowledgement that healthcare can be dangerous, the world can be dangerous. I would hope that this gives us a chance to not so much worry about the numbers, but to commit to zero preventable harm. Zero preventable harm for healthcare workers at all levels, whether you’re cleaning the room, or you’re the CEO of the hospital. Zero preventable harm for patients, whether you have COVID, or whether you came in there for a knee replacement. And that, I think, is hopefully the core message that gets reiterated. Zero preventable harm, higher liability. That’s the path we need to go toward. This effort talks about high reliability, but in kind of a narrow way. OK, I get it. You can’t boil the ocean. But a high reliability organization is what we need to be the aspiration for healthcare.

ICT®: Stop me if I’m comparing apples and oranges. But what do you think the World Health Organization's approach to infection prevention is? Is it better than the CDC’s?

Millenson: I think it is apples and oranges. The World Health Organization is subject to a lot of different political pressures. And the developed countries and the underdeveloped and all that. They put out a lot of good things on hand hygiene. They’ve done a lot of good things on infection. But it's kind of like comparing the United Nations’ army to the army of a real country. Right? There’s a reason they call them peacekeepers, because that’s what they’re good at. Showing up with white helmets and saying, “Please don’t shoot.” They’re not a real kind of army. And the WHO does good things, but they’re kind of the people who show up with the white helmets and say, “Don’t shoot.” They depend on cooperation in a way that, yes, the CDC does. But the CDC is also part of the federal government. And everybody in the United States knows that, behind that nice, cooperative CDC, they’re regulators and litigators and all the rest. And so, it’s apples and oranges. I agree with you. Everybody’s got issues, right? Great Britain, after having a lot of scandals, gave patient safety a huge priority, because they had terrible scandals that actually hurt confidence in the National Health Service and the government. Have they followed through? Somewhat. Not as much as you would hope. The European Union has declarations about patient safety. I think the problems with patient safety are the same problems you see with evidence-based medicine, and quality improvement, and for that matter, patient experience of care, and everything else in there. It’s that Western Medicine, whether you’re talking about in America, France, Australia, anywhere, or these days, China and everybody else is training in the same kind of style of medicine. All has certain assumptions, all has certain priorities, or a certain way of doing things. And that has placed a huge premium on individual physician autonomy, which in some areas can be good, in some areas not so good. And so, every country, every system, struggles. How do we preserve appropriate clinician autonomy, while also having accountability for cost, accountability for infection, accountability for quality improvement, accountability for longitudinal care for people who fall through the cracks? Everyone is struggling with the same system and these issues, even those people who start off as Health Maintenance Organizations, National Health Systems, everything. Because the training is designed for autonomy, and we’re trying to make people be systems, as opposed to…. There are always comparisons to the military, right? Well, nobody puts a bunch of sailors into an aircraft carrier and says, “All of you do kind of what you want. We trained you all. You all went through training and I want you to do what you think is best in your own mind. And, you know, sure try to work together. Don’t get me wrong. Still try to work together. But don’t let anyone tell you too much what to do.” And that’s what we sort of do in a clinical environment. Then we wonder why teamwork is difficult. And that’s where we are.

ICT®: OK, so Project Firstline could be a good first step. Have you thought about what could possibly be a good second step?

Millenson: I think to me, when I look at it, I want the analysis of it to be very cleareyed. I want them to look at it and ask, “What did we achieve? And what didn’t we achieve?” And frankly, if they achieve some really important kinds of goals, even narrowly, even in certain places, I want them to be bold and build on that success. I want an effort that is cleareyed about what’s achieved, cleareyed about what’s not achieved, and is willing to then build upon the successes and really, really go with it. I mean, you know, if this were a product…. If this was Clorox wipes, instead of cleaning out infections, whoever the product manager is for Clorox wipes: “You know what? We didn’t sell as many as we thought. Why not? We sold a lot over here in Nebraska. But we didn't sell very many in Missouri. Why not? And why was one place more successful than others?” I’d like the folks who do this to apply that same kind of hard-headed logic to why were we successful here. Why weren’t we successful here? And what do we need to do to keep growing that success?

ICT®: Anything you want to add that I neglected to ask you that you think might be pertinent?

Millenson: You brought up what this means for grassroots infection preventionists. And I think what an interesting question will be is the extent to which people who’ve been in infection control already, get involved—or are allowed to get involved and have their own wisdom built upon—are able to run with this. I don’t know those answers. They could have all been involved. But I think it’s going to be really important that the grassroots people who’ve been working in this field for quite a while to be allowed to really help make it succeed to the best of their ability.

This interview has been edited for clarity and length.