Why It Matters
Like many in the health care quality world, Arjun Srinivasan, MD, CAPT USPHS, was heartened by the progress being made in recent years on problems like healthcare-associated infections. But the Centers for Disease Control and Prevention (CDC) Associate Director for Healthcare Associated Infection Prevention Programs has been alarmed by how quickly the effects of COVID-19 undid many of those gains. In the following interview, he talks about what has been lost but also how we can learn from the best aspects of pandemic response.
In the third year of the COVID-19 pandemic, what concerns you most about health care quality, especially patient safety?
What has been most concerning about health care quality and safety during the pandemic are the enormous losses we’ve seen in the overall safety and quality of care. I spend a lot of my time focusing on healthcare-associated infections and antibiotic resistance. Over the past five years, there was tremendous progress. We had seen drops by as much as 50 percent in rates for certain types of infections that happen in hospitals. During the pandemic, we’ve seen a rise in these infections by about 50 percent. In another words, [the pandemic] wiped away five years of hard work by all our health care providers.
And I think it’s important to remember that behind every one of those infections is the story of a patient who has suffered a harm in health care. For example, we know that somewhere in the range of 20 percent of patients who get central line-associated bloodstream infections will die from those infections. This means we saved patients from COVID through enormous scientific advances and the incredible care that we provided for patients, and then we lost many of these same patients to a healthcare-associated infection. It’s no individual’s fault. This is a systems problem. Our systems were not prepared to deliver safe care in the face of challenges that few of us would ever have anticipated.
This leaves us with a health care system that is less safe than it was five years ago. So, how do we move forward? How do we get back those safety gains? More importantly, how do we redesign the health care system so that this never happens again? Can we build a system in which safety is so strongly embedded into our workflow and our practices that — even in the face of enormous adversity — we can still deliver the safe care that every patient deserves and that all of us expect? I believe we can.
As the pandemic has continued, public health departments and public health officials have sometimes been demonized for doing their jobs. What can be done about this?
It has been a very difficult time for folks who work in public health, especially those at the state and local levels who are very much on the front lines of the pandemic. They have been demonized, victimized, and even sometimes physically attacked. Their families have been verbally assaulted. It’s been awful. It's been so sad.
It reflects the tenor of where our public discussions sometimes go when issues become controversial. I think people need to understand that the goal of public health is to make recommendations we think are in the best interests of the largest number of people. We try to keep everyone safe in the face of a lot of uncertainty. That sometimes means we ask people to restrict activities or to do things like wear masks. These decisions are based on data and science and reflect what we know about the virus at a given moment in time.
I don’t know the ultimate answer to solving this problem, but part of it might be people recognizing and understanding more about public health. Many people probably aren’t aware that we have a substantial public health infrastructure here in the United States where you’ve got the CDC and state health departments and local health departments. There are hundreds of health departments who are working day in and day out to keep the public safe from health threats. It’s a huge spectrum of things that they do. It’s not only safety in health care facilities, but it’s also food safety, water safety. Public health also delves into other harms like diabetes and heart disease.
I think the pandemic raised some awareness of what public health does, but I think there’s still a real gap in understanding. We’re so much more than the people who tell people when to wear a mask or who tell people to get a vaccine. I think we would all be better served if people can begin to understand the ways in which public health works to make life better and safer for everyone.
Health care and public health systems had to adapt very quickly to deal with COVID-19. What are some changes compelled by the pandemic that you hope will continue beyond COVID?
One of the biggest changes that I would love to see continued is the speed with which new practices and new interventions were brought online and widely disseminated. We were building this plane as we were flying it. Based on the data on managing ventilation, for example, we learned you don’t have to put everybody on a ventilator. High-flow oxygen was a great intervention.
Instead of taking 20 years for recommendations to move broadly into practice, during the pandemic we did these huge collaborative studies in which thousands of patients were enrolled in a matter of weeks. We gathered the data and posted it online and practice moved in days and weeks. Wouldn’t we all love to see a world in which a new, evidence-based safety practice is identified, and it gets broadly adopted in a matter of weeks and not years?
Another change that I would love to see continue is the way people came together. Especially at the very beginning, there was so much information sharing and sharing of best practices. I hadn’t seen anything like that before, and it was fantastic. It happened in health care, but also in public health as well. We had a daily, hour-long phone call with the Centers for Medicare & Medicaid Services (CMS). Initially, we were talking with CMS seven days a week. We talked about what we were learning about how to prevent the spread of infections and they asked, “How can we help? How can we disseminate the best practices through some of our quality improvement work? How can we alter payment structures to promote those practices? How can we alter the regulatory and oversight framework both to ensure implementation, but also to give people the flexibility they need?”
We saw a level of collaboration both in health care and in public health that was tremendous. And we are hoping that continues. We’ve already been talking with CMS about how to build on the collaboration we started.
What are you working on now to help the US prepare for the next pandemic?
We’re focused on trying to understand what led to the breakdowns in safety. We know people were very busy. We didn’t always have time to do the things we normally do to keep people safe. Checklists and safety rounds, for example, sometimes fell by the wayside.
But now we need to spend time to understand what we could have done differently that would have allowed these practices to continue. Are there ways more teams could have kept using checklists or doing safety rounds or [using other tools and practices]? How could we have kept those going even in the face of shortages of equipment and personnel and all the other challenges that we faced?
To answer those questions, we’ll be looking for the bright spots or the positive deviance. Were there places that despite the COVID challenges still found ways to [maintain their safety practices]? We know there are, and we want to learn from them.
This is a huge collaborative effort. No one group is going to own this. All of us have to come together to learn from this experience to figure out what we can put in place now that’s going to help us in the future.
How were you first introduced to IHI?
I started working with IHI on the 100,000 Lives Campaign. There was a recognition that certain infections were responsible for a lot of morbidity and mortality and were highly preventable. Over the years, we’ve done a lot of work with IHI on things like antibiotic stewardship. IHI helped us develop a driver diagram. We brought what we knew, and IHI brought its deep experience in quality improvement and its connection to lots of hospitals interested in quality improvement. In the future, there will be more opportunities for collaboration. We are good at aligning our strengths and identifying opportunities for improvement and using all of our efforts to help the whole field move forward.
Editor’s note: This interview has been edited for length and clarity.