The Tyranny of Zero Tolerance

Think about the most complicated infection control patient you have ever had. My worst patient was admitted with necrotizing fasciitis that had eroded almost the full circumference of of her trunk and spread to her perineal area. Naturally, she had an indwelling urinary catheter and several central lines. Her wounds were constantly draining and she was able to spend, at most, an hour a day out of bed. Our goal was to keep her from acquiring both a BSI and an SSI. She was with us about 2 months before she acquired each type of infection.

Zero tolerance is generally accepted as the mantra for demonstrating commitment to reducing HAIs. According to APIC zero tolerance generally means that no one on a healthcare team believes that even one HAI is acceptable. The assumption is that zero tolerance will eventually result in zero HAIs.

The zero tolerance approach represents a shift from believing HAIs as a normal risk of hospitalization. Certainly no one wants to go back to that way of thinking. But is zero tolerance realistic? Does it support the culture of blame that many quality officers are trying to eliminate?

We all know that healthcare is a complicated service compounded by the fact that peoples’ bodies break down, including their immune systems. Was it realistic to think we could prevent our patient from getting HAIs given the massive assault on her body from her first infection? Good nursing care during her admission resulted in a reduction of her initial wounds to about half of their original size. Unfortunately, the initial infection was not treatable and it spread to other sites despite aggressive care. It was at the time of that spread that the other infections occurred.

If I had strictly ascribed to the zero tolerance policy, my course of action would have been to conduct quality analyses and try to determine which staff performed poorly and/or what they had done that was wrong. That would have been followed by remedial actions including the possibility of staff discipline.

But in this case I believed that the concept of zero tolerance was not appropriate. There seemed no point in discussing the infection prevention strategies that might have been breached. The staff were familiar with prevention strategies. They were devastated when the HAIs developed. Reviewing prevention strategies or threatening punishment would have been viewed as a punishment and, I believe, a disincentive for future prevention efforts.

The question was whether, given this patient's underlying condition, any prevention strategies would have been successful? The answer was probably not. So I wondered what the teachable moment would be directed toward. I wondered if there was anything positive that could be taken from this situation. It occurred to me that, given the massiveness of the patient's initial infection, what the staff had done was to prevent HAIs for a relatively extended period of time. They had taken the necessary infection control precautions that were successful until the patient’s immune system was overwhelmed.

Is there a place for zero tolerance? Yes, but not as an inviolate goal. To hold that belief without allowing different perspectives may be detrimental to prevention efforts. Sometimes we must give ourselves credit for keeping patients infection-free for as long as possible given the forces that both patients and staff are fighting against. Supporting staff even in the face of failure can be an effective way to reinforce good practice for the many other patients whose conditions will challenge our best efforts.