APIC says it is imperative that all infection prevention stakeholders work together to determine the true incidence of HAIs in order to reward good performance and allow consumers to make informed choices about their healthcare.
Olmsted acknowledges that this reporting requirement adds to an already- busy IP's workload. "With the concerns and attention placed of HAIs by almost every facet of society -- patients, consumer advocates, providers, payors, accreditation agencies, public health, and regulatory agencies -- the demands on the IP's time have grown exponentially," Olmsted says. "This means time management is a critical skill that IPs have to deploy as their subject matter expertise can have dramatic impact if the IP can be supporting the care team at the bedside instead of behind their computer work station. Some strategies to address the innumerable and growing demands on the time of the IP is to refresh their facility-based risk assessment on a periodic basis, and at a minimum annually. Identify areas of priority so attention and resources can be focused. APIC, with primary support from its members, has develop a tool to assess an IPC program. Vickie Brown is the lead author of this resource and more details are available at: http://www.apic.org/Content/NavigationMenu/Links/Publications/APICNews/Program_Evaluation_Tool-White_Paper.pdf
This tool will identify gaps between available resources and demands such as public reporting that can be shared with organizational leadership. There is ample evidence that despite the growth in public release of HAI data that there has not been a commensurate increase in staffing effectiveness for the IPC program. This needs to be identified by the organization and at least some plan to begin to address this disconnect. Surveillance technology, such as that demonstrated by this study by Lin, et al in JAMA holds promise to increase the efficiency of surveillance.
APIC has published a position paper on surveillance technology and there was an extensive supplement published in AJIC's April 2008 issue that contains many examples of use of IT to assist the surveillance program. "
CLABSI Definitions
Another concern being raised is an inadequate definition of CLABSI, according to Daniel J. Sexton, MD, from Duke University Medical Center in Durham, N.C. Sexton, along with researchers Luke F. Chen, MBBS, MPH, CIC, FRACP, and Deverick J. Anderson, MD, MPH, write in a commentary in Infection Control & Hospital Epidemiology,, " It appears that the surveillance definition for CLABSI from the Centers for Disease Control and Prevention (CDC) originally aimed to be highly sensitive to capture all cases of CLABSI. Unfortunately, its specificity was a secondary concern. In the past, when rates of CLABSI were higher in most American hospitals, hospital epidemiologists would review the CLABSI rate with the understanding that there was unavoidable 'data noise' because of the highly sensitive and poorly specific definition. This lack of specificity in the definition of CLABSI is an old problem that has moved to the forefront of our awareness for two important reasons. First, external pressures to improve safety outcomes are a concern for all hospitals. This pressure comes from national directives, mandated public reporting, and "pay for performance" that is tied to specific process measures. Second, now that the incidence of CLABSI has substantially decreased, hospitals are realizing that "getting to zero" (i.e., reducing the incidence to zero) is implausible, if not impossible, with the current definition of CLABSI. Additionally, a series of secondary problems and consequences emerge from flaws of the existing definition. These problems and consequences will continue or worsen unless the definition is modified."
Sexton, et al. (2010) point to a recent case at their hospital in which a patient was admitted to an ICU with hypotension and intra‐abdominal injuries following a car accident. The patient received a central line and underwent two laparatomy procedures; surgeons found no macroscopic evidence of established infection and did not collect specimens for microbiologic testing. Cultures of blood drawn from peripheral veins one day after surgical repair grew Pantoea agglomerans and Proteus mirabilis. Sexton, et al. report that "infection preventionists applied the NHSN definition for CLABSI and were unable to label this patient’s bloodstream infection (BSI) as secondary to another source, as there was no clear evidence of infection and no pus was encountered at any of the patient’s surgeries. Furthermore, there were no pathogens cultured from specimens collected from any site to indicate that an infection arose from the gastrointestinal tract or abdomen, even though there were compelling clinical reasons to suggest that this had occurred. Our infection preventionists argued that failure to follow the 'CDC definitions' would make our hospital’s data 'dishonest.' Moreover, failure to include this infection as a case of CLABSI would undermine their authority and hurt the morale of our infection control team." Sexton, et al. continue, "We believe that this case and many other cases of gram‐negative bacteremia or fungemia in seriously ill patients in ICUs likely occur either because of translocation of microorganism from edematous, abnormal, or adynamic segments of bowel or because of microscopic or macroscopic defects in the bowel wall. As in the case we describe, absence of proof (of an established infection at a site other than a central vascular catheter as a source of bacteremia or fungemia) cannot be cited as proof of absence. In fact, the origin of some episodes of bacteremia or fungemia is impossible to determine. To assign, by default, all such BSIs to a category of 'central‐line associated' simply because a central line has been inserted is not only folly, it is also intellectually and operationally incorrect."
Sexton, et al. assert that, "Hospital epidemiologists and infection preventionists now face an unnecessary dilemma when adjudicating whether a patient with bacteremia has a CLABSI or a secondary BSI. As a result of the issues raised above, we suspect that criteria used to determine whether there is a secondary source of infection vary from hospital to hospital. Indeed, it is likely that some epidemiologists would conclude on the basis of circumstantial evidence that our patient who had Pantoea and Proteus organisms recovered from blood had bacteremia secondary to a peritoneal infection. However, other hospital epidemiologists might strictly apply existing criteria and come to the opposite conclusion. In fact, informal discussions with other hospital epidemiologists have led us to believe that such adjudication based on circumstantial evidence and intuition is commonly but nonuniformly applied at individual hospitals. Such unnecessary subjectivity undermines the utility and reliability of publicly reported data on rates of CLABSI. The current NHSN definition of CLABSI is also deficient because some microorganisms that are likely to be contaminants are considered to be pathogens. Specifically, we believe the inclusion in the definition of laboratory‐confirmed BSI of the criterion that a single blood culture positive for enterococci can be considered recovery of a 'recognized pathogen' rather than as a 'common skin contaminant' is incorrect …The time for a change is now, because the CLABSI rate has emerged as an important performance measure. This rate is widely used to perform time‐trend analysis on performance within individual units and to compare performance between units within a hospital and between hospitals. Erroneous data that overestimate rates of CLABSI can damage morale and lead to false conclusions about quality of care. Erroneously attributing a BSI to a vascular device damages the credibility of our infection prevention team and undermines the credibility of all the data we collect and disseminate. Finally, incorrect data on rates of CLABSI decrease, if not eliminate, the utility of publicly reported data on the incidence of these infections."
References:
Lin MY, et al. Quality of Traditional Surveillance for Public Reporting of Nosocomial Bloodstream Infection Rates. JAMA. 2010;304[18]:2035-2041.
Sexton DJ, Chen LF and Anderson DJ. Commentary: Current Definitions of Central Line–Associated Bloodstream Infection: Is the Emperor Wearing Clothes? Infect Control Hosp Epidemiol 2010;31:1286-1289.
Niedner MF. The harder you look, the more you find: Catheter-associated bloodstream infection surveillance variability. Am J Infect Control 2010;38:585-95.
APIC Position Paper: The Use of Administrative (Coding/Billing) Data
for Identification of Healthcare-Associated Infections (HAIs) in US Hospitals. October 12, 2010. Available at: http://www.apic.org/Content/NavigationMenu/GovernmentAdvocacy/PublicPolicyLibrary/ID_of_HAIs_US_Hospitals_1010.pdf
Brown V, et al., APIC IP Program Evaluation Tool. April 2010. Available at: http://www.apic.org/Content/NavigationMenu/Links/Publications/APICNews/IP_Program_Evaluatio.htm
Wright MO, Hebden JN, Allen-Bridson K, et al. Healthcare-associated Infections Studies Project: An American Journal of Infection Control and National Healthcare Safety Network Data Quality Collaboration. Am J Infect Control 2010;38:416-8.