Dear Helpdesk: Handling Requests to Remove Reported Health Care-Associated Infections

Dear Helpdesk: inoculating your work life with IP Wisdom from Infection Control Today. An IP Lifeline column.

Dear Helpdesk,

I have been told to remove a health care-associated infection (HAI) despite the HAI meeting the National Health Safety Networks (NHSN) surveillance criteria. What do I do?

Dear HAI Conundrum,

I can only imagine how much this is weighing on you, and I am so sorry you are in this position. I also appreciate your strength in bringing up a situation that creates a strong visceral reaction. I do not have an easy, straightforward answer. I offer questions for you to consider, which will guide the next steps.

Without knowing the background of this request or the organization's culture, I will provide 2 responses, 1 assuming positive intent and the other if the request was a directive from your leadership.

First off, what comes up for me is to wait to react. Instead, I invite you to pause, step back, and reflect on the situation. A few questions to ask yourself are: (1) Who told me to remove the HAI, (2) what was the intention behind the request, and (3) what level of knowledge or understanding of HAIs did the person making this request have?

Positive Intent: Ideally, the person making the request is open to a conversation on how the HAI in question did not meet the NHSN criteria from their perspective. If this is the case, I invite you to ask if they have time to talk about it in person, just the 2 of you. When you meet, I recommend approaching the conversation from a place of curiosity. Perhaps something along the lines of:

“I am always looking to improve my HAI surveillance skills, and I thought that case met the definition. I would appreciate it if you could walk me through the case from your perspective so I can see what I missed.”

A woman concerned, looking at her laptop.

(Image credit: author with AI.)

The goal of this approach is to acknowledge it is possible the HAI did meet criteria and use this as a learning opportunity. Also, reviewing the case together allows you to check for understanding and walk through the surveillance definition together. If this discussion reaches a place where you still feel it meets the definition and the other person does not, you have 2 options.

However, before you respond, I invite you to consider how supportive your leadership would be in submitting the details of the HAI to NHSN for their thoughts.

• If you feel this is worth a try, recommend using this as a learning opportunity and see if you can get a commitment from your leadership to allow NHSN to adjudicate the case. If NHSN responds that it meets the HAI criteria, it should be reported.
• If you are unsure, consider how your leadership may react and discuss with a peer or colleague for their thoughts. If you suspect the reaction will be less than favorable, move into “Directive from Leadership” below.

Directive from Leadership: I need to start by saying that you are not alone in this. I have been in this situation, had fellow infection preventionists (IPs), and had coaching clients come to me with this scenario. Ultimately, how you approach this scenario will depend on your relationship with your leadership, medical director, and organization's culture.

To help you navigate this space, I invite you to reflect on the best-case scenario. How will removing the HAI from NHSN impact you? What are you most afraid of? What is the worst thing that can happen to the organization if the HAI is not reported?

Example: Is this HAI at risk of being identified in an internal or external validation survey?

I recommend jotting down your answers and any feelings that come up. Sometimes, what may come up is about more than this HAI.

March's trending topic for Infection Control Today: Patient Safety

When you are ready, consider how you feel and your trust level with your regulatory or risk management team. How might sharing this concern with them inform how you might approach it? If you do not feel you can share this within your organization, what experienced IP in your network do you feel comfortable confiding in? The goal is to identify your support system so you are not navigating this situation or decision alone.

Now, here are a couple of options for your consideration:

1. If you feel strongly that you need to speak up about your concerns, I recommend blocking some time to consider who you will approach to have a crucial conversation with. What are your concerns, and what is the risk to the organization for not reporting? Bring specific concerns and documentation to the meeting. In this scenario, recommend approaching as a concerned employee to notify your leadership of a possible risk.
2. If you feel that bringing the topic up might result in a negative outcome for you, you decide not to take any further action at this time.

This is the worst-case scenario, and you may need to choose what you are and are not comfortable with. Please consider creating a written timeline of events for your personal records, including who directed you to do what and what your actions were. Include any supporting documentation, such as emails. Lastly, depending on the nature of the HAI, you may consider submitting it to NHSN to validate that it met the criteria.

In navigating this challenging situation, it is crucial to prioritize patient safety and ethical reporting practices. Whether the request to remove the HAI comes from a place of positive intent or a directive from leadership, taking thoughtful steps is key. Remember to pause, reflect, and gather information before reacting. Engaging in open, curious conversations can often lead to a better understanding of perspectives and potential resolutions. Consider reaching out to trusted colleagues or mentors for support and guidance.

Ultimately, your decision should align with your values, professional standards, and commitment to upholding the integrity of infection prevention practices. Keeping detailed records of conversations and actions taken is important for your own clarity and accountability. By approaching this problem with care, professionalism, and a commitment to patient welfare, you are embodying the essence of the infection prevention role. Trust your judgment, seek support when needed, and know that you are not alone in facing these complex challenges within the health care background.

References/Resources

1. NHSN External FAQs webpage. CDC. Last reviewed April 14, 2023. Accessed March 28, 2024. https://www.cdc.gov/nhsn/validation/validation-faqs.html
2. Centers for Disease Control and Prevention (CDC), NHSN Help Desk webpage: https://www.cdc.gov/nhsn/about-nhsn/helpdesk.html