Honesty and fairness in public reporting: Some wishes for the New Year

In the latest issue of Critical Care Medicine there is a study that attempts to determine the role of cross-transmission in the development of nosocomial infections. The two-year study was performed in 11 ICUs in 2 large German hospitals. Surveillance for nosocomial infections was performed and all isolates from cultures which yielded 6 indicator organisms (E. faecium, E. faecalis, K. pneumoniae, P. aeruginosa, Acinetobacter, and S. aureus) were archived for genotyping. Also included were MRSA strains obtained from active surveillance. Over the two years, 1,216 nosocomial infections were identified. Molecular typing revealed that there were 462 episodes of cross transmission (i.e., patients shared the same strain).

What are the implications of this study?
(1) 38% of nosocomial infections had an exogenous source (the infection occurred due to an organism transmitted to the patient in the ICU). One could argue that nearly all of these infections could be prevented by better hand hygiene compliance and perhaps to some degree by reduced contamination of healthcare worker clothing (e.g., a bare below the elbow approach to prevent contamination of sleeves) and decontamination of shared patient care equipment.
(2) 62% of infections had an endogenous source (the infection arose from the patient's own microbial flora). Some of these infections could be eliminated with practices such as central line and ventilator bundles, as well as chlorhexidine bathing. However, there will always be infections in this group which are not preventable (e.g., bloodstream infections of enteric origin in the neutropenic patient). Even if 100% of exogenous and 75% of endogenous infections could be eliminated, that would still leave 15% of all nosocomial infections as non-preventable (i.e., the irreducible minimum).

So in an era of heightened transparency and accountability with public reporting of healthcare associated infections, what needs to be done? Here are my wishes for 2010:
(1) CDC needs to improve surveillance definitions to improve specificity. For example, enterococcal bacteremias in the neutropenic patient should be not classified as line associated infections since these are mostly non-preventable infections with endogenous flora.
(2) States with mandatory public reporting of HAIs need to focus on validation of data submitted by hospitals so that consumers can compare apples to apples. In an informal survey of hospital epidemiologists, I recently learned that some hospitals disregard the CDC central line associated bloodstream infection (CLABSI) definition in the case of enterococcal bacteremia in the neutropenic patient, though a strict interpretation of the CDC definition would not allow this. Were we to do this at my hospital, our CLABSI rates in the medical ICU would fall significantly since enterococci are the predominant bloodstream pathogens in that unit.
(3) CDC also needs to allow hospitals to count each central line present in denominator calculations. Currently, one line day per patient can be counted, even though patients may have more than one line present, each of which is a risk factor for infection. This overestimates the CLABSI rates in my medical and surgical ICUs by 20% and punishes hospitals who care for the sickest patients.
(4) CDC and the professional societies need to educate the public with an honest approach to the concept that most, but not all, healthcare associated infections are avoidable. Stop the APIC-driven "targeting zero" doublespeak (zero infections is not attainable but it's an aspirational goal)! It's confusing to patients, punishes the people who are working hard to prevent infections (ICPs, hospital epidemiologists and front-line providers), and undermines the credibility of ICPs in the medical community.

I still believe that public reporting is the right thing to do. But it sure would be helpful to have a level playing field.


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