Tuesday, March 23, 2010

Defining our way to zero?

Here is a quote from an Emerging Infections Network post today, regarding how we define central-line associated bloodstream infections (CLABSI):

Is it really worthwhile to adjudicate blood stream infections in patients with central lines as "primary" or "secondary"? The adjudication according to the "definition" is still subjective. For example, a Klebsiella bacteremia in a pt with a PICC and PEG was ascribed to "gastroenteritis" since the pt had some coincident diarrhea and stool fecal leukocyte+ (hence bacteremia was considered secondary). A candidemia was attributed to pneumonia since the pt was immunocompromised (on steroids for BOOP), had a fluctuating CXR and had Candida in his sputum (hence the candidemia was considered secondary). I was told that these attributions were completely reasonable since they were compatible with the definitions and that the institution regularly passes muster when audited. It is distasteful to argue but anyone looking closely would see a discrepancy between the clinical diagnosis and the adjudicated diagnosis. Since the public is taking these numbers seriously, there is a problem.
This EIN post goes to the heart of a very important issue in healthcare associated infection reporting—the subjective interpretation of National Healthcare Safety Network (NHSN) definitions. Of course we already know that ventilator associated pneumonia (VAP) rates are a load of crap (I’ll leave it to Klompas and Platt to explain why). It is less well recognized how much fiddling is going on with the CLABSI definition. The post above is a great example of what is happening across the country in hospitals that are under increasing pressure to “get to zero”, and as public reporting of infection rates becomes the norm rather than the exception. Hence those hospitals that apply the NHSN CLABSI definition very strictly are punished with higher CLABSI rates. Meanwhile, hospitals celebrating “zero” rates may in fact be no more “safe” than before they began fudging their definitions.

How to fix this? Either via an expensive and cumbersome validation system for public reporting (any ideas for CDC and state public health departments on how to do this?), or via more specific definitions from NHSN.

2 comments:

  1. Last week at the Decennial Meeting, Trish Perl's group presented a survey of hospital infection programs related to this topic. She found that 20% of the programs surveyed do not always follow the CDC CLABSI definitions in cancer patients, effectively lowering their CLABSI rates. While I agree that these are probably not true CLABSI infections, this is unfair to hospitals like mine who carefully apply the CDC case definitions as written. As Dan states, we need both validation of publicly reported HAI rates and definitions with higher specificity.

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  2. I agree that the ability to mold definitions to fit goals is a problem. As others get to "zero", our ICU staff lobby strongly not to have BSI classified as CLA-BSI. To try to get around this, we have done 2 things:
    1) We count all HA-BSI (CLA-BSI, other primary, secondary)
    2) I've created a new field in our database for the IPs to use for the tough cases: they can check the box next to "meets the definition but doesn't feel good!" (Believe it or not, it has helped.)

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