Myopic consequences

The May issue of American Journal of Infection Control has a survey of infection prevention programs in US hospitals assessing the impact of the CMS policy to restrict payment for hospital-acquired central line associated bloodstream infections (CLABSI), catheter associated UTI (CAUTI), and selected surgical site infections. Five hundred hospitals were randomly selected to participate and the response was 64%.

While the survey contained some good news, primarily that hospitals were making efforts to get urinary and central venous catheters removed more quickly, 3 disturbing findings were uncovered:

• 32% of respondents reported a shift in resources to address the policy, as only 15% of hospitals increased resources to infection prevention programs to meet the mandate. While not directly addressed in this paper, the implication is that hospitals stopped performing surveillance for certain infections in order to perform surveillance for CAUTI (more on this below).
• 27% reported that in response to the policy it has become routine practice to obtain urine cultures on patients admitted with urinary catheters in order to determine whether an infection was present on admission
• 13% reported that it has become routine practice to obtain blood cultures on patients admitted with central venous catheters

Obtaining cultures on patients without signs or symptoms of infection is a terrible practice. Any positive results are extremely likely to be contaminants or colonizers, yet it is likely that a sizable fraction of these patients may receive unwarranted antibiotic therapy. This increases the cost of care, adds to the problem of antibiotic resistance, and increases the risk for C. difficile infection.

A companion paper in Medical Care Research and Review by some of the same authors is a qualitative study using semi-structured interviews with 36 infection preventionists to assess the impact of the Medicare policy. In addition to the issues noted in the survey, a few other unintended consequences emerged:

• Providers intentionally not documenting infections in the medical record
• Surgeons refusing to operate on patients at high risk of infection
• IPs were concerned that in order to meet the mandate to perform surveillance for CAUTIs, they stopped surveillance for infections that were deemed to be clinically more important in their hospitals

To those of us who work in the field of infection prevention, none of this is surprising. In fact, we predicted all of these things would happen. It doesn't take a lot of imagination to think through a proposed mandate to envision adverse unintended consequences.

Graphic:  Pie and Coffee