Working the refs

As the Miami Heat and Oklahoma City Thunder prepare to do battle in the NBA finals, we should recognize the importance of home court advantage and the pressure placed on referees by coaches and players. There are data that home teams benefit from fewer fouls, and everyone knows coaches and players who are good at “working the refs” to influence their calls. There are also data that as the pressure mounts (game 7 in a 7 game series), referee influence is even greater.

Now, as a mental exercise, picture your infection preventionists (IPs) in referee outfits. It shouldn’t be surprising that as the pressure mounts for hospitals to eliminate reportable HAIs, the refs (those who “make the calls” as to whether an event meets the NHSN criteria for an HAI) are under increasing pressure. We’ll soon publish survey data revealing how commonly hospitals use “consensus methods” (e.g. adjudication panels that include clinical leaders and/or hospital administrators) or even allow clinicians to “veto” HAI calls. These approaches all drive HAI rates lower, as I know of no hospitals where clinicians or hospital administrators bring cases to the IPs to ask why they failed to report them as HAIs. They are also corrosive of the prevention culture, and contribute to IP burnout.

However, even if all hospitals stopped these practices immediately, the increasing pressure to demonstrate HAI elimination would remain a problem. The celebrations units have when they reach “zero” for a period of time, and the massive disappointment when a single VAP or CLABSI ruins the celebration, are akin to the crowds and coaches during game 7, cheering a call for the home team and booing a call for the opposition. And in those centers where financial rewards and penalties accrue to unit directors based upon HAI rates, the pressure is even greater. 

The answer? Eliminate subjectivity in HAI definitions, and move to objective definitions that are amenable to electronic reporting. These HAI events may no longer correlate well with the infectious disease syndromes we diagnose and treat at the bedside, but as long as they are associated with important adverse outcomes (length of stay, mortality) and are preventable, they should suffice (see VAC vs. VAP).