CAUTI SCHMAUTI ! (part 3)

I've blogged before about the waste of time, effort and resources being utilized to prevent CAUTI (see here and here), and a new paper in Infection Control and Hospital Epidemiology adds fuel to my fire. This two-year study was performed in the adult ICUs at the Mayo Clinic and analyzed 105 CAUTI episodes. In 97% of cases fever was the primary indication for obtaining the urine culture, but on analysis 2/3 of the patients with CAUTI had alternative diagnoses to explain the fever. Thus it appears that CAUTI is highly over diagnosed. Moreover, preventability is relatively low and secondary bacteremias are uncommon. The authors "question the utility of surveillance for this low-frequency, low-morbidity HAI, which does not serve as a valuable patient-centered outcome." And they conclude: "CAUTIs, as currently defined by NHSN (even with the 2015 definition changes), are not clinically relevant, and efforts to reduce CAUTI may be better directed at other more serious healthcare infections."

  

The paper is accompanied by an excellent editorial by Dan Livorsi and Eli Perencevich. They thoughtfully dissect all the problems with the CAUTI metric and offer some alternatives. They note that it is debatable whether a NHSN-defined CAUTI represents an episode of preventable harm. And they remind us that the opportunity cost is significant.

It's time to end the war on CAUTI.

Graphic: Living with a Catheter

Dollars, denominators, and risk adjustment

Because not everyone who reads this blog reads the comments, I wanted to highlight these particularly insightful observations about Mike’s post on denominators for CLABSI (emphasis mine):

"The thought experiment works with the assumption these two ICUs are indistinguishable except for the frequency of CVC use. Historically, I think the justification for comparative rates using CVC denominators was a no-brainer. These devices were critical to saving lives, and the variations in device utilization probably reflected differences in patient populations, even within similar types of locations. Accounting for the overwhelming primary risk (the CVC) made sense, since these devices were critical to care. The problem you’re outlining now is very real -- as the clinical environment has proven that a lot of the variations in CVC use may in fact be personal preference. Just like the argument with CAUTIs (where foley use is deemed less critical to care) to use a patient-day denominator is strong, we may be at a time where the CLABSI argument is as strong. Improving the classification of ICU types, by more objective criteria than currently used in NHSN (i.e. the 80% rule), would really advance the comparative metric substantially, and likely provide more valid risk adjustment with patient-day denominators than we currently have with these archaic classification schemes (e.g., "med-surg icu"). Advancing the use of composite administrative data to classify patient locations to a more objective, reliable, and granular level, based on fractions of patient-days that have key underlying diagnosis, procedures, etc. is greatly needed."

Given the millions of dollars that are now at stake based upon a hospital’s performance on healthcare-associated infection (HAI) metrics, it’s hard to overemphasize the pressure that is now being placed on the NHSN definitions, and the importance of ensuring that the definitions keep pace with evolving approaches to patient care. When I was a medical resident (yes, way back then), the presence of a CVC was a good indicator of severity of illness and likely served well as built-in risk adjustment for the broad categories of ICU. The same cannot be said now; the device utilization ratios (and percentile ranks compared across NHSN units) vary markedly between different ICU types in our hospital, and do not correlate well with illness severity. And as we’ve learned with CAUTI, the device days that are most amenable to reduction (the “low hanging fruit”) are always the lowest risk device days.

Denominators matter

Let's perform a thought experiment. At St. Eligius Hospital there are two ICUs. These two ICUs have the same number of beds, the same number of patient days (12,000/year), and the same case mix index. In fact, they're essentially identical, except that ICU A has an annual CLABSI rate of 2.7/1,000 central line days and ICU B has a CLABSI rate of 5.0/1,000 central line days. Which ICU is better performing with regards to CLABSI? Well, without any other data to consider, we'd be greatly tempted to conclude that ICU A is the better performer since it's CLABSI rate is nearly one-half that of ICU B. Now, let's add another piece of information: ICU B focused on reducing central line placement as a safety intervention--so at year's end, ICU A had 7,500 central line days and ICU B had 3,000 central line days. This means that ICU A finished the year with 20 CLABSIs, and ICU B had 15. Now it's clear that ICU B is the better performer despite having the higher rate.

This is not just a theoretical problem. During my first rotation on the Infectious Diseases Consultation Service at the University of Iowa last year, I was struck by the low prevalence of central lines in the medical ICU. Turns out my perception was spot on--when I looked at our NHSN data, I saw that 3 of our 5 adult ICUs have central line utilization ratios less than the 15th percentile nationally. This is not an accidental occurrence; clinicians in those ICUs have worked hard to avoid placement of devices that are associated with infection. The problem is that the central lines that do get placed in these units are concentrated in a group of patients that are sicker and more likely to develop CLABSI, since the less sick patients will be managed without a central line. Moreover, the denominator is reduced. And the result is higher CLABSI rates. Here, no good deed goes unpunished.

But there's an easy fix. Instead of using device days as the denominator, use patient days. In our thought experiment, we would see that ICU A would have a CLABSI rate of 1.7/1,000 patient days and ICU B would have a rate of 1.2/1,000 patient days. The better performer (ICU B) will now have the lower rate, as expected. Makes sense, no? CDC should move to address this given the financial penalties hospitals now face based on CLABSI rates. Changing the denominator would provide an incentive for hospitals to aggressively reduce device insertion. And since NHSN has collected patient days for decades, there would be no loss of long-term trending. Lastly, use of patient-days as a denominator produces a patient-centered metric. Think about it: do we really care at what rate catheters become infected? No! Our focus should be on what rate of and how many patients become infected, which is also more intuitive for providers at the sharp edge of patient care.

It's time to kill MRSA exceptionalism

For nearly two decades, we've lived in a delusional state where many in the field of infection prevention somehow believed that MRSA was so much worse than MSSA that it needed to be treated in a special way. We needed to find all those who are colonized and isolate them (aka search and destroy). We needed to wrap ourselves in plastic before entering their room. We needed to destroy any unused disposable products that remained in the room at the time of hospital discharge. We needed to terminally clean the room in a special way. And on and on and on.... All because MRSA was special. We didn't need to do any of those special things for plain old MSSA.

Some of us have been baffled by this magical thinking from the start. After all, MRSA and MSSA are transmitted in exactly the same ways. We're even more baffled after we see the evidence that in the endemic setting search and destroy doesn't work and contact precautions don't work either. And can anyone honestly say that MSSA invasive infections are benign?

A new multicenter study of invasive S. aureus infections in hospitalized infants published in JAMA Pediatrics should drive another nail in the coffin of MRSA exceptionalism (free full text here). Nearly 4,000 infected babies were studied and outcomes were compared between MSSA and MRSA infections. MSSA infections were nearly three times more common. Although there was no difference in mortality rates between the two groups, twice as many babies died of MSSA infections.

We need to quit chasing pathogen-based approaches (vertical strategies) to infection prevention and focus on horizontal strategies that reduce infections from all pathogens (e.g., hand hygiene, stethoscope disinfection, bare below the elbows, chlorhexidine bathing). Because all pathogens are important. I often joke that I've never had a patient tell me that they don't want a MRSA infection, but they'll take an MSSA. And that is definitive proof that patients figured out that MRSA exceptionalism was a bad idea long before most hospital epidemiologists.

Photo:  CDC.

Reader Survey: White coats contribute to the unsafe hierarchical culture in healthcare

Following on the heels of Mike's bare-below the elbows debate at IDWeek, I posted a quick survey to gauge your impression of the level of acceptable harm associated with white coats. I'm still working on the power calculations that will be informed by the survey, but wanted to say thank you to the many who answered the questions. In the meantime, I also wanted to post the comments left by you, our readers. I've posted almost all of the comments thus far apart from those with swearing or those that mention their answers to question #1 of the survey.

One thing that struck me when reading the comments is that the white coat is a symbol that perpetuates hierarchy and is part of an unsafe culture. We need to create healthcare systems without hierarchy and it seems that the white coat contributes to a system where 58% of nurses that see harm are afraid to speak up "and people need to be able to speak up." Thus, even if you are in the minority who believes that white coats are not involved in pathogen transmission, your white coat might be harming patients by contributing to an unsafe hierarchal culture.

An interesting patient-centered quote that seems to run counter to the current thinking associating white coats with professionalism: "If there are better options that would reduce transmission of infection then burn the white coats. As a patient I dislike them - intensely. Reminds me of a butcher shop or auto mechanic- not reassuring at all."

Pro White Coat:

"Not an issue as long as changed daily and sleeves rolled up above the elbow and they don't carry medical equipment in the pockets"

"The white coat continues to be an important identifier of the profession, and symbols are important"

"It is certainly useful to carry things but also represents antiquated power hierarchy. Although there is no evidence, it plausible that they could transmit infections. Then again so could stethoscopes which have more direct patient contact."

"Can't prove it is causing resistance-- and I think patients like it"

"Needs an RCT. Anything else is nonsense ... unless we say all healthcare providers put on and remove scrubs at work"

"We have white coats with short sleeves. This is no problem in my opinion. BUt bare below the elbows has become the standard in most Dutch hospitals. Probably the turning point was a documentary with a hidden camera showing that healthcare workers knew that handhygiene was important that they should not wear jewelry, but they just didn't take the rules serious. Sometimes we don't need science but a good mirror and public response"

"Fashion item"

Pro Bare Below Elbow (OK with eliminating White Coats):

"It's merely a badge of authority and seniority masquerading as cleanliness and something "sciencey"

"A disease-ridden, antiquated symbol. They project the same professional and scientific insecurity as when doctors started wearing them to appropriate the public legitimacy of science."

"I appreciate that for many, the white coat is a status symbol and helps create an instant first impression on patients. That being said, times are changing. The physician is not the most important person in the room. The healthcare team is what should be the focus now. Tear off the coat and tear down the hierarchy"

"I understand white coats as a part of PPE when you don't want to get something on yourself or to prevent things on you from spreading. But when the white coat goes EVERYWHERE you go, it doesn't maintain it's protective qualities. Also, as a pharmacist, I'd much rather have normal, professional or consulting coversations as a professionally dressed human than a white coat."

"If it's a vector for microorganisms, eliminate it. Simple"

"Not necessary. Wear scrubs like everyone else. If your ego needs the coat, get therapy"

"I hate it. Adds to elitism and difference. Separates us from our humanness"

"White gets filthy too quickly"

"In the past, it was a status symbol for physicians; this is now translated to our students, ancillary staff and physician extenders. It is not represent amount of fundamental knowledge or the ability to care for patients. It was an extension of the laboratory part of our profession transitioned from black coats earlier in the last century. Currently, it is nothing more than a status symbol or accessory"

"White coats offer no benefit. We should try to prevent infections by any means necessary"

"I don't think white coats are necessary, but then I'm also not American!"

"Don't wear them in Australia. If you're worried about getting dirty, wear scrubs"

"It's part of a bygone age"

"Given the association with pathogenic transmissions, I am appalled we are still handing them out to our medical trainees!"

"I work at a pediatric hospital where most physicians do not wear white coats. Anecdotally, pediatricians seem to eschew white coats in order to be more friendly and approachable. Don't know what impact this has on HAI at our hospital"

"Doctors don't walk around with head mirrors anymore; the white coat makes about as much sense to me. Why do we still have this thing that exists for no other reason than a vector for disease?!"

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image source: NYT

The White Coat Debate Needs Your Opinion!

The white coat debate continues. If you'd like to see the latest and greatest discussion concerning the doctors white coat, head over to Phil Lederer's blog and read his White Coat FAQs. In the meantime, I have a couple quick questions for you. Thanks for taking our survey!

Debating Bare Below the Elbows

At IDWeek in San Diego this past Saturday, I debated Neil Fishman on bare below the elbows, a topic that regular readers of this blog know is one of my favorites. I had 10 minutes to deliver the pro argument and Neil had the same for the con. You can read an unbiased account of the debate here.

So in my 10 minutes, here's what I argued:

• We have conclusive evidence that healthcare workers' clothing becomes contaminated with pathogens during the care of patients.
• There is some in vitro evidence that pathogens can be transmitted from clothing to patients.
• There is no evidence that intervening (removing white coats and neckties and having HCWs go bare below the elbows) reduces healthcare associated infections, though of course, absence of evidence is not necessarily absence of effect.
• The literature on patient preference for physician attire shows mixed results in weak studies where patients look at pictures of doctors in different attire, while studies that randomized attire show no difference in patient satisfaction, and others that add context show that attire is one of the least important characteristics that patients consider in evaluating their physician.
• On the basis of biologic plausibility, I argued that we should recommend (but not mandate) bare below the elbows.

Neil argued the following (and I've added my comments in italics):

•  We already have too many metrics to follow and we shouldn't add one more. We can't be the "fashion police." (There's no added work to implement bare below the elbows. Give HCWs permission to do it and provide some encouragement).
• Bare below the elbows is not enforceable (With no mandate there is nothing to enforce).
• Arms are just as likely to be contaminated as the sleeves of the white coat (True, but you can wash your arms between patients; in a survey of physicians that we published, nearly 20% reported that they had NEVER washed their white coats).
• 5% of the population has eczema or psoriasis, and these individuals have higher rates of staphylococcal colonization (True, but we usually don't formulate policy on the 5% exception). 
• If the white coat goes, all measures of hygiene will decline. (This is a borderline insane argument borrowed from Stephanie Dancer, that I previously blogged about here).

So what was the verdict? Before the debate, 37% of the audience supported bare below the elbows, and after the debate 42% were in support. So in 10 minutes I moved the needle 5 percentage points. Not dramatic, but I'll take it. But just imagine having this debate 10 years ago, or even 5 years ago; I suspect supporters would account for <10%.

Any intervention that involves changing behavior produces incremental results. But from firsthand experience, I know it can be done. At VCU, we recommended a bare below the elbows approach to inpatient care in 2009. It was a very soft rollout--no mandate, just a recommendation. Gonzalo Bearman, Mike Stevens and I consistently wore scrubs and others slowly joined in. It started with just three people. Last year before I left VCU, we did a 12-week prevalence survey and we were pleasantly surprised to see that 69% of inpatient encounters were via HCWs bare below the elbows. This year, it has increased to 80%. Compliance was boosted when the medical school bought their students scrubs and nylon vests (see the photo of Gonzalo with some VCU medical students). I think this is an amazing accomplishment, and I will venture a guess that 10 years from now, the vast majority of doctors in the US will look just like those in that picture.

Nationwide survey of ID physicians and pharmacists

Guest Post: Charlie Garland from the Healthcare Innovation & Technology Laboratory (HITLAB*) @ Columbia University Medical Center is conducting a nationwide survey of Infectious Disease physicians and pharmacists around treatment patterns for carbapenem resistant bacterial infections, and he would like your participation and expertise to help in this research.  

This survey will only require 10 – 15 minutes to complete, but the results will be extremely valuable.  We will gladly share the results of our research with each participant, which will help you and your colleagues to understand how your individual strategies compare to those of your peers – within your region, and across the US.

The link below will connect you to this survey, which will ask you:

·        A few demographic questions about the hospital at which you practice.

·        5 scenario-specific questions around treatment strategies that you would most likely employ in each case.

·        7 follow-up strategies, based on different patient responses to the initial Rx.

·        An option to enter your name/email if you’d like to receive the survey results (aggregated).

The information we gather will be de-identified and only reported in the aggregate.

Take the survey now: SHARE ID Treatment Survey https://www.surveymonkey.com/r/LC235N9

Please feel free to forward this link on to colleagues whom you believe would like to participate.  We are asking participation of infectious disease physicians, fellows, residents, interns, and pharmacists.

Kind regards,

Charlie Garland, HITLAB/Senior Fellow
Healthcare Innovation & Technology Laboratory
(@ Columbia University Medical Center)

*The Healthcare Innovation and Technology (HIT) Lab is a cross-disciplinary, academically based, research cooperative located at the Columbia University Medical Center in New York City. The HIT Lab consists of Columbia faculty, staff, students, alumni, and members of the Washington Heights community collaborating to improve healthcare through thoughtfully designed and implemented technology

CDC Prevention Epicenters expanded!

Regular readers know that we often call for increased funding for infection prevention. So naturally we’re very excited that CDC is expanding their Prevention Epicenters program from five centers to eleven. The University of Iowa is honored to be one of the newly added Prevention Epicenters (we’re actually rejoining this program after being a Prevention Epicenter for the first two cycles, from 1997-2005). The principal investigator for the Iowa Prevention Epicenter is fellow blogger Eli Perencevich, with additional project leadership by Loreen Herwaldt, Phil Polgreen, Marin Schweizer, and support and collaboration from many other investigators both at Iowa and at other centers across the country. 

You can read more about the program expansion at CDC's Safe Healthcare blog (post to go up later today), and from the CDC press release. And of course we’ll continue blogging periodically about work funded by this program. All I would add is that this is a good start: if we were to provide funding commensurate to the magnitude of the problem of healthcare associated infections, we’d expand the Prevention Epicenter network another 10-fold or more. To do so would not be a major investment in the context of other funding priorities. For example, the total of $11 million dollars awarded to the six new Epicenters is $3 million dollars less than the annual cost of establishing a redundant Catfish Inspection Office.

Stewardship, Stewardship, Stewardship

There has been a plethora of antimicrobial stewardship scholarship published these past few weeks. I'm currently on the inpatient medicine service and have even been harassed by the antimicrobial stewardship team (humor), so I only have a moment to briefly highlight three can't miss articles:

(1) Manisha Juthani-Mehta and co-authors just published an excellent JAMA Viewpoint discussing Antimicrobials at the End of Life.  It is open-access (free), so I hope you have a chance to read it thoroughly, but the main points include:

1. "Evidence-based and goal-directed counseling about infection management at the end of life must be a routine part of advance care planning and treatment discussions between clinicians and patients with advanced illness."
2. "Clinical algorithms aimed at improving antimicrobial stewardship from an infectious disease standpoint must also integrate treatment preferences when applied to patients near the end of life." 
3. "To the extent that inadequate outcome data hinder decision making, researchers should consider whether there is adequate clinical equipoise and need to justify a carefully designed randomized trial comparing symptom control and survival among patients with advanced illness who receive antimicrobials vs high-quality palliative care for suspected infections."

(2) Dan Livorsi and colleagues at the Sidney and Lois Eskenazi Hospital and the Richard Roudebush Veterans Affairs Medical Center in Indianapolis just published an important qualitative study in September's ICHE of factors that influence antibiotic prescribing among inpatient physicians (10 resident and 20 staff physicians). I'm happy to add that Dan Livorsi has just joined our group in Iowa City, where he is helping to jump-start our stewardship programs. Key findings of his study include:

1. "Antibiotic overuse is recognized but generally accepted; 
2. the potential adverse effects of antibiotics have a limited influence on physician decision making;
3. physicians-in-training are strongly influenced by the antibiotic prescribing behavior of their supervising staff physicians; and
4. other physicians’ prescribing decisions are sometimes questioned, but there is limited peer-to-peer feedback or critique."

(3) Nick Daneman and colleagues in Ontario examined antibiotic use and secondary harms in 607 nursing homes housing 110,656 residents in a recent JAMA Internal Medicine. Their findings are quite striking (if not surprising) in that antibiotic use varied from a low of 20.4 antibiotic days to a high of 192.9 antibiotic days per 1000 resident days. Antibiotic-related adverse events were higher in "high-use" nursing homes even among patients who did not receive antibiotics. An interesting finding (for someone in Iowa) was that rural facilities were overrepresented in the highest tertile of antibiotic use (see figure below), but after accounting for other nursing home– and patient-level characteristics, rurality was found to be protective against antibiotic-related harms." Would be interesting to figure out why rurality is associated with higher antibiotic use but fewer harms but my guess is that rural folks are just awesome. Of note, Lona Mody and Chris Crnich published an accompanying editorial that is worth reading.