Unwarping the playing field

Easing comfortably into my role as a "blogger," I've realized how easy it is to adopt a few key platform issues that tend to drive one a bit mad.  This blog isn't so fond of CAUTI, contact precautions, or devices that blow moist, warm particles over sterile fields (but then again, who is?).  We love diagnostic stewardship, influenza vaccination (um, mostly), and fecal transplantation.

Add advocating for better risk-adjustment of publically-reported HAI performance to my list.  A few months ago, I blogged about this issue and poor reporting validation by CMS -- now some excellent papers on improving risk adjustment have emerged, both from many FOB (friends of the blog) with senior authorship by Anthony Harris and his group at Maryland.  One focuses on SSI and one on CLABSI.  Their methodology is very similar and has some key features:

• They used comorbid conditions that are components of the Charlson and Elixhauser comorbidity indices
• These conditions were captured by diagnostic discharge coding that are currently routinely collected and submitted to CMS, limiting the data collection burden 
• They used conditions identified using Delphi consensus methodology from a survey of ID and infection prevention experts, providing some clinical credibility to the process

The authors examined the model performance and assessed changes in hospital rankings when compared to the traditional NHSN models. For SSI, a model containing procedure type, patient age, race, smoking history, diabetes, liver disease, obesity, renal failure and malnutrition showed good discrimination, and 86% of hospitals changed ranks within the cohort when the risk-adjusted model was used -- with 4 hospitals changing by >10 ranking spots.  For CLABSIs within the ICU, a model using coagulopathy, paralysis, renal failure, malnutrition and age showed improved predictability when compared to the NHSN ICU model, and 45% of hospitals changed ranking.  The authors note the clear limitations, including some of the challenges with using coded data, but these papers are important advances in the area of publically-reported HAI data.

You can read some of my more detailed thoughts in the accompanying editorial for the CLABSI paper (shameless plug).  At a time when there are many consequences for a hospital's performance on these surveillance metrics (e.g. last year my hospital received a draft quality incentive contract from a private insurer that required our large, tertiary care center to have ZERO of the Big 6 reported HAIs, to the tune of several million dollars in incentives), leveling the playing field to adjust for those factors that lead to HAIs that are beyond the control of the hospital is essential.  Thankfully, the CDC and HICPAC have recently chartered a new NHSN work group (disclaimer: Hilary and I serve on this group) and the issue of improved risk adjustment seems to be a major emphasis - fingers crossed that the field will start to level soon.

When prevention success stagnates? Treat the patient!

Prevention is paramount – I do believe this, and I know that is so much of what healthcare epidemiologist strive for; however we often become very myopic and focus exclusively on “modifiable risk factors.” It is refreshing to read a nicely done epidemiologic study to illustrate what an impact the infectious disease community can have by improving the way we approach patient treatment. When reading the recent article in JAMA IM by Michihiko Goto and colleagues I was expecting a nice ecologic study showing an impressionistic picture of how improved treatment processes correlate with improved MRSA bacteremia mortality - but our VA colleagues working with big data have painted more of a realistic 

Le Déjeuner sur l’herbe Painting 

by Édouard Manet, 

1863 Musée d’Orsay, Paris

Google Arts & Culture

than an impressionistic picture. Using the VA database, capturing deaths occurring during both the inpatient stay and the post-discharge period, they quantify improved survival at the patient level is driven by improved processes of care for S. aureus bloodstream infection (Association of Evidence-Based Care Processes With Mortality in Staphylococcus aureus Bacteremia at Veterans Health Administration Hospitals, 2003-2014 JAMA IM).

I have been pushing for transitioning efforts to prevent S. aureus (more specifically MRSA) bacteremia to the post-discharge setting, worried that the recent reductions observed among hospital-onset MRSA BSI are not being realized in the post-acute care setting. We’re getting stuck; in fact we have been stuck for a while at preventing community-associated MRSA BSI (See figure). 

Goto and colleagues provide some clarity to preventing deaths related to MRSA BSI (and S. aureus BSI overall) even during periods of prevention stagnation such as we may be in currently. Of note, the incidences of healthcare-associated and hospital-onset MRSA BSI decreased in VHA hospitals between 2003 and 2014, whereas the incidence of CA bacteremia was stable. This is identical to trends illustrated nationally using CDC's EIP data, suggesting the VA analysis may be reflective of what is going on nationally.

Goto utilized the national Veterans Health Administration (VHA) health care system to first determine how to best risk adjust mortality; and then determine the independent effect of each of three pillars of guideline directed processes of care for managing S. aureus bacteremia (SAB): (1) appropriate antibiotic therapy, (2) echocardiography, and (3) consultation with ID specialists. They report lower risk-adjusted mortality among patients with SAB when they received (1), (2), or (3), and there was a nice dose-response relationship between the number of care processes and mortality. They estimate “57.3% of the decrease in risk-adjusted mortality among patients with SAB between 2003 and 2014 could be attributed to increased use of these evidence-based care processes.”

Their paper also sheds some light on the importance of capturing post-discharge data when quantifying mortality related to processes or infections related to the hospital setting!. Risk-adjusted mortality decreased from 23.5% in 2003 to 18.2% in 2014, regardless of MRSA, MSSA, and place of acquisition (Figure).

From Supplemental Figures, Goto et. al.

I was caught by the discrepancy between these mortality rates and the mortality reported by the CDCs Emerging Infections Program invasive MRSA Surveillance, reported around 12%. The latter is limited to in-hospital or 30 day mortality, whichever comes first. Recent data at IDWeek by one Emerging Infection Program site identified another 30% of deaths among patients with MRSA BSI occurred post-discharge. The Goto paper captures these deaths, making their conclusions more realistic. In addition, their risk adjustment for mortality included over 13 comorbidities, timing of infection, and susceptibility. They did an outstanding job of trying to evaluate the relative importance of each care process while accounting for changes/absence/presence of these underlying predictors of mortality (both inpatient and post-discharge). They even did a sensitivity analysis to account for early deaths, before these care processes could occur. Furthermore, the impact of receiving the care processes was similar regardless if the SAB was hospital-onset or community-onset!

The bottom line – following evidence base care processes does save lives. Their analysis support their conclusion that “there is a need for continued implementation of quality improvement initiatives to increase the adoption of these evidence-based care processes for patients with SAB.” Let’s be bold and call these what they are: performance measures! Here we have a potential metric (proportion of SAB receiving said care process), that are closely linked to improved survival, and can be captured electronically in an objective manner (at least in the VA!) improving the reliability of these metrics across facilities. I was glad to find through a google search that IDSA recently (December 2016) urged CMS to move in this direction -- although the details of the status of this proposed measure (#407) are not clear to me.

While we anticipate novel therapeutics for MRSA BSI including immunotherapy adjuvants or vaccines to become available in the not to distant future; quality improvement efforts in the evidence-based processes of care for SAB now will likely improve our patient’s outcome. I hope we can turn our attention here soon -- and have hospitals rewarded for doing so.

ICD Coding and MDRO - If you don't bill for it, it doesn't exist

Fact 1: Infectious Disease specialists are among lowest paid physicians in the US

Fact 2: Many infectious diseases, including HAI, are absent from ICD billing codes or are poorly coded, and thus the true population health impact of infections, particularly MDROs, is invisible

Hypothesis: If we could improve ICD codes for infectious diseases, ID salaries would increase and the field could be saved from extinction

Many of us on the blog have lamented about the current state of ID with a particular focus on low relative salaries compared to other medical subspecialties and concerns about the annual fellowship match. If we focus on academic ID, the folks who supposedly will train the next generation, we also need to worry about low levels of NIH funding for anything other than HIV research; a trend that is slowly improving. (Fact 1, above)

Our group has looked at the accuracy of ICD billing codes for both HAI and MRSA and the results are not pretty. Michi Goto completed a systematic review of ICD code accuracy for CDI, SSI, VAP/VAE, CLABSI, CAUTI, post-procedure pneumonia and MRSA. He found that apart from CDI and orthopedic SSI, the codes have poor sensitivity and specificity. Marin Schweizer looked at the validity of the V09 code pre-2008 for MRSA and found it to be a very poor at detecting proven incident MRSA infection. (Fact 2, above)

Since many of those studies were completed, there have been new codes added for CLABSI (October 2011), VAE/VAP (October 2008), MRSA infections (October 2008), and post-procedure pneumonia (October 2012). So there is some hope that HAI and MRSA will become better recognized. But what about MDROs?  Investigators from Wash U (including co-blogger Hilary) just published a research letter in ICHE that calculated the sensitivity of ICD-9 codes for various MDRO at their hospital between 2006 and 2015. The gold-standard was a culture at a sterile site or BAL/brochial wash culture with an MDR-Enterobacteriaceae, Enterococcus spp., Staphylococcus aureus, Pseudomonas aeruginosa, or Acinetobacter spp.

As you can see in their Table 1, apart from MRSA (after 2008 code added) and P. aeruginosa, ICD organism coding had poor sensitivity and MDRO/V09 codes were - terrible. The authors concluded: "ICD-9-CM diagnosis codes cannot be used to estimate the burden of MDRO infections in hospitals."  I think we'd all agree. I would have liked to see more information on the specificity and positive/negative predictive values of individual codes (I understand this was a Research Letter).  I'm not sure what the ultimate solution is, but perhaps SHEA or IDSA (or ASM) could work to update ICD-10 codes and come up with ways to encourage accurate coding for infectious diseases. If we don't make sure infections "exist" in administrative data, the field of infectious diseases might not exist for long.

image source

When the US opioid epidemic causes a Serratia outbreak

We are in the midst of an almost unprecedented opioid epidemic in the U.S.  Last year (2016), overdoses caused 64,000 deaths, which was a 22% increase from the previous year, while fentanyl-associated deaths increased by 540% over the past three years. (I wanted to add a thousand exclamation points after the 540, but thought better of it)

Fifteen years ago, Belinda Ostrowsky reported a 26-patient outbreak of S. marcescens bacteremia in a surgical ICU that was ultimately linked to contamination of fentanyl by a respiratory therapist who had diverted the narcotic for their own use. (The CDC has a nice webpage describing 30-years of HAIs associated with drug diversion by healthcare workers)

Given the current opioid epidemic, we should expect an increase in hospital outbreaks associated with narcotic diversion. So, it is not surprising to read about a five-patient cluster of S. marcescens bacteremia linked to narcotic diversion by a PACU nurse just described in ICHE by Nasia Safdar and colleagues at University of Wisconsin. Even before the Serratia cluster was identified, a nurse found hydromorphone and morphine PCA syringes with the tamper-evident caps no longer intact and drug levels undetectable in a locked automated medication dispensing cabinet. The subsequent investigation eventually found 42 syringes had been tampered with and narcotics replaced with saline or lactate ringers before the nurse was fired. Unfortunately, even though the outbreak was clonal, the tampered syringes were destroyed before they could be cultured. However, four patients were epi-linked to the PACU nurse and the fifth patient was the nurse's father. (I resisted adding an exclamation point here too)

There you have it, but if you want to read beyond the ICHE report, there is an interview of Dr. Safdar over at STAT. We certainly don't need more things to worry about with the current opioid epidemic, but we should all make sure we keep talking with our pharmacy colleagues about narcotic thefts and keeping our theft policies and prevention practices up to date.

Donation

What a terrible couple of weeks. Hurricanes Harvey and Irma, not to mention a huge earthquake in Mexico, pummeled North America. If possible, one of the things that we can do in these situations is donate to recovery efforts. Here are a couple suggestions for places where you can donate:

UNICEF has sent teams to Chiapas and Oaxaca and has expanded their fundraising efforts to cover those affected by the hurricanes and earthquakes. Donate please

The five living past Presidents have started the One America Appeal, which initially responded to Harvey but has been expanded to assist with Florida's recovery. Donate please

Finally - and we have been hesitant to even mention this -  many SHEA members have completed races to raise funds for antimicrobial stewardship scholarships through the SHEA Education & Research Foundation's "Race Against Resistance." Runners have included fellow bloggers Tom and Scott. Not to be outdone, the University of Iowa has put together a team 5k run on September 30th.  We hope you can contribute to this important educational and prevention effort. Donate please

Thank you

Are "One-Offs" Becoming Routine

one–off

play

adjective \ˌwən-ˈȯf\

After eight years investigating hospital outbreaks, and about 15 years trying to make the best possible use of surveillance data while at CDC, I still struggle with the tensions inherent in mixing surveillance and performance measurement. The past decade has been a roller-coaster of thrills and perhaps some spills in terms of attention, resources, refinement, and usefulness of HAI surveillance led by CDC; yes, you could probably blame me for several aspects of NHSN reporting you may find unsatisfying (take your pick – perhaps I will expand another day). However, I having recently retired from CDC and am transitioning to Emory Healthcare and Emory University. Although It has been almost eight months. It has been a fascinating transition. The learning curve is steep, and not just for re-entering clinical medicine (that is another story), but also navigating the pathway which integrates the business of healthcare delivery, quality of healthcare delivery, and research opportunities. Slightly easier was learning how to navigate the Emory Parking situation (took 3 months). Much easier was recognizing that the performance quality metrics linked to HAI prevention are getting a lot of attention and a lot of action. It only took a few sessions listening to the quality improvement teams reporting on their target HAIs to understand two things. First, the C suite leaders really care. I had assumed this while at CDC, but it was illuminating to see up close how hard these teams worked to influence HAI prevention. Second, it was becoming somewhat routine to report out on “exceptions to the rules” of HAI reporting. There are many names for those scenarios when an HAI is justifiably reported, but either considered not preventable with evidence based prevention practices or not clinically the infectious event represented by the HAI. While at CDC we routinely heard about these: CLABSIs that “shouldn’t really be counted”, MRSA BSIs that really “weren’t ours”, CAUTIs that really don’t represent an infection. Now these reported HAIs were being called “one-offs.”

The NYT reports the term ”one-off” comes from earlier industrial beginnings with the quantity of items produced in manufacturing process, such as taking one-off, two-off, or twelve-off the line to sample or give-away. However nowadays it can refer to any exception of the rule – such as a recent one-off boxing match that really should not ever have happened. 

In an HAI paradigm where we aim for 0 infections, one-offs may either be unavoidable (not preventable) or wrongly attributed to the device, location, procedure. I have historically known of these in terms of byproduct of using proxy measures. I had previously published an editorial on the value of proxy measures of infection as a tool for quality improvement (Meaningful measure of performance: A foundation built on valid, reproducible findings from surveillance of health care-associated infections).

In that editorial, we outlined necessary steps to reduce the inaccuracies inherent in using such an approach. Now that progress has been made in HAI prevention since 2010/2012, many of these HAI events that conspicuously remain and continue to plague our patients, often don’t fit neatly into the intent of the surveillance definitions. Left with these “one-offs,” it is often difficult to know what to do more to prevent them. Surgical patients with fistulas and central lines that don’t have an infection related to insertion or maintenance processes, neutropenic patients that don’t quite meet the definition of MBI-BSI, I have even heard of tissue transplantation related bacteremia categorized as CLABSI. No doubt, changes have occurred since 2011 to improve CAUTI reporting, and neutropenia-related bacteremia. However, the pace is slow. The one-offs are starting to pile up. Perhaps improved risk adjustment of HAI data will mitigate the influence of the one-offs on healthcare facility performance measures. Until then, kudos to the quality folks and infection control teams making prevention progress. However, I hope we can reward them soon with improved performance measures. Perhaps there are surveillance lessons that can be learned from these one-offs after all. 

If you are interested in sharing one-off stories I have started a registry here - maybe we can fill in some gaps and accelerate the process of changes in surveillance methods.