Are "One-Offs" Becoming Routine


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.


  1. Welcome to the blog, Scott. Great post! Given the advances in technology and communication, with all of the resultant improvements in workflow, I continue to be amazed at CDC's unwilligness to fix these issues. It isn't that hard. None of this is carved in stone. CDC needs to join the real world and improve their work in real time like the rest of us.

    1. We often hear that certain government agencies should/could do things and often times I agree. However, after spending 15 years (got my pin) in VA, I've noticed that it often becomes complicated to try to change a whole system when you have large, small, urban and rural hospitals for example. I guess this is my way of asking Scott and Mike (and any others), how would you operationally change CDC to be more responsive - it seems to me that this would require merging CDC with CMS or some other drastic change would be needed, but I'm not an expert in the world outside VA.

    2. I think you could have a small panel of experts (internal and external) empowered to rapidly address emerging questions. For example, the panel could address the question of whether Paenibacillus (which in pre-MALDI days was simply Bacillus spp), should indeed be classified just like Bacillus with regards to whether it's a contaminant when found in blood cultures. This isn't rocket science. The reality is that hospitals working hard to reduce infection rates are being punished for employing technologies that improve care because CDC either can't get its act together to fix this or simply doesn't care.

    3. I think the later isn't true, i.e, CDC HAI teams care. I will suggest the perspective differs. There are likely lots of obstacles to having a smooth frequency updated methods/operations - but at its core is the twice annually updates for such a complex software program/surveillance program doesn't allow for such rapid and fluid updates as you suggest.


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