Metrics, Decision Makers and Hospital Epidemiologists

This is a guest post by Silvia Munoz-Price, MD, PhD, Enterprise Epidemiologist and Professor of Medicine, Division of Infectious Diseases, Froedtert and the Medical College of Wisconsin.

During the past few weeks I have been mulling over two issues related to Quality and Infection Control that have to do with metrics, their use, and the impact that they have in our hospitals. Two separate topics but related to a certain degree.

1. My hospital has a strong Quality Department and a stronger culture of safety. For the most part we have very few serious infections and even fewer MRSA, VRE, and almost no multidrug resistant Gram negative rods. Our compliance with hand hygiene is 73% (as per >5000 observations collected over a couple of months by managers from units that are not their own and concordant readings obtained by the Infection Control Department. I am trying to tell you that 73% is probably close to accurate). From my perspective, if indeed true, this is an acceptable rate. I think we should concentrate on preserving this rate and maybe focus on areas/providers that need more attention. However, my hospital wants this number to be close to 100%. So, here are my questions: should we invest more time, effort, and money to push for higher compliance with hand hygiene? What would be the return on investment of increasing our hand hygiene compliance and how could we measure its impact? What type of infections would we prevent by increasing hand hygiene compliance? Yes, our CLABSIs and CAUTI rates could be better, but would they noticeably improve by pushing hand hygiene above 80%? (I’m intentionally not discussing C. difficile infections as these have a different etiology in my hospital). And most importantly what other interventions would we be overlooking by focusing so much on hand hygiene? Who decides where to allocate time, effort and money?

2. Over the past couple of decades I have observed a shift in Infection Control throughout the various places I have worked at from minimal interest/resources given to Infection Control, to a phase where more visibility was given to Infection Control matters --probably due to metrics--to the allocation of more interest/resources, to publicly reported metrics, to institutional notoriety and reimbursements linked to metrics, to a tunneled vision about metrics. On this topic, many years ago I observed a human behavior that since I have observed multiple times: when we started placing fluorescent powder on surfaces and giving feedback to providers on the degree of removal, cleaning rates improved (https://www.ncbi.nlm.nih.gov/pubmed/21460514). Feedback was then given weekly and in a public manner, with a substantial amount of pressure placed on EVS to improve. The numbers got much better. We eventually figured out that EVS providers bought their own ultraviolet lamps to find the fluorescent markers and spot clean them. What happened? The metric made sense at the beginning, initially it probably achieved its intended outcome (more frequent cleaning) but then a threshold was crossed, after which what mattered was the metric (as a number) and no longer the intended outcome (more frequent cleaning).  I think the same is happening to our hospitals. Metrics were beneficial initially (more resources for Infection Control, more visibility, more engagement of staff, lower infections) but I would argue that we are on the other phase of the metrics (unintended consequences).  All the pressure we are placing for lower and lower metrics (get to zero CAUTIs!) might be backfiring. We are deploying large teams and resources to decrease certain conditions which is shifting our capability to address issues that might be equally or even more important in our respective hospitals   (e.g. post craniotomy  SSIs).  So, who decides how to allocate our limited resources? I would argue that Quality is now the main decision maker and that these decisions are strongly guided by publicly reported metrics. Is this good or bad for our patients? I am not sure. Is this good for the field of Hospital Epidemiology? I don't think it is. Hospital Epidemiologists need to re-think their involvement in Quality and become their hospitals’ Chief Quality Officers. That is the only way I see that we will impart some sense to the decisions of resource allocation. However, the opportunity for our specialty to lead in this field might have already passed.     

Recognizing the Value of Infection Control in Addressing the AMR Crisis

One of the challenges that all infection control and QI programs face is obtaining the necessary funding to complete all their required activities such as surveillance, reporting and prevention. Anthony Harris from the University of Maryland spent a great deal of time (e.g. SHEA White Paper on Necessary Infrastructure) as SHEA President pushing for increased resources for hospital epi activities. In a recent BMJ Quality and Safety editorial, Anthony offered suggestions for advancing the recognition and resources for infection control and QI activities, including societies (i.e. SHEA, APIC, ESCMID) partnering with governments to create comprehensive recommendations for infection control programs and funding.

Specifically, he recommends:

(a) guidelines by major organisations outlining the optimal reimbursement and full time employee (FTE) of hospital epidemiologists and infection preventionists for healthcare facilities in various settings. Currently, agencies such as CMS list certain conditions of participation for institutions relative to infection control and soon to be antibiotic stewardship; however, details of these requirements are vague and should be expanded

(b) as reimbursement moves away from fee per service and more towards quality outcomes driving reimbursement and penalties, we need more effective and novel methods of directing resources for day-to-day infection prevention. For example, an infection prevention fee could be imposed on all procedures that require significant infection prevention resources such as surgery or central line insertion and maintenance

(c) funding for state health departments to assist individual hospitals in establishing effective infection prevention programmes

(d) novel reimbursement models such as a fixed fee per surveillance culture reviewed, a fee for each chart reviewed to assess the appropriateness of antibiotic selection or an hourly fee for performing outbreak investigation may be warranted

(e) certification requirements for hospital epidemiology and QI experts that will help recruit and establish more experts to the field.

The full editorial (free full text access) is well worth reading. (COI alert: I'm a co-author)

Hospital epidemiologists and the IRB: Two views

Viewpoint 1:
Silvia Munoz-Price

During the past few years, my hospital has experienced high rates of Clostridium difficile infections especially in one inpatient unit. This situation is of major concern to Hospital Administration, the Quality Department, the Infection Control Department, as well as medical and nursing leadership. As the Hospital Epidemiologist, my main duty is to better understand the pathophysiology of the infection control problems so that interventions can be tailored to our specific needs. My initial questions in this particular situation focused on where the acquisition of C. difficile strains were occurring. Are patients acquiring C. difficile at home, in the outpatient clinic, or in the inpatient units? If they were already colonized upon admission to the inpatient unit, then that would certainly explain why infection control bundles had been ineffective in controlling this problem for the past year. Or is it that the hospital environment is acting as a reservoir for C. difficile due to inappropriate disinfection? In order to answer these questions, we started a quality Improvement project, testing the unit with DAZO, culturing the environment, and performing active surveillance cultures of consecutive patients on admission and weekly thereafter. These stool surveillance cultures aimed to detect asymptomatic carriers presenting from the community.

After a couple of months of pursuing these initiatives, I am now getting questioned in regards to my lack of IRB approval. Pondering this issue, to me it is clear that as a hospital epidemiologist I am mandated to investigate the answers to the above questions. Should I get IRB approval ahead of time before each of these projects? I think the answer should be no. If we are not testing any invasive procedure or drugs, but rather we are trying to understand how to prevent infections in our patients, we should not be required to get an IRB approval ahead of time. I do think the IRB should be involved once we determine that the data collected merits publication. THAT is the time when hospital epidemiologists should get the IRB involved. Otherwise, we handicap ourselves on the investigations that we do as part of our duties. Another situation that should warrant IRB approval from the start is multicenter studies of infection control interventions, given that their intent from the start is to publish the findings.

It is true that our job duties fall in the gray zone between quality and research, and some of us tend to publish a great deal of what is done as part of our paid job. However, we should always be guided by this initial question: Is the primary goal of the project to help my patients and my hospital or is the primary goal to publish the results? If it is the former, I say do not ask for permission to do your job. If it is the latter, then by all means, IRB approval is necessary.

Viewpoint 2:

Mike Edmond

I agree with Silvia that this is a problematic issue for hospital epidemiologists, and also agree that the interventions she describes should not require submission to the IRB. My view is that you need IRB approval if your intent is to answer a research question, and that you don’t need IRB approval if the intent is to do quality improvement, particularly if you are implementing interventions that have already been shown to be effective in published studies. I don’t think the intent to publish results has anything to do with the decision to submit for IRB review. For example, if I roll out chlorhexidine bathing to the entire hospital and find that our infection rates fall (or increase, or even if nothing happens at all), I don’t think I need IRB approval regardless of whether I choose to publish the results. On the other hand, if I want to do a trial of chlorhexidine bathing and randomize hospital units to test the hypothesis that chlorhexidine reduces infection rates, that would require IRB approval.

If you would like the US Department of Health and Human Services official opinion on what constitutes research and requires IRB review, I have attached their algorithms below. Once you go through those algorithms, it will all be crystal clear!

 

The new healthcare epidemiologist

The April issue of Infection Control and Hospital Epidemiology has a white paper on skills and competencies for the healthcare epidemiologist. True to form, the paper reflects the rather timid approach that SHEA never seems able to shake. As a disclaimer, I should state that I sit on the Board of Trustees of SHEA, and I’m not saying anything in this post that I haven’t shared previously.

While the paper mentions that the healthcare epidemiologist should have an understanding of quality improvement and safety, and is a valuable partner to the Chief Quality Officer (CQO), what it should state is that the healthcare epidemiologist is uniquely qualified to be the CQO. Infection prevention was the first QI program ever to emerge and remains better developed than QI and patient safety. Many healthcare epidemiologists have advanced degrees in public health or epidemiology, and the skill set is directly transferable to QI and safety. Increasingly hospitals are developing CQO positions, but very few of these positions are held by healthcare epidemiologists. In some cases, CQOs may not have a true appreciation for the value of the healthcare epidemiologist, and some of us fear that healthcare epidemiologists as we know them may ultimately be replaced by less trained individuals. Interestingly, Dick Wenzel published a book on quality improvement in 1992, but unfortunately, SHEA chose to remain confined to infectious adverse outcomes rather than expanding into the quality realm.

So my recommendations are these:

1. SHEA should move aggressively and quickly into the quality and safety space.
2. To broaden the skillset of the healthcare epidemiologist, SHEA needs to sponsor education on leadership, implementation science, human factors engineering, Six Sigma, Lean, and other quality improvement and patient safety topics.
3. As much as I hate to talk about certification given the absolute mess the American Board of Internal Medicine has made of our certification processes, I continue to believe that healthcare epidemiology will never be seen as a valid entity until there is certification. Once certification occurs, then it becomes possible to build the requirement for a healthcare epidemiologist into payer’s conditions of participation, hospital accreditation, and hospital quality rankings. We need to make the healthcare epidemiologist indispensable. 
4. SHEA’s journal, Infection Control and Hospital Epidemiology, should specifically solicit papers focused on noninfectious adverse outcomes, quality improvement and patient safety. 

In a nutshell, SHEA should define the role of the healthcare epidemiologist more broadly, which in the long run will help its members more easily achieve leadership positions in hospitals and have a seat at the table when important decisions are made.

Graphic: Stratabridge 

What is Healthcare Quality Improvement?

Dr. Mike Evans, a staff physician at St. Michael's Hospital in Toronto, and his team at the Evans Health Lab have released another excellent whiteboard video. This time they cover QI in healthcare.  Brilliant and clear as always.