Public reporting of HAIs: Getting it right

The October issue of American Journal of Infection Control has an important commentary on public reporting of healthcare associated infections (HAIs). The authors, who include Don Goldmann, stress the need for reliability and validity in publicly reported metrics, two important concepts that have been largely ignored by many states that have mandated public reporting. They call on the CDC to develop online clinical vignettes which could be completed by ICPs in order to assess the accuracy of case ascertainment. This is a great idea and should be a relatively easy way to begin the process of improving validity. While the CDC HAI case definitions appear straightforward when simply read, in the context of application in real time numerous questions arise. My ICPs not uncommonly ask me to review cases where ambiguities preclude their ability to decide whether the patient's clinical picture meets the definition of an HAI. Moreover, in preparing ICPs for mandated reporting in Virginia, we developed case vignettes for training and testing, and found wide discrepanices in the application of definitions, even among ICPs who were epxerienced in NHSN methodology. Hopefully, funding to states from the American Recovery and Reinvestment Act will be used for training of ICPs to improve case ascertainment, as well as to establish programs to assess validity of data submitted by hospitals.

Save the masks!

In our flu planning meeting yesterday I learned from our materials management director that we are having difficulty obtaining surgical masks and that our in-house supply is being depleted. Whether this is a local problem or whether it's more widespread I don't know. But it concerns me that hospitals are implementing policies requiring asymptomatic healthcare workers to wear surgical masks at all times, in some cases those refusing to get vaccinated, in other cases universally in high-risk areas of the hospital. Perhaps we all need to take a step back and think through the long-term implications of such policies.

It seems to me that we are seeing an exceptionalism applied to H1N1 much like that applied to MRSA--that is, we are singling out certain diseases to focus attention and apply interventions while other diseases or organisms, perhaps of equal risk and impact, are not given the same attention. With regard to H1N1, the two major differences from seasonal influenza being observed are a larger population of susceptible individuals due to the antigenic shift the virus has undergone and the overall milder disease course (though there are certainly severe cases being reported). So if you think that all healthcare workers, or even just the unvaccinated fraction, should wear masks at all times during H1N1 season, are you prepared to do the same in all subsequent influenza seasons? Even if the flu season is prolonged? Even if the vaccine and circulating strains are mismatched, meaning in essence that all healthcare workers are unvaccinated? What are the triggers for starting and stopping masking? Is prolonged mask use a practical strategy? I could go on, but you get the point, I'm sure. I think a lot of policy is being driven by the media's attention on certain diseases and organisms with a short-term focus, rather than on priorities that are grounded in the magnitude of risk and impact and the long-term implications. Perhaps key questions to ask are: How many patients died in your hospital in the last month from a catheter-related bloodstream infection? How many died from ventilator-associated pneumonia? How many died from a surgical site infection? And how many died of nosocomial H1N1?

I long for the post-H1N1 era......

Mandatory flu shot smackdown!

Our occupational health doc forwarded this link to me, a listserve posting by the medical director of the occupational health clinic at Vanderbilt (my alma mater!). Read it for yourself, but it is a concise critique of the references that IDSA cites in support of their mandatory vaccination position.

Pay particular attention to the conflict-of-interest issue to which she repeatedly refers. Regular readers of this blog know that this is a popular topic here. As well-meaning as they may be, strong proponents of mandatory vaccination always should disclose all of their financial relationships with vaccine manufacturers….and if they wish to maintain credibility in the long run, they should attempt to limit relationships that extend beyond legitimate research funding.

Questioning the ethics of MRSA active surveillance

For some time, Dan and I have questioned the ethics of performing active surveillance cultures for MRSA in order to isolate colonized patients. In this week's BMJ, Dr. Michael Millar from London, notes the ethical issues surrounding the policy of mandating MRSA screening of all patients electively admitted to English hospitals. In addition to the ethical issues, we believe there are other effective ways to control MRSA that also control other pathogens, and do so in a more patient friendly and cost effective manner.

Wait 'til next year

Regardless of your view on mandatory influenza immunization of healthcare workers, I can tell you from personal experience that this year is not the best time to institute a mandatory program. We chose this path here, and it has been an unproductive distraction during a very busy time.

For starters, we felt we couldn’t mandate a vaccine for which the supply was then uncertain, so we only mandated the seasonal vaccine….putting us in the awkward position of mandating the vaccine that doesn’t cover the predominant circulating strain. Moving ahead now to mandate the nH1N1 vaccine might place us in the equally ridiculous position of forcing healthcare workers to be vaccinated just as the nH1N1 epidemic is waning, or even after the epidemic, depending upon when the full vaccine supply arrives and how long our local H1N1 activity lasts (we haven’t received a single dose as of today, and H1N1 activity is already widespread on our area, and will soon be widespread across the state).

The mandate also resulted in our union filing an injunction to suspend the program, setting up an immediate adversarial relationship with many of our healthcare workers at a time when we most need to foster trust and communication (e.g. during a pandemic response!).

So if you don’t already have a mandatory flu vaccine program for healthcare workers, my advice mirrors that of Cub fans everywhere: “Wait ‘til next year”. Dr. Thoman Freiden, head of the CDC, said the same about NY State’s program recently:

“This is just not the right flu season to take this on”

Nonetheless, IDSA has decided now is the right time to recommend mandating the nH1N1 vaccine. You can link to their reasoning from the front page of the IDSA website.

H1N1: Pay me now or pay me later...

The New York Times reports today that areas of high H1N1 activity last spring are now enjoying low disease activity. Conversely, the hardest hit areas currently had relatively little flu activity in the spring.

Killing the live vaccine?

A Denver television station is reporting that some hospitals there are refusing to administer the intranasal (live) H1N1 vaccine because of concerns of transmission of the virus to immunosuppressed patients. While CDC recommends that the vaccine should not be administered to healthcare workers in contact with severely immunocompromised patients (e.g., bone marrow transplant patients), I have heard from a number of clinicians who are expressing concerns regarding whether workers in contact with other immunosuppressed patients (e.g., solid organ transplant patients) should be vaccinated.