In a phone interview this week, Niedner explained how some physician and nursing practices can vary so much. "If you send lots of blood cultures of high blood volume at a lower temperature threshold, and more proactively, you are increasing the sensitivity of that same test," he said.
For example, a doctor at one hospital might be worried about a patient with a weak immune system who has several invasive catheter devices. The physician knows that the patient is on therapies that mask a fever, and so he sends surveillance cultures every day or every other day to make sure to stay ahead of any infection. That same hospital may also have a practice to send larger volumes of blood, or draw from numerous ports.
With that level of aggressive surveillance, more infections are likely to be caught, he says.
At another hospital with different practices, a doctor might take a different approach: He might note that the hospital usually takes good care of its lines, "so we won't need to take blood from this patient every day.” This approach would not require as many or any blood draws, which could lead to the patient requiring a blood transfusion, which carries its own risk of bad outcomes, Niedner explains.
Moreover, in that second hospital scenario, the cultures are only sent when the child has a significant fever.
Niedner acknowledges that the issue is shadowed by hospital leaders’ concerns about financial penalties and public attention generated by websites such as Hospital Compare.
With pay for performance and public attention to the issue of how a hospital looks on a national website, "there's more angst and tension over this issue," Niedner says.
"From an improvement perspective, you want aggressive surveillance,” he notes. “But from a pubic reputation, and pay for performance perspective, you can maybe create some inappropriate incentives to not look as hard for these things. If there's wiggle room in how you go about looking for them and how you go about applying the definition for inclusion, you can see how people could be incentivized" to maybe not meet the standards to the degree of fidelity you would want."
Niedner explains that the issue of surveillance and reporting aggressiveness would have been a "drop in the bucket" important a few years ago when infection rates were higher, 10 to 20 per 1,000 line days.
But now, what was once low-hanging fruit has been picked, and infection rates at many institutions are at zero, or 2 to 5 per 1,000 line days. "Now, these definition issues are no longer trivial. They float to the surface."