A Call for Standardized Infection Detection Practices

As hospitals brace themselves against financial penalties and public reporting of catheter infections, a test score that all the world can see, a disturbing report released last week says all hospitals are not taking the same exam.

In fact, they are taking the test in different ways, submitting answers to just some of the questions, says Matthew F. Niedner MD, assistant professor of pediatrics and communicable diseases at Mott Children's Hospital in Ann Arbor, MI.

When he and his team asked 16 pediatric intensive care units to explain the standards they use to look for, measure, and report catheter-associated bloodstream infections, he discovered that some hospitals look a lot more aggressively than others.

"There is substantial variability in catheter-associated bloodstream infection practices on multiple fronts: from the application of diagnostic strategies to interpretations of the CDC definition itself," he and colleagues wrote in October's edition of the American Journal of Infection Control.

In the article, entitled in part "The Harder You Look, The More You Find," he explains that some hospitals have written policies but others don't. Some hospitals include some reports of infections from some catheter sites but not others. Some test daily when a child has a low-grade fever but others, not so much.

He says his study, done in conjunction with the 2008 National Association of Children's Hospitals and Related Institutions Pediatric Intensive Care Unit Patient Care FOCUS Group, was "the first stab" at trying to understand whether units with more aggressive surveillance practices result in higher infection rates.

And, he says, his findings raise a compelling argument to standardize the way all hospitals look for such infections—not just pediatric institutions, but adult acute care facilities, too.

"If we're now to be judged and have our economic prosperity attached to these performance metrics...some of the energy being put into this problem ought to be applied to establishing and implementing standardized practices, at the clinician level," he said.

Niedner's team did not look at variability in adult care institutions, but, he says, "the principles are extrapolatable."

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."

Even with the opportunity to improve systems with better detection, some hospitals may try to "game the system," Niedner adds. By using more lax reporting criteria they "may be able to hide some (cultures) that maybe were infections or maybe weren't, saying since it was a 'maybe,' we'll count it out so it won't be included in public reporting and 'we won't get dinged financially.' "

But that kind of thinking, Niedner says, cripples quality improvement.  "You can't see the defects or potential defects in care—including the near misses."

Niedner emphasizes that much of the problem has to do with education rather than in rewriting any definitions of what constitutes a catheter-associated bloodstream infection.

"Everyone says we use the CDC definitions, but if you actually ask them how they would rule on this case or that case, [you realize] they aren't using a definition,” adds Niedner. “Are standards being applied consistently? No. But do people think they're applying them consistently? Yes."

Niedner's report highlights an important weakness in the way hospitals are now being measured, with significant implications for quality reporting.

It's a failing that really could be addressed with a more standardized surveillance system as we enter the brave new age of hospital-acquired condition reporting. Patients, payers and providers can and will use it to judge and compare each institution's quality, so it's important that facilities be on a level playing field.

We need to make sure that everyone is taking the same test.