As it's probably clear, it's been a great honor for me to work (and blog) with Dan Diekema, MD, FACP, and Mike Edmonds, MD, FACP, over the past 8 years. One of the things that stands out when talking shop is their ability to see both sides of an argument even while pushing for the changes they support. Many times, their ability to see both sides clearly is possible because they've lived both sides. Mike has been an infectious disease chief and hospital epidemiologist and is now our chief quality officer, and Dan is an infectious disease chief, hospital epidemiologist and clinical microbiologist. You know, if I was a fellow or faculty member looking for a hospital epidemiologist position with great mentorship and support, I would move to Iowa, but I digress.
One specific area where understanding competing goals is critically important is the interplay between the increasing sensitivity and precision of microbiologic tests and the growing pressure to reduce health care acquired infections (HAI). As you can imagine, with 3% of Centers for Medicare and Medicaid Services (CMS) payments potentially at risk, anything that could impact HAI rates in a negative fashion is bound to be a flashpoint for hospital administrators. With that in mind, I point you to Dan's excellent commentary just published in the Journal of Clinical Microbiology that examines the implications of advances in microbiological testing on HAI rates and provides specific suggestions for how hospital epidemiology programs and clinical microbiology labs can work together to respond to these changes.
Initially, Dan provides three scenarios where changes in the micro lab could directly impact HAI rates (1) The effect of matrix-assisted laser desorption/ionizationon central-line acquired bloodstream infection rates (2) The shift from enzyme immunoassay to nucleic-acid amplification tests (NAAT) for Clostridium difficile detection and (3) Pressure to block urine culture ordering to reduce catheter-acquired urinary tract infections. After delving into the current CMS reimbursement landscape, the unintended consequences of improvements in diagnostic testing and the use/misuse of surveillance definitions, he provides six valuable recommendations that clinical microbiology labs (CML) and infection prevention programs (IPP) should consider:
(1) CML leadership should select diagnostic approaches with the goal of improving individual patient outcomes
(2) Hospital and IPP leadership should not pressure the CML to alter diagnostic practices based on the need to demonstrate lower HAI rates for pay-for-performance measures.
(3) Public health authorities (CDC/NHSN) must be proactive in adjusting HAI metrics to changing CML technology
For recommendations 4-6, you're gonna have to read his commentary. But a hint at #6: CML and IPP leadership need to collaborate and advocate for their needs, because, unlike at Iowa, both sides aren't always present in the mind of a single person.
Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.