Blog | Tuesday, December 3, 2013

HICPAC lays down the letter of the law

A recent issue of Annals of Internal Medicine has a paper entitled “Public Reporting of Health Care–Associated Surveillance Data: Recommendations from the Healthcare Infection Control Practices Advisory Committee” (HICPAC). It’s a somewhat misleading title, as the paper isn’t about public reporting, it’s about what happens in hospitals before health care acquired infections (HAI) data are publicly reported. The primary message is this: if a case meets criteria for HAI sensu stricto, it’s an HAI, dammit! Don’t go asking a doctor for her clinical opinion on whether it’s an infection and then erasing that case from your line list if she says, “Doesn’t look like an infection to me.”

I have mixed feelings about this. On the one hand, in order to allow for valid inter-facility comparisons of infection rates, everyone has to play by the same rules. I think we all get that. But it’s incredibly frustrating to review a case that is clearly not an HAI, yet be forced to label it as such. And it’s not an uncommon occurrence. Last week, one of my infection preventionists brought me a case of a patient admitted with pneumonia and because the patient’s condition worsened after admission, we were forced to label the case a possible ventilator-associated pneumonia. This morning, an infection preventionist from another state e-mailed me a case of a patient who was admitted with an infected wound, went to the OR, and subsequently developed a surgical site infection, which had to be categorized as an HAI. The infection preventionist notes, “The same patient, without the surgery, would have a community-acquired wound infection and would not be counted as an HAI.”

Even more commonly, hospitals with large oncology populations see many cases of bloodstream infections with enteric flora in patients who just so happen to have a central line. While I give CDC credit for now allowing us to classify cases as mucosal barrier injury related bloodstream infections, it’s of little value, as these infections are still publicly reported as central line-associated bloodstream infections (CLABSI). And to add insult to injury, those poor infection preventionists in Pennsylvania have to send patients a letter telling them they suffered an HAI that wasn’t an HAI.

All of these problems with post-ascertainment veto and adjudication are occurring because the stakes are high. Most of the time, this is done in good faith, I believe. There is a big push in hospitals to hold staff accountable for adverse events, and it really stings to have the finger pointed at you for an event that was not preventable, or maybe not even an event. It undermines the credibility of IPs and hospital epidemiologists with clinicians when you call a single positive vancomycin-resistant enterococci blood culture in a neutropenic leukemic patient a CLABSI. To mitigate that, I find myself appearing at committee meetings to explain that while this case technically meets the criteria for CLABSI, all evidence tells us this is an infection not related to the central line, and is in fact, not preventable. Some hospitals keep two sets of books, the official publicly reported set, and the internally “correct” set.

So while I agree with HICPAC in spirit, this paper only addresses a part of the problem. It ignores the fact that we need definitions with more specificity, and those definitions are needed now. The mucosal barrier injury infection definition has been validated, so let’s use it for public reporting. Task IPs to send in descriptions of cases where the definitions are not working, catalog them, categorize them, and start fixing the definitions in a timely manner. Allow for relatively rapid tweaking of definitions instead of acting as if definitions are carved in stone and represent some absolute truth.

While we will never be able to have perfect case definitions in the murky world of medicine, fixing the underlying problem to the degree that it can be fixed would decrease the drive for post-ascertainment veto and adjudication. Or how about embracing adjudication but have it occur at a central level? In a world of electronic communication, it wouldn’t be that difficult.

And one last thing: I think that any official statement from HICPAC should be in the public domain, not behind a journal paywall. Perhaps this paper is also posted somewhere on CDC’s website, but I was not able to locate it, if it is indeed there.

Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. This post originally appeared at the blog Controversies in Hospital Infection Prevention.