Is 'Good Enough' the Standard for Reporting Bloodstream Infections?

A new study looking at how hospitals report catheter-associated bloodstream infections found a whole lot of inconsistency, and little in the way of standards.

New research looking at how hospitals identify pediatric patients who develop catheter-associated bloodstream infections (CA-BSI) found significant inconsistencies in the methods used to report the number of patients who develop them.

Findings from the study, led by Matthew Niedner, MD, assistant professor of pediatrics and communicable diseases at University of Michigan C.S. Mott Children’s Hospital, could have serious implications as health care reform takes shape.

“There is an intense amount of attention being placed on measures of quality performance that have significant implications in pay-for-performance, and reimbursement,” said Niedner in a statement. “What you have is a desire to measure quality but a lack of perfect measures. Measures are often ‘good enough’ to enable quality improvement, but can leave undesirable ambiguity when used comparatively as a metric of clinical performance.”

Bloodstream infections are the most common hospital-associated infections in pediatric intensive care units (PICUs) and a significant source of in-hospital deaths, increased length of stay, and added medical costs. Both adult and pediatric patients who have catheters inserted into their blood vessels face increased risk of developing an infection along the invasive plastic devices that can become deadly as it spreads into the bloodstream.

In the study, which is published in the American Journal of Infection Control, surveys were distributed to 16 PICUs. The researchers found that all 10 infection control departments reported inclusion or exclusion of central line types inconsistent with the CDC’s CA-BSI definition, half calculated line-days inconsistently, and only half used a strict, written policy for classifying BSIs.

Infection control departments report substantial variation in methods, timing, and resources used to screen and adjudicate BSI cases. Greater than 80% of centers report having a formal, written policy about obtaining blood cultures, although less than 80% of these address obtaining samples from patients with central venous lines, and any such policies are reportedly followed less than half of the time. In assessing attitudes and beliefs, there was much greater confidence in the validity of CA-BSI as an internal/historical benchmark than as an external/peer benchmark.

All of the surveyed infection control practitioners said they used the CDC’s definition for CA-BSI, but none actually did, says Niedner, which has significant implications in the era of mandatory public reporting, pay-for-performance, and Medicare’s ‘never events.’

The study also showed that more aggressive surveillance efforts correlate with higher catheter-associated bloodstream infections rates. This suggests “that the harder one looks for CA-BSIs, the more likely they are to find them.”

“From an internal perspective, you want an aggressive surveillance system that is inclusive of all possible cases, but from a public reporting or pay-for-performance standpoint, you’d like to exclude as many cases as you can,” Niedner said. “There are no definitive national standards as to how to go about doing CA-BSI surveillance at the clinical practice level. It leaves wiggle room that pits hospital economics and reputation against quality improvement teams.”

“If you are interested in improving quality of care, you look hard, if you’re interested in reputation and reimbursement, maybe you don’t look so hard,” Niedner adds.

Click here to read the study in American Journal of Infection Control.

What do you think of these study results? Do you believe that a lack of standards can pit hospital reputation against quality improvement?