CAUTIs and CLABSIs: Do Physicians REALLY Know What They Are?

BACKGROUND: The incidences of hospital-acquired conditions, such as catheter-associated urinary tract infections (CAUTIs) and central line-associated blood stream infections (CLABSIs) are being used to compare quality at institutions and determine reimbursements. These data come from the University HealthSystem Consortium (UHC) administrative database that relies almost exclusively on physician documentation as opposed to objective U.S. Centers for Disease Control and Prevention (CDC) guidelines. We hypothesize that the UHC-identified rates of CAUTIs and CLABSIs are inaccurate compared with the CDC definitions for these infections. METHODS: We performed a retrospective study from January 2012 through September 2013 comparing the incidences of CLABSIs and CAUTIs, as identified through our UHC database to those identified by the Department of Epidemiology using strict CDC guidelines. We performed subset analysis on those infections identified by UHC but not CDC to determine the causes for these discrepancies. RESULTS: There were a total of 221 CAUTIs and 238 CLABSIs identified during this time frame. Of these, 16 CAUTIs (7.2%) and 44 (18.5%) CLABSIs were detected by both UHC and CDC. 72.4% (42/58) of the CAUTIs and 52.7% (49/93) of the CLABSIs identified by UHC were not identified by CDC. 91% (163/179) of the CAUTIs and 77% (145/189) of the CLABSIs identified by CDC were not identified by UHC. The cause of these differences in identification included lack of culture data, lack of positive cultures, and catheters present on admission. CONCLUSIONS: There is a major disconnect between identification of infections depending on what process is used. This can lead to inappropriate treatment and inaccurate institutional comparisons that impact reimbursements. Because UHC identification of infections are primarily based on physician documentation, educating providers should result in more accurate recognition of infections thereby ensuring appropriate use of therapy.

Understanding Gram-negative Central Line-Associated Blood Stream Infection in a Surgical Trauma ICU.

The purpose of this study was to review central line-associated blood stream infection (CLABSI) data from a surgical trauma intensive care unit to better understand patient risk factors, pathogens, and treatment interventions. We performed a retrospective review of all surgical ICU patients who met the Centers for Disease Control definition for Gram-negative CLABSI from 2006 through 2013. Demographics, pathogens, interventions, and outcomes were evaluated. A total of 40 patients were included with an average age of 49.9 ± 19 years and 72.5 per cent male. The average length of central venous line (CVL) was 11 ± 5.9 days with average time from line placement to positive culture 9.4 ± 6.8 days. Most common organisms were Enterobacter species (37.5%) with 17.8 per cent of all cultured organisms considered multidrug resistant. Piperacillin-tazobactam (67.5%) was the most commonly used antibiotic. Overall mortality rate was 22.5 per cent. A total of 11 patients who developed a recurrence did so at 10.7 ± 8 days and were similar to those without recurrence. Predominant pathogens associated with surgical trauma intensive care unit CLABSI in this study are different from those Gram-negative bacteria associated with published studies in the general hospital population. Further investigation into risk factors for infection and relapse is important to minimize such consequences. Understanding appropriate line placement and use as well as clarifying optimal duration of therapy is integral in improving outcomes.

The Impact of Discontinuing Contact Precautions for VRE and MRSA on Device-Associated Infections.

The impact of discontinuing contact precautions for patients with MRSA and VRE colonization/infection on device-associated hospital-acquired infection rates at an academic medical center was investigated in this before-and-after study. In the setting of a strong horizontal infection prevention platform, discontinuation of contact precautions had no impact on device-associated hospital-acquired infection rates.

Active surveillance cultures are not required to control MRSA infections in the critical care setting.

Although the effectiveness of active surveillance cultures to identify and isolate patients colonized with methicillin-resistant Staphylococcus aureus (MRSA) remains debated, hospitals are under increasing pressure to begin active surveillance programs. We analyzed our data on device-associated MRSA infections in the intensive care unit setting over a 4-year period during which multiple evidence-based interventions to reduce hospital-acquired infections were introduced without performing active surveillance cultures for MRSA. We observed reductions in all infections, including those caused by MRSA, and conclude that control of MRSA in the critical care setting does not require active surveillance cultures.

Surgical site infection surveillance for neurosurgical procedures: a comparison of passive surveillance by surgeons to active surveillance by infection control professionals.

ISSUE: Surveillance methods for surgical site infections (SSIs) range from patient self-report to active surveillance by infection control professionals (ICPs). Surgeon questionnaires surveying SSIs are typically suboptimal due to bias, lack of standardized criteria to diagnose infection, and poor response rate. Although concurrent surveillance of SSIs by ICPs at our medical center documented an incidence of 2.2 SSIs per 100 procedures, the neurosurgeons perceived a much higher rate of SSIs. PROJECT: The neurosurgeons provided a list of patients they had clinically identified with SSIs over a 7 month period. This list was compared with a line listing of SSIs independently identified by ICPs via concurrent surveillance utilizing the Centers for Disease Control and Prevention (CDC) definitions. RESULTS: A total of 766 procedures were performed. Active surveillance by ICPs detected 17 infections (2.2/100 procedures). Of the 14 cases identified by the neurosurgeons, 3 did not meet the CDC definition of a nosocomial infection. The ICPs identified 6 SSIs not documented by the neurosurgeons. Compared to active surveillance by ICPs, the sensitivity and specificity of the neurosurgeon's identification of SSIs was 64% and 99.6%, respectively. The positive predictive value was 78.6% and the negative predictive value was 99.2%. LESSONS LEARNED: An active surveillance program is necessary for accurate identification of SSIs. The primary problem with passive surveillance by surgeons is failure to capture cases; surgeons missed 36% of cases compared to active surveillance by ICPs.

A statewide survey of nosocomial infection surveillance in acute care hospitals.

Increasingly, states are considering mandating the reporting of nosocomial infection data. To determine the impact of potential legislation, a questionnaire was mailed to the infection control department of each hospital in Virginia to assess the size of the infection control workforce and methodologies used for nosocomial infection surveillance. Most hospitals (64%) had 1 ICP full-time equivalent (FTE), and, at 86% of hospitals, the ICPs had other major responsibilities. The estimated mean additional ICP FTE required to perform hospital-wide surveillance was 1.7. Statewide, an additional 160 ICPs at an estimated annual cost of 11.5 million dollars would be required if reporting of all nosocomial infections were mandated.

The case of the cold thermometers.

BACKGROUND: A temporal artery thermometer was introduced at our hospital. Immediately staff noted subnormal temperature readings. METHODS: Three serial evaluations of patient temperatures were done: August 2000 (initial), September 2000 (posteducation), and December 2000 (after removal of temporal artery thermometer). RESULTS: In the initial review, 89% of the readings were < 98.6 degrees F. Comparison of the readings from the last and first surveys showed a statistical increase in the proportion of readings > or =100.0 degrees F and decrease of readings <98.6 degrees F (P <.001). CONCLUSIONS: Our experience underscores the importance of performance data for quality monitoring of new products.