Healthcare-associated infections (HAIs), a term coined by the National Health Safety Network in 2005, refer to infections that arise in any inpatient or outpatient setting and appear within 48 hours after hospitalization, within 30 days after receiving healthcare, or up to 90 days after undergoing certain surgical procedures. There is a substantial economic burden, morbidity and mortality, and risk of antibiotic resistance associated with these infections. Therefore, hospitals are encouraged and, in many states, mandated by state legislation to report HAIs. National Health Safety Network is the largest tracking system across the U.S. and has an extensive guide defining HAIs.
Prevention of two HAIs, catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSI), keeps hospitalists particularly engaged. Hospital systems invest heavily in preventing these infections by establishing multi-disciplinary committees including nurses, physicians, and infection prevention personnel. Hospital leadership routinely measures HAI performance as it can affect patients as well as hospitals’ quality metrics and can result in financial losses and reputational damage when performance is lower than desired. The patient-level, administrative, and financial negative effects of CLABSI and CAUTI have made HAI prevention an important goal for all hospitalists.
Cases
Case 1: A 69-year-old woman with uncontrolled diabetes and heart failure was admitted to the ICU for septic shock, placed on vasopressors, and had strict monitoring of urine output. She improved and was later transferred to the floor with a Foley catheter in place on day five of her hospitalization. The Foley was removed that afternoon on the medical floor. Later that day, the patient developed a fever, and after appropriate assessment, the patient was diagnosed with a urinary tract infection that was defined as a CAUTI due to the Foley being present the same day. Per hospital policy, the general medical unit and the current treating hospitalist were “responsible” for the CAUTI and underwent an event review.
Case 2: A 72-year-old man was admitted to the ICU for septic shock from the emergency department, where a central line had been placed. He was able to be stabilized, and on day five, was transferred to the floor for further care with the central line in place due to the absence of other vascular access. After two attempts at peripheral access, the patient declined further attempts and requested to leave the central line in place after extensive counseling on the risks of doing so. The patient had a fever on day seven of hospitalization, was found to be bacteremic, and was diagnosed with CLABSI. The infection was attributed in the performance measurement system to the hospitalist group and the current treating hospitalist.
Discussion
The cases above illustrate some of the difficulties of using HAIs as an individual hospitalist or hospital medicine group performance metric. The goal for hospitalists is always to reduce harm to patients and the system through appropriate Foley catheter and central line stewardship. This requires more nuance than a simple measure, however, as many patient- and system-level factors should be considered.
Hospitalists can influence CAUTI and CLABSI rates by using evidence-based indications for indwelling catheter placement, evaluating ongoing need for indwelling catheters, and removing indwelling catheters as soon as they are not required or indicated. Procedural hospitalists can also reduce infection rate by using proper sterile techniques with central line placement. Hospitalists should also practice “culture stewardship” and order urine or blood cultures only when clinically indicated. However, as noted in case scenarios above, attribution can be a challenge when using CAUTI and CLABSI as a performance indicator for an individual hospitalist or a hospital-medicine group— especially if the metric is used for financial incentives, financial penalties, or other punitive action.
Apart from challenges with determining appropriate attribution, there are unintended consequences of CAUTI and CLABSI reduction efforts.
If not approached thoughtfully, overzealous administrative efforts to reduce CAUTI and CLABSI rates can result in deviation from the standard of care when managing patients who would typically benefit from indwelling urinary or central venous catheters. Such efforts may also undermine patient preferences. Hospitalists may be directly or indirectly incentivized to treat possible catheter-associated infections empirically rather than according to culture-and-sensitivity-driven antimicrobial therapy, and instead of following best practice recommendations from expert consensus guidelines. Many hospitalists may be incentivized to avoid catheter utilization above all else, resulting in unintended patient harm. Foley catheter avoidance may lead to urethral trauma from repeated straight catheterization and significant patient dissatisfaction. Central venous catheter avoidance may lead to tissue necrosis from vasopressor infiltration in a peripheral IV. Finally, health systems may divert valuable resources to optimize CAUTI and CLABSI rates rather than investing in clinical practices that would lead to improved clinical outcomes.
Focusing only on hospitalists’ behaviors can distract from efforts to develop initiatives such as nurse-driven protocols for catheter removal, adoption of devices that may reduce CAUTI and CLABSI risk (such as external urinary catheters, peripherally inserted central catheters, and midline catheters), and creating a culture of safety where reducing HAIs is an interprofessional, enterprise-wide endeavor.
Conclusion
While acknowledging the vital importance of reducing CAUTI and CLABSI rates, we recommend rates as a high-stakes measure for individual hospitalists or hospitalist groups. If hospital medicine groups are required to include CAUTI and CLABSI rates as a performance metric, we would suggest process measures as opposed to outcome measures. An example of a process measure would be the frequency of documentation of the indication for placement and the ongoing need for indwelling catheters. Documentation that reflects daily assessment, justification, and challenges to timely removal (which may include patient preferences, end-of-life considerations, or other challenges) should be encouraged. Hospitalists should continue to be involved in hospital-wide and unit-based interprofessional CAUTI and CLABSI prevention measures and HAI prevention committees, and should work in collaboration with nurses and infection prevention personnel to reduce these highly avoidable events throughout organizations.
The authors are members of SHM’s Performance Measurement and Reporting Committee, which created this series to explore quality measures common in hospital medicine.
Dr. Bruti
Dr. Golla
Dr. Vora
Dr. Barrett
Dr. Bruti is an associate professor of internal medicine and pediatrics and the chief of the division of hospital medicine in the department of internal medicine at Rush University in Chicago. Dr. Golla is a clinical associate professor in the department of internal medicine at UT Southwestern Medical Center and an associate medical director of utilization management, medical director of the progressive care unit, and chair of the performance measurement committee for the Parkland Health and Hospital System, both in Dallas. Dr. Vora is the medical director for hospital medicine at Riverside Regional Medical Center and the physician advisor for utilization management at Riverside Health System, both in Newport News, Va. Dr. Barrett is the senior medical director and vice president of quality at WorkItHealth, and president of the American Medical Women’s Association.