Rising Stakes for Health Care-Associated Infection Prevention: Implications for the Clinical Microbiology Laboratory

Abstract

Health care-associated infection (HAI) rates are subject to public reporting and are linked to hospital reimbursement from the Centers for Medicare and Medicaid Services (CMS). The increasing pressure to lower HAI rates comes at a time when advances in the clinical microbiology laboratory (CML) provide more-precise and -sensitive tests, altering HAI detection in ways that may increase reported HAI rates. I review how changing CML practices can impact HAI rates and how the financial implications of HAI metrics may produce pressure to change diagnostic testing practices. Finally, I provide suggestions for how to respond to this rapidly changing environment.KEYWORDS clinical microbiology, infection prevention, nosocomial, pay for performance, health care-associated infections C onsider the following three scenarios related to the role of the clinical microbiology laboratory (CML) in health care-associated infection (HAI) surveillance and prevention. In scenario 1, during an investigation of rising rates of central-line-associated bloodstream infection (CLABSI), the infection prevention program (IPP) notes that some CLABSIs were due to organisms that grew in only one of several blood cultures and which, prior to the institution of matrix-assisted laser desorption-ionization time of flight (MALDI-TOF) mass spectrometry for organism identification, would have been classified as contaminants. An example included a CLABSI attributed to an unusual species of Actinomyces that previously would have been categorized as a "diphtheroid." Your hospital leadership requests that you either revert to former identification methods or change your reporting in a way that prevents these events from being classified as CLABSIs.In scenario 2, since you changed to a nucleic acid amplification test (NAAT) for Clostridium difficile detection, your positivity rate has increased by over 100%. The rate of hospital-onset C. difficile infection (HO-CDI) has increased similarly. During an investigation of the increase in CDI, you find that many samples positive by NAAT are toxin negative by enzyme immunoassay (EIA) and that many patients with a low pretest probability of disease are being tested. However, after an initiative to improve testing practices, your HO-CDI lab identification (LabID) event rate remains high (standardized infection ratio [SIR], Ͼ1). Concerned about how this rate will impact the value-based purchasing (VBP) and health care-associated condition (HAC) scores, your hospital leadership asks you to consider a change back to EIA for CDI diagnosis.In scenario 3, even after a campaign to reduce your hospital's rate of catheterassociated urinary tract infection (CAUTI) through a reduction in catheter use and improvement in catheter placement and care, the CAUTI rate remains unacceptably high. Your hospital epidemiologist sets up a meeting with you to discuss how to reduce the number of urine cultures ordered or performed by the laboratory as another way to reduce both the CAUTI rate and unnecessary antibiotic use. She is...

National Healthcare Safety Network laboratory-identified Clostridium difficile event reporting: A need for diagnostic stewardship

“…Enhanced NHSN LabID risk adjustment for test method (NAAT, EIA, all others) might help account for increased sensitivity of NAAT. 8 Additional changes to the metric would be required if facilities were to adopt screening and use of contact precautions for asymptomatic C. difficile colonized patients. 9 In the absence of changes to the metric, inflation of the reported HO-CDI could become even more pronounced.…”

Identification of Clostridium difficile Asymptomatic Carriers in a Tertiary Care Hospital

“…We did not detect any positive C. difficile results by PCR in the healthcare workers that took care of C. difficile patients. Recently, it has been noted that advances in clinical microbiology have led to more sensitive tests that may falsely increase HAI rates and not result in safer care [ 13 ].…”

Overpromised and Underdelivered

“…Finally, because these metrics impact both patient perception and federal reimbursement, there is concern that hospitals might make clinical decisions that produce favorable metrics even when that outcome doesn't reflect the most advanced science. An example of this tension is the increasing sensitivity and precision of laboratory testing versus penalties for health care-associated infections, such as Clostridium difficile [16].…”