Support for the APIC VA Recommendations

 I submit these comments in recognition and support of the comprehensive review submitted by APIC Chapter 12 of Virginia.  The APIC VA review of the proposed additional reporting requirements addresses the general state of hospital acquired infection reporting today. The area that I suggest VDH explore before placing an additional burden on hospital Infection Preventionist is the support our IPs currently receive by their facilities. In the era of increased costs and decreased reimbursement several of our Virginia hospitals have opted to reduce staffing support of their Infection Prevention Departments, even reducing full time positions to part time or eliminating positions.  Reporting requirements have not decreased thus leaving the IP staff reducing time spent in educating front-line staff who actually implement protocols that reduce hospital acquired infections.

 In addition to current published comments, I propose the following considerations.

 1. Central line-associated bloodstream infections in one adult inpatient medical ward and one adult inpatient surgical ward are to be reported to NHSN. Wards selected should be those with longest length of stay during the previous calendar year, excluding cardiology, obstetrics, hospice, and step-down units. Data ... risk.

 Instead of requiring number of wards for reporting of Central line-associated bloodstream infections, why not consider percentages? The current requirement would place all our hospital in-patients except the birthing center into the reporting category, since we have one ICU, one medical, and one surgical unit for a total of approximately 75 beds. Our small hospital does not have a data-mining systems and currently no procedure for identifying central-line days for the surgical and medical units. These responsibilities would be an additional burden with limited resources. In small hospitals such as ours, the step-down unit patients are considered part of the medical floor and identifying the step-down patient to remove them from review of central lines would be difficult and time consuming. Therefore instead of proposing 3 units, consider a range of beds such as 10 to 15%.  The IHI campaign and the CUSP project currently implemented by VHHA propose the five steps to reduce CLABSI: Hand hygiene, Full Barrier Precautions, Chlorhexidine Site Preparation, Appropriate Site (avoid the femoral), and Daily Assessment for removal which we have implemented house-wide. The movement of reporting beyond ICU is a great concept to ensure all our patients receive the same standard of care, but I believe an undue burden on our already over-worked and under-staffed Infection Prevention staff.

2. Clostridium difficile infection, laboratory-identified events on inpatient units facility-wide - shall include patient days.

I fully agree with this INOVA statement: Data analysis does not accurately differentiate between community-acquired, hospital-acquired or other healthcare-associated, i.e. non-acute care faculty. Rather than simply publicizing the number of cases identified at a facility, VDH should assist hospitals with the development of programs shown to reduce CDI, for example, antibiotic stewardships and public education.

 In addition, I propose that this type of reporting to the public may results in physicians not testing for C. diff, but alternately treating without testing. Again as related earlier, the sensitivities of testing methods vary and a patient may test positive on admission to the hospital even though they were appropriately treated prior. To accurately identify prior disease confirmation and treatment requires precious time to review records, make phone calls, talk to patients and etc to assess the course of the disease events. In addition this proposal limits review of healthcare contacts to the reporting hospital and does not include other facilities where colonization may have occurred. With public reporting of antibiotics given on admission to patients diagnosed with pneumonia, we see more patients diagnosed with C diff because even one dose of ceftriaxone stimulates C diff replication in the colonized patient and positive test results. Reporting of this case appears punitive to the hospital that implements the required treatment for pneumonia.

3.       SCIP (Surgical Care Improvement Project) core measures ... reported quarterly to the VDH.

I support the INOVA view: SCIP data is currently publicly reported; reporting to VDH the same data will be a duplicated effort. Surgical site infection reporting should align with the Centers for Medicare and Medicaid Services indicators.