In 2005, the National Health Safety Network introduced the term Healthcare-associated infections (HAIs), referring to occurrences of infections in inpatients or outpatients within a specific window after hospitalization or healthcare receipt. These infections pose economic burdens, morbidity, mortality risks and potentially foster antibiotic resistance.
Hospitals, particularly those where state legislation mandates it, report these infections, tracked by the National Health Safety Network, the most comprehensive system of this kind in the U.S. Among HAIs, catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSI) are particularly concerning, necessitating concerted prevention efforts from hospital systems, given their adverse impacts on patients, hospital quality metrics, and reputational risk for healthcare facilities.
To describe this issue more concretely, let’s review two cases. The first involves a 69-year-old woman who, due to a hospital policy, had a catheter-associated urinary tract infection (CAUTI) attributed to her treating hospitalist, which resulted in an event review. The second case is a 72-year-old man, who developed a central line-associated bloodstream infection (CLABSI) attributed to his treating hospitalist following a refusal to remove a central line due to lack of other vascular access.
These instances demonstrate the complexity of using HAIs as a performance metric for individual hospitalists or hospital medicine groups. The aim is always to minimize patient harm and system vulnerabilities via careful Foley catheter and central line management. However, evaluating these HAIs as performance measures should consider patient- and system-related factors. Proper sterile techniques with central line placement, evidence-based catheter placement, and timely catheter removal can all be used to influence CAUTI and CLABSI rates.
Yet, in cases like the two noted, attribution of CAUTI and CLABSI becomes a challenge, particularly when these metrics are tied to financial incentives, penalties, or other punitive actions. Furthermore, overzealous efforts to reduce CAUTI and CLABSI rates could lead to departures from standard care, unintentional patient harm, and potential disregard for patient preferences.
As such, we propose careful re-thinking of these metrics, suggesting process measures as opposed to outcome measures if CAUTI and CLABSI rates are necessarily used as performance metrics. Documenting the need for indwelling catheters and reasons for delayed removal could be exemplary process measures. Hospitalists should also participate in interprofessional prevention measures and HAI prevention committees to collaborate with nurses and infection prevention personnel on reducing these largely preventable events. Remember, the ultimate goal is to reduce and, where possible, eliminate healthcare-associated infections while preserving the standard of care and respect for patient preferences.