Hurricane Maria, Bloodstream Infections, Lung Cancer in Women
Practice Operations
Are All Regulations Well Thought Out? Point of View!
Current medicine is complex, with patients presenting in the ICU with multiorgan dysfunction. The art and science of medicine is being replaced by protocolized medicine. To help streamline the care, societies and colleges are coming up with guidelines. The guideline, though, changes from year to year what has been practiced in the past has been obsolete, and what is current may not hold true in the future. With increasing health-care costs affecting physician and hospital practices, innovations are being undertaken on a daily basis. The payers, on the other hand, are trying to come up with regulations, whether one likes it or not, that have become the beacon for penalty and reward. Sometimes those regulations conflict with what is sound judgment and prudent care, cornering the providers in the box with unnecessary penalties.
Approximately 250,000 bloodstream infections occur in the United States yearly, mostly attributed to the presence of intravascular devices. The rate of central line-associated blood stream infection (CLABSI) in the United States is 0.8 per 1,000 central line days. The desirable rate is zero rate of CLABSI. The hospitals are being pushed to be prudent with the use of central lines and removal if not needed. The technique and sterile field along with appropriate innovation in dressing technique have been effective in reducing the CLABSI by 46% from 2008 to 2013. The hospitals and ICUs are being very vigilant in trying to avoid CLABSI and are striving to achieve the goal of a zero percentage CLABSI rate, leading to almost a state of paranoia. The efforts are being undertaken in many institutions to get all the cultures on admission to identify the organism on admission so as to be designated as a bloodstream infection (BSI) due to other causes and to avoid the CLABSI attribution. The CLABSI attribution follows a complex algorithm with no waiver for the exception outside the strict definition that is changing (The 2015 definition change resulted in an 83% increase in CLABSI rate.).
We hereby present a simple scenario for point of view, where there is very clear-cut evidence of the bloodstream infection due to abdominal sources but that BSI would be designated as CLABSI as defined by National Healthcare Safety Network (NHSN). The patient postoperatively presents with fever, nausea, and abdominal discomfort. The CT scan showed fluid collection suggestive of infection. Culture from the abscess grew Escherichia coli and the blood culture grew Bacteroides fargilis. This patient was labeled as BSI due to intra-abdominal cause. On the other hand, patient has pus pockets in the abdominal wall with swelling and tenderness. Cultures from the pustule grew Streptococcus Group B and the blood culture grew Staphylococcus aureus. This would be classified as soft tissue infection and primary BSI and if the patient has the central line for 2 days, it would be classified as CLABSI, even though there was a clear cut source from where the infection originated. On the other hand, if a patient has a CT scan of the abdomen or any imaging study done, which showed the pus pocket, and even if there is no abscess culture done, and if there is BSI, it would be labelled as BSI due to intra-abdominal cause rather than CLABSI.
