iPNewbe: What's in an infection definition? Everything.
What's in an infection definition? Everything.
We need to know if it happened on our watch
By Patti Grant, RN, BSN, MS, CIC
Ah, the good old days when infections were classified as "nosocomial" (hospital-acquired) or not. There wasn't anything else but "we didn't do this thing" or "yes, this is our infection because we gave this to this person at our hospital."
Infections were classified as nosocomial or not. Come to think of it, some of you "IP Newbie" health care workers may not know, exactly, what that nostalgic statement means. Not to worry; not all nostalgia is good, progress must be made, and we adjust and move forward.
The first time I saw the term health care-associated infection (HAI) was in the "Guidance on Public Reporting of Healthcare-Associated Infections: Recommendations of the Healthcare Infection Control Practices Advisory Committee" (Am J Infect Control 2005; 33:217-226).
It made a lot of sense because for at least 20 years, more "health care" was being provided outside traditional hospitals. What didn't click immediately was the overall impact of the HAI terminology and philosophy in reference to defining infection. It seemed simple enough to:
a) change the word "hospital" to "health care" while;
b) emphasizing that most of these infections are associated, and not necessarily acquired, when factoring in patient intrinsic risk factors; and acknowledging that;
c) many of the requisite life-saving procedures are the main portal of entry for HAIs.
Yet gradually, the HAI definition has started to blur the black-and-white educational message we send to the bedside staff about infection surveillance: We did or did not do this thing to this patient. An example of multiple HAI definitions for an infection is Clostridium difficile (C. diff) as proposed in the article "Recommendations for surveillance of Clostridium difficile-associated disease (Infect Control Hosp Epidemiol 2007; 28:140-145).
This article, albeit scientifically grounded, proposed several different definitions for Clostridium difficile–associated disease (CDAD) that included subtle differences between the "onset" and "associated" varieties of both the community and the health care facility definitions. These definitions are based on the epidemiology of the disease; however, as a result there is some potential for confusion at the bedside where impact through surveillance feedback can make a difference. Health care workers need to know what happened "on their watch," what infection was associated with their health care facility.
The goal remains meaningful feedback
Therefore, as a new infection preventionist, you and your committee need to make a decision about what message, what definition, you are going to send with your surveillance. The goal remains to provide meaningful feedback, so they can track their successes and opportunities for improvement. How clear or muddied is that HAI message going to be?
Many have chosen to call what happened in "their facility" an HAI and everything else community-acquired, even when they know the infection came from the facility across town — it keeps the message to the bedside clear and is a useful educational tool. The caveat being that your program defines (yes, defines!) what "community-acquired" means, and in most cases that interpretation can mean "it didn't happen here."
This is not something all that new. I remember filing three separate reports for surgical-site infection surveillance in the early 1990's: one for my committee that used strict CDC definitions, one for my corporate headquarters that didn't include any "readmits," and yet another for a collaborative surveillance program. The message to our bedside staff regarding surgical-site infections, however, remained the same: We did this or we did not, using the strict CDC definitions and with "community-acquired," meaning it didn't happen here, on our watch.Ah, the good old days when infections were classified as "nosocomial" (hospital-acquired) or not. There wasn't anything else but "we didn't do this thing" or "yes, this is our infection because we gave this to this person at our hospital."
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