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Compare to like settings or you’re flying blind
With the vast majority of infection-rate data and guidelines targeted at acute care settings, specialty medical settings face a void of comparative data for much needed benchmarking. Such was the case for six long-term acute care facilities in northwest Louisiana, a state that defines the setting as caring for patients with an average length of stay greater than 25 days.
"They are not residents; they are ill patients," explains Jimmie Norwood, MT (ASCP), director of infection control, Lagniappe Hospital in Shreveport, LA.
"These are all referral patients. We are reimbursed on a per-diem basis, so we can keep patients as long as we need to in order for them to get well."
With managed care conditions ensuring that is definitely not the case in acute care hospitals, comparative data from traditional settings are virtually meaningless. For example, long-term acute patients hospitalized for such periods have lines and ventilators in place too long to be compared to acute care hospital patients.
"We were trying to compare apples to oranges, and it wasn’t working," she says. To address the problem, infection control professionals at the six facilities - representing a total of 205 patient beds - banded together to compare data.
"We focused on device associated infections," she says.
Centers for Disease Control and Prevention definitions were used to standardize surveillance on the following infection types: ventilator-associated pneumonia (VAP), foley catheter-related urinary tract infection (F-UTI), and central line-related blood stream infection (CL-BSI).
A data collection tool was created, and blinded quarterly data were submitted from each facility. Data were aggregated by infection type with quarterly and annual reports generated by comparing each facility to the current mean.
Decreases in the surveyed infection types were noted. The VAP rate decreased from 4.7/1000 ventilator days in 1998 to 3.2 in 1999. The F-UTI rate decreased from 7.6/1000 foley catheter days in 1998 to 6.4 in 1999. The CL-BSI rate decreased from 3.4/1000 central line days in 1998 to 3.2 in 1999.
In addition to overall lowering of rates, outliers were identified and could focus on their newfound problems.
"In one of the facilities, the ventilator pneumonia rate was a lot higher," Norwood says. "Of course, they focused on that. But they had thought they were fine because they had nothing to compare it to. Once they were able to realize that [they were an outlier], they were able to do some focused interventions and get the rate down."
In addition to targeted interventions, the creation of valid external benchmarks helped ICPs focus resource use, network with colleagues, and better meet requirements of regulatory bodies such as the Joint Commission of Accreditation of Healthcare Organizations and the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration), she says. Moreover, the decrease in infection rate means generated over a two-year period reinforced the effectiveness of external benchmarks.
"We now have a target or some idea of where we should be for comparative purposes," she says. "It gives us an idea of whether we are in a reasonable ballpark or not."
Such collaborative benchmarking projects might be useful to other special medical settings along the continuum. "I would recommend it," Norwood says. "Otherwise you have no idea how you are doing. You have nothing to compare to."