Infection control professionals questioning CMS' approach on ESRD QIP clinical measure

The Association for Professionals in Infection Control and Epidemiology is questioning CMS' decision in the 2014 proposed rule for the End-Stage Renal Disease Quality Incentive Program to redirect the National Healthcare Safety Network (NHSN) dialysis event reporting measure to a clinical measure, saying dialysis providers lack the experience to track the data accurately.

The nonprofit, multidisciplinary organization, representing more than 14,000 infection preventionists, said in its Aug.t 19 letter to CMS administrator Marilyn Tavenner that while measurement of positive blood cultures in outpatient dialysis centers is reliable and easy to collect, “it is not, however, specific enough to detect health care-associated infections related to care at individual dialysis centers. It may include blood cultures associated with a primary infection at another site as well as cultures that would be considered contaminated at the time of collection.”

(Bloodstream infections and preventable dialysis deaths)

APIC president Patricia S. Grant, RN, BSN, MS, CIC wrote that measuring positive blood cultures without controlling for other potential causes, like contamination at the time of culture, will result in overestimation of the frequency of dialysis-associated blood stream infections and limit the capability to develop reliable benchmark data.

“The overestimation of dialysis-related BSI in this fashion would also make it difficult to assess the true impact of primary dialysis-associated bacteremia infection that can be measured over time to track improvement,” Grant wrote. “Converting the dialysis event measure from a reporting to a clinical measure creates the likelihood that dialysis centers would be penalized financially for infections that are not directly associated with dialysis. The CDC states that the goal of the dialysis event reporting is to capture data reliably, but that it will not perfectly capture all desired data completely, nor will it be captured without error. APIC believes that this specific indicator should be refined further before transitioning it to a clinical indicator.”

Grant said dialysis facilities should report at least a full 12 months of blood stream infection data before the measure is changed to a clinical measure. “Monthly reporting of dialysis events requires designated staff to collect and report data into NHSN. Few ESRD facilities have staff dedicated solely to infection prevention and instead rely on facility staff or consultants to perform infection prevention and reporting duties in addition to their other tasks,” she said. “The NHSN measure is sufficiently complex to require a longer period of acclimation to its requirements. Without 12 consecutive months of reporting, an accurate baseline rate cannot be calculated.”

Once outpatient dialysis centers gain more experience in collecting surveillance data, Grant said that CMS should consider adding NHSN dialysis event-specific indicators, such as local access site infection, access-related bloodstream infection, and vascular access infection. These specific indicators should be implemented in a staggered approach and would better represent HAIs specific to dialysis centers. Choosing one or more of these indicators would encourage centers to develop bundled measures and specific interventions to improve the quality of care in their specific populations, Grant wrote. This would also allow for a more appropriate ESRD national benchmark to be developed, she said.