RESEARCH ARTICLE
Comparison of Administrative Data Versus Infection Control Data in Identifying Central Line–Associated Bloodstream Infections in Children’s Hospitals AUTHORS J. Mitchell Harris II, PhD,1 James C. Gay, MD, 2 John M. Neff, MD,3 Stephen W. Patrick, MD, MPH, MSc,4 Aileen Sedman, MD, FAAP, FASPN5 1
Children’s Hospital Association, Alexandria, Virginia; Vanderbilt University School of Medicine, Nashville, Tennessee; 3 Center for Children with Special Needs, Seattle Children’s Hospital, Seattle, Washington; 4 Department of Pediatrics, Division of Neonatal– Perinatal Medicine, University of Michigan Health System, Ann Arbor, Michigan; and 5 University of Michigan Medical School, Ann Arbor, Michigan 2
KEY WORDS billing and compliance, infection control, medical error, patient safety, vascular catheter–related infections
abstract OBJECTIVE: As of July 2012, the Centers for Medicare and Medicaid Services prohibited state Medicaid programs from paying for medical care related to certain provider-preventable conditions. The most prevalent providerpreventable condition in pediatrics is central line–associated bloodstream infections (CLABSIs), which cause significant morbidity and mortality. The objective of this study was to compare the uses of administrative data and infection control data in measuring CLABSIs. METHODS: Retrospective chart reviews were performed in 3 children’s hospitals to compare CLABSIs identified according to administrative data diagnostic coding versus infections identified by hospital infection control departments. Clinical criteria from the Centers for Disease Control and Prevention and reported to the National Healthcare Safety Network were used.
ABBREVIATIONS ACA: Patient Protection and Affordable Care Act AHRQ: Agency for Healthcare Research and Quality CDC: Centers for Disease Control and Prevention CLABSI: central line–associated bloodstream infections CMS: Centers for Medicare & Medicaid Services NHSN: National Healthcare Safety Network ICD-9-CM: International Classification of Diseases, Ninth Revision, Clinical Modification POA: present on admission PPC: provider-preventable conditions PSI: patient safety indicators
RESULTS: A total of 166 CLABSIs were identified in 35 698 discharges in the 3 children’s hospitals in 2010. Using the Centers for Disease Control and Prevention criteria as the standard, administrative data had 34.78% sensitivity and 99.92% specificity. The positive predictive value was 63.16% whereas the negative predictive value was 99.75%.
This study is solely the work of the authors and does not represent the opinion of the Children’s Hospital Association.
Central line–associated bloodstream infections (CLABSIs) are a significant source of morbidity, mortality, and added medical costs for hospitalized children and adults.1,2 Documentation of these complications in the literature spurred national quality improvement efforts aimed at reducing CLABSIs. These efforts, mainly aimed at decreasing the rates through standardizing practice, resulted in dramatic reductions in CLABSIs among both adults and children.3,4 For instance, in a collaborative study in 29 children’s hospitals sponsored by the Children’s Hospital Association, Miller et al5 reported a drop in infection rates from 5.2 infections per 1000 line days to 2.3 infections per 1000 line days, with sustained and continuously decreasing rates over 3 years.
www.hospitalpediatrics.org doi:10.1542/hpeds.2013-0048 Address correspondence to J. Mitchell Harris II, PhD, Director, Children’s Hospital Association, 401 Wythe St, Alexandria, VA 22314. E-mail: [email protected] HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154 - 1663; Online, 2154 - 1671). Copyright © 2013 by the American Academy of Pediatrics (Continued on last page)
CONCLUSIONS: Administrative data and National Healthcare Safety Network criteria identify discordant numbers of CLABSIs.
Because CLABSIs occur commonly, are potentially preventable, and are harmful to patients, the Centers for Medicare & Medicaid Services (CMS), the Joint Commission, and the Agency for Healthcare Research and Quality (AHRQ) sought to design methods to quantify the number of CLABSIs in individual hospitals for
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HOSPITAL Pediatrics ®
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use as measures of quality. AHRQ included the measure “infection due to medical care” in their patient safety indicators (PSIs), which originally identified CLABSIs via administrative data by using a nonspecific diagnostic code that included infections associated with any device such as pacemakers, venous lines, and arterial lines.6 The AHRQ pediatric quality indicators were created in 2006 in response to many issues in PSIs that were not appropriate for children7 but maintained the use of the nonspecific diagnostic code for “infection due to medical care.” Both PSIs and pediatric quality indicators had risk adjustment methods that were helpful in comparative reporting. In October 2007 a specific International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code (999.31) was created to identify “infections due to central venous catheter,” with the intent of more accurately identifying CLABSIs by using administrative data. The code included all venous catheters that were placed centrally, including classically placed central lines such as subclavian and femoral lines, peripherally inserted central lines, and umbilical venous catheters, but specifically excluded arterial and peripheral venous catheters that are not threaded into a central venous vessel.8,9 In 2008, Medicare initiated a nonpayment policy for hospitalizations with a documented hospital-acquired condition to provide incentives to hospitals to reduce CLABSIs and other iatrogenic conditions in adults.10 The Patient Protection and Affordable Care Act (ACA) of 2010 mandated that Medicaid adopt a similar nonpayment policy. The Medicaid providerpreventable conditions (PPCs) were created in 2011 by CMS as a set of
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hospital-acquired complications for which hospitals would not be reimbursed for Medicaid patients.11 There is a lack of data regarding the accuracy of ICD-9-CM code 999.31. Therefore, researchers at 3 children’s hospitals began working with the Children’s Hospital Association to compare administrative reporting of CLABSI to infection control clinician reporting of CLABSI to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN). Although the NHSN reporting is voluntary, all 3 of these hospitals report all CLABSIs into the system. The authors tested the hypothesis that the PPC criteria would identify more CLABSIs than those identified by using the strict NHSN criteria because the NHSN criteria were more restrictive than the PPC criteria.
METHODS Patient discharges from January 1 to December 31, 2010, at University of Michigan CS Mott Children’s Hospital, Monroe Carell Jr. Children’s Hospital at Vanderbilt, and Seattle Children’s Hospital were examined for occurrences of CLABSIs. Identification of CLABSIs was done by using: (1) hospital administrative data and CMS PPC criteria: and (2) hospital infection control data and NHSN criteria (Table 1). All 3 hospitals use medical record coders to assign ICD-9-CM codes to the diagnoses documented by clinicians as part of their standard universal billing submission process. Medical record coders have specialized training in coding and must follow strict standards and are audited for accuracy. Coders review the hospital chart and assign codes according to the clinician notes. They can only code what a clinician
has specifically noted as a diagnosis and cannot extrapolate from laboratory values or vague references. In the case of a CLABSI (ICD-9-CM code 999.31 during our study), clinicians must designate that a bloodstream infection is “line associated” or use terminology that specifically associates the infection with the central catheter. If only terms such as “sepsis,” “bacteremia,” or “bloodstream infection” are designated, the code 999.31 cannot be used. Once patient chart coding was completed at the individual hospitals, copies of the information were submitted to the Children’s Hospital Association Comparative Case Mix Data Program. CLABSIs were identified from the Case Mix database according to CMS PPC methods, which use the 999.31 ICD9-CM diagnosis code. All the children’s hospitals involved in the study also report CLABSIs to the NHSN in a similar manner. The children’s hospitals’ microbiology laboratories all produce automated reports of positive blood culture results. Lists of these results are sent to the infection control professionals, who then review the cultures and the charts of the patients identified to judge whether the cultures fulfill the standardized NHSN criteria for CLABSI infection (Table 1). Data for patients discharged in 2010 were also collected from the infection control departments by the investigators in each hospital identifying CLABSIs submitted to the NHSN. The number of CLABSIs identified by both methods were entered in a 2 × 2 table and analyzed for sensitivity (ie, the probability that the test result will be positive when the condition is present), specificity (ie, the probability that the test will be negative when the condition is absent), positive predictive
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HOSPITAL Pediatrics ®
AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS
TABLE 1 CLABSI Measurement Definitions12,13 CMS PPC: vascular catheter–associated infectiona ICD-9-CM code 999.31 (infection due to central venous catheter) appears as a secondary diagnosis and Secondary diagnosis is not coded as POA (ie, POA code of N [not present on admission] or U [insufficient documentation]). CDC NHSN central line–associated bloodstream infection criteria Laboratory-confirmed bloodstream infections that: (1) are not secondary to a community-acquired infection or a health care–associated infection meeting CDC NHSN criteria at another body site; and (2) are central line–associated (ie, central line in place at the time of, or within 48 h before, onset of the event). Laboratory-confirmed bloodstream infection (must meet 1 of the following criteria): Criterion 1: Patient has a recognized pathogen cultured from 1 or more blood cultures and organism cultured from blood is not related to an infection at another site. Criterion 2: Patient has at least 1 of the following signs or symptoms: fever, chills, or hypotension and signs and symptoms and positive laboratory results are not related to an infection at another site and common commensal is cultured from 2 or more blood cultures drawn on separate occasions. Criterion 3: Patient
Comparison of Administrative Data Versus Infection Control Data in Identifying Central Line–Associated Bloodstream Infections in Children’s Hospitals AUTHORS J. Mitchell Harris II, PhD,1 James C. Gay, MD, 2 John M. Neff, MD,3 Stephen W. Patrick, MD, MPH, MSc,4 Aileen Sedman, MD, FAAP, FASPN5 1
Children’s Hospital Association, Alexandria, Virginia; Vanderbilt University School of Medicine, Nashville, Tennessee; 3 Center for Children with Special Needs, Seattle Children’s Hospital, Seattle, Washington; 4 Department of Pediatrics, Division of Neonatal– Perinatal Medicine, University of Michigan Health System, Ann Arbor, Michigan; and 5 University of Michigan Medical School, Ann Arbor, Michigan 2
KEY WORDS billing and compliance, infection control, medical error, patient safety, vascular catheter–related infections
abstract OBJECTIVE: As of July 2012, the Centers for Medicare and Medicaid Services prohibited state Medicaid programs from paying for medical care related to certain provider-preventable conditions. The most prevalent providerpreventable condition in pediatrics is central line–associated bloodstream infections (CLABSIs), which cause significant morbidity and mortality. The objective of this study was to compare the uses of administrative data and infection control data in measuring CLABSIs. METHODS: Retrospective chart reviews were performed in 3 children’s hospitals to compare CLABSIs identified according to administrative data diagnostic coding versus infections identified by hospital infection control departments. Clinical criteria from the Centers for Disease Control and Prevention and reported to the National Healthcare Safety Network were used.
ABBREVIATIONS ACA: Patient Protection and Affordable Care Act AHRQ: Agency for Healthcare Research and Quality CDC: Centers for Disease Control and Prevention CLABSI: central line–associated bloodstream infections CMS: Centers for Medicare & Medicaid Services NHSN: National Healthcare Safety Network ICD-9-CM: International Classification of Diseases, Ninth Revision, Clinical Modification POA: present on admission PPC: provider-preventable conditions PSI: patient safety indicators
RESULTS: A total of 166 CLABSIs were identified in 35 698 discharges in the 3 children’s hospitals in 2010. Using the Centers for Disease Control and Prevention criteria as the standard, administrative data had 34.78% sensitivity and 99.92% specificity. The positive predictive value was 63.16% whereas the negative predictive value was 99.75%.
This study is solely the work of the authors and does not represent the opinion of the Children’s Hospital Association.
Central line–associated bloodstream infections (CLABSIs) are a significant source of morbidity, mortality, and added medical costs for hospitalized children and adults.1,2 Documentation of these complications in the literature spurred national quality improvement efforts aimed at reducing CLABSIs. These efforts, mainly aimed at decreasing the rates through standardizing practice, resulted in dramatic reductions in CLABSIs among both adults and children.3,4 For instance, in a collaborative study in 29 children’s hospitals sponsored by the Children’s Hospital Association, Miller et al5 reported a drop in infection rates from 5.2 infections per 1000 line days to 2.3 infections per 1000 line days, with sustained and continuously decreasing rates over 3 years.
www.hospitalpediatrics.org doi:10.1542/hpeds.2013-0048 Address correspondence to J. Mitchell Harris II, PhD, Director, Children’s Hospital Association, 401 Wythe St, Alexandria, VA 22314. E-mail: [email protected] HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154 - 1663; Online, 2154 - 1671). Copyright © 2013 by the American Academy of Pediatrics (Continued on last page)
CONCLUSIONS: Administrative data and National Healthcare Safety Network criteria identify discordant numbers of CLABSIs.
Because CLABSIs occur commonly, are potentially preventable, and are harmful to patients, the Centers for Medicare & Medicaid Services (CMS), the Joint Commission, and the Agency for Healthcare Research and Quality (AHRQ) sought to design methods to quantify the number of CLABSIs in individual hospitals for
Downloaded from http://hosppeds.aappublications.org/ at Florida International University, Medical Library on May 27, 2015
| 307
HOSPITAL Pediatrics ®
AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS
use as measures of quality. AHRQ included the measure “infection due to medical care” in their patient safety indicators (PSIs), which originally identified CLABSIs via administrative data by using a nonspecific diagnostic code that included infections associated with any device such as pacemakers, venous lines, and arterial lines.6 The AHRQ pediatric quality indicators were created in 2006 in response to many issues in PSIs that were not appropriate for children7 but maintained the use of the nonspecific diagnostic code for “infection due to medical care.” Both PSIs and pediatric quality indicators had risk adjustment methods that were helpful in comparative reporting. In October 2007 a specific International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code (999.31) was created to identify “infections due to central venous catheter,” with the intent of more accurately identifying CLABSIs by using administrative data. The code included all venous catheters that were placed centrally, including classically placed central lines such as subclavian and femoral lines, peripherally inserted central lines, and umbilical venous catheters, but specifically excluded arterial and peripheral venous catheters that are not threaded into a central venous vessel.8,9 In 2008, Medicare initiated a nonpayment policy for hospitalizations with a documented hospital-acquired condition to provide incentives to hospitals to reduce CLABSIs and other iatrogenic conditions in adults.10 The Patient Protection and Affordable Care Act (ACA) of 2010 mandated that Medicaid adopt a similar nonpayment policy. The Medicaid providerpreventable conditions (PPCs) were created in 2011 by CMS as a set of
308 |
hospital-acquired complications for which hospitals would not be reimbursed for Medicaid patients.11 There is a lack of data regarding the accuracy of ICD-9-CM code 999.31. Therefore, researchers at 3 children’s hospitals began working with the Children’s Hospital Association to compare administrative reporting of CLABSI to infection control clinician reporting of CLABSI to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN). Although the NHSN reporting is voluntary, all 3 of these hospitals report all CLABSIs into the system. The authors tested the hypothesis that the PPC criteria would identify more CLABSIs than those identified by using the strict NHSN criteria because the NHSN criteria were more restrictive than the PPC criteria.
METHODS Patient discharges from January 1 to December 31, 2010, at University of Michigan CS Mott Children’s Hospital, Monroe Carell Jr. Children’s Hospital at Vanderbilt, and Seattle Children’s Hospital were examined for occurrences of CLABSIs. Identification of CLABSIs was done by using: (1) hospital administrative data and CMS PPC criteria: and (2) hospital infection control data and NHSN criteria (Table 1). All 3 hospitals use medical record coders to assign ICD-9-CM codes to the diagnoses documented by clinicians as part of their standard universal billing submission process. Medical record coders have specialized training in coding and must follow strict standards and are audited for accuracy. Coders review the hospital chart and assign codes according to the clinician notes. They can only code what a clinician
has specifically noted as a diagnosis and cannot extrapolate from laboratory values or vague references. In the case of a CLABSI (ICD-9-CM code 999.31 during our study), clinicians must designate that a bloodstream infection is “line associated” or use terminology that specifically associates the infection with the central catheter. If only terms such as “sepsis,” “bacteremia,” or “bloodstream infection” are designated, the code 999.31 cannot be used. Once patient chart coding was completed at the individual hospitals, copies of the information were submitted to the Children’s Hospital Association Comparative Case Mix Data Program. CLABSIs were identified from the Case Mix database according to CMS PPC methods, which use the 999.31 ICD9-CM diagnosis code. All the children’s hospitals involved in the study also report CLABSIs to the NHSN in a similar manner. The children’s hospitals’ microbiology laboratories all produce automated reports of positive blood culture results. Lists of these results are sent to the infection control professionals, who then review the cultures and the charts of the patients identified to judge whether the cultures fulfill the standardized NHSN criteria for CLABSI infection (Table 1). Data for patients discharged in 2010 were also collected from the infection control departments by the investigators in each hospital identifying CLABSIs submitted to the NHSN. The number of CLABSIs identified by both methods were entered in a 2 × 2 table and analyzed for sensitivity (ie, the probability that the test result will be positive when the condition is present), specificity (ie, the probability that the test will be negative when the condition is absent), positive predictive
VOLUME 3 • ISSUE 4 www.hospitalpediatrics.org Downloaded from http://hosppeds.aappublications.org/ at Florida International University, Medical Library on May 27, 2015
HOSPITAL Pediatrics ®
AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS
TABLE 1 CLABSI Measurement Definitions12,13 CMS PPC: vascular catheter–associated infectiona ICD-9-CM code 999.31 (infection due to central venous catheter) appears as a secondary diagnosis and Secondary diagnosis is not coded as POA (ie, POA code of N [not present on admission] or U [insufficient documentation]). CDC NHSN central line–associated bloodstream infection criteria Laboratory-confirmed bloodstream infections that: (1) are not secondary to a community-acquired infection or a health care–associated infection meeting CDC NHSN criteria at another body site; and (2) are central line–associated (ie, central line in place at the time of, or within 48 h before, onset of the event). Laboratory-confirmed bloodstream infection (must meet 1 of the following criteria): Criterion 1: Patient has a recognized pathogen cultured from 1 or more blood cultures and organism cultured from blood is not related to an infection at another site. Criterion 2: Patient has at least 1 of the following signs or symptoms: fever, chills, or hypotension and signs and symptoms and positive laboratory results are not related to an infection at another site and common commensal is cultured from 2 or more blood cultures drawn on separate occasions. Criterion 3: Patient
