Central Line Bloodstream Infections & Pay for Performance

The topic of central line bloodstream infection (CLBSI) is interesting to review because of its inclusion as one of the so-called “pay-for-performance” indicators and there is a large amount of research to look at. I want to focus on one aspect of the issue, which is the difference between information obtained from an administrative database and what is clinical valid.

Published ahead of print in the Journal of the American College of Surgeons is an article from the data mines of the Veterans Administration showing that some 63% of CLBSIs seen at VA hospitals over a 5 year period were actually coded incorrectly. They were falsely positive; the patients did not have CLBSIs.

You might wonder, “How can this be?”

Here’s how. When scrutinized carefully by clinician chart review, 27% had thrombophlebitis at a peripheral IV site, 7% had infected surgically placed arterial graft infections and 6% had cellulitis at an IV site that was not a central line. The rest of the false positives were as follows: chart coded as having a CLBSI when the work-up was actually negative for infection; the patient had no evidence of ever having had a central line; the patient had a CLBSI that was present on admission to the hospital and therefore not preventable during the admission being reviewed.

The problem is that the ICD-9 codes used during the study period (2003-2007) were not specific enough. New codes have been developed but are still not suitable as justification to withhold money from hospitals.

The paper also points out that the CDC has published three different sets of criteria for determining whether a central line is infected.

ICD-9 codes were created for billing purposes, not for studying clinical problems. They are also subject to coding errors as the paper clearly depicts. This is one of a number of papers that illustrate the problems associated with the use of administrative data in analyzing clinical problems.

I’m not necessarily against the pay-for-performance concept, but it must be based on accurate data.

What do you think about "pay-for-performance"?

This post appeared on Sermo yesterday and 84% of those physicians voting did not favor the use of pay for performance.

Ultrasound-Guided Central Venous Catheter Insertion

Despite the large amount of published evidence (here, here, and here) that ultrasound guidance reduces the failure rate of central venous catheterization, especially for cannulation of the internal jugular vein, some physicians still claim that there is no difference between the success rate of ultrasound guidance and the landmark method. This was the subject of a brief discussion regarding the safety of central venous catheter insertion in coagulopathic patients on Twitter. 

I have a couple of anecdotes to share. I was called to insert a line in an obese patient with idiopathic thrombocytopenic purpura (also called immune/autoimmune thrombocytopenic purpura or ITP). The patient’s platelet count was 2,000. Despite the short, bulky neck, a physician assistant (PA) who had done only 20 previous internal jugular sticks, accessed the vein on the first attempt using ultrasound guidance and there were no complications.

We were called to insert a central line in a morbidly obese man (see photos) who was hypotensive. A PA who had done fewer than 10 previous central line insertions successfully cannulated his right internal jugular vein on the first try using ultrasound.

I would not have attempted to cannulate the first patient without ultrasound guidance. The second patient would have probably had a subclavian approach which would have been difficult.

I was skeptical regarding ultrasound for vascular access for years. Now I would not insert a central venous catheter without using it.