One of These Things Is Not Like the Others: Consideration of Healthcare-Associated Infection Risk in Burn Patients and Other Critically Ill Populations

Authors:
Megan Yoerg, Laura Johnson, Lauren Nosanov

Body of Abstract:
Introduction: Healthcare-associated infections (HAI) are a significant source of preventable morbidity, with the Centers for Disease Control and Prevention (CDC) estimating a prevalence of 3.2% in patients receiving inpatient care. Reporting and benchmarking common HAI is crucial to efforts in prevention and quality improvement. Risk for HAI is elevated in critically ill populations, but the variance based on specific illness and injury patterns is underappreciated. The pathophysiology of severe burn injury induces profound immunocompromise; coupled with loss of the barrier function provided by intact integumentary, this results in uniquely elevated infection risk. Prolonged hospitalization, persistent open wound burden, device days, and frequent surgical interventions additionally contribute. Broadly accepted HAI surveillance definitions may therefore be insufficient and under-stratified when applied to burn patients, with subsequent implications on reimbursement and quality benchmarking.

Methods: An in-depth review was conducted of the 2024 CDC National Healthcare and Safety Network (NHSN) Patient Safety Component Manual (PSCM). NHSN is the largest and most widely used tracking system for HAI in the United States, accounting for approximately 25,000 medical facilities, with the Patient Safety Component Manual serving as the prevailing document outlining surveillance definitions and standardization. Populations used to define HAI surveillance and case definitions were identified, with specific attention paid to representation of the burn patient population. Central Line-associate Bloodstream Infections (CLABSI) and Catheter-associated Urinary Tract Infections (CAUTI) were specifically reviewed due to their common and pervasive risk profiles across critically ill patients.

Results: The PSCM explicitly mentions burn units throughout, they are generally grouped based on number of device days and length of stay. Referent groups included units specializing in labor and delivery, neurology, telemetry, and medical surgical, with care provided to patients with vastly different pathophysiology, critical illness, and immunocompromise.

Conclusions: Improved understanding of HAI risk in disparate patient populations is crucial. Beyond optimization of patient outcomes, HAI risk identification and mitigation has implication on resource utilization, insurance reimbursement, and reporting of hospital outcomes data. The value of benchmarking can only aid quality improvement efforts when patient populations are considered in comparison to others sharing equivalent risk profiles. As currently structured, the NHSN PSCM may be unfairly penalizing facilities providing the required specialized care to save and rehabilitate critically ill burn patients. Evidence-based re-evaluation of the PSCM referent groups is needed, however efforts will likely be hindered by the paucity of burn-specific HAI literature currently available.