Does The National Surgical Quality Improvement Program Identify Valid Urinary Tract Infections Postoperatively?
Samantha J. Ganick, MD1, Vikrant Uberoi, MD1, Lori Lerner, MD2.
1Boston Medical Center, Boston, MA, USA, 2Veterens Administration Medical Center, Boston, MA, USA.
The National Surgical Quality Improvement Program (NSQIP) is a quality improvement tool that came about due to the perceived gap between operative mortality rates at Veterans Affairs (VA) hospitals versus the private sector. In the mid 1980’s Congress passed law 99-166 that mandated the VA system to annually report surgical outcomes. At VA Boston Healthcare System, the post operative urinary tract infection (UTI) rate in Fiscal Year 2008 was 2.6%, which was above the national rate of 1.9% and an internal review was requested. We reviewed postoperative UTI in 36 patients and several problems with the NSQIP criteria were recognized. Our aim was to determine where NSQIP failed and if modifications to the existing criteria should be proposed.
All patients who met NSQIP criteria for post operative UTI underwent chart review. All information captured by NSQIP was analyzed, including patient symptoms, catheterization history, urine cultures, and antibiotic treatment of documented UTI. These data points were reviewed in the context of NSQIP criteria and determination of valid UTI diagnosis was made.
Of the 36 patients evaluated, 24 had valid UTI’s in the authors’ opinion. Of the 12 improperly classified: 2 were local/regional cases without instrumentation of the urinary tract and preexisting risk factors; 2 had voiding dysfunction and negative cultures and were treated unnecessarily; 5 patients were asymptomatic and had contaminated cultures; 1 had a positive culture at catheter placement but was never treated; and 2 were treated for another infection (wound, pneumonia, etc) and urine culture was ignored.
NSQIP is the first nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care. Review of postoperative diagnosis of UTI in our cohort identified inherent deficiencies with the criteria. While the current NSQIP criteria capture UTI by using objective data and symptoms commonly associated with UTI, we feel they lack exclusionary criteria. In addition, some of the symptom criteria (voiding complaints and fever) used by NSQIP can be seen with voiding dysfunction and/or other illnesses and are unrelated to a urinary infection. Laboratory findings such as leukocyte esterase which is positive in patients who have been instrumented/catheterized, is not necessarily diagnostic of infection. Furthermore, patients who undergo a work-up for fever and are diagnosed and treated for a non urologic-infection such as pneumonia, are not excluded, even when they are not treated for the positive urine culture. Patients who developed UTIs secondary to preexisting conditions (diabetes, benign prostatic hyperplasia) who had non urologic outpatient procedures under local/regional blocks without urethral instrumentation were also not excluded. Lastly, there were no standards stated for specimen collection, such as indwelling/new foley/clean catch, or exclusions for contaminated or inappropriately collected urines. In summary, NSQIP criteria as they currently exist do not accurately capture valid UTI and modifications should be made. In light of recent decreased reimbursement for nosocomial UTI’s, it is crucial that Urologists work with these surgical programs to ensure that the criteria used to make these diagnoses are valid.