Toward better benchmarking.

There is good news and bad news about nosocomial infections in general and surgical-site infection (SSI) surveillance in particular. The good news is the increasing attention our society is paying these problems. For example, some state legislatures are requiring hospitals to report their nosocomial infection rates; the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has developed new performance standards regarding perioperative antibiotic prophylaxis1; Medicare will begin to pay hospitals according to their performance2; and the Institute for Healthcare Improvement has targeted nosocomial infections in its effort to prevent 100,000 deaths each year.3 It is difficult to recall another time when so great an opportunity existed to make meaningful strides in preventing the burden of morbidity, mortality, and costs that these infections impose. The bad news is that hospitals do not have important information about their own infection rates that would make the efforts noted above as effective as they should be, and prospective patients cannot know whether their risk of infection will be higher in one hospital than another because the hospitals themselves do not know how they compare with others performing the same procedures. Without that information, no one knows which hospitals should be models for good care. Much of the current research will not provide this information in the foreseeable future. This issue of Infection Control and Hospital Epidemiology provides three examples of surveillance research addressing SSIs.4-6 Mitt et al. used a combination of telephone calls to patients, healthcare worker questionnaires, and review of outpatient medical records to assess infections following cesarean section in approximately 300 women in an Estonian teaching hospital.6 In Italy, Moro et al. conducted a 1-month survey of 6,167 procedures of many types performed in 31 hospitals; postdischarge infections were identified by telephone contacts and forms that patients brought with them to their postoperative medical visits.5 Geubbels et al. describe a Dutch study of nearly 14,000 hip arthroplasties performed in 36 hospitals; postdischarge surveillance was performed through registration cards completed by surgeons and optional record review by infection control practitioners.4 Although these studies had different goals, each invested a great deal of effort in surveillance systems to identify SSIs that occurred during and after hospitalization. Admirable as these efforts are, we need a different, or at least an additional, conversation about SSIs. The most important issues for us to address are (1) ensuring that clinicians and hospitals use established best practices and (2) developing postoperative SSI surveillance systems that more effectively support benchmarking and require less expenditure of scarce resources. Regarding best practices, in most situations we should simply act on credible information in the literature rather than invest the effort required to demonstrate that it holds in additional settings. The new JCAHO measure regarding selection, timing, and duration of perioperative antibiotic prophylaxis is an important example. As an aside, that measure might be better if it allowed hospitals to vary from the standard, if they could justify their reasons for doing so. As written, the JCAHO prophylaxis standard appears not to permit a hospital with a high rate of methicillinresistant Staphylococcus aureus infection to use vancomycin routinely for prophylaxis.7 It also does not appear to allow a hospital to conduct research to identify better prophylaxis regimens. The JCAHO prophylaxis measure does, however, have the advantage of focusing hospitals on ensuring the delivery of prophylaxis.