SB Infection-Rate Reporting:
Making It Add Up for Patient Safety
By Kelly M. Pyrek
As of press time in late September, California is close to joining four other states which have enacted legislation aimed at curbing healthcare-acquired infections (HAIs) that kill as many as 90,000 people annually in the United States, according to the Centers for Disease Control and Prevention (CDC). Another 1.9 million people nationwide who develop such infections endure longer stays in the hospital getting treated and recovering from infection-related illnesses. Approximately 5 percent to 10 percent of all hospital patients develop infections, which add nearly $5 billion to the nations healthcare-spending tab.
SB 1487, introduced by Sen. Jackie Speier, was approved by California lawmakers and now awaits its fate at the hands of Gov. Arnold Schwarzenegger, who will decide whether to not to sign the bill into law.
The quickest route to reducing hospital-infection rates is to make this information public, says Speier. For hospitals, there is no greater incentive than the need to respond to informed consumers demanding the quality of care they deserve.
In California, the Department of Health Services estimates 7,200 to 9,600 deaths occur annually from HAIs. California spends millions of dollars to cover hospital infection-related treatment for those who depend on state and local government-sponsored healthcare programs.
On average, as many as 26 Californians die from infections they acquire in the hospital every day, said Earl Lui, senior staff attorney with Consumers Unions West Coast office. More people die from hospital infections in California than from auto accidents and homicides combined. Consumers Unions StopHospitalInfections.org project is working to enact public disclosure laws so that consumers can select the safest hospitals and so that competition among hospitals will force the worst to improve.
Studies show that healthcare facilities can reduce infection rates significantly by proper implementation of infection control practices, especially handwashing. Nonetheless, many hospitals have not done so; the National Quality Forum says most studies report handwashing compliance rates that are generally less than 50 percent.
Many hospitals track their own infection rates, but they are not currently required to report this information to any regulatory agency in California. They cannot compare their performance to other area hospitals, and patients have no way of knowing if their hospital is doing a good job minimizing infection risks. In California, hospitals are required to report information about each patient that is discharged to the Offi ce of Statewide Health Planning & Development (OSHPD). SB 1487 would require that they also report the rate at which their patients develop infections during treatment and mandates that the agency disclose this information to the public. Similar hospital infection reporting requirements recently have been adopted in Illinois, Pennsylvania, Missouri, and Florida. In 2003, Illinois became the fi rst state to pass a specific law requiring that hospitals make public their record on hospital infections.
Several states have established mandatory hospital reporting requirements for such things as the outcome of heart surgeries, which has helped to improve the quality of care that patients receive. Likewise, public reporting of hospital-acquired infection data will give hospitals a much stronger incentive to reduce the rate of infections.
When it comes to hospital infections, sunshine is the best disinfectant, says Lisa McGiffert, director of the Stop Hospital Infections campaign. Once healthcare consumers are informed of how well their local hospital is controlling this deadly problem, hospitals will have a greater incentive to clean up their act.
The CDC reports that one in 20 patients gets an infection while hospitalized. A single hospital infection is estimated to add $38,600 to the cost of medical care and as much as $58,000 for a serious bout with postoperative sepsis.
The cost in human lives of these mostly preventable infections is astounding, McGiffert says. Add to that the financial cost to our healthcare system and you have an inexcusable situation.
The Centers for Medicare and Medicaid Services (CMS) has been holding public meetings in an attempt to standardize the kind of data hospitals collect and voluntarily report to the federal government about patient quality of care to make hospital performance information more accessible to the public. Several CMS programs already focus on providing information to consumers regarding quality of healthcare facilities, including the National Voluntary Hospital Reporting Initiative, the Premier Hospital Quality Incentive Demonstration Project, the Hospital Three-State Pilot Project (Arizona, Maryland, and New York) and the Nursing Home Quality Initiative.
Beginning in 2005, CMS will link payment with performance by requiring hospitals to submit data on 10 performance indicators that measure processes of healthcare, such as pneumonia patients who receive their first dose of antibiotics within four hours after arrival at the hospital. Hospitals must submit this data by July 1, 2004 to comply with the Medicare Prescription Drug, Improvement and Modernization Act. CMS states that Hospitals that do not submit performance data for the 10 quality measures will receive 0.4 percent smaller Medicare payments in fiscal year 2005 than hospitals that do report quality data.
Mandatory infection-rate reporting has been building and has evolved over time, says Kathleen Meehan Arias, MS, CIC, of Arias Infection Control Consulting, LLC. CMS has been one of the biggest proponents, and Consumers Union has been pushing legislative bodies in each state to develop some kind of reporting requirement. Arias, who is a member of the board of the Association for Professionals in Infection Control and Epidemiology (APIC), and is the liaison between the groups Practice Guidance Council and its board of directors, says APIC has been involved in the issue for a long time.
In 1998, APICs Surveillance Initiative Working Group issued its position statement, Release of Nosocomial Infection Data, which was designed to assist infection control practitioners (ICPs) when asked for infectionrate data by third-party payors, managed-care organizations and other agencies. The document emphasizes, Infection surveillance strategies in each healthcare organization are best determined after assessing the types of patients served. Surveillance can address nosocomial infections or related processes which impact the highest-risk patients, which occur with high frequency, or which may result in the most significant outcomes.
The document also specifies, For each surveillance strategy to be valid, it must include (1) consistent surveillance intensity, (2) application of standardized definitions of infections, and (3) methods to adjust for differences in patient-related risk.
You cant use a crude or overall infection rate, Arias emphasizes, such as hospital A has an overall infection rate of 3 percent; you have to target specific infections like bloodstream infections associated with central lines, because that is risk adjusted by the fact that a patient has a central line, so youre not comparing apples to oranges. Acute patients in a tertiary-care hospital cannot be compared to less-acute patients in a community hospital. If you did an overall rate for tertiary-care hospitals, its obvious patients there would have a higher infection rate. You must ensure that surveillance methods are the same in all the different facilities, are risk-adjusted, and that the formula for calculating the rate is the same for all facilities. Thats what APIC has always said and will continue to say.
Arias reports that the CDCs Healthcare Infection Control Practices Advisory Committee (HICPAC) is developing a guidance document on the subject of mandatory infection-rate reporting, and says she hopes HICPACs document will reflect some of APICs recommendations. We hope that we can work with CMS and other organizations to achieve standardization, Arias adds. Our concern is that if each state comes up with its own requirements, we may have 50 different definitions of infections, and 50 different sets of requirements that will be neither good for hospitals nor for the public. Were hoping the report card requirement will be the same throughout the country.
Arias says infection reporting is not new, as ICPs have been doing it since the 1980s. Weve always used this kind of data, and since the 1990s there have been many articles in the literature reporting various findings by facilities that have calculated their data the same as the CDCs National Nosocomial Infections Surveillance System (NNIS) a system that has been around since the 1970s.
It used to be just counting beans, but people started realizing that if you targeted specific infections, you could use that data, trended over time, as benchmarks; especially if you collected data like the NNIS, and if you used the same infection definitions as the NNIS. You could research the literature to see what is known about preventing ventilator-associated pneumonia, and use that data to ensure that your practices are approaching the ideal numbers that you want, then watch your rates over time. If they trend downward, then thats definitely performance improvement.
Mandatory infection-rate reporting has met with some resistance from healthcare facility administrators who are concerned about costs associated with the practice, Arias says, and admits that it could place a burden on facilities struggling with razor-thin profit margins and soft bottom lines. It is going to create more work and cost more, but it comes down to patient safety.
Another struggle is to ensure that ICPs are involved in the surveillance and in the number crunching. There are many studies that show if its done by medical records personnel, its not accurate. The rates are actually much higher because they are not taught to distinguish between community-acquired infections (CAIs) and HAIs. If you do it by coding, you will pick up all infections, including infections patients came in with, which is a major reason for being admitted to the hospital. The ICP is trained to discard the CAIs and look at HAIs.
Arias adds, The best thing ICPs can do at this point is to monitor what is happening in their state to see if there is movement to require reporting of HAIs. They should take an active role in working with their state legislators and representatives to ensure that the measures they choose to monitor, such as catheter-associated bloodstream infections, are valid.
APIC Surveillance Initiative Working Group. Release of Nosocomial Infection Data. 1998.
Quality Indicator Study Group. An approach to the evaluation of quality indicators of the outcome of care in hospitalized patients, with a focus on nosocomial infection indicators. Infect Control Hosp Epidemiol. 1995;16:308-316. SHEA position paper available at www.shea-online.org.
Burke JP. Infection control: a problem for patient safety. N Eng J Med. 2003;348:651-656.
Gaynes R, et al. Feeding back surveillance data to prevent hospital-acquired infections. Emerg Infect Dis., March-April 2001, 7(2):295-98. Available at http://www.cdc.gov/ncidod/eid/vol7no2/gaynes.htm.
Archibald LK, Gaynes RP. Hospital-acquired infections in the United States. The importance of inter-hospital comparisons. Infect Dis Clin North Am. 1997. Jun;11(2):245-55.
Centers for Medicare and Medicaid Services (CMS)
CMS Hospital Quality Initiative
http://www.cms.hhs.gov/quality/hospital or http://www.cms.hhs.gov/quality/hospital/overview.pdf
Centers for Medicare and
Medicaid Services (CMS)
CMS Nursing Home Quality Initiative
National Quality Forum