SB Infection-Rate Reporting:

November 1, 2004

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 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.

Recommended Reading:

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

Burke JP. Infection control: a problem for patient safety. N
Eng J Med.

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

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.

Web Sites:

Centers for Medicare and Medicaid Services (CMS)
CMS Hospital
Quality Initiative or

Centers for Medicare and
Medicaid Services (CMS)
CMS Nursing Home Quality Initiative

National Quality Forum