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Making It Add Up for Patient Safety
By Kelly M. Pyrek
As of press time in late September, California is close to joining four otherstates which have enacted legislation aimed at curbing healthcare-acquiredinfections (HAIs) that kill as many as 90,000 people annually in the UnitedStates, according to the Centers for Disease Control and Prevention (CDC).Another 1.9 million people nationwide who develop such infections endure longerstays in the hospital getting treated and recovering from infection-relatedillnesses. Approximately 5 percent to 10 percent of all hospital patientsdevelop infections, which add nearly $5 billion to the nationshealthcare-spending tab.
SB 1487, introduced by Sen. Jackie Speier, was approved byCalifornia lawmakers and now awaits its fate at the hands of Gov. ArnoldSchwarzenegger, who will decide whether to not to sign the bill into law.
The quickest route to reducing hospital-infection rates isto make this information public, says Speier. For hospitals, there is nogreater incentive than the need to respond to informed consumers demanding thequality of care they deserve.
In California, the Department of Health Services estimates7,200 to 9,600 deaths occur annually from HAIs. California spends millions ofdollars to cover hospital infection-related treatment for those who depend onstate and local government-sponsored healthcare programs.
On average, as many as 26 Californians die from infectionsthey acquire in the hospital every day, said Earl Lui, senior staff attorneywith Consumers Unions West Coast office. More people die from hospital infections in California thanfrom auto accidents and homicides combined. Consumers UnionsStopHospitalInfections.org project is working to enact public disclosure laws sothat consumers can select the safest hospitals and so that competition amonghospitals will force the worst to improve.
Studies show that healthcare facilities can reduce infectionrates significantly by proper implementation of infection control practices,especially handwashing. Nonetheless, many hospitals have not done so; theNational Quality Forum says most studies report handwashing compliance ratesthat are generally less than 50 percent.
Many hospitals track their own infection rates, but they arenot currently required to report this information to any regulatory agency inCalifornia. They cannot compare their performance to other area hospitals, andpatients have no way of knowing if their hospital is doing a good job minimizinginfection risks. In California, hospitals are required to report informationabout each patient that is discharged to the Offi ce of Statewide HealthPlanning & Development (OSHPD). SB 1487 would require that they also reportthe rate at which their patients develop infections during treatment andmandates that the agency disclose this information to the public. Similarhospital infection reporting requirements recently have been adopted inIllinois, Pennsylvania, Missouri, and Florida. In 2003, Illinois became the first state to pass a specific law requiring that hospitals make public theirrecord on hospital infections.
Several states have established mandatory hospitalreporting requirements for such things as the outcome of heart surgeries, whichhas helped to improve the quality of care that patients receive. Likewise,public reporting of hospital-acquired infection data will give hospitals a muchstronger incentive to reduce the rate of infections.
When it comes to hospital infections, sunshine is the bestdisinfectant, says Lisa McGiffert, director of the Stop Hospital Infectionscampaign. Once healthcare consumers are informed of how well theirlocal hospital is controlling this deadly problem, hospitals will have a greaterincentive to clean up their act.
The CDC reports that one in 20 patients gets an infectionwhile hospitalized. A single hospital infection is estimated to add $38,600 tothe cost of medical care and as much as $58,000 for a serious bout withpostoperative sepsis.
The cost in human lives of these mostly preventableinfections is astounding, McGiffert says. Add to that the financial costto our healthcare system and you have an inexcusable situation.
The Centers for Medicare and Medicaid Services (CMS) has beenholding public meetings in an attempt to standardize the kind of data hospitalscollect and voluntarily report to the federal government about patient qualityof care to make hospital performance information more accessible to the public.Several CMS programs already focus on providing information to consumersregarding quality of healthcare facilities, including the National VoluntaryHospital Reporting Initiative, the Premier Hospital Quality IncentiveDemonstration 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 byrequiring hospitals to submit data on 10 performance indicators that measureprocesses of healthcare, such as pneumonia patients who receive their firstdose of antibiotics within four hours after arrival at the hospital.Hospitals must submit this data by July 1, 2004 to comply with the MedicarePrescription Drug, Improvement and Modernization Act. CMS states that Hospitals that do not submit performancedata for the 10 quality measures will receive 0.4 percent smaller Medicarepayments in fiscal year 2005 than hospitals that do report quality data.
Mandatory infection-rate reporting has been building andhas evolved over time, says Kathleen Meehan Arias, MS, CIC, of AriasInfection Control Consulting, LLC. CMS has been one of the biggestproponents, and Consumers Union has been pushing legislative bodies in eachstate to develop some kind of reporting requirement. Arias, who is a memberof the board of the Association for Professionals in Infection Control andEpidemiology (APIC), and is the liaison between the groups Practice GuidanceCouncil and its board of directors, says APIC has been involved in the issue fora long time.
In 1998, APICs Surveillance Initiative Working Group issuedits position statement, Release of Nosocomial Infection Data, which wasdesigned to assist infection control practitioners (ICPs) when asked forinfectionrate data by third-party payors, managed-care organizations and otheragencies. The document emphasizes, Infection surveillance strategies in eachhealthcare organization are best determined after assessing the types ofpatients served. Surveillance can address nosocomial infections or relatedprocesses which impact the highest-risk patients, which occur with highfrequency, or which may result in the most significant outcomes.
The document also specifies, For each surveillancestrategy to be valid, it must include (1) consistent surveillance intensity, (2)application of standardized definitions of infections, and (3) methods toadjust for differences in patient-related risk.
You cant use a crude or overall infection rate, Ariasemphasizes, such as hospital A has an overall infection rate of 3 percent;you have to target specific infections like bloodstream infections associatedwith central lines, because that is risk adjusted by the fact that a patient hasa central line, so youre not comparing apples to oranges. Acute patients in atertiary-care hospital cannot be compared to less-acute patients in a communityhospital. If you did an overall rate for tertiary-care hospitals, its obviouspatients there would have a higher infection rate. You must ensure thatsurveillance methods are the same in all the different facilities, arerisk-adjusted, and that the formula for calculating the rate is the same for allfacilities. Thats what APIC has always said and will continue to say.
Arias reports that the CDCs Healthcare Infection ControlPractices Advisory Committee (HICPAC) is developing a guidance document on thesubject of mandatory infection-rate reporting, and says she hopes HICPACsdocument will reflect some of APICs recommendations. We hope that we canwork with CMS and other organizations to achieve standardization, Arias adds.Our concern is that if each state comes up with its own requirements, we mayhave 50 different definitions of infections, and 50 different sets ofrequirements that will be neither good for hospitals nor for the public. Werehoping the report card requirement will be the same throughout the country.
Arias says infection reporting is not new, as ICPshave been doing it since the 1980s. Weve always used this kind of data, and since the 1990sthere have been many articles in the literature reporting various findings byfacilities that have calculated their data the same as the CDCs NationalNosocomial Infections Surveillance System (NNIS) a system that has beenaround since the 1970s.
It used to be just counting beans, but people startedrealizing 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 couldresearch the literature to see what is known about preventingventilator-associated pneumonia, and use that data to ensure that your practicesare approaching the ideal numbers that you want, then watch your rates overtime. If they trend downward, then thats definitely performance improvement.
Mandatory infection-rate reporting has met with someresistance from healthcare facility administrators who are concerned about costsassociated with the practice, Arias says, and admits that it could place aburden on facilities struggling with razor-thin profit margins and soft bottomlines. It is going to create more work and cost more, but it comes down topatient safety.
Another struggle is to ensure that ICPs are involved in thesurveillance and in the number crunching. There are many studies that show ifits done by medical records personnel, its not accurate. The rates areactually much higher because they are not taught to distinguish betweencommunity-acquired infections (CAIs) and HAIs. If you do it by coding, you willpick up all infections, including infections patients came in with, which is amajor reason for being admitted to the hospital. The ICP is trained to discardthe CAIs and look at HAIs.
Arias adds, The best thing ICPs can do at this point is tomonitor what is happening in their state to see if there is movement to requirereporting of HAIs. They should take an active role in working with their statelegislators and representatives to ensure that the measures they choose tomonitor, such as catheter-associated bloodstream infections, are valid.
APIC Surveillance Initiative Working Group. Release ofNosocomial Infection Data. 1998.
Quality Indicator Study Group. An approach to the evaluationof quality indicators of the outcome of care in hospitalized patients, with afocus 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. NEng J Med. 2003;348:651-656.
Gaynes R, et al. Feeding back surveillance data to preventhospital-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 theUnited States. The importance of inter-hospital comparisons. Infect Dis ClinNorth Am. 1997. Jun;11(2):245-55.
Centers for Medicare and Medicaid Services (CMS)
CMS HospitalQuality Initiative
Centers for Medicare andMedicaid Services (CMS)
CMS Nursing Home Quality Initiative
National Quality Forum