Health-Care-Associated Infections in Hospitals
Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on These Infections Gao ID: GAO-08-673T April 16, 2008According to the Centers for Disease Control and Prevention (CDC), health-care-associated infections (HAI)--infections that patients acquire while receiving treatment for other conditions--are estimated to be 1 of the top 10 causes of death in the nation. This statement summarizes a report issued in March and released today, Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on These Infections (GAO-08-283). In this report, GAO examined (1) CDC's guidelines for hospitals to reduce or prevent HAIs and what HHS does to promote their implementation, (2) Centers for Medicare & Medicaid Services' (CMS) and hospital accrediting organizations' required standards for hospitals to reduce or prevent HAIs, and (3) HHS programs that collect data related to HAIs and integration of the data across HHS. To conduct the work, GAO reviewed documents and interviewed HHS agency and accrediting organization officials.
In its March report, which is summarized in this statement, GAO found CDC has 13 guidelines for hospitals on infection control and prevention, which contain almost 1,200 recommended practices, but activities across HHS to promote implementation of these practices are not guided by a prioritization of the practices. Although most of the practices have been sorted into categories primarily on the basis of the strength of the scientific evidence for the practice, other factors to consider in prioritizing, such as costs or organizational obstacles, have not been taken into account. While CDC's guidelines describe specific clinical practices recommended to reduce HAIs, the infection control standards that CMS and the accrediting organizations require of hospitals describe the fundamental components of a hospital's infection control program. The standards are far fewer in number than CDC's recommended practices and generally do not require that hospitals implement all recommended practices in CDC's guidelines. Multiple HHS programs have databases that collect data on HAIs, but limitations in the scope of information collected and a lack of integration across the databases constrain the utility of the data. GAO concluded that the lack of department-level prioritization of CDC's large number of recommended practices has hindered efforts to promote their implementation. GAO noted that a few of CDC's strongly recommended practices were required by CMS or the accrediting organizations but that it was not reasonable to expect CMS or the accrediting organizations to require additional practices without prioritization. GAO also concluded that HHS has not effectively used the HAI-related data it has collected through multiple databases across the department to provide a complete picture of the extent of the problem.
GAO-08-673T, Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on These Infections
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Testimony:
Before the Committee on Oversight and Government Reform, House of
Representatives:
United States Government Accountability Office:
GAO:
For Release on Delivery:
Expected at 11:00 a.m. EDT:
Wednesday, April 16, 2008:
Health-Care-Associated Infections in Hospitals:
Leadership Needed from HHS to Prioritize Prevention Practices and
Improve Data on These Infections:
Statement of Cynthia A. Bascetta:
Director, Health Care:
GAO-08-673T:
GAO Highlights:
Highlights of GAO-08-673T, a testimony before the Committee on
Oversight and Government Reform, House of Representatives.
Why GAO Did This Study:
According to the Centers for Disease Control and Prevention (CDC),
health-care-associated infections (HAI)”infections that patients
acquire while receiving treatment for other conditions”are estimated to
be 1 of the top 10 causes of death in the nation. This statement
summarizes a report issued in March and released today, Health-Care-
Associated Infections in Hospitals: Leadership Needed from HHS to
Prioritize Prevention Practices and Improve Data on These Infections
(GAO-08-283). In this report, GAO examined (1) CDC‘s guidelines for
hospitals to reduce or prevent HAIs and what HHS does to promote their
implementation, (2) Centers for Medicare & Medicaid Services‘ (CMS) and
hospital accrediting organizations‘ required standards for hospitals to
reduce or prevent HAIs, and (3) HHS programs that collect data related
to HAIs and integration of the data across HHS. To conduct the work,
GAO reviewed documents and interviewed HHS agency and accrediting
organization officials.
What GAO Found:
In its March report, which is summarized in this statement, GAO found
the following:
* CDC has 13 guidelines for hospitals on infection control and
prevention, which contain almost 1,200 recommended practices, but
activities across HHS to promote implementation of these practices are
not guided by a prioritization of the practices. Although most of the
practices have been sorted into categories primarily on the basis of
the strength of the scientific evidence for the practice, other factors
to consider in prioritizing, such as costs or organizational obstacles,
have not been taken into account.
* While CDC‘s guidelines describe specific clinical practices
recommended to reduce HAIs, the infection control standards that CMS
and the accrediting organizations require of hospitals describe the
fundamental components of a hospital‘s infection control program. The
standards are far fewer in number than CDC‘s recommended practices and
generally do not require that hospitals implement all recommended
practices in CDC‘s guidelines.
* Multiple HHS programs have databases that collect data on HAIs, but
limitations in the scope of information collected and a lack of
integration across the databases constrain the utility of the data.
GAO concluded that the lack of department-level prioritization of CDC‘s
large number of recommended practices has hindered efforts to promote
their implementation. GAO noted that a few of CDC‘s strongly
recommended practices were required by CMS or the accrediting
organizations but that it was not reasonable to expect CMS or the
accrediting organizations to require additional practices without
prioritization. GAO also concluded that HHS has not effectively used
the HAI-related data it has collected through multiple databases across
the department to provide a complete picture of the extent of the
problem.
What GAO Recommends:
In its report, GAO recommended that the Secretary of HHS identify
priorities among the recommended practices in CDC‘s guidelines and
establish greater consistency and compatibility of the data collected
across HHS on HAIs. HHS generally agreed with GAO‘s recommendations.
GAO also incorporated comments from the accrediting organizations as
appropriate.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-673T]. For more
information, contact Cynthia A. Bascetta at (202) 512-7114 or
bascettac@gao.gov.
[End of section]
Mr. Chairman and Members of the Committee:
I am pleased to be here today to discuss our work on federal government
efforts to address the problem of health-care-associated infections
(HAI)[Footnote 1] in hospitals and to provide a summary of our report,
which you are releasing today, entitled Health-Care-Associated
Infections in Hospitals: Leadership Needed from HHS to Prioritize
Prevention Practices and Improve Data on These Infections.[Footnote 2]
According to the Centers for Disease Control and Prevention (CDC), HAIs
are infections that patients acquire while receiving treatment for
other conditions[Footnote 3] and are estimated to be 1 of the top 10
causes of death in the United States. For example, a patient may
acquire an infection from bacteria on a device used to treat them, such
as a needle or tube to deliver medicine, fluids, or blood. According to
CDC, the most common HAIs are urinary tract infections, surgical site
infections, pneumonia, and bloodstream infections.
HAIs can be expensive. In 2005 the average payment for a
hospitalization in Pennsylvania was over six times higher for patients
who contracted a hospital-acquired infection than for patients who did
not acquire infections, according to a report by the Pennsylvania
Health Care Cost Containment Council.[Footnote 4] A 2007 study of 1.69
million patients who were discharged from 77 hospitals found that the
additional cost of treating a patient with an HAI averaged
$8,832.[Footnote 5] The costs of HAIs are borne not only by the
patients who suffer infections, but also by those who pay for care,
such as the Centers for Medicare & Medicaid Services (CMS). According
to the American Hospital Association, Medicare paid for over one-third
of all hospital costs in 2005.[Footnote 6]
Although not all HAIs are preventable, public and private organizations
have established standards and other activities aimed at controlling
and preventing them. CMS has established health and safety standards--
known as conditions of participation (COP)--with which hospitals must
comply in order to be eligible for payment by Medicare and Medicaid and
which include the COP for infection control.[Footnote 7] Hospitals may
choose one of two ways to show that they have met these or equivalent
standards: they may be certified by a state agency under agreement with
CMS to survey the hospital's compliance with the COPs or they may be
accredited by one of two private organizations--the Joint Commission or
the Healthcare Facilities Accreditation Program of the American
Osteopathic Association (AOA).[Footnote 8] Most hospitals are
accredited by the Joint Commission.[Footnote 9] Other activities within
the Department of Health and Human Services (HHS) aimed at addressing
the problem of HAIs in hospitals include the development of guidelines
by CDC, which contain recommended practices that hospitals may adopt,
and the management of several databases in different parts of HHS that
contain information about HAIs in hospitals. According to the Institute
of Medicine, prevention of HAIs through implementation of evidence-
based guidelines can lead to improvements in quality of care.[Footnote
10] Furthermore, the collection of national data on these infections
can provide a benchmark for individual hospitals to gauge their
performance and design targeted interventions.
Federal and state lawmakers are also concerned about HAIs and have
taken action to reduce them. With the passage of the Deficit Reduction
Act of 2005 (DRA),[Footnote 11] the Congress took steps to revise the
way Medicare pays hospitals so that beginning on October 1, 2008, they
would not receive higher payments for patients that acquire certain
preventable conditions (including any of three HAIs) during their
hospital stays.[Footnote 12] The HAI-related preventable conditions
that CMS identified in the final regulation implementing subsection
5001(c) of the DRA were urinary tract infections caused by catheters,
infections caused by vascular catheters, and mediastinitis following
coronary artery bypass graft surgery.[Footnote 13] According to
Consumers Union--a nonprofit organization that has a campaign to stop
HAIs--23 state legislatures have enacted laws that require public
reporting of hospital HAI rates or HAI-related information.[Footnote
14]
My statement today is based on the report that you are releasing
today.[Footnote 15] In that report, we examined (1) CDC's guidelines
for hospitals to reduce or prevent HAIs, and what HHS does to promote
their implementation; (2) CMS's and the accrediting organizations'
required standards for hospitals to reduce or prevent HAIs, and how
compliance is assessed; and (3) HHS programs that collect data related
to HAIs in hospitals, and the extent to which the data are integrated
across HHS.
In carrying out this work for the report you are releasing today, we
interviewed officials from CDC, CMS, the Agency for Healthcare Research
and Quality (AHRQ), the Food and Drug Administration, the Joint
Commission, and AOA. We also interviewed selected experts in the field
of infection control. In addition, we reviewed and analyzed CDC's
infection control and prevention guidelines issued from 1981 through
2007; minutes of the Healthcare Infection Control Practices Advisory
Committee; the World Health Organization's guideline on hand
hygiene;[Footnote 16] CMS's COPs for hospitals and interpretive
guidelines,[Footnote 17] which describe the COPs and provide survey
procedures used to determine compliance with them; the Joint
Commission's standards for hospitals and its hospital standards manual;
and AOA's standards for hospitals and its hospital standards manual. We
refer to the guidance that CMS provides about its COPs in the
interpretive guidelines, and that the Joint Commission and AOA provide
about their standards in their respective manuals, as "standards
interpretations."[Footnote 18] We also reviewed manuals and other
documents that explain the HHS programs that collect HAI-related data,
and related publications and data analyses conducted by the agencies
based on the data collected. We conducted the performance audit for the
report you are releasing today from January 2007 to March 2008, in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives. A detailed explanation of
our methodology is included in our report.
In brief, we found that federal authorities and private organizations
have undertaken a number of activities to address the problem of HAIs.
CDC has 13 guidelines for hospitals on infection control and
prevention, which contain almost 1,200 recommended practices. However,
activities across HHS to promote implementation of these practices are
not guided by a prioritization of the practices. Although most of the
practices have been sorted into categories primarily on the basis of
the strength of the scientific evidence for the practice, other factors
to consider in prioritizing, such as costs or organizational obstacles,
have not been taken into account. We concluded that a lack of
department-level prioritization of CDC's large number of recommended
practices has hindered efforts to promote their implementation. While
CDC's guidelines describe specific clinical practices recommended to
reduce HAIs, the infection control standards that CMS and the
accrediting organizations require of hospitals describe the fundamental
components of a hospital's infection control program. The standards are
far fewer in number than CDC's recommended practices and generally do
not require that hospitals implement all recommended practices in CDC's
guidelines. We noted that a few of CDC's strongly recommended practices
were required by CMS or the accrediting organizations but that it was
not reasonable to expect CMS or the accrediting organizations to
require additional practices without prioritization. Other federal
efforts include multiple HHS programs that collect data on HAIs, but
limitations in the scope of information collected and a lack of
integration across the programs' databases constrain the utility of the
data. We concluded that HHS has not effectively used the HAI-related
data it has collected through multiple databases across the department
to provide a complete picture about the extent of the problem.
In order to help reduce HAIs in hospitals, we recommended that the
Secretary of HHS take the following two actions: (1) Identify
priorities among CDC's recommended practices and determine how to
promote implementation of the prioritized practices, including whether
to incorporate selected practices into CMS's conditions of
participation (COP) for hospitals. (2) Establish greater consistency
and compatibility of the data collected across HHS on HAIs to increase
information available about HAIs, including reliable national estimates
of the major types of HAIs. In commenting on a draft of our report, HHS
generally agreed with our recommendations. It indicated that CMS would
consider whether to incorporate some of CDC's recommended practices
into CMS's hospital COPs, and it identified some steps CMS would take
to achieve greater consistency and compatibility of the data collected
on HAIs. In response to comments from the Joint Commission, we
clarified our discussion of Joint Commission activities; in addition,
we incorporated technical comments from the Joint Commission and AOA.
CDC Has 13 Infection Control and Prevention Guidelines Containing
Almost 1,200 Recommended Practices, but Activities across HHS to
Promote Implementation Are Not Guided by Prioritization of Practices:
CDC has 13 guidelines for hospitals on infection control and
prevention, and in these guidelines CDC recommends almost 1,200
practices for implementation to prevent HAIs and related adverse
events. (See table 1.) The guidelines cover such topics as prevention
of catheter-associated urinary tract infections, prevention of surgical
site infections, and hand hygiene. An example of a recommended practice
in the hand hygiene guideline is the recommendation that health care
workers decontaminate their hands before having direct contact with
patients. Most of the practices are sorted into five categories--from
strongly recommended for implementation to not recommended--primarily
on the basis of the strength of the scientific evidence for each
practice. Over 500 practices are strongly recommended. CDC and AHRQ
have conducted some activities to promote implementation of recommended
practices, such as disseminating the guidelines and providing research
funds. However, these steps have not been guided by a prioritization of
recommended practices. One factor to consider in prioritization is
strength of evidence, as CDC has done. In addition to strength of
evidence, an AHRQ study identified other factors to consider in
prioritizing recommended practices, such as costs or organizational
obstacles. Furthermore, the efforts of the two agencies have not been
coordinated. For example, we found that CDC and AHRQ independently
examined various aspects of the evidence related to improving hand
hygiene compliance, such as the selection of hand hygiene products and
health care worker education. Although this could have been an
opportunity for coordination, an official from the HHS Office of the
Secretary told us that no one within the office is responsible for
coordinating infection control activities across HHS.
Table 1: CDC's Infection Control and Prevention Guidelines, with Number
of Recommended Practices, Issued between 1981 and 2007:
1; Guideline (issue date): Guideline for Prevention of Catheter-
associated Urinary Tract Infections (1981);
Total number of recommended practices: 24.
2; Guideline (issue date): Guideline for Infection Control in Health
Care Personnel (1998);
Total number of recommended practices: 183.
3; Guideline (issue date): Guideline for Prevention of Surgical Site
Infection (1999);
Total number of recommended practices: 63.
4; Guideline (issue date): Guidelines for Preventing Opportunistic
Infections among Hematopoietic Stem Cell Transplant Recipients (2000);
Total number of recommended practices: [A].
5; Guideline (issue date): Guidelines for the Prevention of
Intravascular Catheter-Related Infections (2002);
Total number of recommended practices: 111.
6; Guideline (issue date): Guideline for Hand Hygiene in Health-Care
Settings (2002);
Total number of recommended practices: 42.
7; Guideline (issue date): Recommendations for Using Smallpox Vaccine
in a Pre-Event Vaccination Program (2003);
Total number of recommended practices: [B].
8; Guideline (issue date): Guidelines for Environmental Infection
Control in Health-Care Facilities (2003);
Total number of recommended practices: 329.
9; Guideline (issue date): Guidelines for Preventing Health-Care-
Associated Pneumonia (2003);
Total number of recommended practices: 208.
10; Guideline (issue date): Guidelines for Preventing the Transmission
of Mycobacterium Tuberculosis in Health-Care Settings (2005);
Total number of recommended practices: [B].
11; Guideline (issue date): Influenza Vaccination of Health-Care
Personnel (2006);
Total number of recommended practices: 6.
12; Guideline (issue date): Management of Multidrug-Resistant Organisms
in Healthcare Settings (2006);
Total number of recommended practices: 80.
13; Guideline (issue date): Guideline for Isolation Precautions:
Preventing Transmission of Infectious Agents in Healthcare Settings
(2007);
Total number of recommended practices: 152.
Total:
Total number of recommended practices: 1,198.
Source: GAO analysis of CDC guidelines.
[A] For the purpose of this table, we do not include a count of the
recommended practices in this guideline because the guideline is
targeted to a specific patient population that not all hospitals treat.
However, for the hospitals that do treat such patients, this guideline
provides at least another 164 recommended practices.
[B] The practices in these guidelines are not organized in a way that
supports counting the total number of practices.
[End of table]
CMS's and Accrediting Organizations' Required Hospital Standards
Describe Components of Infection Control Programs, and Compliance with
These Standards Is Assessed through On-Site Surveys:
While CDC's infection control guidelines describe specific clinical
practices recommended to reduce HAIs, the infection control standards
that CMS and the accrediting organizations require as part of the
hospital certification and accreditation processes describe the
fundamental components of a hospital's infection control program. These
components include the active prevention, control, and investigation of
infections. Examples of standards and corresponding standards
interpretations that hospitals must follow include educating hospital
personnel about infection control and having infection control policies
in place. The standards are far fewer in number than the recommended
practices in CDC's guidelines--for example, CMS's infection control COP
contains two standards. Furthermore, CMS and the accrediting
organizations generally do not require that hospitals implement all
recommended practices in CDC's infection control and prevention
guidelines. Only the Joint Commission and AOA have standards that
require the implementation of certain practices recommended in CDC's
infection control guidelines. For example, the Joint Commission and AOA
require hospitals to annually offer influenza vaccinations to health
care workers, whereas CMS's interpretive guidelines, or standards
interpretations, are more general, stating that hospitals should adopt
policies and procedures based as much as possible on national
guidelines that address hospital-staff-related issues, such as
evaluating hospital staff immunization status for designated infectious
diseases. CMS, the Joint Commission, and AOA assess compliance with
their infection control standards through direct observation of
hospital activities and review of hospital policy documents during on-
site surveys.
Multiple HHS Programs Collect Data on HAIs, but Lack of Integration of
Available Data and Other Problems Limit Utility of the Data:
Multiple HHS programs collect data on HAIs, but limitations in the
scope of information they collect and the lack of integration across
the databases maintained by these separate programs constrain the
utility of the data. Three agencies within HHS--CDC, CMS, and AHRQ--
currently collect HAI-related data for a variety of purposes in
databases maintained by four separate programs: CDC's National
Healthcare Safety Network (NHSN) program, CMS's Medicare Patient Safety
Monitoring System (MPSMS), CMS's Annual Payment Update (APU) program,
and AHRQ's Healthcare Cost and Utilization Project (HCUP). Each of
these databases presents only a partial view of the extent of the HAI
problem because each focuses its data collection on selected types of
HAIs and collects data from a different subset of hospital patients
across the country. (See table 2.) Although officials from the various
HHS agencies discuss HAI data collection with each other, we did not
find that the agencies were taking steps to integrate any of the
existing data by creating linkages across the databases, such as
creating common patient identifiers. Creating linkages across the HAI-
related databases could enhance the availability of information to
better understand where and how HAIs occur. For example, data on
surgical infection rates and data on surgical processes of care are
collected for some of the same patients in two different databases that
are not linked. As a consequence, the potential benefit of using the
existing data to monitor the extent to which compliance with the
recommended surgical care processes leads to actual improvements in
surgical infection rates has not been realized. Although none of the
databases collect data on the incidence of HAIs for a nationally
representative sample of hospital patients, CDC officials have produced
national estimates of HAIs. However, those estimates derive from
assumptions and extrapolations that raise questions about the
reliability of those estimates.
Table 2: Selected Characteristics of HHS Databases That Contain HAI-
Related Information:
Responsible agency and database: CDC's National Healthcare Safety
Network (NHSN);
HAI-related data collected: Infection types;
* central-line-associated BSI;
* catheter-associated UTI;
* VAP;
* postprocedure pneumonia;
* SSI;
* MDRO[A];
* other[B];
Population for which data are collected: Most hospitals report on
patients in selected critical care units and those undergoing selected
procedures such as coronary bypass surgery and colon surgery.
Responsible agency and database: CMS's Medicare Patient Safety
Monitoring System (MPSMS);
HAI-related data collected: Infection types[C];
* central-line-associated BSI;
* catheter-associated UTI;
* postoperative pneumonia;
* antibiotic-associated C. difficile;
* MRSA;
* VRE;
Population for which data are collected: National sample of
hospitalized Medicare patients.
Responsible agency and database: CMS's Annual Payment Update (APU)
database;
HAI-related data collected: Practices to prevent or reduce SSIs;
* providing antibiotics within 1 hour of surgery;
* selecting appropriate antibiotics to prevent surgical infections;
* stopping the administration of the antibiotics within 24 hours of end
of surgery;
Population for which data are collected: National inpatient population
for selected surgical procedures.[D]
Responsible agency and database: AHRQ's Healthcare Cost and Utilization
Project (HCUP) database, Nationwide Inpatient Sample;
HAI-related data collected: Infection types;
* postoperative sepsis[E];
* "infection due to medical care" (focused on intravenous and catheter
infections);
Population for which data are collected: A sample of inpatients in
hospitals in 37 states.
Source: GAO analysis of CDC, CMS, and AHRQ information.
Notes: BSI is bloodstream infection; C. difficile is Clostridium
difficile; MDRO is multidrug-resistant organism; MRSA is methicillin-
resistant Staphylococcus aureus; SSI is surgical site infection; UTI is
urinary tract infection; VAP is ventilator-associated pneumonia; and
VRE is vancomycin-resistant enterococci.
[A] For patients whose infections are laboratory-confirmed, NHSN
collects data on the pathogens identified, and for specified pathogens
(including those responsible for MRSA and VRE), the result of any
testing of their resistance to specific antibiotics. Participating
hospitals have the option to report separately the number of times in a
given month that they tested specimens of any of eight specified
organisms for resistance to selected antibiotics, as well as the
results of those tests. From these data, NHSN produces rates of
antimicrobial resistance relative to the number of nonduplicative
specimens tested (i.e., excluding multiple tests for the same organism
in the same patient). This part of NHSN does not distinguish between
MDRO infections acquired in the hospital and community-acquired
infections present at admission.
[B] Hospitals can choose to submit to NHSN data on other types of HAIs,
such as skin and soft tissue infections, cardiovascular system
infections, and gastrointestinal system infections. CDC does not
provide data collection protocols for these types of infections, but
they can be entered into NHSN as "custom events" using definitions
provided separately by CDC.
[C] In 2007, CMS added catheter-associated UTIs, VAP, MRSA, and VRE to
MPSMS and dropped insertion-site infections associated with central
vascular catheters, BSIs, and postoperative-associated UTIs.
[D] The three practice measures are assessed for certain categories of
surgeries: coronary artery bypass graft; other cardiac surgery; colon
surgery; hip arthroplasty; knee arthroplasty; abdominal hysterectomy;
vaginal hysterectomy; and vascular surgery.
[E] The rate of postoperative sepsis is computed only for patients
undergoing elective surgeries.
[End of table]
Concluding Observations:
HAIs in hospitals can cause needless suffering and death. Federal
authorities and private organizations have undertaken a number of
activities to address this serious problem; however, to date, these
activities have not gained sufficient traction to be effective.
We identified two possible reasons for the lack of effective actions to
control HAIs. First, although CDC's guidelines are an important source
for its recommended practices on how to reduce HAIs, the large number
of recommended practices and lack of department-level prioritization
have hindered efforts to promote their implementation. The guidelines
we reviewed contain almost 1,200 recommended practices for hospitals,
including over 500 that are strongly recommended--a large number for a
hospital trying to implement them. A few of these are required by CMS's
or accrediting organizations' standards or their standards
interpretations, but it is not reasonable to expect CMS or accrediting
organizations to require additional practices without prioritization.
Although CDC has categorized the practices on the basis of the strength
of the scientific evidence, there are other factors to consider in
developing priorities. For example, work by AHRQ suggests factors such
as costs or organizational obstacles that could be considered. The lack
of coordinated prioritization may have resulted in duplication of
effort by CDC and AHRQ in their reviews of scientific evidence on HAI-
related practices.
Second, HHS has not effectively used the HAI-related data it has
collected through multiple databases across the department to provide a
complete picture of the extent of the problem. Limitations in the
databases, such as nonrepresentative samples, hinder HHS's ability to
produce reliable national estimates on the frequency of different types
of HAIs. In addition, currently collected data on HAIs are not being
combined to maximize their utility. HHS has made efforts to use the
currently collected data to understand the extent of the problem of
HAIs, but the lack of linkages across the various databases results in
a lost opportunity to gain a better grasp of the problem of HAIs.
HHS has multiple methods to influence hospitals to take more aggressive
action to control or prevent HAIs, including issuing guidelines with
recommended practices, requiring hospitals to comply with certain
standards, releasing data to expand information about the nature of the
problem, and soon, using hospital payment methods to encourage the
reduction of HAIs. Prioritization of CDC's many recommended practices
can help guide their implementation, and better use of currently
collected data on HAIs could help HHS--and hospitals themselves--
monitor efforts to reduce HAIs. We concluded that leadership from the
Secretary of HHS is currently lacking to do this. Without such
leadership, the department is unlikely to be able to effectively
leverage its various methods to have a significant effect on the
suffering and death caused by HAIs.
Mr. Chairman, this completes my prepared remarks. I would be happy to
respond to any questions you or other members of the committee may have
at this time.
Contact and Acknowledgments:
For further information about this statement, please contact Cynthia A.
Bascetta at (202) 512-7114 or bascettac@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this statement. Key contributors to this statement
were Linda T. Kohn, Assistant Director; Shaunessye Curry; Shannon
Slawter Legeer; Eric Peterson; and Roseanne Price.
[End of section]
Appendix I: Abbreviations:
AHRQ: Agency for Healthcare Research and Quality:
AOA: Healthcare Facilities Accreditation Program of the American
Osteopathic Association:
APU: Annual Payment Update:
BSI: bloodstream infection:
CDC: Centers for Disease Control and Prevention:
CMS: Centers for Medicare & Medicaid Services:
COP: condition of participation:
DRA: Deficit Reduction Act of 2005:
DRG: diagnosis-related group:
FDA: Food and Drug Administration:
HAI: health-care-associated infection:
HCUP: Healthcare Cost and Utilization Project:
HHS: Department of Health and Human Services:
MDRO: multidrug-resistant organism:
MPSMS: Medicare Patient Safety Monitoring System:
MRSA: methicillin-resistant Staphylococcus aureus:
NHSN: National Healthcare Safety Network:
SSI: surgical site infection:
UTI: urinary tract infection:
VAP: ventilator-associated pneumonia:
VRE: vancomycin-resistant enterococci:
[End of section]
Footnotes:
[1] See app. I for a list of abbreviations used in this statement.
[2] GAO, Health-Care-Associated Infections in Hospitals: Leadership
Needed from HHS to Prioritize Prevention Practices and Improve Data on
These Infections, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-
283] (Washington, D.C.: March 31, 2008).
[3] In general, HAIs are distinct from community-acquired infections,
that is, infections that patients may have acquired before entering the
hospital.
[4] See Pennsylvania Health Care Cost Containment Council, Hospital-
Acquired Infections in Pennsylvania (Harrisburg, Pa.: November 2006).
[5] See D. Murphy et al., Dispelling the Myths: The True Cost of
Healthcare-Associated Infections (Washington, D.C.: Association for
Professionals in Infection Control and Epidemiology, February 2007).
[6] Medicare is a federal health insurance program that serves over 42
million elderly and certain disabled beneficiaries and pays for health
care needs, such as inpatient hospital stays and physician visits.
[7] See 42 C.F.R. § 482.1 (2007).
[8] Section 1865(b)(1) of the Social Security Act also provides that
any other national accreditation body that meets certain requirements
as determined by the Department of Health and Human Services may
accredit hospitals.
[9] In calendar year 2007, about 81 percent of hospitals were
accredited by the Joint Commission, state survey agencies certified
approximately 16 percent of hospitals, and less than 2 percent were
accredited by AOA. Less than 1 percent of hospitals were accredited by
both the Joint Commission and AOA. The Joint Commission was formerly
known as the Joint Commission on Accreditation of Healthcare
Organizations or "JCAHO."
[10] See K. Adams et al., Priority Areas for National Action:
Transforming Health Care Quality, Institute of Medicine of the National
Academies (Washington, D.C.: The National Academies Press, 2003).
[11] Pub. L. No. 109-171, § 5001(c), 120 Stat. 4, 30.
[12] Under Medicare, hospitals generally receive fixed payments for
inpatient stays based on diagnosis-related groups (DRG), a system that
classifies stays by patient diagnoses and procedures. Some DRGs take
account of certain comorbidities or complications associated with a
diagnosis or procedure and pay at a higher rate than would otherwise be
paid for the diagnosis or procedure. In a final regulation implementing
section 5001(c) of the DRA, CMS identified certain preventable
conditions it would not consider as a comorbidity or complication that
would lead to the higher payment. See 72 Fed. Reg. 47130, 47200-217
(Aug. 22, 2007). The DRA also requires hospitals to indicate the
diagnoses that were present in patients at the time of admission in
order for CMS to determine if a preventable condition developed during
a patient's hospital stay.
[13] Mediastinitis is inflammation of the area between the lungs (the
heart, the large blood vessels, the trachea, the esophagus, the thymus
gland, and connective tissues). Additional preventable conditions that
will no longer result in higher payments to hospitals include hospital-
acquired injuries, such as fractures, pressure ulcers, objects left in
the body during surgery, air embolisms, and blood incompatibility. CMS
plans to propose additional conditions in the fiscal year 2009 Hospital
Inpatient Prospective Payment Systems proposed rule. See 72 Fed. Reg.
47130 (Aug. 22, 2007).
[14] See Consumers Union, "State Hospital Infection Disclosure Laws,"
available at [hyperlink,
http://www.consumersunion.org/campaigns/stophospitalinfections/learn.htm
l], accessed on March 10, 2008.
[15] [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-283].
[16] See World Health Organization, WHO Guidelines on Hand Hygiene in
Healthcare (Advanced Draft): Global Patient Safety Challenge 2005-2006:
Clean Care Is Safer Care (Geneva, Switzerland, 2006).
[17] In addition to reviewing CMS's interpretive guidelines that can be
found in CMS's State Operations Manual, we reviewed CMS's revised
interpretive guidelines for the infection control COP, which were
published in November 2007. Throughout this report, where we refer to
the interpretive guidelines for infection control we are referring to
the November 2007 revision.
[18] Standards interpretations are given by CMS primarily in its State
Operations Manual, which is arranged by COP (Appendix A of the State
Operations Manual contains the COPs for hospitals); by the Joint
Commission in its Comprehensive Accreditation Manual for Hospitals: The
Official Handbook, which identifies rationales and performance
expectations that are used to measure each standard and is organized
into 11 chapters of safety and quality standards, such as "Medication
Management" and "Leadership;" and by AOA's standards manual,
Accreditation Requirements for Healthcare Facilities, which provides
explanations for surveyors and the scoring procedures along with its
standards and is organized into 32 chapters.
[End of section]
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