Health-Care-Associated Infections in Hospitals
An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections
Gao ID: GAO-08-808 September 5, 2008
Health-care-associated infections (HAI) are infections that patients acquire while receiving treatment for other conditions. Normally treated with antimicrobial drugs, HAIs are a growing concern as exposure to multidrug-resistant organisms (MDRO) becomes more common. Infections caused by MDROs, such as methicillin-resistant Staphylococcus aureus (MRSA), lead to longer hospital stays, higher treatment costs, and higher mortality. In response to demands for more public information on HAIs, some states began to establish HAI public reporting systems. The federal Centers for Disease Control and Prevention (CDC) developed a system--the National Healthcare Safety Network (NHSN)--to collect HAI data from hospitals and some states have chosen to use it for their programs. In addition, some hospitals have adopted initiatives to reduce MRSA by routinely testing some or all patients and isolating those who test positive for MRSA from contact with other patients. GAO was asked to examine (1) the design and implementation of state HAI public reporting systems, (2) the initiatives hospitals have undertaken to reduce MRSA infections, and (3) the experience of certain early-adopting hospitals in overcoming challenges to implement such initiatives. GAO interviewed state officials, reviewed documents, and surveyed or conducted site visits at hospitals with MRSA-reduction initiatives.
GAO identified 23 states that had established mandatory HAI public reporting systems through February 2008; most have used similar approaches to design their programs and address resource and technological challenges that affect their implementation. Most states have designed programs that focus on a few measures that were developed or endorsed by the CDC. Three states have chosen to collect information on hospital-associated MRSA infections. In addition, a majority of states have chosen to adopt the CDC's NHSN. Adopting NHSN allows states to minimize some of the resource and technological challenges that they confront in implementing HAI reporting systems including providing training for hospital staff in data collection and developing systems to collect HAI data that meet accepted infection control standards. GAO reviewed a sample of 14 hospitals (including several hospital systems) with MRSA-reduction initiatives that were selected to provide variation in location, teaching status, and population of metropolitan area. GAO found all use routine testing for MRSA, although they chose different patient populations to test and used various testing methodologies. Three hospitals tested all patients for MRSA, while the other hospitals almost universally tested patients in adult or neonatal intensive care units. The hospitals reported changing their general infection control policies or practices as part of their initiatives--all 14 made changes for hand hygiene and more than half made changes to their contact precautions or disinfection of environmental surfaces. The hospitals GAO reviewed reported needing varying levels of funding and staff resources to implement and operate their initiatives, but all hospitals that tracked MRSA infection rates reported a decline in MRSA infections as a result of their initiatives. Two hospital systems that GAO visited overcame a similar set of challenges in implementing MRSA-reduction programs. Both systems had to design and execute processes to put the elements of their MRSA-reduction initiatives into effect and promote compliance with those processes by hospital staff. In designing their systems, both hospital systems incorporated these processes as much as possible into the normal workflow of hospital staff and promoted staff compliance through a combination of concerted leadership and specific procedures designed to facilitate staff compliance reinforced through detailed feedback on their performance. However, the two hospital systems took different approaches in obtaining resources for their initiatives. One directed substantial financial resources into its MRSA-reduction initiative to implement the initiative simultaneously for all patients at all three of its hospitals, while the other relied largely on existing resources and implemented its initiative more incrementally at selected hospitals and in selected units. GAO received technical comments from the Department of Health and Human Services and oral comments from the American Hospital Association on a draft of this report.
GAO-08-808, Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections
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Report to the Chairman, Committee on Oversight and Government Reform,
House of Representatives:
United States Government Accountability Office:
GAO:
September 2008:
Health-Care-Associated Infections In Hospitals:
An Overview of State Reporting Programs and Individual Hospital
Initiatives to Reduce Certain Infections:
GAO-08-808:
GAO Highlights:
Highlights of GAO-08-808, a report to the Chairman, Committee on
Oversight and Government Reform, House of Representatives.
Why GAO Did This Study:
Health-care-associated infections (HAI) are infections that patients
acquire while receiving treatment for other conditions. Normally
treated with antimicrobial drugs, HAIs are a growing concern as
exposure to multidrug-resistant organisms (MDRO) becomes more common.
Infections caused by MDROs, such as methicillin-resistant
Staphylococcus aureus (MRSA), lead to longer hospital stays, higher
treatment costs, and higher mortality.
In response to demands for more public information on HAIs, some states
began to establish HAI public reporting systems. The federal Centers
for Disease Control and Prevention (CDC) developed a system”the
National Healthcare Safety Network (NHSN)”to collect HAI data from
hospitals and some states have chosen to use it for their programs. In
addition, some hospitals have adopted initiatives to reduce MRSA by
routinely testing some or all patients and isolating those who test
positive for MRSA from contact with other patients.
GAO was asked to examine (1) the design and implementation of state HAI
public reporting systems, (2) the initiatives hospitals have undertaken
to reduce MRSA infections, and (3) the experience of certain early-
adopting hospitals in overcoming challenges to implement such
initiatives.
GAO interviewed state officials, reviewed documents, and surveyed or
conducted site visits at hospitals with MRSA-reduction initiatives.
What GAO Found:
GAO identified 23 states that had established mandatory HAI public
reporting systems through February 2008; most have used similar
approaches to design their programs and address resource and
technological challenges that affect their implementation. Most states
have designed programs that focus on a few measures that were developed
or endorsed by the CDC. Three states have chosen to collect information
on hospital-associated MRSA infections. In addition, a majority of
states have chosen to adopt the CDC‘s NHSN. Adopting NHSN allows states
to minimize some of the resource and technological challenges that they
confront in implementing HAI reporting systems including providing
training for hospital staff in data collection and developing systems
to collect HAI data that meet accepted infection control standards.
GAO reviewed a sample of 14 hospitals (including several hospital
systems) with MRSA-reduction initiatives that were selected to provide
variation in location, teaching status, and population of metropolitan
area. GAO found all use routine testing for MRSA, although they chose
different patient populations to test and used various testing
methodologies. Three hospitals tested all patients for MRSA, while the
other hospitals almost universally tested patients in adult or neonatal
intensive care units. The hospitals reported changing their general
infection control policies or practices as part of their
initiatives”all 14 made changes for hand hygiene and more than half
made changes to their contact precautions or disinfection of
environmental surfaces. The hospitals GAO reviewed reported needing
varying levels of funding and staff resources to implement and operate
their initiatives, but all hospitals that tracked MRSA infection rates
reported a decline in MRSA infections as a result of their initiatives.
Two hospital systems that GAO visited overcame a similar set of
challenges in implementing MRSA-reduction programs. Both systems had to
design and execute processes to put the elements of their MRSA-
reduction initiatives into effect and promote compliance with those
processes by hospital staff. In designing their systems, both hospital
systems incorporated these processes as much as possible into the
normal workflow of hospital staff and promoted staff compliance through
a combination of concerted leadership and specific procedures designed
to facilitate staff compliance reinforced through detailed feedback on
their performance. However, the two hospital systems took different
approaches in obtaining resources for their initiatives. One directed
substantial financial resources into its MRSA-reduction initiative to
implement the initiative simultaneously for all patients at all three
of its hospitals, while the other relied largely on existing resources
and implemented its initiative more incrementally at selected hospitals
and in selected units.
GAO received technical comments from the Department of Health and Human
Services and oral comments from the American Hospital Association on a
draft of this report.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-808]. For more
information, contact Cynthia A. Bascetta at (202) 512-7114 or
bascettac@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
States Have Designed Broadly Similar Mandatory HAI Public Reporting
Systems, with Resource and Technological Challenges Affecting
Implementation:
Hospital MRSA-Reduction Initiatives Share Multiple Components, but Vary
in Scope and Resource Requirements:
Two Hospital Systems Addressed Similar Challenges in Implementing MRSA-
Reduction Initiatives:
Concluding Observations:
Comments from HHS and the American Hospital Association and Our
Evaluation:
Appendix I: Characteristics of Selected Hospitals with MRSA-Reduction
Initiatives:
Appendix II: Changes Made by Selected Hospitals with MRSA-Reduction
Initiatives:
Appendix III: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: States We Reviewed with HAI Public Reporting for Hospitals, by
Date Data Collection Begins:
Table 2: Outcome Measures by States We Reviewed with HAI Reporting, by
Defining Entity:
Table 3: Process Measures by States We Reviewed with HAI Reporting:
Table 4: Data Collection Systems, by States We Reviewed with HAI
Reporting:
Table 5: Patient Populations Screened with Active Surveillance Testing,
by Selected Hospital:
Table 6: Policy or Practice Changes Implemented by Selected Hospitals
as Part of MRSA-Reduction Initiatives:
Table 7: Hand Hygiene Changes by Selected Hospitals with MRSA-Reduction
Initiatives:
Table 8: Contact Precaution Changes by Selected Hospitals with MRSA-
Reduction Initiatives:
Table 9: Environmental Cleaning Changes by Selected Hospitals with MRSA-
Reduction Initiatives:
Table 10: Antibiotic Stewardship Changes by Selected Hospitals with
MRSA-Reduction Initiatives:
Table 11: Decolonization Characteristics by Selected Hospitals with
MRSA-Reduction Initiatives:
Figure:
Figure 1: Selected Hospital-Reported Financial Resource Needs for MRSA-
Reduction Initiative, by Type of Screening and Test Method:
Abbreviations:
AHA: American Hospital Association:
AHRQ: Agency for Healthcare Research and Quality:
AST: active surveillance testing:
BSI: bloodstream infection:
CDC: Centers for Disease Control and Prevention:
CMS: Centers for Medicare & Medicaid Services:
EMR: electronic medical record:
ENH: Evanston Northwestern Healthcare:
HAI: health-care-associated infection:
HICPAC: Healthcare Infection Control Practices Advisory Committee:
HHS: Department of Health and Human Services:
ICP: infection control professional:
ICU: intensive care unit:
IHI: Institute for Healthcare Improvement:
IPPS: inpatient prospective payment system:
MDRO: multidrug-resistant organism:
MRSA: methicillin-resistant Staphylococcus aureus:
NHSN: National Healthcare Safety Network:
NNIS: National Nosocomial Infections Surveillance:
NQF: National Quality Forum:
PCR: polymerase chain reaction:
POA: present on admission:
PSI: Patient Safety Indicator:
SCIP: Surgical Care Improvement Project:
SSI: surgical site infection:
UPMC: University of Pittsburgh Medical Center:
UTI: urinary tract infection:
VAP: ventilator-associated pneumonia:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
September 5, 2008:
The Honorable Henry Waxman:
Chairman:
Committee on Oversight and Government Reform:
House of Representatives:
Dear Mr. Chairman:
Health-care-associated infections (HAI) are one of the top 10 causes of
death in the United States, according to estimates from the Centers for
Disease Control and Prevention (CDC). Although patients can acquire
HAIs in a wide variety of health care settings, including nursing homes
and ambulatory surgery centers, hospital patients are especially
vulnerable to HAIs. Normally treated with antimicrobial drugs, HAIs are
a growing concern as multidrug-resistant organisms (MDRO) become more
common.[Footnote 1] Infections caused by MDROs lead to longer hospital
stays, higher treatment costs, and higher mortality because they are
more difficult to treat than infections caused by other organisms. A
particular MDRO, methicillin-resistant Staphylococcus aureus (MRSA),
[Footnote 2] has gained attention recently. In 2003, it accounted for
64 percent of infections in intensive care units (ICU) caused by
Staphylococcus aureus, one of the most common HAI pathogens, up from 36
percent in 1992.[Footnote 3] Researchers estimate that the average cost
of treating a MRSA infection exceeds $35,000.
In a separate report to you, we found that federal activities have not
effectively addressed the HAI problem.[Footnote 4] We also found that
the extent of the problem, including the level of antimicrobial
resistance, is uncertain because the data that CDC as well as other
agencies of the Department of Health and Human Services (HHS)--such as
the Centers for Medicare & Medicaid Services (CMS)--collect on HAIs are
limited in scope and lack integration across multiple databases. CDC
has created a data infrastructure that allows hospitals to voluntarily
collect and input data using a uniform set of definitions on the
incidence of selected HAIs in their own hospitals and to compare their
rates with benchmarks derived from the data submitted by all
participating hospitals. This began in the 1970s with the National
Nosocomial Infections Surveillance (NNIS) system and continued with its
replacement, the more sophisticated National Healthcare Safety Network
(NHSN), introduced in 2005.
In response to demands for more public information on HAIs, some states
have begun to develop and implement HAI public reporting systems--some
using CDC's NHSN--to collect and disseminate HAI data from hospitals.
Some states have also recently passed legislation relating specifically
to MRSA, such as requiring specific actions for hospitals to prevent
the spread of MRSA based in part on guidelines issued by CDC and
collecting data from hospitals on MRSA cases that occur. In addition,
some hospitals have implemented strategies for reducing MRSA by testing
some or all patients and isolating those who test positive for MRSA
from contact with other patients.
In response to your interest in these nonfederal efforts to address
HAIs, including the role played by CDC's NHSN and its practice
guidelines, we examined (1) the design and implementation of state HAI
public reporting systems, (2) the initiatives hospitals have undertaken
to reduce MRSA infections, and (3) the experience of certain early-
adopting hospitals in overcoming challenges to implement such
initiatives.
To describe the design and implementation of state HAI public reporting
systems, we identified 23 states that were designing or had implemented
state-mandated HAI public reporting systems through February 2008. We
identified these programs through multiple sources, including resources
maintained by organizations that track state infection control
programs. We then collected information directly from each of those 23
states. However, we did not independently verify that there were no
state-mandated HAI public reporting programs planned or underway in any
of the remaining states. We excluded from consideration programs in
several states that collect limited data about HAIs, but do not report
hospital-specific HAI data to the public.[Footnote 5] For each of the
23 states, we reviewed the available legislation, administrative and
departmental rules and regulations, advisory panel reports, and other
documents for each system to compare the systems across states.
However, the information that we collected does not provide a
description or assessment of the legal requirements in any state
regarding the collection and public reporting of data about HAIs or a
comparison of the legal requirements among states regarding those
requirements.
We also interviewed state officials and state hospital association
representatives in 5 of the 23 states about the design, development,
and implementation of their systems, including challenges they
encountered, how they overcame those challenges, and how they validated
the data from hospitals. We selected Missouri, New York, and
Pennsylvania because each had relatively extensive experience in
collecting HAI data, but used different data reporting systems. We
selected Illinois and New Jersey because they had established mandatory
reporting programs on MRSA infections designed to provide information
on the performance of individual hospitals--as distinct from the
communicable disease reporting systems that many state health
department have operated for decades, which are designed primarily to
provide an alert when new outbreaks of particular pathogens occur. What
we learned about the challenges faced and implementation strategies
adopted in those 5 states cannot be generalized to other states with
HAI public reporting programs.
To describe the initiatives hospitals have undertaken to reduce MRSA
infections, we consulted knowledgeable experts, and conducted a Web
search to generate a list of hospitals or hospital systems[Footnote 6]
with MRSA-reduction initiatives. From among those, we selected 17 that
provided the greatest diversity in terms of location, teaching status,
and population of metropolitan area. To obtain information about the
hospitals' MRSA-reduction initiatives, we visited 2 hospitals and sent
surveys to officials at the remaining 15 hospitals, 12 of which
responded. In total, we collected information from 14 hospitals with
MRSA-reduction initiatives. Information on their characteristics is
provided in appendix I. The information that we obtained from these 14
hospitals pertains specifically to those hospitals, and can not be
generalized to other hospitals with MRSA-reduction initiatives.
To describe how early-adopting hospitals overcame challenges to
implement MRSA-reduction initiatives, we visited Evanston Northwestern
Healthcare (ENH) and the University of Pittsburgh Medical Center
(UPMC). Both implemented MRSA-reduction initiatives several years ago
and have published or otherwise publicly presented data on their
outcomes. We interviewed key administrative and clinical personnel at
each site to examine specific MRSA intervention options considered,
challenges confronted, steps taken to overcome those challenges, and
required financial and staff resources. Because these were case
studies, what we found at these two hospitals can not be generalized to
other hospitals with MRSA reduction initiatives.
We conducted this performance audit from October 2007 to September 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.
Results in Brief:
Most of the 23 states we reviewed with state-mandated HAI public
reporting programs have used similar approaches to design their
programs and address resource and technological challenges that affect
their implementation. Most of these states have relied at least to some
extent on advisory committees or technical advisors and designed
programs that focus on a few measures that were developed or endorsed
by CDC. Three states have chosen to collect information on hospital-
associated MRSA infections. In addition, although some states developed
their own data collection systems, a majority of the states we reviewed
have chosen to use NHSN, the HAI data collection system developed by
CDC. Adopting CDC-endorsed measures and the NHSN for data collection
allowed states to minimize some of the resource and technological
challenges that they confronted in implementing HAI reporting systems.
These challenges included providing training for hospital staff in data
collection as well as developing systems to collect HAI data that met
accepted infection control standards and were user-friendly for those
entering data.
The 14 hospitals with MRSA-reduction initiatives that we reviewed all
conduct routine testing for MRSA, although they chose different patient
populations to test and used various testing methodologies. Three
hospitals tested all patients for MRSA, while the remaining hospitals
almost universally tested patients in adult or neonatal intensive care
units. The hospitals reported changing a number of general infection
control policies or practices as part of their initiatives--all 14 made
changes for hand hygiene and more than half made changes to their
contact precautions or disinfection of environmental surfaces. The
hospitals we reviewed reported needing varying levels of funding and
staff resources to implement and operate their initiatives, but all
hospitals that tracked MRSA infection rates reported a decline in MRSA
infections as a result of their initiatives.
The two hospital systems that we visited overcame a similar set of
challenges in implementing multifaceted MRSA-reduction initiatives.
Both systems had to design and execute processes to put the elements of
their MRSA-reduction initiatives into effect and promote compliance
with those processes by hospital staff. In designing their MRSA-
reduction initiatives, both hospital systems incorporated these
processes as much as possible into the normal workflow of hospital
staff and promoted staff compliance through a combination of concerted
leadership on the part of the physicians who led their infection
control programs and specific procedures designed to facilitate staff
compliance reinforced through detailed feedback on their performance.
However, the two hospital systems took different approaches to
obtaining resources for their initiatives. One directed substantial
financial resources into its MRSA-reduction initiative to implement the
initiative simultaneously for all patients at all three of its
hospitals, while the other relied largely on existing resources and
implemented its initiative more incrementally at selected hospitals and
on selected units.
We obtained technical comments from HHS that we incorporated as
appropriate. In addition, the department highlighted the scientific
contributions that CDC has made pertaining to the detection,
measurement, and prevention of HAIs and MRSA. The American Hospital
Association (AHA) provided oral comments that underscored the
importance of using HAI data to prevent and reduce infections and that
raised serious concerns about using unvalidated NHSN data for public
reporting of hospital performance on HAIs.
Background:
HAIs are infections that patients may acquire during the course of
receiving medical treatment for other conditions.[Footnote 7] HAIs
occur as the result of patient exposure to a variety of pathogens and
affect many different body systems. According to CDC estimates, urinary
tract infections (UTI), surgical site infections (SSI), bloodstream
infections (BSI), and pneumonia account for more than 80 percent of all
HAIs. Frequently, an infectious pathogen is introduced by an invasive
procedure, such as surgery or insertion of a urinary catheter, central
line,[Footnote 8] or ventilator. As a result, a subset of UTIs are
identified as catheter-associated UTIs, a subset of BSIs are identified
as central line-associated BSIs, and a subset of pneumonia HAIs are
identified as ventilator-associated pneumonia (VAP).
Hospital Practices to Reduce HAIs:
Any acute care hospital that participates in Medicare or Medicaid or is
accredited through the Joint Commission must have an infection control
program with a designated person in charge.[Footnote 9] Infection
control professionals (ICPs) receive specialized training to prepare
them to lead and staff these programs. ICPs identify cases of HAI and
promote infection control practices that help to reduce the occurrence
and spread of HAIs. These practices include rigorous maintenance of
hand hygiene standards as well as contact precautions, which involve
the use of gloves, gowns, and sometimes masks worn by health care
workers to prevent them from carrying the pathogen from an infected
patient to other patients. One approach has focused on ensuring that
each item on a short list of specific practices is consistently
implemented. For example, the Institute for Healthcare Improvement
(IHI)[Footnote 10] has developed "bundles" or "components of care"
designed to reduce the incidence of central line-associated BSIs, SSIs,
VAP, and MRSA. Each of these bundles consists of four to six specific
practices that research has shown affect the incidence of that type of
infection. These practices include hand hygiene and contact
precautions, where appropriate.
Strong clinical evidence indicates that contact precautions help to
reduce the incidence of HAIs. However, for contact precautions to work,
they have to be carefully and consistently followed. Hospitals need to
closely monitor and reinforce staff compliance with these and related
activities such as hand hygiene and environmental cleaning.[Footnote
11] At the same time, some research suggests that patients placed under
contact precautions may receive less attention from clinicians, receive
lower quality care, and experience more adverse events such as falls or
pressure ulcers.[Footnote 12]
MRSA:
MRSA is a particularly prevalent MDRO. It can cause virtually any type
of HAI, including skin infections, BSIs, pneumonia, SSIs, and UTIs.
MRSA-positive patients may either have an active MRSA infection or be
colonized with the organism. Colonized patients carry the bacteria in
some part of their body, such as on their skin or in their nose,
without showing any symptoms of infection themselves. Patients
colonized with MRSA represent a primary source for transmission of the
organism to other patients, often via the hands, clothing, or equipment
of hospital staff. Individuals who acquire MRSA in a health care
setting, such as a hospital, are referred to as having health-care-
associated MRSA. Individuals who develop a MRSA infection outside of
such settings and who do not have a history of recent hospitalization
or surgery are referred to as having community-associated MRSA.
Because patients colonized with MRSA do not exhibit signs and symptoms
of infection, the only way to identify them is through laboratory
testing of specimens from asymptomatic patients. Specimens taken from a
patient's nose can identify up to 80 percent of colonized patients and
are therefore recommended for MRSA screening. Laboratory methods for
MRSA testing use routine culture media, selective media, or polymerase
chain reaction (PCR). Routine culture media require laboratory staff to
culture specimens in a nutrient material, such as agar in a Petri dish,
and then examine and test the organisms that grow in that medium. This
process usually takes 2 to 5 days to produce results. Selective media
are laboratory culture media that have been developed to identify the
presence of specific organisms. Clinical specimens are swabbed onto
culture plates containing selective media. The selective media allow
certain organisms to grow while preventing other organisms from
growing. In some cases, the selective media can also cause specific
organisms to appear a certain color. MRSA test results using selective
media are generally available within 24 hours. PCR is a highly
sensitive, molecular testing technique that detects MRSA-specific DNA.
PCR testing can identify a somewhat higher proportion of MRSA-positive
patients than the alternative testing methods and it can generate
results within 2 to 4 hours, but it is substantially more expensive
than testing using routine or selective media. PCR screening costs $25
to $30 per test, while screening using selective media costs about $5
per test.[Footnote 13]
Several European countries have largely eradicated transmission of MRSA
to other patients by adopting procedures to identify and isolate MRSA-
positive patients on admission, demonstrating that hospitals can keep
the MRSA infection rate low or nonexistent. In the United States, the
consensus among experts is that hospitals should take measures to
prevent the transmission of the MRSA organism from any patient known to
be infected or colonized with MRSA to other patients in the hospital.
CDC's guidelines for reducing the incidence of MDROs, including MRSA,
emphasize the importance of implementing several recommended practices
when treating MRSA-positive patients, including contact precautions,
hand hygiene, and effective environmental cleaning.[Footnote 14] The
guidelines recommend placing MRSA-positive patients in private rooms or
"cohorting" them by placing them in rooms with other MRSA-positive
patients. In addition, the guidelines recommend that hospitals exercise
antibiotic stewardship by implementing processes that encourage and
facilitate judicious use of antimicrobial agents to maximize
therapeutic impact while minimizing the development of antibiotic
resistance.
Infection control experts differ as to the scope of routine MRSA
testing, known as active surveillance testing (AST), they recommend to
identify MRSA-positive patients. Some recommend as much routine testing
as is necessary to identify all MRSA-positive patients in a hospital,
which, depending on the prevalence of MRSA in that hospital or
community, can mean testing all admitted patients--universal AST. Other
experts, as well as CDC guidelines, recommend targeted AST--testing
populations within a hospital who are more likely than others to be
colonized with MRSA. Populations targeted include patients in intensive
care units, dialysis patients, and patients transferred from nursing
homes or prisons. Targeted testing requires fewer resources than
universal testing, but misses infected individuals outside of the
targeted population.
Decolonization protocols have been developed to remove MRSA bacteria
from a colonized patient's body, in order to reduce the likelihood that
the patient will get an active infection or transmit the bacteria to
someone else. Decolonization therapy can involve applying an antibiotic
ointment in the nose for 5 days, bathing in chlorhexidine, or doing
both. However, the clinical evidence supporting the effectiveness of
these protocols in eradicating MRSA is limited, and researchers have
reported that extensive use of this treatment can lead to increased
MRSA resistance to the antibiotic in the nasal ointment. As a result,
experts differ as to if and when to implement these protocols.
Federal Activities:
CDC is the lead federal agency with respect to HAIs. It sets clinical
definitions for identifying HAIs and has defined 13 categories of HAIs,
including BSIs, SSIs, UTIs, and pneumonia. CDC's definitions and
procedures for distinguishing HAIs from other infections, which rely on
detailed clinical information obtained from patient medical records and
direct observation, are widely accepted as the most appropriate
technical standard by ICPs and others in the field.[Footnote 15] CDC's
Healthcare Infection Control Practices Advisory Committee (HICPAC)
publishes guidelines that assemble and assess practices intended to
reduce particular types of infections.[Footnote 16]
Since the 1970s, CDC has managed systems to collect HAI data from
hospitals on a strictly voluntary and confidential basis. Following the
transition from the NNIS to the NHSN in 2005, participation in CDC's
system has grown from approximately 300 hospitals to approximately
1,000 hospitals as of December 2007. Through the NHSN, CDC has
established protocols for hospitals to report outcome data on central
line-associated BSIs, SSIs, catheter-associated UTIs, VAP, and
postprocedure pneumonia.[Footnote 17] These protocols include questions
about the organisms causing the reported infections and the results of
any laboratory tests of their antibiotic susceptibility. NHSN also
collects data that enable hospitals to risk adjust their HAI rates to
take account of differences in the severity of illness of their
patients and in the complexity of procedures they perform. The use of
risk-adjusted rates allows hospitals to more accurately compare their
own progress in infection prevention and control to that of other
hospitals, as well as to their own rates in the past. Though
participation in the NHSN remains voluntary and is free of charge,
enrolling hospitals must agree to follow these protocols in collecting
the data that they submit. As was true of the NNIS, CDC releases data
from the NHSN only in the form of aggregate rates for different types
of infections, with information on the individual participating
hospitals legally protected from disclosure.
In contrast to the confidentiality guaranteed to hospitals
participating in CDC's data systems, there has been a movement in
recent years toward making information about the quality of care
provided by individual hospitals publicly available. Several
organizations have developed indicators to measure how often patients
receive certain recommended processes of care for certain conditions
(called process measures) and to measure how often adverse outcomes,
such as infections, occur in certain patient populations (called
outcome measures). For example, the Surgical Care Improvement Project
(SCIP) has adopted a series of process measures to assess hospital
compliance with practices designed to minimize SSIs, as well as other
adverse events from surgery.[Footnote 18] CMS routinely publishes the
scores that hospitals receive for these SCIP measures on its Hospital
Compare Web site, along with process and outcome measures for other
medical conditions.[Footnote 19]
States Have Designed Broadly Similar Mandatory HAI Public Reporting
Systems, with Resource and Technological Challenges Affecting
Implementation:
Of the 23 states we reviewed that have state-mandated HAI public
reporting programs, most have adopted similar approaches to address
resource and technological challenges that affect their implementation.
Most of these states have designed, and the early-adopting states have
implemented, programs that focus on a few outcome and process measures
that were developed or endorsed by CDC and are widely accepted by ICPs.
Three states have decided to collect data on hospital-associated MRSA
infections. In addition, after some early efforts by states to develop
their own data collection systems, a majority of the states we reviewed
have chosen to use NHSN, the HAI data collection system developed by
CDC. Adopting CDC-endorsed measures and the NHSN for data collection
allows states to minimize some of the resource and technological
challenges that they confront in implementing HAI reporting systems.
States Have Designed HAI Public Reporting Systems with Most Using
Similar Approaches:
We reviewed 23 states that have state-mandated HAI public reporting
systems (see table 1). By early 2008, 14 states had started to collect
HAI data from hospitals. Most of the 23 states have adopted similar
approaches involving (1) the use of advisory committees, (2) selection
of many of the same measures, (3) decisions on systems for data
collection, and (4) steps taken to validate the HAI data collected.
Table 1: States We Reviewed with HAI Public Reporting for Hospitals, by
Date Data Collection Begins:
State: Pennsylvania;
Date data collection began or planned to begin: Jan 2004.
State: Florida;
Date data collection began or planned to begin: April 2005.
State: Missouri;
Date data collection began or planned to begin: Jul 2005.
State: Vermont;
Date data collection began or planned to begin: Nov 2006.
State: Maine;
Date data collection began or planned to begin: Jan 2007.
State: New York;
Date data collection began or planned to begin: Jan 2007.
State: Colorado;
Date data collection began or planned to begin: Jul 2007.
State: Illinois;
Date data collection began or planned to begin: Jul 2007.
State: South Carolina;
Date data collection began or planned to begin: Jul 2007.
State: California;
Date data collection began or planned to begin: Jan 2008.
State: Connecticut;
Date data collection began or planned to begin: Jan 2008.
State: Delaware;
Date data collection began or planned to begin: Jan 2008.
State: New Hampshire;
Date data collection began or planned to begin: Jan 2008.
State: Tennessee;
Date data collection began or planned to begin: Jan 2008.
State: Maryland;
Date data collection began or planned to begin: Jul 2008.
State: Massachusetts;
Date data collection began or planned to begin: Jul 2008.
State: Oklahoma;
Date data collection began or planned to begin: Jul 2008.
State: Virginia;
Date data collection began or planned to begin: Jul 2008.
State: Washington;
Date data collection began or planned to begin: Jul 2008.
State: Minnesota;
Date data collection began or planned to begin: Jan 2009.
State: New Jersey;
Date data collection began or planned to begin: Jan 2009.
State: Oregon;
Date data collection began or planned to begin: Jan 2009.
State: Texas;
Date data collection began or planned to begin: To be determined.
Sources: State documents and communication with state government and
hospital association officials.
Note: Some states have or will collect data on a pilot basis from the
date listed above, but did not or will not publicly release data on
hospitals until the pilot period, usually 6 months to a year, is
completed.
[End of table]
Use of advisory committees:
We identified 19 states that have instituted HAI advisory committees or
use technical advisors. Many of these committee members and technical
advisors are drawn from related occupations, organizations, or
interests. These include clinicians such as physicians or nurses (13
states), consumers (10 states), hospital administrators or hospital
association officials (11 states), and officials from the state health
department (9 states). A few states also appoint advisory committee
members who are academic researchers, technical specialists in
microbiology or statistics, and representatives of health insurers,
employers, and labor unions.
States seek input from their advisory committees or technical advisors
on many of the same issues but differ in how extensively they rely on
them. These issues include the initial selection of measures, data
collection methods, the format of public reports, the selection of
additional measures over time, data analysis techniques such as risk
adjustment, and data validation methods. Several states have or plan to
consult with advisory committees or technical advisors regarding all or
nearly all these issues. Other states appear to restrict such
consultation to as few as one or two of these issues.
Selection of HAI measures:
More state reporting systems have chosen to collect data on HAI
outcomes, such as the rate at which certain types of HAIs occur, than
collect data on compliance with processes intended to prevent HAIs.
Twenty-one states have selected or are actively considering one or more
outcome measures (see table 2) compared to 13 states that have selected
or are actively considering one or more process measures (see table 3).
Eleven states have selected or are considering both outcome and process
measures.
Table 2: Outcome Measures by States We Reviewed with HAI Reporting, by
Defining Entity:
State[A]: Pennsylvania[E];
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold];
HAI outcome measure: SSI[C]: CDC[Bold];
HAI outcome measure: VAP: CDC[Bold];
HAI outcome measure: Catheter-associated UTI: CDC[Bold];
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].
State[A]: Florida;
HAI outcome measure: Central line-associated BSI[B]: [Empty];
HAI outcome measure: SSI[C]: [Empty];
HAI outcome measure: VAP: [Empty];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: AHRQ.
State[A]: Missouri;
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold];
HAI outcome measure: SSI[C]: CDC[Bold];
HAI outcome measure: VAP: [Empty];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].
State[A]: Vermont;
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold];
HAI outcome measure: SSI[C]: CDC[Bold];
HAI outcome measure: VAP: [Empty];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].
State[A]: Maine;
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold];
HAI outcome measure: SSI[C]: [Empty];
HAI outcome measure: VAP: [Empty];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].
State[A]: New York;
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold];
HAI outcome measure: SSI[C]: CDC[Bold];
HAI outcome measure: VAP: [Empty];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].
State[A]: Colorado;
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold];
HAI outcome measure: SSI[C]: CDC[Bold];
HAI outcome measure: VAP: [Empty];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].
State[A]: Illinois;
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold];
HAI outcome measure: SSI[C]: [Empty];
HAI outcome measure: VAP: [Empty];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].
State[A]: South Carolina;
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold];
HAI outcome measure: SSI[C]: CDC[Bold];
HAI outcome measure: VAP: [Empty];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].
State[A]: California;
HAI outcome measure: Central line-associated BSI[B]: [Empty];
HAI outcome measure: SSI[C]: [Empty];
HAI outcome measure: VAP: [Empty];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].
State[A]: Connecticut;
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold];
HAI outcome measure: SSI[C]: [Empty];
HAI outcome measure: VAP: [Empty];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].
State[A]: Delaware;
HAI outcome measure: Central line-associated BSI[B]: CDC;
HAI outcome measure: SSI[C]: CDC;
HAI outcome measure: VAP: [Empty];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].
State[A]: New Hampshire;
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold];
HAI outcome measure: SSI[C]: CDC[Bold];
HAI outcome measure: VAP: CDC[Bold];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].
State[A]: Tennessee;
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold];
HAI outcome measure: SSI[C]: CDC[Bold];
HAI outcome measure: VAP: [Empty];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].
State[A]: Maryland;
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold];
HAI outcome measure: SSI[C]: CDC[Bold];
HAI outcome measure: VAP: [Empty];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].
State[A]: Massachusetts;
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold];
HAI outcome measure: SSI[C]: CDC[Bold];
HAI outcome measure: VAP: [Empty];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].
State[A]: Oklahoma;
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold];
HAI outcome measure: SSI[C]: [Empty];
HAI outcome measure: VAP: CDC[Bold];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: AHRQ.
State[A]: Virginia;
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold];
HAI outcome measure: SSI[C]: [Empty];
HAI outcome measure: VAP: [Empty];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].
State[A]: Washington;
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold];
HAI outcome measure: SSI[C]: CDC[Bold];
HAI outcome measure: VAP: CDC[Bold];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].
State[A]: Minnesota;
HAI outcome measure: Central line-associated BSI[B]: [Empty];
HAI outcome measure: SSI[C]: [Empty];
HAI outcome measure: VAP: [Empty];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].
State[A]: New Jersey;
HAI outcome measure: Central line-associated BSI[B]: CDC;
HAI outcome measure: SSI[C]: CDC;
HAI outcome measure: VAP: [Empty];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].
State[A]: Oregon;
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold];
HAI outcome measure: SSI[C]: CDC[Bold];
HAI outcome measure: VAP: [Empty];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].
State[A]: Texas;
HAI outcome measure: Central line-associated BSI[B]: CDC;
HAI outcome measure: SSI[C]: CDC;
HAI outcome measure: VAP: [Empty];
HAI outcome measure: Catheter-associated UTI: [Empty];
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].
Sources: State documents and communication with state government and
hospital association officials.
Notes:
CDC[Bold]: State has decided to collect data for this measure in
accordance with CDC definitions and NHSN specifications.
CDC: State is considering collection of data for this measure in
accordance with CDC definitions and NHSN specifications.
AHRQ: State has decided to collect data for "selected infections due to
medical care" and "postoperative sepsis" in accordance with Agency for
Healthcare Research and Quality (AHRQ) specifications.
[A] States listed in order of when they began collecting HAI data, as
shown in table 1.
[B] Most states have chosen to collect data on this measure for ICU
patients only.
[C] Most states have chosen to collect data on this measure only for
patients undergoing one or more selected procedures, such as coronary
artery bypass surgery, hysterectomy, and hip and knee replacement.
[D] One patient safety indicator captures selected infections due to
medical care, which includes many device-related infections such as
central line-associated BSIs. Another indicator identifies cases of
postoperative sepsis, which is aimed at certain infections in surgical
patients but is distinct from surgical site infections.
[E] Pennsylvania collected data on these measures according to CDC
definitions but not according to NHSN specifications between 2004 and
2007. In January 2008, the state began using NHSN specifications.
[End of table]
Table 3: Process Measures by States We Reviewed with HAI Reporting:
State[A]: Pennsylvania;
HAI process measures: Antibiotics administered prior to surgery[B]:
[F];
HAI process measure: Health care worker influenza vaccination: [Empty];
HAI process measure: Central line insertion practices[C]: [Empty];
HAI process measure: Central line bundle[D]: [F];
HAI process measure: VAP prevention practices[E]: [F];
HAI process measure: Ventilator bundle[E]: [Empty].
State[A]: Florida;
HAI process measure: Antibiotics administered prior to surgery[B]:
State has decided to collect data for this measure;
HAI process measure: Health care worker influenza vaccination: [Empty];
HAI process measure: Central line insertion practices[C]: [Empty];
HAI process measure: Central line bundle[D]: [Empty];
HAI process measure: VAP prevention practices[E]: [Empty];
HAI process measure: Ventilator bundle[E]: [Empty].
State[A]: Missouri;
HAI process measure: Antibiotics administered prior to surgery[B]:
[Empty];
HAI process measure: Health care worker influenza vaccination: [Empty];
HAI process measure: Central line insertion practices[C]: [Empty];
HAI process measure: Central line bundle[D]: [Empty];
HAI process measure: VAP prevention practices[E]: State has decided to
collect data for this measure[G];
HAI process measure: Ventilator bundle[E]: [Empty].
State[A]: Vermont;
HAI process measure: Antibiotics administered prior to surgery[B]:
State has decided to collect data for this measure;
HAI process measure: Health care worker influenza vaccination: State is
considering collection of data for this measure;
HAI process measure: Central line insertion practices[C]: [Empty];
HAI process measure: Central line bundle[D]: State has decided to
collect data for this measure[H];
HAI process measure: VAP prevention practices[E]: [Empty];
HAI process measure: Ventilator bundle[E]: [Empty].
State[A]: Maine;
HAI process measure: Antibiotics administered prior to surgery[B]:
State has decided to collect data for this measure;
HAI process measure: Health care worker influenza vaccination: [Empty];
HAI process measure: Central line insertion practices[C]: [Empty];
HAI process measure: Central line bundle[D]: State has decided to
collect data for this measure;
HAI process measure: VAP prevention practices[E]: [Empty];
HAI process measure: Ventilator bundle[E]: State has decided to collect
data for this measure.
State[A]: New York;
HAI process measure: Antibiotics administered prior to surgery[B]:
[Empty];
HAI process measure: Health care worker influenza vaccination: [Empty];
HAI process measure: Central line insertion practices[C]: [Empty];
HAI process measure: Central line bundle[D]: [Empty];
HAI process measure: VAP prevention practices[E]: [Empty];
HAI process measure: Ventilator bundle[E]: [Empty].
State[A]: Colorado;
HAI process measure: Antibiotics administered prior to surgery[B]:
[Empty];
HAI process measure: Health care worker influenza vaccination: [Empty];
HAI process measure: Central line insertion practices[C]: [Empty];
HAI process measure: Central line bundle[D]: [Empty];
HAI process measure: VAP prevention practices[E]: [Empty];
HAI process measure: Ventilator bundle[E]: [Empty].
State[A]: Illinois;
HAI process measure: Antibiotics administered prior to surgery[B]:
State has decided to collect data for this measure;
HAI process measure: Health care worker influenza vaccination: [Empty];
HAI process measure: Central line insertion practices[C]: [Empty];
HAI process measure: Central line bundle[D]: [Empty];
HAI process measure: VAP prevention practices[E]: [Empty];
HAI process measure: Ventilator bundle[E]: [Empty].
State[A]: South Carolina;
HAI process measure: Antibiotics administered prior to surgery[B]:
[Empty];
HAI process measure: Health care worker influenza vaccination: [Empty];
HAI process measure: Central line insertion practices[C]: [Empty];
HAI process measure: Central line bundle[D]: [Empty];
HAI process measure: VAP prevention practices[E]: [Empty];
HAI process measure: Ventilator bundle[E]: [Empty].
State[A]: California;
HAI process measure: Antibiotics administered prior to surgery[B]:
State has decided to collect data for this measure;
HAI process measure: Health care worker influenza vaccination: State
has decided to collect data for this measure;
HAI process measure: Central line insertion practices[C]: State has
decided to collect data for this measure;
HAI process measure: Central line bundle[D]: [Empty];
HAI process measure: VAP prevention practices[E]: [Empty];
HAI process measure: Ventilator bundle[E]: [Empty].
State[A]: Connecticut;
HAI process measure: Antibiotics administered prior to surgery[B]:
[Empty];
HAI process measure: Health care worker influenza vaccination: [Empty];
HAI process measure: Central line insertion practices[C]: [Empty];
HAI process measure: Central line bundle[D]: [Empty];
HAI process measure: VAP prevention practices[E]: [Empty];
HAI process measure: Ventilator bundle[E]: [Empty].
State[A]: Delaware;
HAI process measure: Antibiotics administered prior to surgery[B]:
[Empty];
HAI process measure: Health care worker influenza vaccination: State is
considering collection of data for this measure;
HAI process measure: Central line insertion practices[C]: [Empty];
HAI process measure: Central line bundle[D]: [Empty];
HAI process measure: VAP prevention practices[E]: [Empty];
HAI process measure: Ventilator bundle[E]: [Empty].
State[A]: New Hampshire;
HAI process measure: Antibiotics administered prior to surgery[B]:
State has decided to collect data for this measure;
HAI process measure: Health care worker influenza vaccination: State
has decided to collect data for this measure;
HAI process measure: Central line insertion practices[C]: State has
decided to collect data for this measure;
HAI process measure: Central line bundle[D]: [Empty];
HAI process measure: VAP prevention practices[E]: [Empty];
HAI process measure: Ventilator bundle[E]: [Empty].
State[A]: Tennessee;
HAI process measure: Antibiotics administered prior to surgery[B]:
[Empty];
HAI process measure: Health care worker influenza vaccination: [Empty];
HAI process measure: Central line insertion practices[C]: [Empty];
HAI process measure: Central line bundle[D]: [Empty];
HAI process measure: VAP prevention practices[E]: [Empty];
HAI process measure: Ventilator bundle[E]: [Empty].
State[A]: Maryland;
HAI process measure: Antibiotics administered prior to surgery[B]:
State has decided to collect data for this measure;
HAI process measure: Health care worker influenza vaccination: State
has decided to collect data for this measure;
HAI process measure: Central line insertion practices[C]: [Empty];
HAI process measure: Central line bundle[D]: [Empty];
HAI process measure: VAP prevention practices[E]: [Empty];
HAI process measure: Ventilator bundle[E]: State has decided to collect
data for this measure.
State[A]: Massachusetts;
HAI process measure: Antibiotics administered prior to surgery[B]:
[Empty];
HAI process measure: Health care worker influenza vaccination: State is
considering collection of data for this measure;
HAI process measure: Central line insertion practices[C]: [Empty];
HAI process measure: Central line bundle[D]: [Empty];
HAI process measure: VAP prevention practices[E]: State is considering
collection of data for this measure;
HAI process measure: Ventilator bundle[E]: [Empty].
State[A]: Oklahoma;
HAI process measure: Antibiotics administered prior to surgery[B]:
[Empty];
HAI process measure: Health care worker influenza vaccination: [Empty];
HAI process measure: Central line insertion practices[C]: [Empty];
HAI process measure: Central line bundle[D]: [Empty];
HAI process measure: VAP prevention practices[E]: [Empty];
HAI process measure: Ventilator bundle[E]: [Empty].
State[A]: Virginia;
HAI process measure: Antibiotics administered prior to surgery[B]:
[Empty];
HAI process measure: Health care worker influenza vaccination: [Empty];
HAI process measure: Central line insertion practices[C]: [Empty];
HAI process measure: Central line bundle[D]: [Empty];
HAI process measure: VAP prevention practices[E]: [Empty];
HAI process measure: Ventilator bundle[E]: [Empty].
State[A]: Washington;
HAI process measure: Antibiotics administered prior to surgery[B]:
[Empty];
HAI process measure: Health care worker influenza vaccination: [Empty];
HAI process measure: Central line insertion practices[C]: [Empty];
HAI process measure: Central line bundle[D]: [Empty];
HAI process measure: VAP prevention practices[E]: [Empty];
HAI process measure: Ventilator bundle[E]: [Empty].
State[A]: Minnesota;
HAI process measure: Antibiotics administered prior to surgery[B]:
State has decided to collect data for this measure[I];
HAI process measure: Health care worker influenza vaccination: [Empty];
HAI process measure: Central line insertion practices[C]: [Empty];
HAI process measure: Central line bundle[D]: [Empty];
HAI process measure: VAP prevention practices[E]: [Empty];
HAI process measure: Ventilator bundle[E]: [Empty].
State[A]: New Jersey;
HAI process measure: Antibiotics administered prior to surgery[B]:
State has decided to collect data for this measure;
HAI process measure: Health care worker influenza vaccination: [Empty];
HAI process measure: Central line insertion practices[C]: [Empty];
HAI process measure: Central line bundle[D]: [Empty];
HAI process measure: VAP prevention practices[E]: [Empty];
HAI process measure: Ventilator bundle[E]: [Empty].
State[A]: Oregon;
HAI process measure: Antibiotics administered prior to surgery[B]:
State has decided to collect data for this measure;
HAI process measure: Health care worker influenza vaccination: [Empty];
HAI process measure: Central line insertion practices[C]: [Empty];
HAI process measure: Central line bundle[D]: [Empty];
HAI process measure: VAP prevention practices[E]: [Empty];
HAI process measure: Ventilator bundle[E]: [Empty].
State[A]: Texas;
HAI process measure: Antibiotics administered prior to surgery[B]:
[Empty];
HAI process measure: Health care worker influenza vaccination: [Empty];
HAI process measure: Central line insertion practices[C]: [Empty];
HAI process measure: Central line bundle[D]: [Empty];
HAI process measure: VAP prevention practices[E]: [Empty];
HAI process measure: Ventilator bundle[E]: [Empty].
Sources: State documents and communication with state government and
hospital association officials.
Notes:
[A] States listed in order of when they began collecting HAI data, as
shown in table 1.
[B] Three measures, developed under the SCIP, are related to the
routine administration of antibiotics to forestall SSIs: (1) the
percentage of surgical patients who received an antibiotic within 1
hour prior to surgery, (2) the percentage of surgical patients who
received the antibiotic recommended for their procedure, and (3) the
percentage of surgical patients whose antibiotics were discontinued
within 24 hours after the procedure's end time.
[C] Central line insertion practices is a set of process measures
developed by CDC to monitor compliance with recommended practices
outlined in CDC's guidelines for the prevention of intravascular
catheter-related infections. They include occupation of the inserter,
hand hygiene, use of sterile barrier precautions, type of skin
preparation, location of insertion site, and type of central line
inserted.
[D] Central line bundle was developed by IHI. It consists of five
components: hand hygiene, using maximal sterile barrier precautions,
chlorhexidine skin antisepsis, optimal catheter site selection, and
prompt removal of lines that are no longer necessary. The bundle
measure represents the percentage of patients for whom all five
components of the bundle were complied with.
[E] VAP prevention practices include head-of-bed elevation and daily
assessments of readiness to discontinue mechanical ventilation. These
are two of the four components of the IHI ventilator bundle, which
represents the percentage of patients for whom all four components of
the bundle were complied with. The other two components of the
ventilator bundle are medication to prevent peptic ulcer disease and
medication or mechanical stimulation to prevent blood clots.
[F] Pennsylvania collects information on VAP prevention practices as
well as some, but not all, items included in two of the other process
measures: antibiotics administered prior to surgery and the central
line bundle. However, it only collects these data for patients who
develop SSIs, central line-associated BSIs, and VAP. It also collects
similar information on patients who develop urinary tract infections.
So Pennsylvania uses these data to help explain the infections that
occur, rather than assess the extent to which hospitals comply with
recommended infection prevention practices.
[G] Missouri hospitals report one VAP prevention measure, head-of-bed
elevation, voluntarily.
[H] Vermont has hospitals self-report which components of the central
line bundle they have adopted and whether they train their staff to
perform those selected components and ensure that staff use them.
[I] Minnesota will also collect data for two additional SCIP infection
prevention measures, one on controlling postoperative blood glucose
levels for cardiac surgery patients and one on appropriate hair
removal.
[End of table]
For the most part, states have chosen to publicly report on a handful
of measures relating to HAI outcomes and process that are well-
established and clearly defined. For the states selecting HAI outcome
measures, all but one have selected or are considering measures
developed by CDC. Among the states that have selected process measures,
most have emphasized the SCIP measures designed to prevent SSIs that
both CDC and CMS helped develop.
The HAI outcome measures selected by the state reporting systems have
largely focused on two types of infections as defined by CDC. Of the 18
states that have selected HAI outcome measures, 17 have chosen to
collect rates of central line-associated BSIs, as defined by CDC and in
accordance with NHSN collection protocols (see table 2). Three other
states are actively considering this measure. Twelve states have chosen
to collect rates of SSIs for specified procedures, as defined by CDC
and in accordance with NHSN collection protocols, while 3 other states
are actively considering this measure. Surgical procedures that states
have selected for this outcome measure include coronary artery bypass
grafts, hip replacements, knee replacements, and hysterectomies. All 12
states selecting the SSI measure were among the 17 that selected the
central line-associated BSI measure. Both central line-associated BSIs
and SSIs were recommended for use in public reporting by CDC's HICPAC
and professional associations in infection control and epidemiology,
and more recently by the National Quality Forum (NQF).[Footnote 20]
The states that have chosen to measure processes of care designed to
prevent HAIs have focused on surgical measures (see table 3).
Specifically, 10 states decided to track the routine administration of
antibiotics to forestall SSIs. Three measures of this process were
adopted under the SCIP program: antibiotic received within 1 hour of
surgery, appropriate antibiotic selection, and antibiotics discontinued
within 24 hours after the surgery end time. These are the same surgical
measures that CMS reports on its Hospital Compare Web site, and they
have also been recommended for use in public reporting by CDC's HICPAC
committee.
A smaller number of states have selected HAI outcome and process
measures for which there is less agreement in the infection control
community. For example, among the outcome measures, VAP and catheter-
associated UTI rates have not been recommended for public reporting by
HICPAC or the professional associations, although both are among the
HAI measures endorsed by NQF.[Footnote 21] Several states have also
selected influenza vaccination for health care workers as a process
measure. While not endorsed by NQF, this measure has been recommended
for public reporting by HICPAC, and CDC plans to include it in the NHSN.
Of the 23 states we reviewed, only 2 have selected HAI outcome measures
that substantially diverge from CDC definitions and protocols. Florida
and Oklahoma selected two measures developed by the Agency for
Healthcare Research and Quality (AHRQ) as part of its Patient Safety
Indicators (PSI).[Footnote 22] One PSI measure identifies "selected
infections due to medical care," which includes (but is not limited to)
device-related infections such as central line-associated BSIs. In
contrast to SSIs, which are infections at the site of the surgery, the
second HAI-related PSI measure, postoperative sepsis, focuses on major,
systemwide infections that occur following surgery. The two PSI
measures are calculated by analyzing combinations of diagnosis and
procedure codes in administrative billing records to identify certain
adverse events using computer software. Both states have also selected
at least one of the measures commonly selected by other states that
accord with CDC definitions and protocols or guidance (see tables 2 and
3).[Footnote 23]
Data collection systems:
With respect to setting up systems for collecting HAI data from
hospitals, states have increasingly relied on CDC's NHSN (see table 4).
In January 2007, New York became the first state to begin collecting
data for public reporting using the NHSN, and by June 2007, CDC had
completed its development of the NHSN sufficiently to open enrollment
in the system to hospitals in every state. Prior to that date, 4 states
developed their own data collection mechanisms, beginning with
Pennsylvania in 2004. Since CDC opened enrollment in NHSN to all
hospitals, no state has chosen not to use NHSN to collect at least some
of its HAI data.[Footnote 24] In addition to New York, Colorado, South
Carolina, and Vermont began collecting data through NHSN in 2007, and
13 other states have decided to use NHSN for their HAI public reporting
programs.[Footnote 25] Included in the latter group is Pennsylvania,
which discontinued its original system in favor of NHSN starting in
January 2008. Meanwhile Minnesota, New Jersey, and Texas are
considering whether to use NHSN to collect HAI data for public
reporting. Currently, only 3 states--Florida, Maine, and Missouri--use
systems that do not rely on the NHSN to collect HAI data, though Maine
and Missouri draw on CDC's definitions.
Table 4: Data Collection Systems, by States We Reviewed with HAI
Reporting:
State[A]: Pennsylvania[B];
Data collection system: NHSN: Data collection system selected;
Data collection system: State developed: [Empty].
State[A]: Florida;
Data collection system: NHSN: [Empty];
Data collection system: State developed: Data collection system
selected.
State[A]: Missouri;
Data collection system: NHSN: [Empty];
Data collection system: State developed: Data collection system
selected.
State[A]: Vermont;
Data collection system: NHSN: Data collection system selected;
Data collection system: State developed: [Empty].
State[A]: Maine;
Data collection system: NHSN: [Empty];
Data collection system: State developed: Data collection system
selected.
State[A]: New York;
Data collection system: NHSN: Data collection system selected;
Data collection system: State developed: [Empty].
State[A]: Colorado;
Data collection system: NHSN: Data collection system selected;
Data collection system: State developed: [Empty].
State[A]: Illinois;
Data collection system: NHSN: Data collection system selected;
Data collection system: State developed: [Empty].
State[A]: South Carolina;
Data collection system: NHSN: Data collection system selected;
Data collection system: State developed: [Empty].
State[A]: California;
Data collection system: NHSN: Data collection system selected;
Data collection system: State developed: [Empty].
State[A]: Connecticut;
Data collection system: NHSN: Data collection system selected;
Data collection system: State developed: [Empty].
State[A]: Delaware;
Data collection system: NHSN: Data collection system selected;
Data collection system: State developed: [Empty].
State[A]: New Hampshire;
Data collection system: NHSN: Data collection system selected;
Data collection system: State developed: [Empty].
State[A]: Tennessee;
Data collection system: NHSN: Data collection system selected;
Data collection system: State developed: [Empty].
State[A]: Maryland;
Data collection system: NHSN: Data collection system selected;
Data collection system: State developed: [Empty].
State[A]: Massachusetts;
Data collection system: NHSN: Data collection system selected;
Data collection system: State developed: [Empty].
State[A]: Oklahoma;
Data collection system: NHSN: Data collection system selected;
Data collection system: State developed: [Empty].
State[A]: Virginia;
Data collection system: NHSN: Data collection system selected;
Data collection system: State developed: [Empty].
State[A]: Washington;
Data collection system: NHSN: Data collection system selected;
Data collection system: State developed: [Empty].
State[A]: Minnesota;
Data collection system: NHSN: Data collection system being considered;
Data collection system: State developed: [Empty].
State[A]: New Jersey;
Data collection system: NHSN: Data collection system being considered;
Data collection system: State developed: [Empty].
State[A]: Oregon;
Data collection system: NHSN: Data collection system selected;
Data collection system: State developed: [Empty].
State[A]: Texas;
Data collection system: NHSN: Data collection system being considered;
Data collection system: State developed: [Empty].
Sources: GAO analysis of state documents and communication with state
government and hospital association officials.
Notes:
A number of states that use the NHSN also use other data collection
systems for measures that are not incorporated into the NHSN, such as
those for antibiotics administered prior to surgery.
[A] States listed in order of when they began collecting HAI data, as
shown in table 1.
[B] From 2004 through 2007 Pennsylvania used its own state data
collection system.
[End of table]
Data validation:
Data collection systems may or may not incorporate procedures to
independently verify the accuracy of the data submitted to them.
However, according to infection control experts as well as state
officials responsible for HAI reporting programs, unless such
procedures are in place, there is a substantial risk that the data
provided by hospitals in a mandatory public reporting system will be
misleading because some hospitals will provide data that are more
accurate and complete than others. This variation in reporting accuracy
and completeness can occur for several reasons. First, as New York
health department officials found, hospitals can provide inconsistent
information because they interpret the relevant definitions
differently. Second, some hospitals are likely to have infection
control programs that are more effective than others in identifying
HAIs, which means that they detect a higher proportion of the HAIs that
occur in their facilities. Finally, the act of publicly reporting
infection rates as a guide for patients to use in selecting a hospital
may encourage hospitals to be less rigorous in seeking to detect HAIs,
since the fewer they find the better they look compared to their
competitors.
Because the HAI data collection systems developed by CDC, including
NHSN, were based on a model of voluntary participation by hospitals for
purposes of internal quality improvement without public disclosure of
the results, CDC systems did not incorporate processes for independent
data validation. Voluntary participation without public disclosure was
presumed to minimize any incentive for hospitals to submit inaccurate
data. Consequently, CDC has not conducted an ongoing or systematic
validation study of the data currently being submitted to
NHSN,[Footnote 26] though it has collaborated with states that adopt
NHSN for mandatory public reporting to develop methods that the states
can use to ensure the submitted data are accurate.
Of the 23 states we reviewed, 4 have plans to validate the accuracy of
the data collected from hospitals, while several others indicated they
may develop such plans in the future. New York has made the most
progress on implementing a broad data validation process. It has hired
five ICPs to review a systematic sample of infection reports submitted
to the NHSN from each New York hospital and compare the reports with
the hospitals' medical records. The ICPs review medical records of ICU
patients with bloodstream infections from each hospital, as well as
records of matched patients with similar surgeries for whom infections
were and were not reported. After identifying which patient medical
records showed HAIs that should have been reported, they compare them
to the infection reports submitted by the hospitals. For any
discrepancies, state officials meet with hospital staff to better
ensure the accuracy of the data for the next reporting period.
Three other states--Pennsylvania, Missouri, and South Carolina--have
undertaken less extensive efforts to validate data they receive from
hospitals. Pennsylvania has conducted inspections of a limited number
of hospitals selected on the basis of statistical anomalies in the HAI
data that they submitted. However, Pennsylvania state officials have
developed plans to emulate New York's approach and hire auditors to
review a sample of patient medical records from each hospital. In
addition, they plan to analyze utilization data obtained from insurance
plans. In Missouri, health department officials conducting annual
onsite inspections of licensed hospitals compare a hospital's HAI
reports with a sample of patient medical records. This is one of many
items covered during a licensing inspection and it is not designed to
be a comprehensive data validation effort. South Carolina has initiated
a pilot program with one hospital system to develop data validation
methods based on linking NHSN data with hospital billing data from the
state's hospital discharge data set.
Officials in other states have indicated similar concerns about the
accuracy of data submitted to HAI public reporting programs, but have
not yet acted on those concerns. Documents from seven states supported
efforts to validate the data submitted by hospitals to ensure their
accuracy.[Footnote 27] However, most of these states are just beginning
to implement their public reporting systems and have not yet begun to
develop data validation methods.
Most States Do Not Require Hospitals to Track MRSA HAIs, though Some
States Collect Limited MRSA Data through Public Reporting or Other
Systems:
States have generally not required MRSA-related outcome measures or
process measures as a part of their public reporting programs, even
though MRSA and other MDROs cause many HAIs. Three exceptions are
Illinois, Maryland, and New Jersey. Illinois plans to collect data on
the number of hospital patients with MRSA infections using diagnostic
codes included in administrative data that hospitals routinely submit
to the state. In January 2008, Illinois made two changes to its
administrative data systems that will enhance its identification of
hospital-associated MRSA infections. First, it required all hospitals
to enter a code for each reported diagnosis to indicate if the
condition was present when the patient was admitted.[Footnote 28] The
state also expanded the number of diagnosis codes that hospitals report
to the state, from a maximum of 9 to 25, which will reduce the chances
of undercounting the number of patients with MRSA infections for
patients with more than 9 diagnoses.
New Jersey is also requiring hospitals to report on MRSA cases acquired
in hospitals. Rather than rely on administrative data, New Jersey plans
to use an MDRO module for the NHSN that CDC is developing and expects
to release in the fall of 2008. Maryland has taken yet another approach
by deciding to collect data on a MRSA-related process measure instead
of outcomes. It will collect information from hospitals on the
proportion of patients in ICUs who undergo AST for MRSA.
States also are able to obtain some data on HAIs caused by MRSA from
the existing NHSN modules. Seventeen states have decided to use the
NHSN to collect outcome measures on one or more types of HAIs for which
there are NHSN protocols.[Footnote 29] These protocols require
hospitals to report available information about the pathogens causing
the infections and the results of any antimicrobial susceptibility
laboratory testing performed. However, these data are limited to the
types of infections that the states require hospitals to report, and
most states have opted not to require hospitals to report on all types
of HAIs in hospitals for which NHSN has developed protocols. Moreover,
the existing NHSN modules do not include community-associated MRSA,
which can only be reported through NHSN as part of the MDRO module to
be released in fall of 2008.
Although MRSA does not appear on CDC's list of nationally notifiable
infectious diseases for 2008, we found 13 states that classify MRSA
infections as a reportable disease under their state communicable
disease programs[Footnote 30]. These programs require hospitals,
laboratories, or other providers to report some or all MRSA cases to
the state or local departments of health periodically. [Footnote 31] In
all but one of these states, those reporting MRSA cases are not asked
to distinguish between health-care-associated and community-associated
infections.
Resource and Technological Challenges Influence How States Implement
HAI Reporting Systems:
State and state hospital association officials we interviewed mentioned
a variety of resource and technology challenges they faced in
implementing their HAI reporting systems. These challenges often
limited the scope of their reporting systems and the timing of their
implementation. Regarding resource challenges, officials in one state
reported that they needed to train and provide technical assistance for
hospital staff, some of whom struggled to implement the clinically
sophisticated NHSN protocols for data collection. A status report
issued by another state noted that the state resources dedicated to
training hospital staff to use the NHSN prevented the state from
conducting other program activities such as data validation. Officials
in several states reported trouble hiring and retaining the staff they
needed to initiate their HAI reporting systems, sometimes due to a lack
of financial resources. State officials underscored their need for
highly trained personnel to effectively implement these reporting
systems. Hospital association and state officials in several states
noted that hospitals did not have enough qualified ICPs, which has
exacerbated implementation challenges. One state official indicated
that although the health department had financial resources to hire
staff, it did not have enough office space.
States also confronted technological challenges when implementing HAI
reporting systems, especially if they developed their own data
collection systems. Missouri officials, for example, found the system
they developed had to balance competing technological demands to (1)
collect all the necessary data elements for proper risk adjustment, (2)
allow hospitals to extract the data using their existing computer
systems, and (3) be user-friendly for those collecting and entering
data. Pennsylvania also experienced technological challenges. For
example, when it began collecting HAI data from hospitals using a data
system that was developed for hospitals to report administrative data,
it generated strong criticisms from hospital officials and clinicians
who argued that this system did not collect the information needed to
risk adjust the reported results as recommended by CDC.[Footnote 32]
CDC had already dealt with such technological issues in developing the
NHSN, building on its decades-long experience in operating the NNIS
system. In June 2007, CDC opened enrollment in the NHSN to all U.S.
hospitals. This made adoption of the NHSN an attractive option for
state officials seeking to address these technological concerns. For
example, New York officials reported to us that they considered
developing their own data collection system tailored to the needs of
the New York program before deciding to adopt the NHSN. Because New
York's law required a reporting system that was functionally similar to
the NHSN, these officials concluded that it made more sense to use the
existing system than attempt to create a new system to perform the same
functions.
These challenges, particularly with respect to resources, have affected
the decisions states have made regarding timelines for implementation,
measures to use, data collection mechanisms, and data validation
processes. To ensure they have sufficient resources to adequately
implement their reporting systems, some states have delayed the
starting date for reporting or limited the number of measures to be
collected. Frequently states restricted the measures that they selected
to patients in certain units, such as ICUs, or those who underwent
selected surgical procedures.
To avoid the resource and technological challenges of developing their
own data collection systems, most states have decided to use the NHSN.
State officials cited numerous reasons for adopting the NHSN, including
that it is free to both the states and the hospitals, accessible on the
Internet, requires no software development by the states or commercial
software purchases by hospitals, uses professionally accepted
definitions, and collects detailed data that hospitals can use for
quality improvement. However, despite widespread recognition among
state officials of the need to validate the data submitted by
hospitals, only in a few states have officials determined how to
accomplish data validation with the resources available to them.
Hospital MRSA-Reduction Initiatives Share Multiple Components, but Vary
in Scope and Resource Requirements:
All the hospitals with MRSA-reduction initiatives that we reviewed use
routine testing for MRSA as part of their initiative, although they
chose different patient populations to test. These hospitals reported
changing a number of general infection control policies or practices as
part of their initiatives, and all included patient or health care
staff decolonization as part of their initiative despite limited
support for such practices among infection control experts. The
hospitals we reviewed reported needing varying levels of funding and
staff resources to operate their initiatives, but all hospitals that
tracked MRSA infection rates reported a decline in MRSA infections as a
result of their initiatives.
All Initiatives Use Routine Testing for MRSA but Vary in How Testing Is
Targeted and Conducted:
All 14 hospitals we reviewed reported that they conduct AST as part of
their MRSA-reduction initiative. However, these hospitals vary in the
patient populations tested (see table 5). Three hospitals conduct
universal AST, testing all patients admitted. The remaining hospitals
conduct targeted AST, screening select patient populations deemed to be
at risk for MRSA colonization. Of the hospitals that conduct targeted
AST, all but one screen patients in adult or neonatal intensive care
units and 5 screen surgical patients.
Table 5: Patient Populations Screened with Active Surveillance Testing,
by Selected Hospital:
Evanston Northwestern Healthcare;
All (Universal): Hospital screens patient population for MRSA;
Targeted screening: Adult intensive care unit: Included in universal
active surveillance testing where all admitted patients are tested;
Targeted screening: Neonatal intensive care unit: Included in universal
active surveillance testing where all admitted patients are tested;
Targeted screening: Surgical: Included in universal active surveillance
testing where all admitted patients are tested;
Targeted screening: Long-term care facility admissions: Included in
universal active surveillance testing where all admitted patients are
tested;
Targeted screening: Jail or prison admissions: Included in universal
active surveillance testing where all admitted patients are tested;
Targeted screening: Dialysis: Included in universal active surveillance
testing where all admitted patients are tested;
Targeted screening: Other: Included in universal active surveillance
testing where all admitted patients are tested.
Medical University of South Carolina;
All (Universal): Hospital screens patient population for MRSA;
Targeted screening: Adult intensive care unit: Included in universal
active surveillance testing where all admitted patients are tested;
Targeted screening: Neonatal intensive care unit: Included in universal
active surveillance testing where all admitted patients are tested;
Targeted screening: Surgical: Included in universal active surveillance
testing where all admitted patients are tested;
Targeted screening: Long-term care facility admissions: Included in
universal active surveillance testing where all admitted patients are
tested;
Targeted screening: Jail or prison admissions: Included in universal
active surveillance testing where all admitted patients are tested;
Targeted screening: Dialysis: Included in universal active surveillance
testing where all admitted patients are tested;
Targeted screening: Other: Included in universal active surveillance
testing where all admitted patients are tested.
Pitt County Memorial Hospital;
All (Universal): Hospital screens patient population for MRSA;
Targeted screening: Adult intensive care unit: Included in universal
active surveillance testing where all admitted patients are tested;
Targeted screening: Neonatal intensive care unit: Included in universal
active surveillance testing where all admitted patients are tested;
Targeted screening: Surgical: Included in universal active surveillance
testing where all admitted patients are tested;
Targeted screening: Long-term care facility admissions: Included in
universal active surveillance testing where all admitted patients are
tested;
Targeted screening: Jail or prison admissions: Included in universal
active surveillance testing where all admitted patients are tested;
Targeted screening: Dialysis: Included in universal active surveillance
testing where all admitted patients are tested;
Targeted screening: Other: Included in universal active surveillance
testing where all admitted patients are tested.
Eastern Idaho Regional Medical Center;
All (Universal): [Empty];
Targeted screening: Adult intensive care unit: Hospital screens patient
population for MRSA;
Targeted screening: Neonatal intensive care unit: Hospital screens
patient population for MRSA;
Targeted screening: Surgical: Hospital screens patient population for
MRSA[A];
Targeted screening: Long-term care facility admissions: Hospital
screens patient population for MRSA;
Targeted screening: Jail or prison admissions: Hospital screens patient
population for MRSA;
Targeted screening: Dialysis: Hospital screens patient population for
MRSA;
Targeted screening: Other: Hospital screens patient population for
MRSA[B].
Centra, Lynchburg General and Virginia Baptist Hospitals;
All (Universal): [Empty];
Targeted screening: Adult intensive care unit: Hospital screens patient
population for MRSA;
Targeted screening: Neonatal intensive care unit: [Empty];
Targeted screening: Surgical: Hospital screens patient population for
MRSA[C];
Targeted screening: Long-term care facility admissions: Hospital
screens patient population for MRSA;
Targeted screening: Jail or prison admissions: [Empty];
Targeted screening: Dialysis: Hospital screens patient population for
MRSA;
Targeted screening: Other: Hospital screens patient population for
MRSA[D].
Wake Forest University Baptist Medical Center;
All (Universal): [Empty];
Targeted screening: Adult intensive care unit: Hospital screens patient
population for MRSA;
Targeted screening: Neonatal intensive care unit: [Empty];
Targeted screening: Surgical: [Empty];
Targeted screening: Long-term care facility admissions: [Empty];
Targeted screening: Jail or prison admissions: [Empty];
Targeted screening: Dialysis: [Empty];
Targeted screening: Other: Hospital screens patient population for
MRSA[E].
Mercy Medical Center;
All (Universal): [Empty];
Targeted screening: Adult intensive care unit: [Empty];
Targeted screening: Neonatal intensive care unit: [Empty];
Targeted screening: Surgical: [Empty];
Targeted screening: Long-term care facility admissions: Hospital
screens patient population for MRSA;
Targeted screening: Jail or prison admissions: [Empty];
Targeted screening: Dialysis: [Empty];
Targeted screening: Other: Hospital screens patient population for
MRSA[F].
Albany Medical Center;
All (Universal): [Empty];
Targeted screening: Adult intensive care unit: [Empty];
Targeted screening: Neonatal intensive care unit: Hospital screens
patient population for MRSA;
Targeted screening: Surgical: Hospital screens patient population for
MRSA;
Targeted screening: Long-term care facility admissions: [Empty];
Targeted screening: Jail or prison admissions: [Empty];
Targeted screening: Dialysis: [Empty];
Targeted screening: Other: [Empty].
Newark Beth Israel Medical Center;
All (Universal): [Empty];
Targeted screening: Adult intensive care unit: Hospital screens patient
population for MRSA;
Targeted screening: Neonatal intensive care unit: Hospital screens
patient population for MRSA;
Targeted screening: Surgical: [Empty];
Targeted screening: Long-term care facility admissions: [Empty];
Targeted screening: Jail or prison admissions: [Empty];
Targeted screening: Dialysis: [Empty];
Targeted screening: Other: [Empty].
Beth Israel Medical Center;
All (Universal): [Empty];
Targeted screening: Adult intensive care unit: Hospital screens patient
population for MRSA;
Targeted screening: Neonatal intensive care unit: [Empty];
Targeted screening: Surgical: Hospital screens patient population for
MRSA[G];
Targeted screening: Long-term care facility admissions: [Empty];
Targeted screening: Jail or prison admissions: [Empty];
Targeted screening: Dialysis: [Empty];
Targeted screening: Other: [Empty].
Rochester General Hospital;
All (Universal): [Empty];
Targeted screening: Adult intensive care unit: Hospital screens patient
population for MRSA;
Targeted screening: Neonatal intensive care unit: [Empty];
Targeted screening: Surgical: Hospital screens patient population for
MRSA[H];
Targeted screening: Long-term care facility admissions: [Empty];
Targeted screening: Jail or prison admissions: [Empty];
Targeted screening: Dialysis: [Empty];
Targeted screening: Other: [Empty].
University of Pittsburgh Medical Center;
All (Universal): [Empty];
Targeted screening: Adult intensive care unit: Hospital screens patient
population for MRSA;
Targeted screening: Neonatal intensive care unit: [Empty];
Targeted screening: Surgical: [Empty];
Targeted screening: Long-term care facility admissions: [Empty];
Targeted screening: Jail or prison admissions: [Empty];
Targeted screening: Dialysis: [Empty];
Targeted screening: Other: [Empty].
Barnes-Jewish Hospital;
All (Universal): [Empty];
Targeted screening: Adult intensive care unit: Hospital screens patient
population for MRSA;
Targeted screening: Neonatal intensive care unit: [Empty];
Targeted screening: Surgical: [Empty];
Targeted screening: Long-term care facility admissions: [Empty];
Targeted screening: Jail or prison admissions: [Empty];
Targeted screening: Dialysis: [Empty];
Targeted screening: Other: [Empty].
Pacific Hospital of Long Beach;
All (Universal): [Empty];
Targeted screening: Adult intensive care unit: Hospital screens patient
population for MRSA;
Targeted screening: Neonatal intensive care unit: [Empty];
Targeted screening: Surgical: [Empty];
Targeted screening: Long-term care facility admissions: [Empty];
Targeted screening: Jail or prison admissions: [Empty];
Targeted screening: Dialysis: [Empty];
Targeted screening: Other: [Empty].
Source: GAO analysis of survey and site visit data.
[A] Screens patients admitted for open mediastinal procedures, total
joint replacements, and open spine procedures.
[B] Screens patients admitted from another acute care hospital.
[C] Screens admissions to the surgical ICU.
[D] Screens patients who live in a household with a MRSA-positive
individual or have been told in the past that they have an MDRO.
[E] Screens patients who have a length of stay in the hospital that is
greater than 6 days and who have been given antibiotics; patients who
have a length of stay greater than 21 days; patients known to have at
least one MDRO; and patients transferred from other health care
facilities.
[F] Screens patients with soft tissue or skin infections.
[G] Some surgical patients are screened.
[H] Screens cardiothoracic patients.
[End of table]
The hospitals we reviewed divide fairly evenly in their choice of
testing methods. Five of the hospitals conduct AST using selective
media, which generally produces results in 24 hours at a cost of
approximately $5 per test. All but one of the remaining hospitals
reported using PCR testing, which provides results in only 2 to 4 hours
but costs about $25 to $30 per test, and the one remaining hospital
reported using routine culture media. Two hospitals reported using more
than one testing method. One of these hospitals reported that PCR
testing is used only when results are needed quickly because of limited
staff availability to operate the equipment.
Hospitals Expanded Infection Control Activities and Information Systems
to Reduce MRSA:
In implementing their MRSA-reduction initiatives, all the hospitals we
reviewed reported changing general infection control policies or
practices. CDC guidelines for managing MDROs include recommended
practices relating to hand hygiene adherence, contact precautions,
environmental cleaning, and judicious use of antibiotics. All 14
hospitals made changes to their existing policies or practices for hand
hygiene, while more than half of the hospitals made changes to their
contact precautions or environmental cleaning policies (see table 6).
[Footnote 33] Fewer hospitals reported making changes to their
antibiotic stewardship policies.
Table 6: Policy or Practice Changes Implemented by Selected Hospitals
as Part of MRSA-Reduction Initiatives:
Evanston Northwestern Healthcare;
Hand hygiene: [Check];
Contact precautions: [Check];
Enhanced environmental cleaning: [Empty];
Antibiotic stewardship: [Check].
Medical University of South Carolina;
Hand hygiene: [Check];
Contact precautions: [Empty];
Enhanced environmental cleaning: [Empty];
Antibiotic stewardship: [Empty].
Pitt County Memorial Hospital;
Hand hygiene: [Check];
Contact precautions: [Empty];
Enhanced environmental cleaning: [Check];
Antibiotic stewardship: [Empty].
Eastern Idaho Regional Medical Center;
Hand hygiene: [Check];
Contact precautions: [Check];
Enhanced environmental cleaning: [Check];
Antibiotic stewardship: [Check].
Centra, Lynchburg General and Virginia Baptist Hospitals;
Hand hygiene: [Check];
Contact precautions: [Check];
Enhanced environmental cleaning: [Empty];
Antibiotic stewardship: [Empty].
Wake Forest University Baptist Medical Center;
Hand hygiene: [Check];
Contact precautions: [Check];
Enhanced environmental cleaning: [Check];
Antibiotic stewardship: [Check].
Mercy Medical Center;
Hand hygiene: [Check];
Contact precautions: [Empty];
Enhanced environmental cleaning: [Check];
Antibiotic stewardship: [Empty].
Albany Medical Center;
Hand hygiene: [Check];
Contact precautions: [Check];
Enhanced environmental cleaning: [Check];
Antibiotic stewardship: [Check].
Newark Beth Israel Medical Center;
Hand hygiene: [Check];
Contact precautions: [Empty];
Enhanced environmental cleaning: [Check];
Antibiotic stewardship: [Check].
Beth Israel Medical Center;
Hand hygiene: [Check];
Contact precautions: [Check];
Enhanced environmental cleaning: [Check];
Antibiotic stewardship: [Empty].
Rochester General Hospital;
Hand hygiene: [Check];
Contact precautions: [Check];
Enhanced environmental cleaning: [Check];
Antibiotic stewardship: [Check].
University of Pittsburgh Medical Center;
Hand hygiene: [Check];
Contact precautions: [Check];
Enhanced environmental cleaning: [Check];
Antibiotic stewardship: [Empty].
Barnes-Jewish Hospital;
Hand hygiene: [Check];
Contact precautions: [Check];
Enhanced environmental cleaning: [Empty];
Antibiotic stewardship: [Empty].
Pacific Hospital of Long Beach;
Hand hygiene: [Check];
Contact precautions: [Check];
Enhanced environmental cleaning: [Check];
Antibiotic stewardship: [Check].
[End of table]
Source: GAO analysis of survey and site visit data.
* Hand hygiene--All of the hospitals we reviewed reported changing hand
hygiene policies as part of their MRSA-reduction initiative. Eleven of
the hospitals reported conducting observation audits to monitor
compliance with hand hygiene protocols. Two of these hospitals noted
that their audits are coupled with immediate feedback to staff who are
noncompliant. More than half of the hospitals also reported increasing
staff training or public awareness campaigns to increase compliance
with hand hygiene among staff or hospital visitors, or both. Multiple
hospitals have increased the use of alcohol-based gel hand sanitizers
as part of their initiatives by providing more product dispensers in
the hospital. In addition, 2 hospitals reported monitoring the
consumption of hand hygiene products, such as hand sanitizer or soap,
to gauge hand hygiene compliance. For more information on the changes
hospitals made to hand hygiene polices, see appendix II, table 7.
* Contact precautions--Most hospitals reported making changes to their
contact precautions as part of their MRSA-reduction initiatives, for
example, by requiring health care workers to wear gowns and gloves when
in contact with a MRSA-positive patient or with equipment used on a
MRSA-positive patient. Two hospitals also began requiring health care
workers to wear masks in addition to gowns and gloves when in contact
with a MRSA-positive patient.[Footnote 34] Multiple hospitals use signs
at room entrances of MRSA-positive patients to remind health care
workers to follow contact precautions when entering those environments.
Hospitals that changed their contact precautions also reported
conducting audits to measure staff compliance with contact precaution
procedures. For more information on the changes hospitals made to their
contact precautions, see appendix II, table 8.
* Environmental cleaning--Most hospitals reported changing
environmental cleaning procedures as part of their MRSA-reduction
initiatives. Three hospitals reported that they disinfect patient
equipment between uses or high-touch areas, such as keyboards and door
knobs. Three hospitals implemented checklists for housekeeping staff to
ensure that rooms are properly cleaned following the discharge of a
MRSA-positive patient. One hospital began changing privacy curtains in
patient rooms as part of its initiative because the curtains often
become contaminated with MRSA. For more information on the changes
hospitals made to environmental cleaning polices, see appendix II,
table 9.
* Antibiotic stewardship--Half of the hospitals created new policies or
revised their existing policies pertaining to antibiotic stewardship.
These changes generally included tracking antibiotic prescriptions or
restricting the use of certain antibiotics. For more information on the
changes hospitals made to antibiotic stewardship policies, see appendix
II, table 10.
In addition to changes in infection control practices, most of the
hospitals we reviewed adapted their information systems to support
their MRSA-reduction initiatives. All but 1 of the 14 hospitals has a
mechanism to identify previously colonized patients readmitted to their
hospital. Most of these hospitals reported that they track patients'
MRSA status in electronic medical records, using flags to identify a
patient as MRSA-positive each time the patient's electronic medical
record is accessed. This enables the staff to immediately implement
contact precautions, without the cost or time needed for additional
screening.
All 14 Hospitals Included Decolonization in Their MRSA-Reduction
Initiatives:
All the hospitals we reviewed included patient or health care staff
decolonization as part of their MRSA-reduction initiatives, despite
limited support for MRSA decolonization among infection control experts
and in CDC's MDRO guidelines. Twelve hospitals reported decolonizing
patients, with 6 of these hospitals decolonizing all MRSA-positive
patients. Seven hospitals reported that they decolonize health care
staff--6 hospitals test health care staff for MRSA colonization during
outbreaks and decolonize those found to be positive while the other
hospital decolonizes staff found to be MRSA-positive during voluntary
testing. For more information on these hospitals' approaches to
decolonization, see appendix II, table 11.
Hospital MRSA Initiatives Reported Needing Varying Levels of Funding
and Staff Resources:
The hospitals we reviewed reported needing varying levels of funding
and staff resources to implement and operate their MRSA-reduction
initiatives. Half of the hospitals reported needing limited or no
additional funding for these initiatives. However, the remaining
hospitals reported that moderate to substantial additional funds were
needed. Six of the seven hospitals that reported needing moderate to
substantial additional funding use the more expensive PCR testing or
screen all patients (see fig. 1). Several of the remaining hospitals
that reported needing limited or no additional resources also use PCR
testing, but all of them conduct AST on targeted patient populations.
Eight hospitals reported needing additional staff to conduct patient
testing, laboratory staff to process the tests, or both.
Figure 1: Selected Hospital-Reported Financial Resource Needs for MRSA-
Reduction Initiative, by Type of Screening and Test Method:
[See PDF for image]
This figure is a matrix of selected hospital-reported financial
resource needs for MRSA-Reduction Initiative, by type of screening and
test method, as follows:
Targeted screening:
Financial resources needed for initiative: Substantial; Testing
methodology: Selective: 1 hospital;
Financial resources needed for initiative: Substantial; Testing
methodology: PCR: 2 hospitals;
Financial resources needed for initiative: Moderate; Testing
methodology: PCR: 1 hospital;
Financial resources needed for initiative: Limited; Testing
methodology: Routine: 1 hospital;
Financial resources needed for initiative: Limited; Testing
methodology: Selective: 1 hospital;
Financial resources needed for initiative: Limited; Testing
methodology: PCR: 2 hospitals;
Financial resources needed for initiative: None; Testing methodology:
Selective: 2 hospitals;
Financial resources needed for initiative: None; Testing methodology:
PCR: 1 hospital.
Universal screening:
Financial resources needed for initiative: Substantial; Testing
methodology: PCR: 2 hospitals;
Financial resources needed for initiative: Moderate; Testing
methodology: Selective: 1 hospital.
Source: GAO.
Note: Reporting hospitals characterized the level of additional
resources needed for their MRSA-reduction initiatives as none, limited,
moderate, or substantial.
[End of figure]
Most hospitals reported that they place all or most MRSA-positive
patients in private rooms as part of their initiative. However, several
of these hospitals noted that the availability of single or semiprivate
rooms was a factor in the approach or scope of their MRSA-reduction
initiative. For example, at Newark Beth Israel, the first priority is
to place all MRSA-positive patients in single rooms. However, when
single rooms are not available, a MRSA-positive patient is placed with
another MRSA-positive patient. Eight hospitals reported at least some
cohorting of MRSA-positive patients.
Hospitals with MRSA Initiatives Consistently Reported Reductions in
MRSA Infection Rates:
Of the 13 hospitals that tracked MRSA infection rates, all found a
decline in MRSA infections as a result of their initiatives. Though
some hospitals simply cited reductions or significant decreases in
their MRSA infections, 5 hospitals provided estimates of the percentage
by which their MRSA infection rates had declined. These estimates
ranged from around 50 to 74 percent. Three hospitals assessed their
reductions quantitatively, but in terms other than percentage or
proportion. Two hospitals noted that infections from all organisms, not
just MRSA, declined. Over half of the hospitals we reviewed reported
that they have tracked MRSA colonization rates as part of their MRSA
initiatives. Of the hospitals that reported tracking MRSA colonization
rates, half reported an observed decrease in the incidence of MRSA
colonization since implementing their initiatives.
Two Hospital Systems Addressed Similar Challenges in Implementing MRSA-
Reduction Initiatives:
The two hospital systems that we visited overcame a similar set of
challenges in implementing multifaceted MRSA-reduction programs. Both
systems designed and executed processes to put the elements of their
MRSA-reduction initiatives into effect and promote compliance with
those processes by hospital staff. Both strove to facilitate the
implementation of these processes by incorporating them as much as
possible into the normal workflow of hospital staff. Both hospital
systems promoted staff compliance with their MRSA-reduction initiatives
through a combination of concerted leadership on the part of the
physicians who led their infection control programs and specific
procedures designed to facilitate staff compliance reinforced through
detailed feedback on their performance. However, the two hospital
systems took different approaches to marshalling resources for their
initiatives. One directed substantial financial resources into its MRSA-
reduction initiative to implement the initiative simultaneously for all
patients at all of its hospitals, while the other relied largely on
existing resources and implemented its initiative more incrementally at
selected hospitals and on selected units.
The Two Systems Faced Process, Compliance, and Resource Challenges in
Implementing Their MRSA Reduction Initiatives:
The two hospital systems that we visited faced a similar set of
challenges in implementing multifaceted MRSA-reduction programs over
the past several years.[Footnote 35] Evanston Northwestern Healthcare
(ENH) and the University of Pittsburgh Medical Center (UPMC)--both
multihospital systems[Footnote 36]--each sought to reduce MRSA
infections by instituting AST of patients for MRSA and ensuring
consistent implementation of hospital procedures, such as hand hygiene
procedures and contact precautions. To achieve these objectives, both
systems had to overcome three challenges: (1) designing and executing
processes to put the elements of their MRSA-reduction initiatives into
effect, (2) promoting compliance with those processes by hospital
staff, and (3) marshalling the required financial and staff resources
to implement their initiatives.
The Two Systems Incorporated Processes to Implement Their MRSA-
Reduction Initiatives into Routine Hospital Workflows:
The two systems put processes in place to ensure that all eligible
patients were tested for MRSA and that any positive results were
quickly communicated to the clinical staff to alert them to initiate
contact precautions for those patients. Both strove to facilitate the
implementation of these processes by incorporating them as much as
possible into the normal workflow of hospital staff. At ENH, the
implementation of universal AST at admission meant that collecting
specimens and submitting them to the laboratory became part of the
routine admission procedure for every patient. Because all patients
were tested, there were no target populations to identify. Although
UPMC did not adopt universal AST, its strategy of screening every
patient in selected hospital units had a similar advantage in terms of
clearly identifying the patients to be tested.[Footnote 37]
Both hospitals devised processes for easing access to the supplies that
staff needed to conduct MRSA testing and to initiate contact
precautions for the patients who tested positive. ENH developed a
packet with all the supplies needed for testing a patient for MRSA. The
housekeeping staff was responsible for leaving this packet on the bed
as it finished preparing each room for the next patient. At ENH,
supplies needed for contact precautions were stocked on isolation
supply carts that were delivered to the room of each patient who tested
positive for MRSA. To reduce the time of the arrival of that cart for
patients undergoing contact precautions, ENH officials revised their
procedure for ordering the carts. Instead of having the nursing staff
order the cart once it had received notice of a patient's positive test
result, ENH officials instructed the laboratory staff to order the cart
directly for all patients with positive test results. According to ENH
officials, this reduced the time from test result to initiation of
isolation precautions by approximately 45 minutes. UPMC staff designed
a special container to install at each patient room that was routinely
kept stocked with the gloves, gowns, and other supplies needed whenever
a patient was placed under contact precautions. Moreover, UPMC
programmed its laboratory information system so that a positive MRSA
test result automatically generated a notification by fax, e-mail, and
pager to the clinical staff on that patient's hospital unit to initiate
contact precautions.
Concerted Leadership and Monitoring of Staff Performance Fostered
Compliance with MRSA-Reduction Initiatives:
Both hospital systems promoted staff compliance with their MRSA-
reduction initiatives through a combination of concerted leadership on
the part of the two physicians who led their respective infection
control programs and specific procedures designed to facilitate staff
compliance reinforced through detailed feedback on their performance.
Much of the impetus for implementing MRSA-reduction programs at ENH and
UPMC came from these two lead physicians, both of whom saw the
potential to achieve substantial decreases in MRSA infection rates by
putting a comprehensive program in place. These lead physicians worked
extensively with hospital administrators and their fellow clinicians to
build support for the MRSA-reduction initiative by documenting the
extent of their existing problem with MRSA, laying out the steps that
they could take to address the problem, and marshalling the evidence
that the resulting initiative was producing positive results once
implementation had begun. They also responded to any problems that
arose during implementation or concerns expressed by the clinicians
affected by the initiative by making adjustments in its operation. To
identify emerging problems and find effective solutions, the lead
physicians established internal working groups with representation
across the affected hospital departments. At UPMC this group continued
to meet regularly to review data on whether patients were being
properly tested and isolated, to discuss any concerns raised by
hospital staff, and to consider specific adjustments to the
implementation of the initiative.
Both hospital systems relied heavily on information technology to
facilitate compliance with the various components of the MRSA
initiative. ENH made a number of specific adaptations to its electronic
medical record (EMR) system.[Footnote 38] For example, it added an
orange banner on the medical record screen that highlighted any patient
who had been admitted until staff entered a confirmation that the MRSA
test had been performed. ENH also created a prominent flag in its EMR
for any patient who had been identified as MRSA-positive during a
previous admission or outpatient encounter; all such patients were
immediately placed under contact precautions. UPMC incorporated similar
reminders into its EMR system and also implemented a flag to identify
patients who had previously tested positive for MRSA so that they could
be immediately placed under contact precautions at subsequent
admissions.
In addition, ENH and UPMC monitored staff compliance with targeted
hospital procedures. At ENH, hospital ICPs used their electronic record
system to measure the length of time it took staff on various units to
perform the MRSA test and to respond to positive test results by
implementing contact precautions. They used these data to provide
feedback to both units and individual staff members on their relative
performance. At UPMC, the infection control department provided similar
feedback at monthly meetings with staff in the individual hospital
units, where they presented data on the proportion of patients who were
tested at UPMC's designated time points.
UPMC also expanded its oversight of staff compliance with standard hand
hygiene procedures in conjunction with its MRSA-reduction initiative.
To obtain more accurate information on staff compliance with those
procedures, UPMC implemented routine audits that used trained,
anonymous observers to assess staff performance. UPMC officials sent
formal letters to clinical staff, including physicians, who were
observed not following hand hygiene procedures. Less formally, UPMC
officials provided immediate, positive feedback to staff members who
were observed complying with their hand hygiene procedures.
One Hospital System Marshalled Substantial Resources to Effect
Systemwide Change While the Other Implemented Incremental Changes with
Existing Resources:
ENH directed substantial financial resources into its MRSA-reduction
initiative to implement the initiative simultaneously for all patients
at all three of its hospitals, while UPMC relied largely on existing
resources and implemented its initiative more incrementally at selected
hospitals and on selected units. For both hospital systems, one key
resource challenge was paying for an increased number of MRSA tests.
Ultimately, both systems conducted analyses indicating that the
increased costs of their initiatives were more than compensated for by
the reduced cost of treating a smaller number of patients with MRSA
infections.
ENH officials made a key strategic decision to move expeditiously to
implement MRSA screening for all patients admitted to ENH's three
hospitals. To do this, they developed an implementation plan based on
an analysis of clinical and financial data. Beginning in 2003, ENH
piloted MRSA AST in one ICU. In 2004, it conducted a one-time
prevalence survey[Footnote 39] that determined that 8.5 percent of all
patients were colonized with MRSA--most of them in units outside of the
ICUs.[Footnote 40] Based on this information and the ICU pilot
experience, ENH officials developed a plan to implement universal AST
within a year and budgeted $1 million per year in additional costs,
mostly for the increased number of MRSA tests performed and additional
laboratory staff. ENH officials conducted a cost-benefit analysis that
concluded that the hospital system would save more from having fewer
patients with MRSA infections needing treatment than it would spend for
increased testing. Because ENH had collected detailed information on
patient costs and charges over a number of years, these officials were
able to develop their own estimates for the additional costs associated
with an MRSA infection in the ENH hospitals.[Footnote 41]
Administrators at ENH provisionally approved the MRSA-reduction
initiative, pending confirmation during its first 2 years that it had
the expected effect on the number of ENH patients who developed MRSA
infections and had not increased overall costs. Ultimately, the number
of MRSA cases at ENH decreased more rapidly than expected following
implementation of the initiative, and the additional costs were less
than expected--approximately $600,000 per year.
The cost-benefit analysis provided ENH officials with support for their
choice of the more expensive PCR testing method. Under the plan, the
projected cost savings from the anticipated reduction in MRSA
infections were greater than the additional costs of the MRSA-reduction
initiative, even using PCR to test every patient at admission. ENH
officials were willing to pay approximately $25 per test to obtain two
advantages offered by PCR testing--faster results and greater
sensitivity in detecting patients with MRSA. Getting results for most
patients no later than 15 hours after testing reduces the amount of
time that MRSA-positive patients spend in the hospital without contact
precautions in place, which in turn reduces the chances that they will
infect other patients.[Footnote 42]
UMPC took a more incremental approach to implementing its MRSA-
reduction initiative and, as a result, did not need additional
resources. It began its initiative in 2002 in one ICU at Presbyterian
Hospital, and expanded it over 4 years to other ICUs in that hospital
and then to all adult ICUs in the 19 other hospitals in the UPMC
system. This measured pace of expansion restricted the number of
additional patients who needed to undergo contact precautions at any
one time, which eased potential logistical problems that stem from the
predominance of semiprivate rooms in UPMC hospitals. UPMC officials
told us that they expect to continue making such incremental decisions
on where and when to expand their MRSA-reduction initiative in the
future. They stated that this could eventually lead to screening of all
inpatient admissions.
UPMC officials have relied, as did their counterparts at ENH, on their
analysis of clinical and financial data in developing and expanding
their MRSA-reduction initiative. UPMC officials selected the initial
hospital unit from those that had the largest number of MRSA infections
and, therefore, the greatest potential for improvement, with additional
consideration given to the readiness of staff on the unit to fully
support the initiative. On that basis, they began with the 20-bed
medical ICU at Presbyterian Hospital. Once the initiative was
implemented and the ICU's MRSA infection rate declined, they made the
case for expanding the initiative to other units within Presbyterian
and to other UPMC hospitals. As with the initial selection of the first
ICU, UPMC officials selected the units for expansion of the initiative
based on those with the highest MRSA rates, and they plan to continue
expanding participation in the initiative on that basis.
Because UPMC began its MRSA-reduction initiative with just one unit,
and monitored its progress for 3 years before expanding to other units,
UPMC officials could implement their initiative with a relatively small
upfront investment of resources. They hired no new staff for the
initiative. Instead, to meet the demand for increased MRSA testing,
they reallocated existing laboratory staff and financial resources.
Other additional costs, such as for increased use of gowns, gloves, and
masks to maintain contact precautions, were relatively minor.[Footnote
43] In selecting which test to use for screening patients, UPMC
officials chose the relatively inexpensive selective media test, which
costs approximately $5 and requires only about 40 seconds of laboratory
technician time to perform. Although using selective media did not
produce results as quickly as PCR would, UPMC officials found that they
could nonetheless identify 81 percent of MRSA-positive patients within
24 hours.
UPMC's MRSA-reduction initiative has achieved large reductions in the
number of MRSA cases at a relatively low cost, resulting in a highly
favorable ratio of benefits to costs. UPMC officials estimate that
their savings in terms of the reduced costs to treat a smaller number
of MRSA cases were 12 to 32 times greater than the costs they incurred
to test patients for MRSA and implement contact precautions for those
who test positive. To calculate those savings, they relied on estimates
from the published literature for determining the difference in
treatment costs for patients with and without MRSA infections,[Footnote
44] and multiplied that figure by the reduction in the number of MRSA
infections that have occurred in their targeted units. UPMC officials
have used these estimates to build support for expanding the MRSA-
reduction initiative into other units of the UPMC hospitals besides
ICUs, including orthopedic units.
Concluding Observations:
Governmental initiatives to reduce HAIs involve a complicated mix of
federal and state activities. The federal government, and in particular
its lead agency for HAIs, CDC, have over the last few decades evolved a
role that involves certain discrete activities. These include the
development of guidelines that assess and recommend specific clinical
practices for reducing HAIs. They also include the development and
promulgation of procedures and definitions that enable ICPs to
determine in a systematic and consistent way which patients have HAIs,
and to measure their HAI rates over time. In addition, CDC has
initiated and maintained data collection programs, such as NHSN, that
provide a mechanism that hospitals can use to both collect information
on their own HAIs and compare their experience with that of other
hospitals using the same set of clinical definitions and data
collection procedures. CDC provides these services to participating
hospitals free of charge, and by law protects the confidentiality of
the data that hospitals submit.
Meanwhile, at least 23 states have taken initiatives that seek to use
comparable information about HAIs for a quite different purpose--
informing consumers about the relative performance of specific
hospitals. As the states have set up these programs, and confronted the
challenges of implementing them with limited resources, many have found
compelling advantages in drawing on CDC's procedures and data
collection systems. CDC protocols for identifying HAIs are widely
respected for their clinical sophistication, and are well known to the
ICPs in individual hospitals who will most likely be the ones to report
the data. NHSN not only incorporates those widely accepted definitions
and procedures, it is also available at no cost to the hospitals that
use it. Thus many states have chosen to implement their public
reporting programs by mandating that hospitals in their states enroll
in NHSN. Although CDC itself may not publicly release HAI data on
individual hospitals enrolled in NHSN, hospitals can give access to the
state agencies to view and analyze their data using the group feature
of NHSN. The state agencies can then use those data for their public
reporting programs.
The increasing number of states opting to use information obtained from
this federal data collection system to publicly report on the relative
performance of individual hospitals raises concerns about the lack of
established mechanisms to check the completeness and accuracy of the
data submitted by hospitals. When the data are released to the public
in order to influence consumers to choose hospitals with lower rates of
HAIs, hospitals may have an incentive to minimize the number of HAI
cases that they identify and report if they believe either that the
hospitals with which they compete for patients could be minimizing the
number of HAIs they reported or that those hospitals have actually
achieved lower rates of HAIs than their own hospital. NHSN was created
under a completely different paradigm, in which hospitals voluntarily
collected the data on HAIs to inform their own internal efforts to
reduce HAIs, with a legal protection from public release. Because the
data were intended strictly for internal use, CDC officials assumed
that hospitals had an incentive to generate the most accurate and
complete data possible. Consequently, the NHSN did not develop any
process or mechanism to audit the accuracy and completeness of the data
that hospitals submitted.
Both CDC and state officials have noted that converting NHSN to a
source for publicly reported data on HAIs fundamentally changes the
incentives for participating hospitals, and thereby creates a need for
procedures to independently validate the data that hospitals submit.
Specifically, CDC has collaborated with states using NHSN for public
reporting to develop and implement data validation as part of their
programs. However, few states have so far acted on this advice.
Specific procedures for validating HAI data need to be developed and
tested, and resources allocated to implement them. To some extent, New
York has done the most to accomplish these tasks, but its experience
indicates that systematic data validation requires substantial staff
resources. Unless other states can marshal the resources needed to
ensure the accuracy and completeness of the HAI data submitted by their
hospitals, they are unlikely to make substantial progress in addressing
this issue.
Comments from HHS and the American Hospital Association and Our
Evaluation:
We obtained written comments on our draft report from HHS, which were
largely technical in nature. Overall, HHS commended GAO for developing
a helpful report on an important topic. The department also highlighted
the contributions that CDC has made, including its research into
understanding the epidemiology of MRSA and HAIs. HHS noted that CDC's
work in this area is reflected in a large number of scientific
publications pertaining to the detection, measurement, and prevention
of HAIs and MRSA. In addition, we incorporated the technical comments
that HHS provided as appropriate.
The vice president of quality and patient safety policy for the
American Hospital Association (AHA) provided oral comments on our draft
report. The AHA appreciated that our report addressed state reporting
programs for HAIs as a whole, along with a detailed review of hospital
initiatives to reduce MRSA. It highlighted the technical and resource
challenges described in our report that hospitals face in conducting
HAI surveillance and prevention activities, which smaller hospitals in
particular may have difficulty overcoming. Therefore, the AHA believes
that it is important to link the collection of HAI data to achieving a
reduction of HAIs including MRSA, and to acknowledge that different
hospitals can use different approaches to accomplish this objective. In
addition, the AHA expressed serious concern about public reporting of
HAI data collected through NHSN. It noted that the NHSN data were not
validated and that hospitals vary in how they collect the data
submitted to NHSN. As a result, the AHA felt that the NHSN data do not
provide a valid comparative assessment of hospital performance. The AHA
also provided technical comments that we incorporated as appropriate.
We agree with HHS that CDC has played a central role in developing both
the science and the data collection systems on which current efforts to
assess and reduce HAIs rest. At the same time, we share AHA's concerns
that to be viable in the long run, systems for collecting HAI data for
public reporting need to produce data that are clinically accurate and
that assist hospitals in their efforts to reduce HAIs. As evidenced by
its widespread adoption, CDC's NHSN has made a substantial contribution
in that direction, though questions remain regarding how best to ensure
that the data it produces are accurate and complete.
As arranged with your office, unless you publicly announce the contents
of this report earlier, we plan no further distribution until 30 days
after its issuance date. At that time, we will send copies of this
report to the Secretary of HHS and other interested parties. We will
also make copies available to others on request. In addition, the
report will be available at no charge on GAO's Web site at [hyperlink,
http://www.gao.gov].
If you or your staff have any questions about this report, please
contact me 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 report. GAO staff who made major contributions
to this report are listed in appendix III.
Sincerely yours,
Signed by:
Cynthia A. Bascetta:
Director, Health Care:
[End of section]
Appendix I: Characteristics of Selected Hospitals with MRSA-Reduction
Initiatives:
Albany Medical Center;
Location: Albany, NY;
Beds: 599;
Teaching hospital[A]: Yes;
Size of Metropolitan Area[B]: 2;
Census region: Middle Atlantic.
Barnes-Jewish Hospital;
Location: Saint Louis, MO;
Beds: 1,183;
Teaching hospital[A]: Yes;
Size of Metropolitan Area[B]: 1;
Census region: West North Central.
Beth Israel Medical Center;
Location: New York, NY;
Beds: 794;
Teaching hospital[A]: Yes;
Size of Metropolitan Area[B]: 1;
Census region: Middle Atlantic.
Centra, Lynchburg General and Virginia Baptist Hospitals;
Location: Lynchburg, VA;
Beds: 494;
Teaching hospital[A]: No;
Size of Metropolitan Area[B]: 3;
Census region: South Atlantic.
Eastern Idaho Regional Medical Center; Location: Idaho Falls, ID;
Beds: 289;
Teaching hospital[A]: No;
Size of Metropolitan Area[B]: 3;
Census region: Mountain.
Evanston Northwestern Healthcare;
Location: Evanston, IL;
Beds: 629;
Teaching hospital[A]: Yes;
Size of Metropolitan Area[B]: 1;
Census region: East North Central.
Pacific Hospital of Long Beach;
Location: Long Beach, CA;
Beds: 171;
Teaching hospital[A]: No;
Size of Metropolitan Area[B]: 1;
Census region: Pacific.
Pitt County Memorial Hospital;
Location: Greenville, NC;
Beds: 761;
Teaching hospital[A]: Yes;
Size of Metropolitan Area[B]: 3;
Census region: South Atlantic.
Medical University of South Carolina;
Location: Charleston, SC;
Beds: 596;
Teaching hospital[A]: Yes;
Size of Metropolitan Area[B]: 2;
Census region: South Atlantic.
Mercy Medical Center;
Location: Cedar Rapids, IA;
Beds: 318;
Teaching hospital[A]: No;
Size of Metropolitan Area[B]: 3;
Census region: West North Central.
Newark Beth Israel Medical Center;
Location: Newark, NJ;
Beds: 407;
Teaching hospital[A]: Yes;
Size of Metropolitan Area[B]: 1;
Census region: Middle Atlantic.
Rochester General Hospital;
Location: Rochester, NY;
Beds: 492;
Teaching hospital[A]: No;
Size of Metropolitan Area[B]: 1;
Census region: Middle Atlantic.
Wake Forest University Baptist Medical Center;
Location: Winston-Salem, NC;
Beds: 953;
Teaching hospital[A]: Yes;
Size of Metropolitan Area[B]: 2;
Census region: South Atlantic.
University of Pittsburgh Medical Center;
Location: Pittsburgh, PA;
Beds: 1,492;
Teaching hospital[A]: Yes;
Size of Metropolitan Area[B]: 1;
Census region: Middle Atlantic.
Sources: American Hospital Association, U.S. Census Bureau, Association
of American Medical Colleges, U.S. Department of Agriculture.
[A] Hospitals were designated as teaching hospitals if they were
members of the Association of American Medical Colleges' Council of
Teaching Hospitals and Health Systems.
[B] All hospitals were located in metropolitan counties according to
the Economic Research Service of the U.S. Department of Agriculture,
using the rural-urban continuum codes defined by the U.S. Census
Bureau. The codes break down as follows: 1= Counties in metropolitan
areas of 1 million population or more; 2= Counties in metropolitan
areas of 250,000 to 1 million population; and 3= Counties in
metropolitan areas of fewer than 250,000 population.
[End of table]
[End of section]
Appendix II: Changes Made by Selected Hospitals with MRSA-Reduction
Initiatives:
Table 7: Hand Hygiene Changes by Selected Hospitals with MRSA-Reduction
Initiatives:
Albany Medical Center;
Hand hygiene compliance audits: [Check];
Enhanced staff training or public education campaigns: [Check];
Increased number of dispensers of alcohol-based hand sanitizer:
[Check];
Monitor consumption of hand hygiene products: [Empty].
Barnes-Jewish Hospital;
Hand hygiene compliance audits: [Check];
Enhanced staff training or public education campaigns: [Check];
Increased number of dispensers of alcohol-based hand sanitizer:
[Empty];
Monitor consumption of hand hygiene products: [Empty].
Beth Israel Medical Center;
Hand hygiene compliance audits: [Check];
Enhanced staff training or public education campaigns: [Check];
Increased number of dispensers of alcohol-based hand sanitizer:
[Empty];
Monitor consumption of hand hygiene products: [Empty].
Centra, Lynchburg General and Virginia Baptist Hospitals;
Hand hygiene compliance audits: [Check];
Enhanced staff training or public education campaigns: [Empty];
Increased number of dispensers of alcohol-based hand sanitizer:
[Empty];
Monitor consumption of hand hygiene products: [Empty].
Eastern Idaho Regional Medical Center;
Hand hygiene compliance audits: [Check];
Enhanced staff training or public education campaigns: [Check];
Increased number of dispensers of alcohol-based hand sanitizer:
ò[Check];
Monitor consumption of hand hygiene products: [Check].
Evanston Northwestern Healthcare;
Hand hygiene compliance audits: [Check];
Enhanced staff training or public education campaigns: [Empty];
Increased number of dispensers of alcohol-based hand sanitizer:
[Empty];
Monitor consumption of hand hygiene products: [Empty].
Pacific Hospital of Long Beach; Hand hygiene compliance audits:
[Empty];
Enhanced staff training or public education campaigns: [Check];
Increased number of dispensers of alcohol-based hand sanitizer:
[Empty];
Monitor consumption of hand hygiene products: [Empty].
Pitt County Memorial Hospital;
Hand hygiene compliance audits: [Check];
Enhanced staff training or public education campaigns: [Empty];
Increased number of dispensers of alcohol-based hand sanitizer:
[Empty];
Monitor consumption of hand hygiene products: [Empty].
Medical University of South Carolina; Hand hygiene compliance audits:
[Empty];
Enhanced staff training or public education campaigns: [Check];
Increased number of dispensers of alcohol-based hand sanitizer:
[Empty];
Monitor consumption of hand hygiene products: [Empty].
Mercy Medical Center; Hand hygiene compliance audits: [Check];
Enhanced staff training or public education campaigns: [Empty];
Increased number of dispensers of alcohol-based hand sanitizer:
[Empty];
Monitor consumption of hand hygiene products: [Empty].
Newark Beth Israel Medical Center; Hand hygiene compliance audits:
[Check];
Enhanced staff training or public education campaigns: [Empty];
Increased number of dispensers of alcohol-based hand sanitizer:
[Check];
Monitor consumption of hand hygiene products: [Check].
Rochester General Hospital; Hand hygiene compliance audits: [Empty];
Enhanced staff training or public education campaigns: [Check];
Increased number of dispensers of alcohol-based hand sanitizer:
[Check];
Monitor consumption of hand hygiene products: [Empty].
Wake Forest University Baptist Medical Center;
Hand hygiene compliance audits: [Check];
Enhanced staff training or public education campaigns: [Empty];
Increased number of dispensers of alcohol-based hand sanitizer:
[Empty];
Monitor consumption of hand hygiene products: [Empty].
University of Pittsburgh Medical Center;
Hand hygiene compliance audits: [Check];
Enhanced staff training or public education campaigns: [Check];
Increased number of dispensers of alcohol-based hand sanitizer:
[Check];
Monitor consumption of hand hygiene products: [Empty].
[End of table]
Source: GAO analysis of survey and site visit data.
Table 8: Contact Precaution Changes by Selected Hospitals with MRSA-
Reduction Initiatives:
Albany Medical Center;
Required gown & gloves for contact with MRSA-positive patients and
their environment: [Check];
Isolation cart/supply holder: [Empty];
Mask required when in contact with MRSA-positive patient: [Empty];
Room entrance signs or checklists to remind staff of MDRO patient:
[Empty];
Enhanced staff training or public awareness campaigns: [Empty];
MRSA-positive patients in private rooms or cohorted: [Check];
Contact precaution compliance audits: [Empty].
Barnes-Jewish Hospital;
Required gown & gloves for contact with MRSA-positive patients and
their environment: [Empty];
Isolation cart/supply holder: [Check];
Mask required when in contact with MRSA-positive patient: [Empty];
Room entrance signs or checklists to remind staff of MDRO patient:
[Empty];
Enhanced staff training or public awareness campaigns: [Check];
MRSA-positive patients in private rooms or cohorted: [Check];
Contact precaution compliance audits: [Check].
Beth-Israel Medical Center;
Required gown & gloves for contact with MRSA-positive patients and
their environment: [Empty];
Isolation cart/supply holder: [Empty];
Mask required when in contact with MRSA-positive patient: [Empty];
Room entrance signs or checklists to remind staff of MDRO patient:
[Check]; Enhanced staff training or public awareness campaigns:
[Check];
MRSA-positive patients in private rooms or cohorted: [Check];
Contact precaution compliance audits: [Check].
Centra, Lynchburg General and Virginia Baptist Hospitals;
Required gown & gloves for contact with MRSA-positive patients and
their environment: [Empty];
Isolation cart/supply holder: [Empty];
Mask required when in contact with MRSA-positive patient: [Empty];
Room entrance signs or checklists to remind staff of MDRO patient:
[Empty];
Enhanced staff training or public awareness campaigns: [Empty];
MRSA-positive patients in private rooms or cohorted: [Check];
Contact precaution compliance audits: [Check].
Eastern Idaho Regional Medical Center; Required gown & gloves for
contact with MRSA-positive patients and their environment: [Check];
Isolation cart/supply holder: [Empty];
Mask required when in contact with MRSA-positive patient: [Check];
Room entrance signs or checklists to remind staff of MDRO patient:
[Empty];
Enhanced staff training or public awareness campaigns: [Check];
MRSA-positive patients in private rooms or cohorted: [Check];
Contact precaution compliance audits: [Empty].
Evanston Northwestern Healthcare;
Required gown & gloves for contact with MRSA-positive patients and
their environment: [Empty];
Isolation cart/supply holder: [Check];
Mask required when in contact with MRSA-positive patient: [Empty];
Room entrance signs or checklists to remind staff of MDRO patient:
[Check];
Enhanced staff training or public awareness campaigns: [Empty];
MRSA-positive patients in private rooms or cohorted: [Check];
Contact precaution compliance audits: [Empty].
Pacific Hospital of Long Beach;
Required gown & gloves for contact with MRSA-positive patients and
their environment: [Empty];
Isolation cart/supply holder: [Empty];
Mask required when in contact with MRSA-positive patient: [Empty];
Room entrance signs or checklists to remind staff of MDRO patient:
[Empty];
Enhanced staff training or public awareness campaigns: [Empty];
MRSA-positive patients in private rooms or cohorted: [Check];
Contact precaution compliance audits: [Empty].
Pitt County Memorial Hospital;
Required gown & gloves for contact with MRSA-positive patients and
their environment: [Empty];
Isolation cart/supply holder: [Empty];
Mask required when in contact with MRSA-positive patient: [Empty];
Room entrance signs or checklists to remind staff of MDRO patient:
[Empty];
Enhanced staff training or public awareness campaigns: [Empty];
MRSA-positive patients in private rooms or cohorted: [Check];
Contact precaution compliance audits: [Empty].
Medical University of South Carolina;
Required gown & gloves for contact with MRSA-positive patients and
their environment: [Empty];
Isolation cart/supply holder: [Empty];
Mask required when in contact with MRSA-positive patient: [Empty];
Room entrance signs or checklists to remind staff of MDRO patient:
[Empty];
Enhanced staff training or public awareness campaigns: [Empty];
MRSA-positive patients in private rooms or cohorted: [Check];
Contact precaution compliance audits: [Empty].
Mercy Medical Center;
Required gown & gloves for contact with MRSA-positive patients and
their environment: [Empty];
Isolation cart/supply holder: [Empty];
Mask required when in contact with MRSA-positive patient: [Empty];
Room entrance signs or checklists to remind staff of MDRO patient:
[Empty];
Enhanced staff training or public awareness campaigns: [Empty];
MRSA-positive patients in private rooms or cohorted: [Check];
Contact precaution compliance audits: [Empty].
Newark Beth Israel Medical Center;
Required gown & gloves for contact with MRSA-positive patients and
their environment: [Empty];
Isolation cart/supply holder: [Empty];
Mask required when in contact with MRSA-positive patient: [Empty];
Room entrance signs or checklists to remind staff of MDRO patient:
[Empty];
Enhanced staff training or public awareness campaigns: [Empty];
MRSA-positive patients in private rooms or cohorted: [Check];
Contact precaution compliance audits: [Empty].
Rochester General Hospital;
Required gown & gloves for contact with MRSA-positive patients and
their environment: [Empty];
Isolation cart/supply holder: [Empty];
Mask required when in contact with MRSA-positive patient: [Empty];
Room entrance signs or checklists to remind staff of MDRO patient:
[Empty];
Enhanced staff training or public awareness campaigns: [Check];
MRSA-positive patients in private rooms or cohorted: [Check];
Contact precaution compliance audits: [Check].
Wake Forest University Baptist Medical Center;
Required gown & gloves for contact with MRSA-positive patients and
their environment: [Check];
Isolation cart/supply holder: [Empty];
Mask required when in contact with MRSA-positive patient: [Empty];
Room entrance signs or checklists to remind staff of MDRO patient:
[Empty];
Enhanced staff training or public awareness campaigns: [Empty];
MRSA-positive patients in private rooms or cohorted: [Check];
Contact precaution compliance audits: [Check].
University of Pittsburgh Medical Center;
Required gown & gloves for contact with MRSA-positive patients and
their environment: [Check];
Isolation cart/supply holder: [Check];
Mask required when in contact with MRSA-positive patient: [Check];
Room entrance signs or checklists to remind staff of MDRO patient:
[Check];
Enhanced staff training or public awareness campaigns: [Check];
MRSA-positive patients in private rooms or cohorted: [Check];
Contact precaution compliance audits: [Check].
[End of table]
Source: GAO analysis of survey and site visit data.
Table 9: Environmental Cleaning Changes by Selected Hospitals with MRSA-
Reduction Initiatives:
Albany Medical Center;
Checklist or electronic notification system for housekeeping staff:
[Check];
Environmental cleaning compliance audits: [Empty];
Enhanced training: [Empty]; Change curtains: [Empty];
Enhanced cleaning of hospital environment or patient equipment:
[Empty];
Dedicated equipment for MRSA-positive patients: [Empty].
Barnes-Jewish Hospital;
Checklist or electronic notification system for housekeeping staff:
[Empty];
Environmental cleaning compliance audits: [Empty];
Enhanced training: [Empty]; Change curtains: [Empty];
Enhanced cleaning of hospital environment or patient equipment:
[Empty];
Dedicated equipment for MRSA-positive patients: [Empty].
Beth Israel Medical Center;
Checklist or electronic notification system for housekeeping staff:
[Check];
Environmental cleaning compliance audits: [Check];
Enhanced training: [Check];
Change curtains: [Empty];
Enhanced cleaning of hospital environment or patient equipment:
[Check];
Dedicated equipment for MRSA-positive patients: [Empty].
Centra, Lynchburg General and Virginia Baptist Hospitals;
Checklist or electronic notification system for housekeeping staff:
[Empty];
Environmental cleaning compliance audits: [Empty];
Enhanced training: [Empty];
Change curtains: [Empty];
Enhanced cleaning of hospital environment or patient equipment:
[Empty];
Dedicated equipment for MRSA-positive patients: [Empty].
Eastern Idaho Regional Medical Center;
Checklist or electronic notification system for housekeeping staff:
[Empty];
Environmental cleaning compliance audits: [Check];
Enhanced training: [Check];
Change curtains: [Empty];
Enhanced cleaning of hospital environment or patient equipment:
[Empty];
Dedicated equipment for MRSA-positive patients: [Empty].
Evanston Northwestern Healthcare;
Checklist or electronic notification system for housekeeping staff:
[Empty];
Environmental cleaning compliance audits: [Empty];
Enhanced training: [Empty];
Change curtains: [Empty];
Enhanced cleaning of hospital environment or patient equipment:
[Empty];
Dedicated equipment for MRSA-positive patients: [Empty].
Pacific Hospital of Long Beach;
Checklist or electronic notification system for housekeeping staff:
[Empty];
Environmental cleaning compliance audits: [Empty];
Enhanced training: [Check];
Change curtains: [Empty];
Enhanced cleaning of hospital environment or patient equipment:
[Empty];
Dedicated equipment for MRSA-positive patients: [Empty].
Pitt County Memorial Hospital;
Checklist or electronic notification system for housekeeping staff:
[Empty];
Environmental cleaning compliance audits: [Empty];
Enhanced training: [Empty];
Change curtains: [Empty];
Enhanced cleaning of hospital environment or patient equipment:
[Empty];
Dedicated equipment for MRSA-positive patients: [Empty].
Medical University of South Carolina;
Checklist or electronic notification system for housekeeping staff:
[Empty];
Environmental cleaning compliance audits: [Empty];
Enhanced training: [Empty];
Change curtains: [Empty];
Enhanced cleaning of hospital environment or patient equipment:
[Empty];
Dedicated equipment for MRSA-positive patients: [Empty].
Mercy Medical Center;
Checklist or electronic notification system for housekeeping staff:
[Empty];
Environmental cleaning compliance audits: [Check];
Enhanced training: [Empty];
Change curtains: [Empty];
Enhanced cleaning of hospital environment or patient equipment:
[Empty];
Dedicated equipment for MRSA-positive patients: [Empty].
Newark Beth Israel Medical Center;
Checklist or electronic notification system for housekeeping staff:
[Empty];
Environmental cleaning compliance audits: [Empty];
Enhanced training: [Empty];
Change curtains: [Empty];
Enhanced cleaning of hospital environment or patient equipment:
[Check];
Dedicated equipment for MRSA-positive patients: [Empty].
Rochester General Hospital;
Checklist or electronic notification system for housekeeping staff:
[Empty];
Environmental cleaning compliance audits: [Empty];
Enhanced training: [Empty];
Change curtains: [Empty];
Enhanced cleaning of hospital environment or patient equipment:
[Check];
Dedicated equipment for MRSA-positive patients: [Check].
Wake Forest University Baptist Medical Center;
Checklist or electronic notification system for housekeeping staff:
[Empty];
Environmental cleaning compliance audits: [Check];
Enhanced training: [Empty];
Change curtains: [Empty];
Enhanced cleaning of hospital environment or patient equipment:
[Check];
Dedicated equipment for MRSA-positive patients: [Empty].
University of Pittsburgh Medical Center;
Checklist or electronic notification system for housekeeping staff:
[Check];
Environmental cleaning compliance audits: [Empty];
Enhanced training: [Empty];
Change curtains: [Check];
Enhanced cleaning of hospital environment or patient equipment:
[Check];
Dedicated equipment for MRSA-positive patients: [Empty].
Source: GAO analysis of survey and site visit data.
[End of table]
Table 10: Antibiotic Stewardship Changes by Selected Hospitals with
MRSA-Reduction Initiatives:
Albany Medical Center;
Description:
* Antibiotic stewardship team;
* Electronic system to track antibiotic usage and evaluate
microorganism combinations;
* Reduced usage of certain antibiotics.
Barnes-Jewish Hospital;
Description: [Empty].
Beth Israel Medical Center;
Description: [Empty].
Centra, Lynchburg General and Virginia Baptist Hospitals;
Description: [Empty].
Eastern Idaho Regional Medical Center;
Description: [Empty].
Evanston Northwestern Healthcare;
Description:
* Tracking of mupirocin resistance;
* Removal by pharmacy of mupirocin ointment from authorized use for
anything other than decolonization to keep resistance under control;
* Tracking of utilization of vancomycin.
Pacific Hospital of Long Beach;
Description:
* Education;
* Implementation of the hospital antibiogram, which tests for the
sensitivity of isolated bacterial strains to different antibiotics.
Pitt County Memorial Hospital;
Description: [Empty].
Medical University of South Carolina;
Description: [Empty].
Mercy Medical Center;
Description: [Empty].
Newark Beth Israel Medical Center;
Description:
* Development of an antibiotic deescalation program;
* Introduction of an antibiotic substitution policy;
* Institution of antibiotic restriction requiring approval by an
infectious diseases specialist.
Rochester General Hospital;
Description:
* Monitor drug selection and duration and make recommendations based on
this review;
* In process of implementing an electronic surveillance system with
antibiotic monitoring capabilities.
Wake Forest University Baptist Medical Center;
Description:
* Two pharmacy positions dedicated to antibiotic stewardship;
* Physician dedicated to the prudent use of antibiotics.
University of Pittsburgh Medical Center;
Description: [Empty].
Source: GAO analysis of survey and site visit data.
[End of table]
Table 11: Decolonization Characteristics by Selected Hospitals with
MRSA-Reduction Initiatives:
Albany Medical Center;
All MRSA-positive patients identified through screening: Hospital
decolonizes these individuals;
Orthopedic surgery patients: Included within "All MRSA-positive
patients" category;
Cardiothoracic surgery patients: Included within "All MRSA-positive
patients" category;
Other: Included within "All MRSA-positive patients" category;
Health care workers: [Empty].
Barnes-Jewish Hospital;
All MRSA-positive patients identified through screening: [Empty];
Orthopedic surgery patients: [Empty];
Cardiothoracic surgery patients: [Empty];
Other: [Empty];
Health care workers: Hospital decolonizes these individuals[F].
Beth Israel Medical Center;
All MRSA-positive patients identified through screening: [Empty];
Orthopedic surgery patients: Hospital decolonizes these individuals;
Cardiothoracic surgery patients: Hospital decolonizes these
individuals;
Other: [Empty];
Health care workers: Hospital decolonizes these individuals[F].
Centra, Lynchburg General and Virginia Baptist Hospitals;
All MRSA-positive patients identified through screening: [Empty];
Orthopedic surgery patients: [Empty];
Cardiothoracic surgery patients: [Empty];
Other: Hospital decolonizes these individuals[B];
Health care workers: [Empty].
Eastern Idaho Regional Medical Center;
All MRSA-positive patients identified through screening: Hospital
decolonizes these individuals;
Orthopedic surgery patients: Included within "All MRSA-positive
patients" category;
Cardiothoracic surgery patients: Included within "All MRSA-positive
patients" category;
Other: Included within "All MRSA-positive patients" category;
Health care workers: Hospital decolonizes these individuals[F,G].
Evanston Northwestern Healthcare;
All MRSA-positive patients identified through screening: Hospital
decolonizes these individuals;
Orthopedic surgery patients: Included within "All MRSA-positive
patients" category;
Cardiothoracic surgery patients: Included within "All MRSA-positive
patients" category;
Other: Included within "All MRSA-positive patients" category;
Health care workers: [Empty].
Medical University of South Carolina;
All MRSA-positive patients identified through screening: [Empty];
Orthopedic surgery patients: [Empty];
Cardiothoracic surgery patients: [Empty];
Other: [Empty];
Health care workers: Hospital decolonizes these individuals[F].
Mercy Medical Center;
All MRSA-positive patients identified through screening: [Empty];
Orthopedic surgery patients: Hospital decolonizes these individuals;
Cardiothoracic surgery patients: [Empty];
Other: [Empty];
Health care workers: [Empty].
Newark Beth Israel Medical Center;
All MRSA-positive patients identified through screening: Hospital
decolonizes these individuals;
Orthopedic surgery patients: Included within "All MRSA-positive
patients" category;
Cardiothoracic surgery patients: Included within "All MRSA-positive
patients" category;
Other: Included within "All MRSA-positive patients" category;
Health care workers: Hospital decolonizes these individuals[F].
Pacific Hospital of Long Beach;
All MRSA-positive patients identified through screening: Hospital
decolonizes these individuals;
Orthopedic surgery patients: Included within "All MRSA-positive
patients" category;
Cardiothoracic surgery patients: Included within "All MRSA-positive
patients" category;
Other: Included within "All MRSA-positive patients" category[C];
Health care workers: [Empty].
Pitt County Memorial Hospital;
All MRSA-positive patients identified through screening: Hospital
decolonizes these individuals;
Orthopedic surgery patients: Included within "All MRSA-positive
patients" category;
Cardiothoracic surgery patients: Included within "All MRSA-positive
patients" category;
Other: Included within "All MRSA-positive patients" category;
Health care workers: Hospital decolonizes these individuals[H].
Rochester General Hospital;
All MRSA-positive patients identified through screening: [Empty];
Orthopedic surgery patients: [Empty];
Cardiothoracic surgery patients: Hospital decolonizes these
individuals[A];
Other: [Empty];
Health care workers: [Empty].
Wake Forest University Baptist Medical Center;
All MRSA-positive patients identified through screening: [Empty];
Orthopedic surgery patients: [Empty];
Cardiothoracic surgery patients: [Empty];
Other: Hospital decolonizes these individuals[D];
Health care workers: [Empty].
University of Pittsburgh Medical Center;
All MRSA-positive patients identified through screening: [Empty];
Orthopedic surgery patients: [Empty];
Cardiothoracic surgery patients: [Empty];
Other: Hospital decolonizes these individuals[E];
Health care workers: Hospital decolonizes these individuals[F].
Source: GAO analysis of survey and site visit data.
Notes:
[A] All cardiothoracic surgery patients, including those who have not
tested positive for MRSA, receive decolonization therapy. Mupirocin
ointment is also applied to chest tube sites when removing chest tubes.
[B] MRSA-positive patients scheduled to undergo implant procedures are
decolonized.
[C] All patients admitted to hospital undergo skin decolonization plus
daily cleansing.
[D] Newly colonized patients are decolonized. Patients with a history
of MRSA are decolonized at a physician's request.
[E] Patients are decolonized only if they request it and if the
physician believes that decolonization is reasonable.
[F] Health care workers are decolonized if identified as MRSA-positive
as part of an outbreak investigation.
[G] All newly hired health care workers are screened and decolonized if
positive.
[H] Health care workers are provided voluntary MRSA screening at annual
physical, and MRSA decolonization is offered at no charge for those who
test positive.
[End of table]
[End of section]
Appendix III" GAO Contact and Staff Acknowledgments:
GAO Contact:
Cynthia A. Bascetta at (202) 512-7114 or bascettac@gao.gov:
Acknowledgments:
In addition to the contact named above, key contributors to this report
were Nancy Edwards, Assistant Director; Donald Brown; Eric Peterson;
Andrea E. Richardson; Shannon Slawter Legeer; and Timothy Walker.
[End of section]
Footnotes:
[1] MDROs develop resistance to antimicrobial drugs when bacteria
change or adapt in a way that allows them to survive in the presence of
antibiotics designed to kill them. In some cases, bacteria become
resistant to all available antibiotics.
[2] Although named for its resistance to methicillin, MRSA is also
resistant to a large group of commonly prescribed antibiotics.
[3] R.M. Klevens et al., "Changes in the Epidemiology of Methicillin-
Resistant Staphylococcus aureus in Intensive Care Units in US
Hospitals, 1992-2003," Clinical Infectious Diseases, 2006, 42:389-91.
These trends are based on data from 1,268 ICUs in 337 U.S. hospitals.
[4] 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.: Mar. 31, 2008).
[5] The HAI public reporting system in Arkansas does not require
hospitals to report data to the state and will report only aggregate
data on HAIs to the public. Nevada and Nebraska will not report any HAI
data publicly. Utah has begun to collect HAI data from hospitals, but
has not yet decided whether it will report these data to the public.
Ohio requires hospitals to report quality data publicly, but did not
include HAI measures in its initial set of measures. An advisory
committee convened to consider and possibly recommend HAI measures for
inclusion. Its final report was expected in August 2008.
[6] In several instances, including the two site visits we conducted,
the MRSA-reduction initiative applied to multiple hospitals that
belonged to the same hospital system. Because our analysis of MRSA-
reduction initiatives examined the variation across the different
initiatives, we use the term hospital in the following discussion to
refer to the single or multiple facilities that adopted a particular
MRSA-reduction initiative.
[7] The term HAI is often used synonymously with hospital-acquired
infection and nosocomial infection. HAIs are distinct from community-
acquired infections, which are infections that were transmitted to
patients prior to their admission to a hospital or other health care
facility.
[8] Central lines are intravenous lines inserted into a large vein
typically in the neck or near the heart.
[9] To be eligible for payment under the Medicare and Medicaid
programs, hospitals must comply with HHS-established health and safety
standards, known as conditions of participation (COP), which include a
COP for infection control. Many hospitals meet this requirement through
accreditation by the Joint Commission.
[10] IHI is an independent, nonprofit organization that works to
improve the quality of health care.
[11] Hand hygiene is a general term that applies to handwashing,
antiseptic handwash, antiseptic hand rub, or surgical hand antisepsis.
Environmental cleaning refers to the disinfection of environmental
surfaces and equipment for infection control efforts in hospitals.
[12] H.T. Stelfox et al., "Safety of Patients Isolated for Infection
Control," Journal of the American Medical Association (Oct. 8, 2003)
290:14, 1899-1905; see also K.B. Kirkland & J.M. Weinstein, "Adverse
effects of contact isolation" (Oct. 2, 1999) The Lancet, 354, 1177-
1178; S. Saint et al., "Do physicians examine patients in contact
isolation less frequently? A brief report," American Journal of
Infection Control, 31:6 (October 2003) 354-356.
[13] These costs do not include laboratory overhead and personnel costs.
[14] J.D. Siegel et al., Management of Multidrug-Resistant Organisms in
Healthcare Settings, 2006, downloaded from [hyperlink,
http://www.cdc.gov/ncidod/dhqp/guidelines.html] on Jun. 5, 2007.
[15] See, CDC/NHSN Surveillance Definition of Health Care-Associated
Infection and Criteria for Specific Types of Infections in the Acute
Care Setting [hyperlink,
http://www.cdc.gov/ncidod/dhqp/nhsn_documents.html] and CDC, The
National Healthcare Safety Network (NHSN) Manual: Patient Safety
Component Protocol, Division of Healthcare Quality Promotion, National
Center for Infectious Diseases (Atlanta, Ga.: updated January 2008).
[16] See [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-283] for
a description of this process.
[17] The NHSN allows hospitals to identify and report HAIs that fall
into any of the other 13 categories of HAIs for which CDC has developed
definitions but without specific data collection protocols.
[18] The CMS and CDC are represented on the SCIP steering committee,
along with such groups as the American College of Surgeons, the
American Hospital Association, the American Society of
Anesthesiologists, the Institute for Healthcare Improvement, and the
Joint Commission.
[19] This Web site can be accessed at [hyperlink,
http://www.hospitalcompare.hhs.gov]. Since 2004, hospitals' submission
of data for a series of process measures has been part of the Medicare
hospital inpatient prospective payment system (IPPS). In addition, CMS
issued a final rule stating that, effective October 1, 2008, hospitals
would no longer receive higher payment under IPPS for eight preventable
outcomes, including three HAIs. See 72 Fed. Reg. 47200, 47217-8 (Aug.
22, 2007).
[20] NQF, "National Voluntary Consensus Standards for the Reporting of
Healthcare-Associated Infection Data" (Washington, D.C.: 2008). NQF is
a voluntary standard-setting, consensus-building organization
representing providers, consumers, purchasers, and researchers.
[21] NQF recently requested that CDC consider revising its definitions
for these two measures. See NQF, "National Voluntary Consensus
Standards for the Reporting of Healthcare-Associated Infection Data,"
p. 12.
[22] AHRQ is an HHS agency that conducts and funds research to promote
more effective and higher quality care.
[23] Florida selected the antibiotics administered prior to surgery
process measures, and Oklahoma selected rates for central line-
associated BSIs and VAP.
[24] A number of these states use other systems to collect data for
measures not incorporated into NHSN, such as the SCIP measures on
antibiotics administered prior to surgery.
[25] Although participation in the NHSN is, from a federal perspective,
voluntary on the part of hospitals, and the confidentiality of the data
they submit is protected by law, the mandatory state reporting programs
require hospitals in those states to enroll in the NHSN and to
authorize access to their data by state officials through the group
feature in NHSN.
[26] CDC researchers did conduct one pilot study in the mid-1990s that
examined the accuracy of HAI reporting at nine hospitals participating
in the voluntary NNIS system that preceded NHSN. In general they found
that the patients that the hospitals reported as having HAIs did have
them, but that an additional number of patients had HAIs that were not
reported to NNIS. The extent of underreporting varied by type of
infection, lower for BSIs and higher for UTIs, for example. The
researchers concluded that "Data integrity is essential and can be
accomplished only when an ongoing and objective method to assess the
quality of the data is included as an integral part of the surveillance
system." See T.G. Emori et al., "Accuracy of Reporting Nosocomial
Infections in Intensive-Care-Unit Patients to the National Nosocomial
Infections Surveillance System: A Pilot Study," Infection Control and
Hospital Epidemiology, 19 (May 1998) 308-316.
[27] The seven states are Colorado, Connecticut, Maryland, New
Hampshire, Oregon, Texas, and Washington.
[28] CMS developed this "present on admission" (POA) indicator to
identify hospital-acquired conditions. All hospitals paid under
Medicare's IPPS must attach this indicator to the diagnosis codes that
they submit with their claims. Certain hospitals that Medicare pays
outside of the IPPS, such as critical access hospitals, are not subject
to this CMS requirement, but Illinois requires all hospitals to report
the POA code.
[29] There are NHSN protocols for central line-associated BSIs, VAP,
catheter-associated UTIs, SSIs, and postprocedure pneumonia.
[30] Several other states require hospitals and other providers to
report only suspected cases of community-associated MRSA.
[31] Some states focus their reporting requirement on cases of invasive
MRSA. The frequency of reporting varies from within 12 hours of
identification in Connecticut to semiannually in Maine.
[32] Pennsylvania's original data collection system recorded each
instance where hospitals found a patient had an HAI. However, it did
not collect information on the number of patients at risk of developing
comparable HAIs, information which the NHSN collects in order to risk
adjust its results. In 2007 the Pennsylvania legislature passed a law
that mandated adoption of NHSN for HAI data collection.
[33] We do not know the extent to which hospitals already had in place
extensive policies for contact precautions, environmental cleaning, or
antibiotic stewardship. We asked hospitals to report changes they made
to these policies for their MRSA-reduction initiatives.
[34] One of these hospitals reported that it included the use of masks
because their use may help prevent health care staff from being
colonized with MRSA in their nasal passages, a common site of MRSA
colonization. However, a hospital official noted that the use of masks
has not been adequately studied.
[35] UPMC and ENH began implementing their MRSA-reduction initiatives
in January 2002 and February 2003, respectively.
[36] ENH is a 3-hospital system located on separate campuses in
Chicago's northern suburbs. All 3 hospitals primarily function as
community hospitals with many surgical and long-term care patients and
relatively few ICU patients. UPMC is a 20-hospital system, largely
located in the Pittsburgh metropolitan area but with some hospitals
scattered across Western Pennsylvania. One of the UPMC hospitals is
Presbyterian Hospital, a large academic medical center with a
substantial number of ICUs and ICU patients. Some of the other
hospitals in the UPMC system function more as community hospitals.
[37] In addition to testing patients for MRSA on admission to the
selected units, UPMC tested them again (unless they had already tested
positive) once a week while on the unit and at the time of discharge
from the unit. UPMC made it easier to ensure that patients were tested
weekly by testing all patients in the unit on the same day of the week,
rather than counting 7 days from each patient's admission date.
[38] In 2003, ENH converted all its patient medical records to an EMR
system. Paper records received from other facilities were scanned and
converted into electronic documents, allowing ENH to become a
completely "paperless" facility.
[39] The prevalence survey determined the number of patients across all
units of the three ENH hospitals who were colonized with MRSA at a
particular point in time.
[40] This contrasted with a report published the previous year that 2.7
percent of patients admitted to Emory University Hospital were MRSA-
positive. J.A. Jernigan et al., "Prevalence of and Risk Factors for
Colonization with Methicillin-Resistant Staphylococcus Aureus at the
Time of Hospital Admission," Infection Control and Hospital
Epidemiology, 24:6 (June 2003) 409-14.
[41] Financial experts at ENH constructed an internal database that
recorded actual costs associated with individual chargable items and
procedures going back to fiscal year 2005. They used these data to
assess the net costs of treating patients with MRSA infections, after
taking account of any higher payments received, compared to the costs
of treating comparable patients who did not have MRSA infections. These
analyses found that ENH absorbed a net cost of approximately $10,000
for each patient with a MRSA-related respiratory infection and a net
cost of $19,000 for each patient with a MRSA-related bloodstream
infection.
[42] Individual PCR tests require only about 2 to 4 hours to produce a
result, but it takes additional time to transport specimens to the
laboratory site and it is more efficient to conduct the tests in
batches.
[43] UPMC officials estimated that the total cost, including testing,
for the first year of the initiative was just over $62,000.
[44] P.W. Stone et al., "A Systematic Audit of Economic Evidence
Linking Nosociomial Infections and Infection Control Interventions:
1990-2000," American Journal of Infection Control, 30 (2002) 145-52.
[End of section]
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