Train or roller coaster? ICPs have caught up on public reporting, can they hold on?
ICPs have gained political access, had voices heard
The explosion of infection rate disclosure laws in recent years caught the health care epidemiology community so off guard, the metaphor used at many early meetings on the phenomenon was that "the train has left the station." The immediate concern was that bad laws — labor-intensive with little clinical benefit — were going to be on the books in a slew of states before infection control professionals could get a seat at the legislative table.
To be sure, the issue still has plenty of momentum, but the runaway train analogy appears to be fading as ICPs have managed to scramble on board, gain political access and get their voices heard.
"What we're trying to do is make sure that people don't go off the deep end with all of this. You can do as much harm as good," says Eddie Hedrick, BS, MT(ASCP), CIC, emerging infections coordinator at the Missouri state health department and one of the principals involved in developing that state's favorably viewed rate-disclosure legislation. A former hospital-based ICP, Hedrick said the national hue and cry over infection rate disclosure laws is yet another in a series of storms the field has weathered over the years. Train? It's more like a roller coaster.
"All of this national attention — in one respect, some of it is unrealistic and inappropriate, but it also is causing everybody to take a look at infection control," he says. "If you've been around long enough, you know this is like a roller coaster. You have years where everybody begins harping and screaming, then it goes away, then suddenly everybody is up in arms again."
In the relative calm before that next steep plunge, Hedrick and national colleagues have not been idle. Trying to bring both salience and common sense to the public reporting issue, they have honed the essentials of the controversial issue down to a "tool kit" that can be referenced by both ICPs and legislators. The kit was created by a working group that includes members from the Association for Professionals in Infection Control and Epidemiology, the Centers for Disease Control and Prevention, the Council of State and Territorial Epidemiologists, and the Society for Healthcare Epidemiology of America. The tool kit provides guidance on the components necessary for a meaningful reporting system in order to assist states and health care facilities facing legislative mandates.
"It's intended for a broad audience, but primarily for legislators and for the hospital epidemiology and infection prevention community that is talking to the legislators [about proposed laws]," says Shannon Oriola, RN, CIC, lead ICP at Sharp Memorial Hospital in San Diego, and a member of the panel that developed the tool kit. "It helps focus on where the research shows you can get the most benefit if you are going to go with public reporting. Transparency can be helpful if it is done in a meaningful scientific manner, and I think this tool kit supports that premise."
Beware unintended consequences
Indeed, proponents of public reporting of health care infections argue that public reporting will promote hospital competition and stimulate quality improvement efforts to improve patient outcomes. However, the tool kit working group also warned about the "unintended consequences" of public reporting. Those include avoiding care of sicker patients to improve outcomes and focusing on a "rate" rather than on prevention of health care associated infections (HAIs). Part of the solution suggested in the tool kit is a focus on a few critical items selected by experts rather than generating data on all manner of infections. In that regard, it's no secret that many ICPs think that Pennsylvania — the first state to adopt a public reporting law — is requiring too many infections to be reported.
"If you look at Pennsylvania — where they are reporting everything under the sun — that is a problem," says Raymond Chinn, MD, hospital epidemiologist at Sharp Memorial Hospital in San Diego, and a member of the working group. "We tried very hard in this tool kit to direct legislative bodies to look at what is proposed by the experts. There is nothing to say that as we gain more knowledge and the science gets better defined that we can't broaden the scope of public reporting. But right now, as it stands, the document outlines what we think are the salient features for something like this."
To avoid unintended consequences and create meaningful comparisons, states and health care facilities must ensure that the data being collected meet standards set by professionals in infection prevention and epidemiology, the workgroup recommended. Moreover, the definitions of selected outcomes measures should not require subjective interpretation. In addition, varying degrees of patient acuity should be reflected by appropriate risk adjustment. The tool kit also includes recommendations for which indicator measures should be used for public reporting of HAIs. In addition to central line-associated bloodstream infections in the intensive care unit, the workgroup also addressed the controversial issue of tracking and reporting surgical site infections.
The tool kit essentially reaffirms principles outlined by the Centers for Disease Control and Prevention, referencing the recommendations by the CDC's Healthcare Infection Control Practices Advisory Committee and emphasizing the importance of CDC surveillance systems. Concerning the latter, the workgroup pointed to a critical future role for the CDC's National Healthcare Safety Network (NHSN), a web-based surveillance system for capturing data on adverse events (both infectious and noninfectious) associated with health care delivery. The NHSN can provide protocols, data collection forms, and data analysis comparing the user's rates with national aggregates, the workgroup noted. Many envision the creation of a national system eventually that will use the CDC's NHSN as its principal data base. In that regard, the National Quality Forum (NQF) is expected to release recommendations from its project on national voluntary consensus standards for the reporting of HAIs in the coming months.
"Many states are using the NHSN as part of their public reporting component," Oriola says. "The hope is that we can [make this] uniform so that the NQF is in line with the NHSN definitions. That's under discussion now and the [draft national standard] should be available for comment some time this spring."
Hedrick concurs, noting that "eventually there will be a national standard. When that happens, you will have to have a repository for that information. The odds are it will be the NHSN system. It is the most experienced, it is designed for what we are talking about, and it is free."
ICPs critical, but must have resources
Meanwhile, however, individual states are expected to continue development of their own laws. In doing so, planners first should identify a responsible state-level agency with expertise in infection prevention, risk adjustment issues, health care epidemiology, and assessment of statistical relevance, the workgroup recommended. "Studies have demonstrated that there is a significant discordance in the quality of data retrieved by those with training in infection prevention and control when compared to those with little or no training," the guidelines state.
That said, if ICPs are to be involved they must be given resources. Each institution must assess the scope of its infection prevention program to ensure that adequate resources are available for any additional surveillance activities needed to meet the legislative mandates of public reporting, the panel recommended. "In today's health care environment, in addition to their traditional roles, ICPs have expanded obligations in various aspects of health care delivery that include, but are not limited to, construction and renovation activities, employee and occupational health, bioterrorism and pandemic influenza preparation, disaster planning, and outpatient services," the working group stated. Additional personnel and resources must offset any further burden placed on ICPs by public reporting, the workgroup emphasized.
"That is a major problem because there are a lot of unfunded mandates by governments," Chinn says. "To make this as seamless as possible we really need to stress the importance of resources. We actually made that recommendation after Missouri came up with their public reporting initiative where they did devote money and more resources."
Indeed, the emphasis on additional resources in Missouri has translated to increased funding to meet the state's law. "We were able to talk our legislature into getting us money," Hedrick says. "In a lot of places this is an unfunded mandate. What we are finding in our system is that [hospitals] are hiring more people, giving them more resources and the [ICPs] that are there have gained some stature in their facilities. People are paying more attention to them. We've had many call to thank us and say they actually have a new practitioner on board so that they can do more."
Missouri recently issued its first infection rate data collected under the new law, reporting rates of central associated bloodstream infections risk stratified by intensive care unit per 1,000 central line days.
"You can pull up hospitals by region [on a computer], put in the kind of ICU you want to look at and it will show all the hospitals in that region that had those kind of ICUs," he says. "It shows how they did compared to other hospitals in the state. It shows how they did in their region and then to the national NHSN data. It's the best that out there so far because it is risk-adjusted."
Getting ICP buy-in key
The state's law was designed to be flexible so that changes can be made as data emerge. Any subsequent discussions in that direction are expected to be conducted in the collaborative atmosphere that marked the development of the state law, he says. "The advisory committee we put together is very inclusive and collaborative," he says. "It has not been an adversarial relationship — a them vs. us, the public vs. the hospitals. Both the legislatures and consumers who are on the committee have learned from one another. They have taught us a lot of things and we have taught them a lot of things."
From the onset, Hedrick worked to get buy-in from the infection control and hospital communities, which was considered critical if the effort was to be successful. "We went out in the field with all of these hospitals months and months ago to teach them how to use this system, get feedback from them and try to answer their questions before we even got started," he says. "These hospitals don't want to infect people on purpose. The one thing about our systems that makes it better than most is that the hospitals and the infection control community have been involved since day one, and they feel it's fair."
A perception of fairness is needed to ensure hospitals and ICPs are not tempted to "game" the system. That said, there are systems in place to detect any efforts to under-report or otherwise circumvent the system. "We have kind of a carrot and stick approach to this," he says. "If they do try to game us, we will catch them."
Encouraged by the positive work in progress underway in his own state, Hedrick has lost a little of his initial skepticism about the ultimate outcome of infection rate reporting laws. "In the beginning, I thought this was all for naught," he says. "I still don't know — and I don't think anybody does — whether this will be of any value to the public in the long run. The primary value to me is that once people know others are looking at things they have a tendency to tighten down the screws.
(Editor's note: The complete tool kit is available at the APIC website at www.apic.org.)