Anatomy of a compromise: Law meant to be flexible

Hospital group says ignore, state says regs required

A controversial health care worker screening provision in a recently enacted Pennsylvania law was intended as compromise language that would appease the governor's office while giving hospitals flexibility in complying, a state legislative official tells Hospital Infection Control. What resulted was mass confusion and open questions about how and if the measure can even be enforced.

"Based on the calls I am receiving from infection control people at various hospitals in Pennsylvania they are reading it in a way that it wasn't intended to be read. Which isn't a good thing. [It should be] clearer than that. The goal was not to require protocols that don't mesh with whatever the current state of the art is," says Michele Hansarick, executive director of the state Senate Public Health and Welfare Committee. Committee chairman Edwin B. Erickson, introduced the legislation.

The Pennsylvania law calls for hospitals to include in their infection control plans "procedures and protocols for staff who may have had potential exposure to a patient or resident known to be colonized or infected with MRSA or MDRO, including cultures and screenings, prophylaxis and follow-up care." Epidemiologists and infection control professionals immediately noted such policies run counter to guidance by the Centers for Disease Control and Prevention, which recommends screening health care workers for MRDOs only in the context of an outbreak or ongoing transmission.

Originally, Gov. Edward G. Rendell's office wanted all health care workers screened for MRSA as part of his Prescription for Pennsylvania plan. "The original [bill] called for universal screening of all health care workers," says Larry Clark, director of legislative affairs in the governor's office of health care reform. "However, during the negotiations it was determined that that would be quite an effort. [The goal was to detect] certain health care workers who have MRSA — who may be just carriers and have no outward signs of the infection — but may transmit it to patients. This was [intended as] a patient safety measure to try to identify those workers and treat them so patients wouldn't become infected."

As more and more states try to address MRSA in the nation's hospitals other laws may call for such universal screening approaches. Given the national attention MRSA infections are receiving, it may seem to be a relatively simple solution to an exceedingly complex problem. However, epidemiologists warn about a host of unintended consequences, including causing even more drug resistance in MRSA strains.

As epidemiologists made such points, the universal screening recommendation in Pennsylvania was dropped in favor of the political compromise language that is currently causing so much consternation. "When you do a law a lot of it is negotiation," Hansarick says. "The governor had wanted [universal] screening. We understood this was not what infection control professionals say that you do. Our goal was to make sure that hospitals have infection control plans that address the issue. So, for example, if you are not supposed to screen workers — if that is not state of the art — then that's what would be in your infection control plan."

The legislative intent was to provide flexibility, but she concedes it could be interpreted differently as enforcement measures are put in place. Well aware that such screening policies run counter to current CDC guidance, the state hospital association is simply telling facilities to reflect in their infection control plans that there are no such protocols or policies for routinely screening workers who may have "potential contact" with an MRSA patient.

"What we are trying to make the hospitals understand is that first and foremost it is only as it relates to those patients who have been 'confirmed' to be colonized," says Melissa Speck, director of policy development at the Hospital & Healthsystem Association of Pennsylvania. "Secondly, in terms of how you are going to address the culturing and screening of your own staff you can simply reflect that at this point in time there are no recommendations to follow. Certainly, we will revise the plan accordingly when such recommendations come out."

However, it appears such an approach will not be viewed favorably by the state health department, which is charged with translating the legislation into enforceable health codes.

"It is up to us to interpret the legislation and then put in requirements we think are reasonable, but I don't think we are in a position to say, 'No, we are not going to do it,'" says Steve Ostroff, MD, state epidemiologist. "We'll be working with various colleagues around the state to be able to determine the circumstances and the situations where such screening would be required."

Reminded that the CDC does not recommend the type of policy he is trying to hammer out, Ostroff said the state health department nevertheless must find some way to put state regulations into place.

"We have to follow what the legislation includes in terms of the requirements," he says. "It clearly indicates workers that have been exposed to either MRSA or other MDROs need to be screened. The rationale for that — well, I probably shouldn't attempt to define a rationale for why that is included in the bill. But the intent is likely that such workers could serve as a route of further transmission within an institution. The intent is MRSA [screening]. It's clearly in the bill."