Infection control surveys planned for hospitals

Is 'pay for prevention' on the horizon?

The Centers for Medicare and Medicaid Services (CMS), which is the single largest payer for healthcare in the United States, is creating a hospital inspection program focused specifically on infection control.

"We have a problem in this country with far too many infections and too many deaths due to infections in hospitals," said Daniel Schwartz, MD, MBA, chief medical officer of the Survey and Certification Group at CMS. "So what can we do to fix this? I don't think it's necessarily CMS alone that is going to fix this, but a hospital should be able to detect when they have a problem. They should have systems in place to recognize and fix those problems."

It doesn't take a great leap of imagination to see this fledging survey concept eventually morphing into CMS "pay for performance" requirements, though the program is being pitched initially as a non-punitive collaborative that can help hospitals improve quality. In the boldest move yet in its dramatically expanding oversight of infection prevention, CMS is planning to train a cadre of inspectors to assess basic infection control measures and follow single hospitalized patients using a "tracer" concept similar to that used by surveyors from The Joint Commission (TJC). The CMS program was discussed earlier this year at a meeting of the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention (CDC).

"Obviously, if we are writing regs and you are writing guidelines, we really want to be on the same page," Schwartz told the HICPAC panel. "We want this to have a major impact on infection control and help reduce healthcare associated infections."

There is a clear precedent for partnership. In the wake of continuing hepatitis outbreaks in ambulatory care settings — most of them linked to improper use of needles and medication vials — CMS worked with the CDC to create an infection control checklist to use for inspecting outpatient facilities. CMS inspectors would likely look for such breaches while assessing basics principles such as hand hygiene, barrier precautions, instrument processing and the like.

As discussed at the CDC meeting, the CMS will create a hospital infection prevention survey that will be reviewed by HICPAC and other key stakeholders and possibly will be opened for public comment. The survey will be "pre-tested" in selected participating hospitals, with an emphasis on using it as a self-assessment tool to improve infection control practices. In that sense, the CMS appears to be trying to launch this inspection process without incurring a lot of pushback from hospitals. For their part, infection preventionists are viewed as an important part of the process and could leverage the CMS involvement into upgraded program resources.

"We want to go into the hospitals and use [the survey] to see what works and what doesn't, get feedback and really make it better," Schwartz says. "In the end, we want everybody to be kind of happy with it. We want it to be, obviously, something the surveyors find to be useful, and we want it to be an assessment opportunity for the hospitals. We want them to be comfortable that if they do these things, not only will they do well on the surveys, but they might be able to [prevent more HAIs]."

Codifying CDC guidelines

With the death of 100,000 people annually due to HAIs, critics have been saying for years that the CMS should use its considerable influence on the hospital bottom-line to put some teeth in the CDC's voluntary infection control guidelines. However, Schwartz rejected that analogy in an interview with AHC Media, parent company of Same-Day Surgery.

He said CMS was charged to create the hospital inspection program as part of the newly formed Partnership with Patients. This recently announced federal, state, and private collaborative will focus on improving patient safety by reducing healthcare associated infections (HAIs) and other hospital-acquired conditions.

"[In terms of the] state of the art in the field I can't think of a better organization, and one that has a better reputation in infection control than the CDC, he says. "It really helps to have this working arrangement with them so that was our starting point [for this survey].

Schwartz said CMS officials have been considering taking this step anyway because the agency have been dealing with ambulatory surgery centers and has had conversations with CDC leaders about infection control issues.

Whatever the program's origin, the future result, possibly within the next nine months, could see CMS inspectors making fairly thorough visits to hospitals. "This will probably involve two surveyors over two days to do the assessment," Schwartz told HICPAC. "We are hoping to make this an easy to use tool that is highly effective."

While CMS usually comes into hospitals only to respond to specific complaints, the scale of the program discussed at the meeting would be much more ambitious in terms of oversight and routine inspection. "When CMS goes into hospitals most of the time the reason is a compliance investigation and we do maybe 4,000 to 5,000 of those, but that's a very limited survey," he said.

The hospital survey initiative certainly reflects the influence of new CMS chief Don Berwick, MD, a longtime healthcare quality and transparency advocate. Under Berwick, the CMS has continued to step up fiscal pressure on hospitals to adopt quality measures and best practices to reduce HAIs. In an interview prior to his CMS appointment in July 2010, Berwick said he hopes the public "gets a bit outraged and mobilized as voters," he said. "[They should] ask why we pay systems the amount of money we are and not have them adopt the best practices."

In that regard, liaison HICPAC member Lisa McGiffert, senior policy analyst on health issues at the Consumers Union, expressed strong support for the CMS initiative, and she described the survey tool as "very important." She does agree it can be used for hospitals "to have help in improving care, but I think ultimately it's [CMS'] responsibility that the environment is safe for patients. You are not there just to help the hospitals."

In particular, McGiffert urged the CMS to ensure that hospitals are tracking and reporting all infections, something that has been questioned as more and more states mandate rate data.

Carolyn Gould, MD, a CDC medical epidemiologist who is collaborating on the CMS project, said, "We do touch on that in the interview portion of it. There are a lot of questions related to the infection prevention program and resources, and that includes surveillance." (For the likely categories of the hospital tool, see story below.)

CMS hospital tool will go beyond ASC survey

Hand hygiene, needle use likely included

A survey tool to assess infection control in ambulatory surgery centers (ASCs) was created by the Centers for Disease Control and Prevention for use by inspectors for the Centers for Medicare & Medicaid Services. As the two agencies discuss creating a similar tool for hospital inspections, an expansion beyond the ambulatory care model is expected. That survey tool included some basic environmental cleaning, disinfection and sterilization requirements along with soliciting a "yes" or "no" response in the following areas:

I. Hand Hygiene

  1. Soap and water are available in patient care areas
  2. Alcohol-based hand rub is available in patient care areas
  3. Staff perform hand hygiene:
    1. Before and after an invasive procedure (e.g., insertion of IV catheter, intubation/extubation, surgical procedure) even if gloves are worn
    2. After contact with blood, body fluids, or nonintact skin (even if gloves are worn)
    3. After contact with used, contaminated medical equipment or visibly contaminated environmental surfaces (even if gloves are worn)

    Note: To ensure consistency between site visits, hand hygiene should be observed during the "follow-through" of patients from arrival to discharge, with particular attention paid to invasive procedures.

  4. Regarding gloves, staff:
    1. Wear gloves for procedures that might involve contact with blood or body fluids
    2. Wear gloves when handling potentially contaminated patient equipment
    3. Remove soiled gloves before moving to next task
    4. If a surgical scrub is required, the surgical team performs surgical hand scrub

II. Injection Practices (medications, saline, other infusates)

  1. Needles and syringes are used for only one patient
  2. Injections are prepared in a clean area that is free from contamination with blood, body fluids, other visible contamination, or used contaminated equipment
  3. The patient's skin is prepped with an antiseptic before IV placement
  4. List all injectable medication/infusates that are in a vial/container used for more than one patient. This should include the medication name, size of vial (cc/mL) and the typical dose per patient (cc/mL)
  5. Single-dose medications/infusates are used for only one patient and not collected or combined (bags of normal saline are ALWAYS single use)
  6. Multidose medications/infusates are used for only one patient (note: a "No" answer here is not necessarily a breach in infection control. Circle N/A if no multidose medications/infusates are used.)
  7. Medication vials used for more than one patient are always entered with a new needle and new syringe
  8. The rubber septum on a medication/ infusate vial is disinfected with alcohol prior to piercing after initial entry
  9. Medications/infusates that are packaged as prefilled syringes are used for only one patient
  10. Medications/infusates are drawn up at start of each procedure
  11. Fluid infusion and administration sets (e.g., intravenous bags, tubing, and connectors) are:
    1. Used for one patient only
    2. Disposed of after use
  12. Needles and syringes are discarded intact in an appropriate sharps container after use.