Infection rate disclosure battle in PA may foretell struggle in other states

State mandates reporting rates of four key infections

In a battle that is expected to unfold in an increasing number of states, infection control professionals in Pennsylvania are facing a demand for public disclosure of infection rates.

Epidemiologists long have stressed that infection data that are not risk adjusted — or otherwise taken out of epidemiologic context — actually could make good hospitals look worse than poor ones. In that regard, ICPs in Pennsylvania have been fighting to ensure the state program will result in meaningful, comparative data.

"Basically, what ICPs are trying to do is come up with something that is valid," says Sharon Krystofiak, MS, MT(ASCP), CIC, infection control manager at Mercy Hospital in Pittsburgh. "If you are going to do something, do it right. The data that they need are something that would be useful for comparison. I don’t think anybody has argued that it is not the right thing to do. Everybody is just saying that they have to be comparative data with some kind of risk stratification."

Though some fear such efforts create disincentives to aggressively pursue and report all infections, sensational press exposés and consumer advocates emboldened by the patient safety movement are fueling the demand for public disclosure. Similar efforts are under way in other states. For example, a bill has been introduced in Missouri (the Hospital Infection Control Act of 2004) that would require reporting of infections and establishes inspection and enforcement measures in that state.

In addition, the Consumers Union, publishers of Consumer Reports, has set up a web site: Citing Centers for Disease Control and Prevention estimates of 90,000 deaths and costs of $5 billion each year, the group emphasizes, "You and I still can’t see information about infection rates and other key measures of quality. Consumers Union is working to ensure we all have access to the information we need to choose a good hospital and avoid a bad one." The group encourages consumers to contact federal regulators and tell them to "report infection rates from every hospital so we can effectively choose among hospitals, and so hospitals will have the strongest possible incentive to improve."

Pennsylvania an early indicator

As the controversy plays out in various states, Pennsylvania will be an early indicator of how such systems will be contested and implemented. The situation there began late last year when the Pennsylvania Health Care Cost Containment Council (PHC) adopted new reporting requirements for nosocomial infections.

"We were supposed to start collecting, basically, housewide surveillance," Krystofiak says. "It really was a huge undertaking."

One of the immediate problems noted by the infection control community was that the state only was requesting numerator data — a raw number of how many, for example, bloodstream infections occurred at a given hospital.

"Those are not good comparable data when you have hospitals with 20 beds and hospitals with a thousand beds," she says. "We are an inner-city hospital, take care of a lot of the uninsured population, have a level trauma center and a burn unit. We would have been having a direct comparison with a 50-bed hospital out in the middle of the state. So it wouldn’t be something that would be helpful."

In a campaign led by the state chapter of the Association for Professionals in Infection Control and Epidemiology (APIC), Pennsylvania ICPs have been urged to write letters expressing concern about the scope, process, and the cost of collecting the data. A letter from the state APIC chapter cited the lack "of clinical input from infection control professionals on how to undertake data collection, specific procedures to assure uniform data collections across facilities, and a reasonable time frame for implementation to allow for appropriate training and changes to information technology that will support data collections. In addition, reports generated by this process may be misleading to the public."

The Hospital & Healthsystem Association of Pennsylvania (HAP) state hospital association also stepped into the fray, arguing that requirements be limited to nosocomial infections that represent the highest risk to patients and result in highest costs.

HAP urged the council to work with clinicians to define the data collection methodology and develop clinically credible public reports that will be useful to the public, purchasers, and clinicians. As a result of the efforts, the state council amended its original plans, paring down a mandate for reports of 14 infections to these key four: surgical site infections, central line-associated bloodstream infections, ventilator-associated pneumonia, and catheter-associated urinary tract infections.

Hospitals also will be granted time extensions as needed beyond the original June 30, 2004, deadline for submission of data.

"We are encouraged that PHC’s action will enable a phase-in of data collection and reporting processes," Carolyn Scanlan, HAP president said in a statement after the action. "We are working collaboratively with the PHC, state agencies, and the legislature to assure nosocomial infection data collection and reporting with a mutual goal of improving patient safety and quality of care."

The state council has not clarified how the data eventually will be made public, but consumer advocacy groups are keeping the pressure on for full disclosure for comparative purposes.

"While the proposal decided by the council is a step forward, hospitals should be required to report infection rates for all areas of the hospital, not just for certain patients or certain units, and to make this information available to the public," says Ami Gadhia, assistant legislative counsel for the Consumers Union. "[That] will allow hospitals to see how they stack up to others in the state and will move hospitals to be accountable if their infection rates are high."

Though hospitals in the state successfully pared down the original mandate to something more streamlined and valid, health care providers have taken some media bashing concerning the "dirty little secret" of nosocomial infections and clinicians who can’t be bothered to wash their hands, Krystofiak points out. "For some of our staff, particularly the nurses working 12-hour shift, they wash their hands 100 times a day," she says. "They are doing everything humanly possible to prevent this. But unfortunately, people come in with bacteria on their skin and bodies; we do things to make them better that put them at risk."

Landmark voluntary effort in same state

Indeed, there is some irony in the fact that even as the debate emerged over releasing infection rates — ostensibly as a quality improvement measure — Krystofiak and ICPs at 41 other Pittsburgh area hospitals were already involved in a nationally recognized patient safety effort. The lofty goal of zero nosocomial infections is a centerpiece initiative by the Pittsburgh Regional Healthcare Initiative (PHRI), a consortium of health care institutions, purchasers, and insurers.

"So people are already doing this on their own," she says. "It’s not that hospitals want to end up with infections. It costs us more, and it is not good for patient care or patient relationships."

While the PHRI espouses the zero infection goal, there are concessions to reality while striving to reach the "theoretical limit," says Naida Grunden, director of communications for the initiative.

"Infections are very tricky," she adds. "You don’t get clean patients. We hear this all of the time. The patient may have an infected or contaminated wound when they walk in. But what we are talking about is things people can get behind. With a central line infection, is zero possible? How close can we get to zero? If the best hospital in the country has four a year, can we get three or two? We refer to it as the theoretical limit. Why wouldn’t we strive for that?"

This position is not unlike the argument by CDC director Julie Gerberding, MD, MPH, that clinicians should not settle for a benchmark range of infections, but strive to protect the "N of one" — the individual patient whose life is threatened. The PHRI has not taken an official advocacy position for or against the release of infection rate data in the state.

"We favor a nonpunitive approach," Grunden says. "We favor people’s right to know and people’s right to protect themselves from infection."

While ICPs are key players in the PHRI, she says the consortium realizes it must preach to someone other than the choir to enact change.

"We are expanding [our message] to physicians, clinicians, and other leaders in the hospital," Grunden adds. "If you are putting the collective burden on one person, instead of deputizing everyone in the entire organization, you are doing it wrong. The ICP is there to be the champion, the knowledge base, and the obstacle remover. They are not there to be the enforcer or the cop for every single employee. Once these ideals pervade an institution — once everyone along the work pathway has the same idea in mind — change comes pretty quickly."