Is AHA washing hands of infection control?

Staff cuts and committee hiatus threaten end to decades of leadership

Dramatically scaling back its long-standing leadership in infection control, the American Hospital Association in Chicago has cut in-house staff positions and scheduled no further meetings of its most prestigious epidemiology panel.

Framed as a limited but necessary response to the fiscal demands of the managed care era in health care, the move was nonetheless seen by some observers as an unfortunate retreat from a half-century of infection control leadership by the AHA. As part of the action, the AHA eliminated its two in-house infection control staff positions and clarified that any future meetings of the Technical Panel on Infections Within Hospitals would be called on an as-needed basis.

The technical panel was apprised of the changes at a Jan. 11-12 meeting. The panel usually meets twice annually, working with AHA staff to identify significant infection control issues for hospitals. While AHA officials and panel members say there was an understanding that the association may consult with panel members on infection control issues as needed, the significance of the action was reduced to a telling colloquialism by one ’deeply disappointed” member of the panel.

Association moves on to other issues

’It was like going to a dance and your partner says, ‘I don’t want to dance with you anymore — you’re a perfectly nice person, but I’ve got my eyes on something else,’” says Richard Garibaldi, MD, AHA panel member and professor of medicine at the University of Connecticut Health Center in Farmington. ’They’re redrafting their mission statement. The AHA has moved on.”

While some panel members contacted by Hospital Infection Control expressed doubt about any future role and influence at the AHA, others were hopeful that ties between the panel and the association could be maintained and ultimately strengthened.

’If we need a meeting, we will hold a meeting — the committee is not dead,” says Margaret Hardy, JD, assistant general counsel at the AHA in Chicago. ’It is still alive and will be available to give us input and expertise. It will just be functioning a little bit differently, just as AHA is functioning a little bit differently.”

While the technical panel may still exist, the move sent a clear signal to some that the AHA is abandoning its more visible role in infection control.

’Although the AHA will continue to participate in national infection control policy, it has given up its leadership function in this area,” says William Schaffner, MD, AHA panel member and chairman of the department of preventive medicine at Vanderbilt University School of Medicine in Nashville, TN. ’This is a profound change. I can tell you that the members of the group — some of whom have had long-term service on this panel — were saddened by this turn of events. This seems to be a response to the managed care era.”

ICPs must seek guidance elsewhere

The staff changes mean infection control practitioners must seek other resources for any day-to-day consultation on infection control practice. The most obvious sources to fill the gap are the Centers for Disease Control and Prevention in Atlanta; state and local chapters of the Washington, DC-based Association for Professionals in Infection Control and Epidemiology (APIC); and the Society for Hospital Epidemiology of America (SHEA) in Woodbury, NJ. A greater concern to many involved is that the loss of the in-house staff and the diminished role of the AHA technical panel could ultimately quiet the infection control community’s voice on national policy issues.

The AHA staff and committee have played critical roles in recent years in getting the ear of hospital administrators during critical infection control debates — most recently the prolonged flap over tuberculosis respirators. In that case, the AHA was one of the front-line opponents to federal occupational health initiatives requiring expensive, uncomfortable high-efficiency particulate air (HEPA) respirators for staff treating TB patients in hospitals. The AHA was among the first groups to call for new respirator certification procedures so equipment more appropriate and affordable could be used in clinical settings. In doing so, the AHA infection control staff and committee helped eliminate the expensive requirements before they became codified in the national TB standard now under development by the Occupational Safety and Health Administration in Washington, DC. The changes were widely credited with saving hospitals millions of dollars. (See Hospital Infection Control, November 1995, pp. 137-141.)

Spearheading the TB effort was former AHA director of infection control and environmental safety Gina Pugliese, RN, MS, who left the hospital association last December for an infection control consulting position with a Chicago-based insurance brokerage firm. Pugliese’s exit coincided with the elimination of the AHA infection control department, which also included one other in-house staff position.

’I personally think that it is a real loss for the infection control community for that office to be closed,” says Marguerite Jackson, RN, PhD, CIC, FAAN, a member of the AHA technical panel and administrative director of the medical center epidemiology unit at the University of California in San Diego. ’The [AHA staff] have played a major role in many of the hot topics the last few years. Obviously, without an office and dedicated staff support, that kind of a role will no longer be played by the AHA.”

The clinically focused departments have been largely eliminated at the AHA, with the infection control program one of the last to be cut, says Pugliese, now vice president of health consulting at Sullivan, Kelly & Associates.

’In all fairness, the changes that are going on really reflect what is going on in health care,” Pugliese says. ’Let’s face it, health care is moving out of the hospital. It’s very difficult for an association to keep up with all of the things that members need. I am a big-picture thinker, and I do have [another] job. I’m disappointed that the AHA, after a five-decade presence, abruptly closed the program. The big void will be in terms of someone speaking to [hospital] administration on major infection control issues. And this is coming on the heels of the whole emerging infections issue.”

Managed care trumps infections

Indeed, the AHA changes occurred in jarring juxtaposition to another event in January — an entire issue of the Journal of the American Medical Association dedicated to the growing problem of emerging infections and antibiotic resistance. One JAMA article warned, ’Hospitals worldwide are facing an unprecedented crisis” with the rapid emergence of antimicrobial-resistant pathogens.1 The authors emphasized the critical role hospital administration must play in the effort, noting ’infection control and infectious diseases specialists do not preside over the complex interdepartmental and multidisciplinary systems that influence the introduction, dissemination, persistence, and control of antimicrobial resistance in their hospitals. Success depends on the hospital leadership — members of the board, the executive administrative staff, and physician opinion leaders.”

Changing financial realities

Nonetheless, more pressing fiscal concerns have motivated an overall shift in the AHA’s mission — away from involvement in hospital clinical practice to place greater resources and emphasis on managed care issues and the evolving nature of health care delivery systems. The administrative leaders of the association’s 4,800 member hospitals are now more focused on restructuring and changing their organizations for a dramatically different payment and delivery system, says Rick Wade, a spokesman at the AHA’s Washington, DC, office.

’Our members are telling us that they need help and resources on those issues — moving to integrated networks, learning how to cope with capitation, learning how to deal with managed care companies, or in fact become managed care entities themselves, becoming community-based networks.” he says. ’Our sense is that our members do a pretty good job of running their institutions internally and they know now where to get the resources for good internal management. We will deal with infection control issues, but there are larger issues looming for all our members. We only have a finite amount of resources.”

Still, the AHA contends it can address any infection control concerns that arise without an in-house staff or regularly scheduled committee meetings.

’We’re confident that we will be able to respond to any issue — time will tell whether we have positioned the resources properly to be able to do the job,” Wade says. ’If we stumble, we will stumble, but we believe that we will be able to provide the kind of advocacy on this issue that is going to well represent our members.’

Though both Hardy and Wade cited the possibility of strengthening liaison and consulting relationships to keep the AHA active in infection control practice, they would not comment on possibly establishing some formal arrangement with the nation’s two major professional groups in the field — APIC and SHEA.

Regardless, several observers noted the AHA action may leave a leadership void that only a heightened national presence by SHEA and APIC can fill, though neither group can claim the clout with hospital administrators enjoyed by the AHA.

’No one has the longstanding tradition, respect, and entree into hospitals that the AHA has — particularly to the administrators of hospitals,” says Garibaldi, a past president of SHEA and a member of the APIC faculty at last year’s educational conference in Las Vegas. ’The AHA has a unique entree that neither SHEA nor APIC have.”

More resources available today

Noting that the AHA also was the major organization involved in infection control that was neither governmental nor volunteer-based, Garibaldi says the association now appears to be ’going into a reactive mode instead of proactive” in the area of hospital epidemiology.

However, many more resources are available in the field than when the AHA first became involved, says technical panel chairman Robert Weinstein, MD, chairman of the division of infectious diseases at Cook County Hospital in Chicago. In addition to the two professional associations, the CDC has formed the Hospital Infection Control Practices Advisory Committee, he notes.

’In light of all of those additional resources, the AHA probably sees some of the things that the technical panel has done in the past as less unique,” Weinstein says. ’The bottom line is that the other groups may be able to make up the gap, but it is always good to have an additional ally. The hospital association — if they don’t continue to pursue infection control issues aggressively — will be one ally lost. This is the sort of thing where the more people on your side, the better off you are.”

Reference

1. Goldmann DA, Weinstein RA, Wenzel RP, et al. Strategies to prevent and control the emergence and spread of antimicrobial-resistant microorganisms in hospitals: A challenge to hospital leadership. JAMA 1996; 275:234-240.