APIC Conference: CMS infection log is not new, not popular

APIC Conference

CMS infection log is not new, not popular

ICPs face the reality of Medicare requirements

There has been considerable reaction and consternation among infection control professionals about "new" requirements to keep a log of all hospital infections or face the wrath of inspectors from the Centers for Medicare & Medicaid Services (CMS). There’s only one problem: the CMS requirement is not new.

"This was actually in the 1997 standards, so this has been out there a long time, but probably what happened is that lot of us didn’t pay attention to it a whole lot," said Deborah M. Nihill, MS, RN, CIC, an ICP at Barnes-Jewish Hospital in St. Louis.

That appears to be changing. The issue now is coming back up because the CMS made additional changes to its condition of participation standards for hospitals last year. With an increasing focus on hospital infection control, the infection log requirement is back on the front burner.

Several speakers addressed the CMS requirements recently in Baltimore at the annual meeting of the Association for Professionals in Infection Control and Epidemiology (APIC).

"[The CMS] says in the interpretive guidelines that [hospitals] must log all incidents related to infections and communicable disease, including those identified through employee health services," Nihill told APIC attendees.

"The infection log standard, although not new, is probably one of the most problematic areas that I am hearing people express interest about. Our own APIC public policy team has been exploring this issue, as is the American Hospital Association and the Society for Healthcare Epidemiology of America," she added.

The CMS requirements were not generally referred to with warm affection at APIC. "It is just a big medical records exercise," said health care epidemiology pioneer Robert Haley, MD, a professor in the department of internal medicine at the University of Texas Southwestern Medical Center in Dallas. Supportive audience applause ensued.

Nihill took a more conciliatory approach, titling her talk on CMS requirements with a rhetorical question: "Nuisance or necessity?"

"It really depends how you look at it," she said. "Really, the way to do this is to look at where we have similarities and crossover with existing regulatory bodies such as the Joint Commission [on Accreditation of Healthcare Organizations]. Look at how to maintain your program for success. That is going to be the key. You framework your program so that your everyday program is good enough for surveyors — whoever shows up on your doorstep at any given time."

The CMS requirement 82.42(a)(2) states that "IC officer(s) must maintain a log of incidents related to infections and communicable diseases." The log is not limited to health care-associated infections, but must include all incidents of infection and communicable diseases.

The log must document infections of patients, staff, contract staff, and volunteers. It should include incidents of postoperative infections in outpatients and inpatients who are discharged soon after surgery.

"The CMS standard says all [infections], and it specifically says not just the patients but also employees if you do cultures on your employees," said Tammy Lundstrom, MD, JD, epidemiologist at Detroit Medical Center.

An approach that works in Michigan

Lundstrom described an approach she uses that has passed muster with state health officials who inspect for CMS compliance in Michigan.

"We offer them our microbiology lab listings, which of course have all of our data from cultures from either occupational health or from our patients — whether they are hospital-associated [infections] or not," she continued.

In addition, the CMS inspectors are told about the hospital’s occupational health monthly report (OSHA 300 Log) to the infection control committee, Lundstrom added.

"We [also] keep a communicable disease reporting log for our state health departments," she said. "So this combination has always satisfied the CMS surveyors in our state. This doesn’t mean it will satisfy every surveyor; but I think if you are at least able to produce these documents, you have a good chance of being able to talk your way through the fact that you do have all of these resources available, and you can get them for the surveyor if they request them."

An ICP in the APIC audience expressed concerns about "double duty," asking Lundstrom if she was replicating the work already done in the lab and other areas.

"When we have a CMS surveyor in, we tell them, If you want that information, we can get it in the lab,’" she added. "Rather then actually keeping physically a log. That’s the whole point of using all of these sources, so that you don’t have to keep an actual physical separate log, which would be really ridiculous."

Inspectors will follow JCAHO

The pattern of CMS inspections seems to follow a survey by the Joint Commission, Lundstrom observed.

"CMS can come in any time on a complaint, but they will come in [after] some proportion of Joint Commission visits, usually about a month and a half or two months after JCAHO," she noted, "just to check things out and make sure that all the conditions of participation are satisfied."

CMS has considerable clout, since they can deny reimbursement for noncompliant hospitals.

"Lack of [CMS] compliance equals no money, so this is really something that administrators pay a lot of attention to," Lundstrom said. "It is a good way to get some support for your infection control and compliance program."

In that regard, CMS requirement 482.42(b) requires that the chief executive officer and other administration personnel must ensure that the hospital addresses "problems identified by IC officer(s)."

"Most of us know that we influence without authority," Nihill said. "We’re out there trying to educate people, trying to lead them to the watering trough but we can’t shove their face in and make them drink the water. So sometimes there needs to be somebody with some teeth higher up on the food chain than us getting people to do what they need to do.

"This [CMS] provision actually gives impetus to administration to provide the teeth on your behalf," she added.