APIC trying to leverage CMS regs to boost ICP resources

MRSA follow-up: Many hospitals not doing enough

Trying to leverage federal reimbursement cuts into support and resources for ICPs, the Association for Professionals in Infection Control and Epidemiology (APIC) has launched a series of educational initiatives in an ambitious follow-up to its ongoing efforts to eradicate methicillin-resistant Staphylococcus aureus (MRSA).

"We are using this as an opportunity to provide greater awareness, to provide educational opportunities, and to position our members as the leaders who can not only save lives but dollars," Kathy L. Warye, chief executive officer of APIC, tells Hospital Infection Control.

The APIC programs will provide a comprehensive package of education, research and guidance for ICPs on infections that the Centers for Medicare & Medicaid Services (CMS) has classified as preventable occurrences: catheter-associated urinary tract infections (UTIs), central line catheter-associated blood stream infections, and mediastinitis. The infections are targeted for reduced federal reimbursement effective October of this year. APIC had previously warned of the "unintended consequences" of the CMS actions, arguing that not all of the infections are preventable and the cuts could spur increased testing and inappropriate treatment for hospital patients on admission. With the regulatory changes apparently inevitable, the association is reminding administrators that their infection control departments have never been more important.

"We continue to align ourselves around what's best for patients," Warye says. "With these CMS regulations, we think we have an opportunity to gain additional clinical and administrative support to reduce these infections."

C. diff prevalence study

In addition to the CMS initiative, APIC also is increasing educational efforts and outreach to prevent Clostridium difficile. Efforts in this area will include a prevalence study to gain a better understanding of the scope of the problem. APIC plans to develop a guide for the elimination of C. diff, including strategies for controlling transmission; an educational Webinar series, and a conference in the fall of 2008 that features the results of the prevalence study. A highly virulent toxigenic strain (ribotype 027) of C. diff has emerged in recent years in a series of hospital outbreaks with increased mortality. There also is growing concern about transmission from asymptomatic carriers and C. diff infections in otherwise healthy people in the community. In that respect, C. diff is somewhat analogous to the broadening threat of MRSA, which was the subject of a landmark APIC prevalence study last year.

"There wasn't a very accurate understanding how much MRSA existed in the community or in health care institutions, so we undertook the prevalence study," she says. "We feel that something similar for C. diff is appropriate. We are hearing from our members that they are seeing more of it. There is a need to understand its prevalence and get a better understanding of different elimination strategies and how transmission can be prevented."

Inaction could result in legislation

There was some backlash when the MRSA study results were first unveiled at the APIC annual conference last year, with some ICPs questioning whether the data would set the stage for legislating clinical practice. Several states, for example, are in various phases of considering or implementing laws requiring active surveillance cultures to identify MRSA patients. On the contrary, it's not the release of infection data, but the failure to act upon it with preventive strategies that draws legislative mandates, Warye emphasizes.

"In over 25 years of dealing with legislatures my perception is that governments — whether they are state, local, or federal — act when they perceive that the responsible parties are not [acting]," she says.

The MRSA prevalence study has been recently published, confirming previous reports that MRSA was found in 46 of every 1,000 patients, eight times higher than previous estimates.1 Those findings were echoed by another study that came to the compelling conclusion that MRSA now kills more Americans annually than HIV/AIDS.2

APIC's MRSA guidelines

APIC guidelines for the elimination of MRSA transmission include a risk assessment to identify high-risk areas for MRSA within the hospital; a surveillance program to outline activities and procedures to identify MRSA cases; adherence to hand hygiene guidelines; use of contact precautions; environmental and equipment cleaning and decontamination (especially items that are close to patients such as bedrails and bedside equipment); and targeted active surveillance cultures of high-risk patients.

"This is not rocket science — this is not something that is yet to be invented," Warye tells HIC. "If we don't want to see more regulation, institutions need to be proactive in implementing those strategies and providing the necessary resources. Otherwise they will be at the mercy of laypeople in legislatures who could increasingly dictate health care practice."

In that regard, a follow-up survey conducted by APIC indicates MRSA — despite increasing attention from the press and public — is not sufficiently on the radar screens of many hospital CEOs. An APIC poll of ICPs found that 50% said their health care facility is not doing as much as it could or should to stop the transmission of MRSA. "It doesn't surprise me," Warye says. "It speaks to the fact that infection prevention and control programs are often not adequately resourced."

The tight purse strings are not only reflected in typical quality measures such as ICP staffing levels, but in less obvious areas such as laboratory resources and the latest diagnostics, she adds. While 59% of the 2,100 ICPs who responded have adopted interventions to address MRSA, it's clear more needs to be done to pressure the health care system to act. Enter CMS, talking the universal language: money.

"There have been a whole series of wake-up calls for health care administrators over the last several months: our prevalence study on MRSA, the CDC study on MRSA, the CMS regulations. But it is going to take everybody in the institutions who has a role to play in reducing infection risk proactively undertaking these activities," she says.


  1. Jarvis WR, Schlosser J, Chinn RY, et al. A national prevalence of methicillin-resistant Staphylococcus aureus in inpatients at U.S. health care facilities, 2006. Am J Infect Cont 2007; 35:631-637.
  2. Klevens RM, Morrian MA, Nadle J. Invasive methicillin-resistant Staphylococcus aureus infections in the United States. JAMA 2007; 298:1,763-1,771.