Health-Care-Associated Infections in Hospitals:

Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on These Infections

GAO-08-283: Published: Mar 31, 2008. Publicly Released: Apr 16, 2008.

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According to the Centers for Disease Control and Prevention (CDC), health-care-associated infections (HAI) are estimated to be 1 of the top 10 causes of death in the United States. HAIs are infections that patients acquire while receiving treatment for other conditions. GAO was asked to examine (1) CDC's guidelines for hospitals to reduce or prevent HAIs and what the Department of Health and Human Services (HHS) does to promote their implementation, (2) Centers for Medicare & Medicaid Services' (CMS) and hospital accrediting organizations' required standards for hospitals to reduce or prevent HAIs and how compliance is assessed, and (3) HHS programs that collect data related to HAIs and integration of the data across HHS. GAO reviewed documents and interviewed officials from CDC, CMS, the Agency for Healthcare Research and Quality (AHRQ), and accrediting organizations.

CDC has 13 guidelines for hospitals on infection control and prevention, which cover a variety of topics, and in these guidelines CDC recommends almost 1,200 practices for implementation to prevent HAIs and related adverse events. Most of the practices are sorted into five categories--from strongly recommended for implementation to not recommended--primarily on the basis of the strength of the scientific evidence for each practice. Over 500 practices are strongly recommended. CDC and AHRQ have conducted some activities to promote implementation of recommended practices, but these activities are not based on a clear prioritization of the practices. Prioritization may consider not only the strength of the evidence, but also other factors that can affect implementation, such as cost and organizational obstacles. In addition to CDC, AHRQ has reviewed scientific evidence for certain HAI-related practices, but the efforts of the two agencies have not been coordinated. The infection control standards required by CMS and hospital-accrediting organizations--the Joint Commission and the Healthcare Facilities Accreditation Program of the American Osteopathic Association (AOA)--describe the fundamental components of a hospital's infection control program. These components include the active prevention, control, and investigation of infections. The standards are far fewer in number than the recommended practices in CDC's guidelines and generally do not require that hospitals implement all recommended practices in CDC's infection control and prevention guidelines. CMS, the Joint Commission, and AOA assess compliance with their infection control standards through direct observation of hospital activities and review hospital policy documents during on-site surveys. Multiple HHS programs collect data on HAIs, but limitations in the scope of information they collect and a lack of integration across the databases maintained by these separate programs constrain the utility of the data. Three agencies within HHS currently collect HAI-related data for a variety of purposes in databases maintained by four separate programs: CDC's National Healthcare Safety Network program, CMS's Medicare Patient Safety Monitoring System, CMS's Annual Payment Update program, and AHRQ's Healthcare Cost and Utilization Project. Each of the four databases presents only a partial view of the extent of the HAI problem because each focuses its data collection on selected types of HAIs and collects data from a different subset of hospital patients across the country. GAO did not find that the agencies were taking steps to integrate data across the four databases by creating linkages across the databases, such as creating common patient identifiers. Creating linkages across the HAI-related databases could enhance the availability of information to better understand where and how HAIs occur. Although CDC officials have produced national estimates of HAIs, those estimates derive from assumptions and extrapolations that raise questions about the reliability of those estimates.

Status Legend:

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  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: In order to help reduce HAIs in hospitals, the Secretary of HHS should identify priorities among CDC's recommended practices and determine how to promote implementation of the prioritized practices, including whether to incorporate selected practices into CMS's conditions of participation (COP) for hospitals.

    Agency Affected: Department of Health and Human Services

    Status: Closed - Implemented

    Comments: In 2009, HHS established a Steering Committee for the Prevention of Healthcare-Associated Infections which developed a department-wide action plan to reduce HAIs and established a framework for prioritizing the recommended practices in four CDC guidelines. As a result, the Steering Committee identified a subset of priority recommendations related to the prevention of four HAIs: catheter-associated urinary tract infections, intravascular catheter-associated infections, surgical site infections, and ventilator-associated pneumonia. CDC is also in the process of identifying prioritized practices related to the prevention of Clostridium difficile and Methicillin Resistant Staphylococcus Aureus-related HAIs. HHS plans to take additional actions to promote implementation by hospitals of the prioritized practices by, for example, developing a national media campaign to elicit support for the implementation of the prioritized practices and by funding an initiative in 10 states to reduce central line-associated bloodstream infections. By establishing the Steering Committee and prioritizing recommended practices, HHS has taken steps to help reduce HAIs in hospitals which addressed our recommendation. However, HHS does not plan to incorporate any of the prioritized practices into Medicare's infection control Conditions of Participation for hospitals.

    Recommendation: In order to help reduce HAIs in hospitals, the Secretary of HHS should establish greater consistency and compatibility of the data collected across HHS on HAIs to increase information available about HAIs, including reliable national estimates of the major types of HAIs.

    Agency Affected: Department of Health and Human Services

    Status: Closed - Implemented

    Comments: HHS has taken several steps which, collectively, address our recommendation. To establish greater consistency and compatibility of the data collected across HHS on HAIs, the following steps have been taken. In 2011, the Centers for Medicare & Medicaid Services (CMS) began requiring hospitals to report central line-associated bloodstream infection (BSI) data to the Centers for Disease Control and Prevention?s (CDC) National Healthcare Safety Network (NHSN) in order to qualify for full payments from Medicare Beginning in 2012, CMS will also require hospitals to report surgical site infection (SSI) and catheter-associated urinary tract infection (UTI) data to NHSN and, in 2013, will require hospitals to report methicillin-resistant Staphylococcus aureus (MRSA) infections, Clostridium difficile infections, and healthcare worker influenza vaccination data to NHSN. To ensure compatibility of HAI data, HHS officials told us that the Agency for Healthcare Research and Quality (AHRQ) has worked with both CDC and CMS to align their definitions and criteria for HAIs under its Common Formats initiative, and that CDC has also adopted CMS's common identifier for participating NHSN hospitals (e.g., CMS certification number (CCN)) within the NHSN system. Additionally, in 2010, AHRQ completed its baseline inventory of HHS data systems and database resources that can be used for HAI measurement entitled ?Longitudinal Program Evaluation of HHS Action Plan to Prevent Healthcare Associated Infections (HAI): Interim Report on Baseline Measures, Inventory and Recommendations.? HHS has also taken the following steps to improve the reliability of national estimates of HAIs. First, CMS has finalized an approach to validating hospital submissions of central line-associated BSIs to NHSN, which will include an annual chart review of 800 randomly selected facilities. In order to further improve the overall reliability of national estimates of HAIs within acute care hospitals, CDC is conducting a national prevalence survey of HAIs, the last phase of which HHS officials expect will end in the summer of 2011. This prevalence survey will help determine the total number of HAIs in acute care hospitals from all causes (i.e., not limited to HAIs associated with specific devices or procedures). In addition, HHS officials told us that CDC and AHRQ have been working together to determine how AHRQ's Healthcare Cost and Utilization Project and data generated by the Medicare Patient Safety Monitoring System can be used to complement national HAI estimates.

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