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of State Reporting Programs and Individual Hospital Initiatives to 
Reduce Certain Infections' which was released on October 2, 2008.

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Report to the Chairman, Committee on Oversight and Government Reform, 
House of Representatives:

United States Government Accountability Office: 
GAO:

September 2008:

Health-Care-Associated Infections In Hospitals:

An Overview of State Reporting Programs and Individual Hospital 
Initiatives to Reduce Certain Infections:

GAO-08-808: 

GAO Highlights:

Highlights of GAO-08-808, a report to the Chairman, Committee on 
Oversight and Government Reform, House of Representatives. 

Why GAO Did This Study:

Health-care-associated infections (HAI) are infections that patients 
acquire while receiving treatment for other conditions. Normally 
treated with antimicrobial drugs, HAIs are a growing concern as 
exposure to multidrug-resistant organisms (MDRO) becomes more common. 
Infections caused by MDROs, such as methicillin-resistant 
Staphylococcus aureus (MRSA), lead to longer hospital stays, higher 
treatment costs, and higher mortality.

In response to demands for more public information on HAIs, some states 
began to establish HAI public reporting systems. The federal Centers 
for Disease Control and Prevention (CDC) developed a system—the 
National Healthcare Safety Network (NHSN)—to collect HAI data from 
hospitals and some states have chosen to use it for their programs. In 
addition, some hospitals have adopted initiatives to reduce MRSA by 
routinely testing some or all patients and isolating those who test 
positive for MRSA from contact with other patients.

GAO was asked to examine (1) the design and implementation of state HAI 
public reporting systems, (2) the initiatives hospitals have undertaken 
to reduce MRSA infections, and (3) the experience of certain early-
adopting hospitals in overcoming challenges to implement such 
initiatives.

GAO interviewed state officials, reviewed documents, and surveyed or 
conducted site visits at hospitals with MRSA-reduction initiatives.

What GAO Found:

GAO identified 23 states that had established mandatory HAI public 
reporting systems through February 2008; most have used similar 
approaches to design their programs and address resource and 
technological challenges that affect their implementation. Most states 
have designed programs that focus on a few measures that were developed 
or endorsed by the CDC. Three states have chosen to collect information 
on hospital-associated MRSA infections. In addition, a majority of 
states have chosen to adopt the CDC’s NHSN. Adopting NHSN allows states 
to minimize some of the resource and technological challenges that they 
confront in implementing HAI reporting systems including providing 
training for hospital staff in data collection and developing systems 
to collect HAI data that meet accepted infection control standards.

GAO reviewed a sample of 14 hospitals (including several hospital 
systems) with MRSA-reduction initiatives that were selected to provide 
variation in location, teaching status, and population of metropolitan 
area. GAO found all use routine testing for MRSA, although they chose 
different patient populations to test and used various testing 
methodologies. Three hospitals tested all patients for MRSA, while the 
other hospitals almost universally tested patients in adult or neonatal 
intensive care units. The hospitals reported changing their general 
infection control policies or practices as part of their 
initiatives—all 14 made changes for hand hygiene and more than half 
made changes to their contact precautions or disinfection of 
environmental surfaces. The hospitals GAO reviewed reported needing 
varying levels of funding and staff resources to implement and operate 
their initiatives, but all hospitals that tracked MRSA infection rates 
reported a decline in MRSA infections as a result of their initiatives. 

Two hospital systems that GAO visited overcame a similar set of 
challenges in implementing MRSA-reduction programs. Both systems had to 
design and execute processes to put the elements of their MRSA-
reduction initiatives into effect and promote compliance with those 
processes by hospital staff. In designing their systems, both hospital 
systems incorporated these processes as much as possible into the 
normal workflow of hospital staff and promoted staff compliance through 
a combination of concerted leadership and specific procedures designed 
to facilitate staff compliance reinforced through detailed feedback on 
their performance. However, the two hospital systems took different 
approaches in obtaining resources for their initiatives. One directed 
substantial financial resources into its MRSA-reduction initiative to 
implement the initiative simultaneously for all patients at all three 
of its hospitals, while the other relied largely on existing resources 
and implemented its initiative more incrementally at selected hospitals 
and in selected units.

GAO received technical comments from the Department of Health and Human 
Services and oral comments from the American Hospital Association on a 
draft of this report.

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-808]. For more 
information, contact Cynthia A. Bascetta at (202) 512-7114 or 
bascettac@gao.gov. 

[End of section] 

Contents:

Letter:

Results in Brief:

Background:

States Have Designed Broadly Similar Mandatory HAI Public Reporting 
Systems, with Resource and Technological Challenges Affecting 
Implementation:

Hospital MRSA-Reduction Initiatives Share Multiple Components, but Vary 
in Scope and Resource Requirements:

Two Hospital Systems Addressed Similar Challenges in Implementing MRSA- 
Reduction Initiatives:

Concluding Observations:

Comments from HHS and the American Hospital Association and Our 
Evaluation:

Appendix I: Characteristics of Selected Hospitals with MRSA-Reduction 
Initiatives:

Appendix II: Changes Made by Selected Hospitals with MRSA-Reduction 
Initiatives:

Appendix III: GAO Contact and Staff Acknowledgments:

Tables:

Table 1: States We Reviewed with HAI Public Reporting for Hospitals, by 
Date Data Collection Begins:

Table 2: Outcome Measures by States We Reviewed with HAI Reporting, by 
Defining Entity:

Table 3: Process Measures by States We Reviewed with HAI Reporting:

Table 4: Data Collection Systems, by States We Reviewed with HAI 
Reporting:

Table 5: Patient Populations Screened with Active Surveillance Testing, 
by Selected Hospital:

Table 6: Policy or Practice Changes Implemented by Selected Hospitals 
as Part of MRSA-Reduction Initiatives:

Table 7: Hand Hygiene Changes by Selected Hospitals with MRSA-Reduction 
Initiatives:

Table 8: Contact Precaution Changes by Selected Hospitals with MRSA- 
Reduction Initiatives:

Table 9: Environmental Cleaning Changes by Selected Hospitals with MRSA-
Reduction Initiatives:

Table 10: Antibiotic Stewardship Changes by Selected Hospitals with 
MRSA-Reduction Initiatives:

Table 11: Decolonization Characteristics by Selected Hospitals with 
MRSA-Reduction Initiatives:

Figure:

Figure 1: Selected Hospital-Reported Financial Resource Needs for MRSA- 
Reduction Initiative, by Type of Screening and Test Method:

Abbreviations:

AHA: American Hospital Association: 

AHRQ: Agency for Healthcare Research and Quality: 

AST: active surveillance testing: 

BSI: bloodstream infection: 

CDC: Centers for Disease Control and Prevention: 

CMS: Centers for Medicare & Medicaid Services: 

EMR: electronic medical record: 

ENH: Evanston Northwestern Healthcare: 

HAI: health-care-associated infection: 

HICPAC: Healthcare Infection Control Practices Advisory Committee: 

HHS: Department of Health and Human Services: 

ICP: infection control professional: 

ICU: intensive care unit: 

IHI: Institute for Healthcare Improvement: 

IPPS: inpatient prospective payment system: 

MDRO: multidrug-resistant organism: 

MRSA: methicillin-resistant Staphylococcus aureus: 

NHSN: National Healthcare Safety Network: 

NNIS: National Nosocomial Infections Surveillance: 

NQF: National Quality Forum: 

PCR: polymerase chain reaction: 

POA: present on admission: 

PSI: Patient Safety Indicator: 

SCIP: Surgical Care Improvement Project: 

SSI: surgical site infection: 

UPMC: University of Pittsburgh Medical Center: 

UTI: urinary tract infection: 

VAP: ventilator-associated pneumonia: 

[End of section] 

United States Government Accountability Office:
Washington, DC 20548:

September 5, 2008:

The Honorable Henry Waxman: 
Chairman: 
Committee on Oversight and Government Reform: 
House of Representatives:

Dear Mr. Chairman:

Health-care-associated infections (HAI) are one of the top 10 causes of 
death in the United States, according to estimates from the Centers for 
Disease Control and Prevention (CDC). Although patients can acquire 
HAIs in a wide variety of health care settings, including nursing homes 
and ambulatory surgery centers, hospital patients are especially 
vulnerable to HAIs. Normally treated with antimicrobial drugs, HAIs are 
a growing concern as multidrug-resistant organisms (MDRO) become more 
common.[Footnote 1] Infections caused by MDROs lead to longer hospital 
stays, higher treatment costs, and higher mortality because they are 
more difficult to treat than infections caused by other organisms. A 
particular MDRO, methicillin-resistant Staphylococcus aureus (MRSA), 
[Footnote 2] has gained attention recently. In 2003, it accounted for 
64 percent of infections in intensive care units (ICU) caused by 
Staphylococcus aureus, one of the most common HAI pathogens, up from 36 
percent in 1992.[Footnote 3] Researchers estimate that the average cost 
of treating a MRSA infection exceeds $35,000.

In a separate report to you, we found that federal activities have not 
effectively addressed the HAI problem.[Footnote 4] We also found that 
the extent of the problem, including the level of antimicrobial 
resistance, is uncertain because the data that CDC as well as other 
agencies of the Department of Health and Human Services (HHS)--such as 
the Centers for Medicare & Medicaid Services (CMS)--collect on HAIs are 
limited in scope and lack integration across multiple databases. CDC 
has created a data infrastructure that allows hospitals to voluntarily 
collect and input data using a uniform set of definitions on the 
incidence of selected HAIs in their own hospitals and to compare their 
rates with benchmarks derived from the data submitted by all 
participating hospitals. This began in the 1970s with the National 
Nosocomial Infections Surveillance (NNIS) system and continued with its 
replacement, the more sophisticated National Healthcare Safety Network 
(NHSN), introduced in 2005.

In response to demands for more public information on HAIs, some states 
have begun to develop and implement HAI public reporting systems--some 
using CDC's NHSN--to collect and disseminate HAI data from hospitals. 
Some states have also recently passed legislation relating specifically 
to MRSA, such as requiring specific actions for hospitals to prevent 
the spread of MRSA based in part on guidelines issued by CDC and 
collecting data from hospitals on MRSA cases that occur. In addition, 
some hospitals have implemented strategies for reducing MRSA by testing 
some or all patients and isolating those who test positive for MRSA 
from contact with other patients.

In response to your interest in these nonfederal efforts to address 
HAIs, including the role played by CDC's NHSN and its practice 
guidelines, we examined (1) the design and implementation of state HAI 
public reporting systems, (2) the initiatives hospitals have undertaken 
to reduce MRSA infections, and (3) the experience of certain early- 
adopting hospitals in overcoming challenges to implement such 
initiatives.

To describe the design and implementation of state HAI public reporting 
systems, we identified 23 states that were designing or had implemented 
state-mandated HAI public reporting systems through February 2008. We 
identified these programs through multiple sources, including resources 
maintained by organizations that track state infection control 
programs. We then collected information directly from each of those 23 
states. However, we did not independently verify that there were no 
state-mandated HAI public reporting programs planned or underway in any 
of the remaining states. We excluded from consideration programs in 
several states that collect limited data about HAIs, but do not report 
hospital-specific HAI data to the public.[Footnote 5] For each of the 
23 states, we reviewed the available legislation, administrative and 
departmental rules and regulations, advisory panel reports, and other 
documents for each system to compare the systems across states. 
However, the information that we collected does not provide a 
description or assessment of the legal requirements in any state 
regarding the collection and public reporting of data about HAIs or a 
comparison of the legal requirements among states regarding those 
requirements.

We also interviewed state officials and state hospital association 
representatives in 5 of the 23 states about the design, development, 
and implementation of their systems, including challenges they 
encountered, how they overcame those challenges, and how they validated 
the data from hospitals. We selected Missouri, New York, and 
Pennsylvania because each had relatively extensive experience in 
collecting HAI data, but used different data reporting systems. We 
selected Illinois and New Jersey because they had established mandatory 
reporting programs on MRSA infections designed to provide information 
on the performance of individual hospitals--as distinct from the 
communicable disease reporting systems that many state health 
department have operated for decades, which are designed primarily to 
provide an alert when new outbreaks of particular pathogens occur. What 
we learned about the challenges faced and implementation strategies 
adopted in those 5 states cannot be generalized to other states with 
HAI public reporting programs.

To describe the initiatives hospitals have undertaken to reduce MRSA 
infections, we consulted knowledgeable experts, and conducted a Web 
search to generate a list of hospitals or hospital systems[Footnote 6] 
with MRSA-reduction initiatives. From among those, we selected 17 that 
provided the greatest diversity in terms of location, teaching status, 
and population of metropolitan area. To obtain information about the 
hospitals' MRSA-reduction initiatives, we visited 2 hospitals and sent 
surveys to officials at the remaining 15 hospitals, 12 of which 
responded. In total, we collected information from 14 hospitals with 
MRSA-reduction initiatives. Information on their characteristics is 
provided in appendix I. The information that we obtained from these 14 
hospitals pertains specifically to those hospitals, and can not be 
generalized to other hospitals with MRSA-reduction initiatives.

To describe how early-adopting hospitals overcame challenges to 
implement MRSA-reduction initiatives, we visited Evanston Northwestern 
Healthcare (ENH) and the University of Pittsburgh Medical Center 
(UPMC). Both implemented MRSA-reduction initiatives several years ago 
and have published or otherwise publicly presented data on their 
outcomes. We interviewed key administrative and clinical personnel at 
each site to examine specific MRSA intervention options considered, 
challenges confronted, steps taken to overcome those challenges, and 
required financial and staff resources. Because these were case 
studies, what we found at these two hospitals can not be generalized to 
other hospitals with MRSA reduction initiatives.

We conducted this performance audit from October 2007 to September 2008 
in accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives.

Results in Brief:

Most of the 23 states we reviewed with state-mandated HAI public 
reporting programs have used similar approaches to design their 
programs and address resource and technological challenges that affect 
their implementation. Most of these states have relied at least to some 
extent on advisory committees or technical advisors and designed 
programs that focus on a few measures that were developed or endorsed 
by CDC. Three states have chosen to collect information on hospital- 
associated MRSA infections. In addition, although some states developed 
their own data collection systems, a majority of the states we reviewed 
have chosen to use NHSN, the HAI data collection system developed by 
CDC. Adopting CDC-endorsed measures and the NHSN for data collection 
allowed states to minimize some of the resource and technological 
challenges that they confronted in implementing HAI reporting systems. 
These challenges included providing training for hospital staff in data 
collection as well as developing systems to collect HAI data that met 
accepted infection control standards and were user-friendly for those 
entering data.

The 14 hospitals with MRSA-reduction initiatives that we reviewed all 
conduct routine testing for MRSA, although they chose different patient 
populations to test and used various testing methodologies. Three 
hospitals tested all patients for MRSA, while the remaining hospitals 
almost universally tested patients in adult or neonatal intensive care 
units. The hospitals reported changing a number of general infection 
control policies or practices as part of their initiatives--all 14 made 
changes for hand hygiene and more than half made changes to their 
contact precautions or disinfection of environmental surfaces. The 
hospitals we reviewed reported needing varying levels of funding and 
staff resources to implement and operate their initiatives, but all 
hospitals that tracked MRSA infection rates reported a decline in MRSA 
infections as a result of their initiatives.

The two hospital systems that we visited overcame a similar set of 
challenges in implementing multifaceted MRSA-reduction initiatives. 
Both systems had to design and execute processes to put the elements of 
their MRSA-reduction initiatives into effect and promote compliance 
with those processes by hospital staff. In designing their MRSA- 
reduction initiatives, both hospital systems incorporated these 
processes as much as possible into the normal workflow of hospital 
staff and promoted staff compliance through a combination of concerted 
leadership on the part of the physicians who led their infection 
control programs and specific procedures designed to facilitate staff 
compliance reinforced through detailed feedback on their performance. 
However, the two hospital systems took different approaches to 
obtaining resources for their initiatives. One directed substantial 
financial resources into its MRSA-reduction initiative to implement the 
initiative simultaneously for all patients at all three of its 
hospitals, while the other relied largely on existing resources and 
implemented its initiative more incrementally at selected hospitals and 
on selected units.

We obtained technical comments from HHS that we incorporated as 
appropriate. In addition, the department highlighted the scientific 
contributions that CDC has made pertaining to the detection, 
measurement, and prevention of HAIs and MRSA. The American Hospital 
Association (AHA) provided oral comments that underscored the 
importance of using HAI data to prevent and reduce infections and that 
raised serious concerns about using unvalidated NHSN data for public 
reporting of hospital performance on HAIs.

Background:

HAIs are infections that patients may acquire during the course of 
receiving medical treatment for other conditions.[Footnote 7] HAIs 
occur as the result of patient exposure to a variety of pathogens and 
affect many different body systems. According to CDC estimates, urinary 
tract infections (UTI), surgical site infections (SSI), bloodstream 
infections (BSI), and pneumonia account for more than 80 percent of all 
HAIs. Frequently, an infectious pathogen is introduced by an invasive 
procedure, such as surgery or insertion of a urinary catheter, central 
line,[Footnote 8] or ventilator. As a result, a subset of UTIs are 
identified as catheter-associated UTIs, a subset of BSIs are identified 
as central line-associated BSIs, and a subset of pneumonia HAIs are 
identified as ventilator-associated pneumonia (VAP).

Hospital Practices to Reduce HAIs:

Any acute care hospital that participates in Medicare or Medicaid or is 
accredited through the Joint Commission must have an infection control 
program with a designated person in charge.[Footnote 9] Infection 
control professionals (ICPs) receive specialized training to prepare 
them to lead and staff these programs. ICPs identify cases of HAI and 
promote infection control practices that help to reduce the occurrence 
and spread of HAIs. These practices include rigorous maintenance of 
hand hygiene standards as well as contact precautions, which involve 
the use of gloves, gowns, and sometimes masks worn by health care 
workers to prevent them from carrying the pathogen from an infected 
patient to other patients. One approach has focused on ensuring that 
each item on a short list of specific practices is consistently 
implemented. For example, the Institute for Healthcare Improvement 
(IHI)[Footnote 10] has developed "bundles" or "components of care" 
designed to reduce the incidence of central line-associated BSIs, SSIs, 
VAP, and MRSA. Each of these bundles consists of four to six specific 
practices that research has shown affect the incidence of that type of 
infection. These practices include hand hygiene and contact 
precautions, where appropriate.

Strong clinical evidence indicates that contact precautions help to 
reduce the incidence of HAIs. However, for contact precautions to work, 
they have to be carefully and consistently followed. Hospitals need to 
closely monitor and reinforce staff compliance with these and related 
activities such as hand hygiene and environmental cleaning.[Footnote 
11] At the same time, some research suggests that patients placed under 
contact precautions may receive less attention from clinicians, receive 
lower quality care, and experience more adverse events such as falls or 
pressure ulcers.[Footnote 12]

MRSA:

MRSA is a particularly prevalent MDRO. It can cause virtually any type 
of HAI, including skin infections, BSIs, pneumonia, SSIs, and UTIs. 
MRSA-positive patients may either have an active MRSA infection or be 
colonized with the organism. Colonized patients carry the bacteria in 
some part of their body, such as on their skin or in their nose, 
without showing any symptoms of infection themselves. Patients 
colonized with MRSA represent a primary source for transmission of the 
organism to other patients, often via the hands, clothing, or equipment 
of hospital staff. Individuals who acquire MRSA in a health care 
setting, such as a hospital, are referred to as having health-care- 
associated MRSA. Individuals who develop a MRSA infection outside of 
such settings and who do not have a history of recent hospitalization 
or surgery are referred to as having community-associated MRSA.

Because patients colonized with MRSA do not exhibit signs and symptoms 
of infection, the only way to identify them is through laboratory 
testing of specimens from asymptomatic patients. Specimens taken from a 
patient's nose can identify up to 80 percent of colonized patients and 
are therefore recommended for MRSA screening. Laboratory methods for 
MRSA testing use routine culture media, selective media, or polymerase 
chain reaction (PCR). Routine culture media require laboratory staff to 
culture specimens in a nutrient material, such as agar in a Petri dish, 
and then examine and test the organisms that grow in that medium. This 
process usually takes 2 to 5 days to produce results. Selective media 
are laboratory culture media that have been developed to identify the 
presence of specific organisms. Clinical specimens are swabbed onto 
culture plates containing selective media. The selective media allow 
certain organisms to grow while preventing other organisms from 
growing. In some cases, the selective media can also cause specific 
organisms to appear a certain color. MRSA test results using selective 
media are generally available within 24 hours. PCR is a highly 
sensitive, molecular testing technique that detects MRSA-specific DNA. 
PCR testing can identify a somewhat higher proportion of MRSA-positive 
patients than the alternative testing methods and it can generate 
results within 2 to 4 hours, but it is substantially more expensive 
than testing using routine or selective media. PCR screening costs $25 
to $30 per test, while screening using selective media costs about $5 
per test.[Footnote 13]

Several European countries have largely eradicated transmission of MRSA 
to other patients by adopting procedures to identify and isolate MRSA- 
positive patients on admission, demonstrating that hospitals can keep 
the MRSA infection rate low or nonexistent. In the United States, the 
consensus among experts is that hospitals should take measures to 
prevent the transmission of the MRSA organism from any patient known to 
be infected or colonized with MRSA to other patients in the hospital. 
CDC's guidelines for reducing the incidence of MDROs, including MRSA, 
emphasize the importance of implementing several recommended practices 
when treating MRSA-positive patients, including contact precautions, 
hand hygiene, and effective environmental cleaning.[Footnote 14] The 
guidelines recommend placing MRSA-positive patients in private rooms or 
"cohorting" them by placing them in rooms with other MRSA-positive 
patients. In addition, the guidelines recommend that hospitals exercise 
antibiotic stewardship by implementing processes that encourage and 
facilitate judicious use of antimicrobial agents to maximize 
therapeutic impact while minimizing the development of antibiotic 
resistance.

Infection control experts differ as to the scope of routine MRSA 
testing, known as active surveillance testing (AST), they recommend to 
identify MRSA-positive patients. Some recommend as much routine testing 
as is necessary to identify all MRSA-positive patients in a hospital, 
which, depending on the prevalence of MRSA in that hospital or 
community, can mean testing all admitted patients--universal AST. Other 
experts, as well as CDC guidelines, recommend targeted AST--testing 
populations within a hospital who are more likely than others to be 
colonized with MRSA. Populations targeted include patients in intensive 
care units, dialysis patients, and patients transferred from nursing 
homes or prisons. Targeted testing requires fewer resources than 
universal testing, but misses infected individuals outside of the 
targeted population.

Decolonization protocols have been developed to remove MRSA bacteria 
from a colonized patient's body, in order to reduce the likelihood that 
the patient will get an active infection or transmit the bacteria to 
someone else. Decolonization therapy can involve applying an antibiotic 
ointment in the nose for 5 days, bathing in chlorhexidine, or doing 
both. However, the clinical evidence supporting the effectiveness of 
these protocols in eradicating MRSA is limited, and researchers have 
reported that extensive use of this treatment can lead to increased 
MRSA resistance to the antibiotic in the nasal ointment. As a result, 
experts differ as to if and when to implement these protocols.

Federal Activities:

CDC is the lead federal agency with respect to HAIs. It sets clinical 
definitions for identifying HAIs and has defined 13 categories of HAIs, 
including BSIs, SSIs, UTIs, and pneumonia. CDC's definitions and 
procedures for distinguishing HAIs from other infections, which rely on 
detailed clinical information obtained from patient medical records and 
direct observation, are widely accepted as the most appropriate 
technical standard by ICPs and others in the field.[Footnote 15] CDC's 
Healthcare Infection Control Practices Advisory Committee (HICPAC) 
publishes guidelines that assemble and assess practices intended to 
reduce particular types of infections.[Footnote 16]

Since the 1970s, CDC has managed systems to collect HAI data from 
hospitals on a strictly voluntary and confidential basis. Following the 
transition from the NNIS to the NHSN in 2005, participation in CDC's 
system has grown from approximately 300 hospitals to approximately 
1,000 hospitals as of December 2007. Through the NHSN, CDC has 
established protocols for hospitals to report outcome data on central 
line-associated BSIs, SSIs, catheter-associated UTIs, VAP, and 
postprocedure pneumonia.[Footnote 17] These protocols include questions 
about the organisms causing the reported infections and the results of 
any laboratory tests of their antibiotic susceptibility. NHSN also 
collects data that enable hospitals to risk adjust their HAI rates to 
take account of differences in the severity of illness of their 
patients and in the complexity of procedures they perform. The use of 
risk-adjusted rates allows hospitals to more accurately compare their 
own progress in infection prevention and control to that of other 
hospitals, as well as to their own rates in the past. Though 
participation in the NHSN remains voluntary and is free of charge, 
enrolling hospitals must agree to follow these protocols in collecting 
the data that they submit. As was true of the NNIS, CDC releases data 
from the NHSN only in the form of aggregate rates for different types 
of infections, with information on the individual participating 
hospitals legally protected from disclosure.

In contrast to the confidentiality guaranteed to hospitals 
participating in CDC's data systems, there has been a movement in 
recent years toward making information about the quality of care 
provided by individual hospitals publicly available. Several 
organizations have developed indicators to measure how often patients 
receive certain recommended processes of care for certain conditions 
(called process measures) and to measure how often adverse outcomes, 
such as infections, occur in certain patient populations (called 
outcome measures). For example, the Surgical Care Improvement Project 
(SCIP) has adopted a series of process measures to assess hospital 
compliance with practices designed to minimize SSIs, as well as other 
adverse events from surgery.[Footnote 18] CMS routinely publishes the 
scores that hospitals receive for these SCIP measures on its Hospital 
Compare Web site, along with process and outcome measures for other 
medical conditions.[Footnote 19]

States Have Designed Broadly Similar Mandatory HAI Public Reporting 
Systems, with Resource and Technological Challenges Affecting 
Implementation:

Of the 23 states we reviewed that have state-mandated HAI public 
reporting programs, most have adopted similar approaches to address 
resource and technological challenges that affect their implementation. 
Most of these states have designed, and the early-adopting states have 
implemented, programs that focus on a few outcome and process measures 
that were developed or endorsed by CDC and are widely accepted by ICPs. 
Three states have decided to collect data on hospital-associated MRSA 
infections. In addition, after some early efforts by states to develop 
their own data collection systems, a majority of the states we reviewed 
have chosen to use NHSN, the HAI data collection system developed by 
CDC. Adopting CDC-endorsed measures and the NHSN for data collection 
allows states to minimize some of the resource and technological 
challenges that they confront in implementing HAI reporting systems.

States Have Designed HAI Public Reporting Systems with Most Using 
Similar Approaches:

We reviewed 23 states that have state-mandated HAI public reporting 
systems (see table 1). By early 2008, 14 states had started to collect 
HAI data from hospitals. Most of the 23 states have adopted similar 
approaches involving (1) the use of advisory committees, (2) selection 
of many of the same measures, (3) decisions on systems for data 
collection, and (4) steps taken to validate the HAI data collected.

Table 1: States We Reviewed with HAI Public Reporting for Hospitals, by 
Date Data Collection Begins:

State: Pennsylvania; 
Date data collection began or planned to begin: Jan 2004.

State: Florida; 
Date data collection began or planned to begin: April 2005.

State: Missouri; 
Date data collection began or planned to begin: Jul 2005.

State: Vermont; 
Date data collection began or planned to begin: Nov 2006.

State: Maine; 
Date data collection began or planned to begin: Jan 2007.

State: New York; 
Date data collection began or planned to begin: Jan 2007.

State: Colorado; 
Date data collection began or planned to begin: Jul 2007.

State: Illinois; 
Date data collection began or planned to begin: Jul 2007.

State: South Carolina; 
Date data collection began or planned to begin: Jul 2007.

State: California; 
Date data collection began or planned to begin: Jan 2008.

State: Connecticut; 
Date data collection began or planned to begin: Jan 2008.

State: Delaware; 
Date data collection began or planned to begin: Jan 2008.

State: New Hampshire; 
Date data collection began or planned to begin: Jan 2008.

State: Tennessee; 
Date data collection began or planned to begin: Jan 2008.

State: Maryland; 
Date data collection began or planned to begin: Jul 2008.

State: Massachusetts; 
Date data collection began or planned to begin: Jul 2008.

State: Oklahoma; 
Date data collection began or planned to begin: Jul 2008.

State: Virginia; 
Date data collection began or planned to begin: Jul 2008.

State: Washington; 
Date data collection began or planned to begin: Jul 2008.

State: Minnesota; 
Date data collection began or planned to begin: Jan 2009.

State: New Jersey; 
Date data collection began or planned to begin: Jan 2009.

State: Oregon; 
Date data collection began or planned to begin: Jan 2009.

State: Texas; 
Date data collection began or planned to begin: To be determined.

Sources: State documents and communication with state government and 
hospital association officials.

Note: Some states have or will collect data on a pilot basis from the 
date listed above, but did not or will not publicly release data on 
hospitals until the pilot period, usually 6 months to a year, is 
completed. 

[End of table] 

Use of advisory committees:

We identified 19 states that have instituted HAI advisory committees or 
use technical advisors. Many of these committee members and technical 
advisors are drawn from related occupations, organizations, or 
interests. These include clinicians such as physicians or nurses (13 
states), consumers (10 states), hospital administrators or hospital 
association officials (11 states), and officials from the state health 
department (9 states). A few states also appoint advisory committee 
members who are academic researchers, technical specialists in 
microbiology or statistics, and representatives of health insurers, 
employers, and labor unions.

States seek input from their advisory committees or technical advisors 
on many of the same issues but differ in how extensively they rely on 
them. These issues include the initial selection of measures, data 
collection methods, the format of public reports, the selection of 
additional measures over time, data analysis techniques such as risk 
adjustment, and data validation methods. Several states have or plan to 
consult with advisory committees or technical advisors regarding all or 
nearly all these issues. Other states appear to restrict such 
consultation to as few as one or two of these issues.

Selection of HAI measures:

More state reporting systems have chosen to collect data on HAI 
outcomes, such as the rate at which certain types of HAIs occur, than 
collect data on compliance with processes intended to prevent HAIs. 
Twenty-one states have selected or are actively considering one or more 
outcome measures (see table 2) compared to 13 states that have selected 
or are actively considering one or more process measures (see table 3). 
Eleven states have selected or are considering both outcome and process 
measures.

Table 2: Outcome Measures by States We Reviewed with HAI Reporting, by 
Defining Entity:

State[A]: Pennsylvania[E]; 
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold]; 
HAI outcome measure: SSI[C]: CDC[Bold]; 
HAI outcome measure: VAP: CDC[Bold]; 
HAI outcome measure: Catheter-associated UTI: CDC[Bold]; 
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].

State[A]: Florida; 
HAI outcome measure: Central line-associated BSI[B]: [Empty]; 
HAI outcome measure: SSI[C]: [Empty]; 
HAI outcome measure: VAP: [Empty]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: AHRQ.

State[A]: Missouri; 
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold]; 
HAI outcome measure: SSI[C]: CDC[Bold]; 
HAI outcome measure: VAP: [Empty]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].

State[A]: Vermont; 
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold]; 
HAI outcome measure: SSI[C]: CDC[Bold]; 
HAI outcome measure: VAP: [Empty]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].

State[A]: Maine; 
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold]; 
HAI outcome measure: SSI[C]: [Empty]; 
HAI outcome measure: VAP: [Empty]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].

State[A]: New York; 
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold]; 
HAI outcome measure: SSI[C]: CDC[Bold]; 
HAI outcome measure: VAP: [Empty]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].

State[A]: Colorado; 
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold]; 
HAI outcome measure: SSI[C]: CDC[Bold]; 
HAI outcome measure: VAP: [Empty]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].

State[A]: Illinois; 
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold]; 
HAI outcome measure: SSI[C]: [Empty]; 
HAI outcome measure: VAP: [Empty]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].

State[A]: South Carolina; 
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold]; 
HAI outcome measure: SSI[C]: CDC[Bold]; 
HAI outcome measure: VAP: [Empty]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].

State[A]: California; 
HAI outcome measure: Central line-associated BSI[B]: [Empty]; 
HAI outcome measure: SSI[C]: [Empty]; 
HAI outcome measure: VAP: [Empty]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].

State[A]: Connecticut; 
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold]; 
HAI outcome measure: SSI[C]: [Empty]; 
HAI outcome measure: VAP: [Empty]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].

State[A]: Delaware; 
HAI outcome measure: Central line-associated BSI[B]: CDC; 
HAI outcome measure: SSI[C]: CDC; 
HAI outcome measure: VAP: [Empty]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].

State[A]: New Hampshire; 
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold]; 
HAI outcome measure: SSI[C]: CDC[Bold]; 
HAI outcome measure: VAP: CDC[Bold]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].

State[A]: Tennessee; 
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold]; 
HAI outcome measure: SSI[C]: CDC[Bold]; 
HAI outcome measure: VAP: [Empty]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].

State[A]: Maryland; 
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold]; 
HAI outcome measure: SSI[C]: CDC[Bold]; 
HAI outcome measure: VAP: [Empty]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].

State[A]: Massachusetts; 
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold]; 
HAI outcome measure: SSI[C]: CDC[Bold]; 
HAI outcome measure: VAP: [Empty]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].

State[A]: Oklahoma; 
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold]; 
HAI outcome measure: SSI[C]: [Empty]; 
HAI outcome measure: VAP: CDC[Bold]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: AHRQ.

State[A]: Virginia; 
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold]; 
HAI outcome measure: SSI[C]: [Empty]; 
HAI outcome measure: VAP: [Empty]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].

State[A]: Washington; 
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold]; 
HAI outcome measure: SSI[C]: CDC[Bold]; 
HAI outcome measure: VAP: CDC[Bold]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].

State[A]: Minnesota; 
HAI outcome measure: Central line-associated BSI[B]: [Empty]; 
HAI outcome measure: SSI[C]: [Empty]; 
HAI outcome measure: VAP: [Empty]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].

State[A]: New Jersey; 
HAI outcome measure: Central line-associated BSI[B]: CDC; 
HAI outcome measure: SSI[C]: CDC; 
HAI outcome measure: VAP: [Empty]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].

State[A]: Oregon; 
HAI outcome measure: Central line-associated BSI[B]: CDC[Bold]; 
HAI outcome measure: SSI[C]: CDC[Bold]; 
HAI outcome measure: VAP: [Empty]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].

State[A]: Texas; 
HAI outcome measure: Central line-associated BSI[B]: CDC; 
HAI outcome measure: SSI[C]: CDC; 
HAI outcome measure: VAP: [Empty]; 
HAI outcome measure: Catheter-associated UTI: [Empty]; 
HAI outcome measure: HAI-related patient safety indicators[D]: [Empty].

Sources: State documents and communication with state government and 
hospital association officials.

Notes:

CDC[Bold]: State has decided to collect data for this measure in 
accordance with CDC definitions and NHSN specifications.

CDC: State is considering collection of data for this measure in 
accordance with CDC definitions and NHSN specifications.

AHRQ: State has decided to collect data for "selected infections due to 
medical care" and "postoperative sepsis" in accordance with Agency for 
Healthcare Research and Quality (AHRQ) specifications.

[A] States listed in order of when they began collecting HAI data, as 
shown in table 1.

[B] Most states have chosen to collect data on this measure for ICU 
patients only.

[C] Most states have chosen to collect data on this measure only for 
patients undergoing one or more selected procedures, such as coronary 
artery bypass surgery, hysterectomy, and hip and knee replacement.

[D] One patient safety indicator captures selected infections due to 
medical care, which includes many device-related infections such as 
central line-associated BSIs. Another indicator identifies cases of 
postoperative sepsis, which is aimed at certain infections in surgical 
patients but is distinct from surgical site infections.

[E] Pennsylvania collected data on these measures according to CDC 
definitions but not according to NHSN specifications between 2004 and 
2007. In January 2008, the state began using NHSN specifications. 

[End of table]

Table 3: Process Measures by States We Reviewed with HAI Reporting:

State[A]: Pennsylvania; 
HAI process measures: Antibiotics administered prior to surgery[B]: 
[F]; 
HAI process measure: Health care worker influenza vaccination: [Empty]; 
HAI process measure: Central line insertion practices[C]: [Empty]; 
HAI process measure: Central line bundle[D]: [F]; 
HAI process measure: VAP prevention practices[E]: [F]; 
HAI process measure: Ventilator bundle[E]: [Empty].

State[A]: Florida; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
State has decided to collect data for this measure; 
HAI process measure: Health care worker influenza vaccination: [Empty]; 
HAI process measure: Central line insertion practices[C]: [Empty]; 
HAI process measure: Central line bundle[D]: [Empty]; 
HAI process measure: VAP prevention practices[E]: [Empty]; 
HAI process measure: Ventilator bundle[E]: [Empty].

State[A]: Missouri; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
[Empty]; 
HAI process measure: Health care worker influenza vaccination: [Empty]; 
HAI process measure: Central line insertion practices[C]: [Empty]; 
HAI process measure: Central line bundle[D]: [Empty]; 
HAI process measure: VAP prevention practices[E]: State has decided to 
collect data for this measure[G]; 
HAI process measure: Ventilator bundle[E]: [Empty].

State[A]: Vermont; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
State has decided to collect data for this measure; 
HAI process measure: Health care worker influenza vaccination: State is 
considering collection of data for this measure; 
HAI process measure: Central line insertion practices[C]: [Empty]; 
HAI process measure: Central line bundle[D]: State has decided to 
collect data for this measure[H]; 
HAI process measure: VAP prevention practices[E]: [Empty]; 
HAI process measure: Ventilator bundle[E]: [Empty].

State[A]: Maine; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
State has decided to collect data for this measure; 
HAI process measure: Health care worker influenza vaccination: [Empty]; 
HAI process measure: Central line insertion practices[C]: [Empty]; 
HAI process measure: Central line bundle[D]: State has decided to 
collect data for this measure; 
HAI process measure: VAP prevention practices[E]: [Empty]; 
HAI process measure: Ventilator bundle[E]: State has decided to collect 
data for this measure.

State[A]: New York; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
[Empty]; 
HAI process measure: Health care worker influenza vaccination: [Empty]; 
HAI process measure: Central line insertion practices[C]: [Empty]; 
HAI process measure: Central line bundle[D]: [Empty]; 
HAI process measure: VAP prevention practices[E]: [Empty]; 
HAI process measure: Ventilator bundle[E]: [Empty].

State[A]: Colorado; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
[Empty]; 
HAI process measure: Health care worker influenza vaccination: [Empty]; 
HAI process measure: Central line insertion practices[C]: [Empty]; 
HAI process measure: Central line bundle[D]: [Empty]; 
HAI process measure: VAP prevention practices[E]: [Empty]; 
HAI process measure: Ventilator bundle[E]: [Empty].

State[A]: Illinois; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
State has decided to collect data for this measure; 
HAI process measure: Health care worker influenza vaccination: [Empty]; 
HAI process measure: Central line insertion practices[C]: [Empty]; 
HAI process measure: Central line bundle[D]: [Empty]; 
HAI process measure: VAP prevention practices[E]: [Empty]; 
HAI process measure: Ventilator bundle[E]: [Empty].

State[A]: South Carolina; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
[Empty]; 
HAI process measure: Health care worker influenza vaccination: [Empty]; 
HAI process measure: Central line insertion practices[C]: [Empty]; 
HAI process measure: Central line bundle[D]: [Empty]; 
HAI process measure: VAP prevention practices[E]: [Empty]; 
HAI process measure: Ventilator bundle[E]: [Empty].

State[A]: California; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
State has decided to collect data for this measure; 
HAI process measure: Health care worker influenza vaccination: State 
has decided to collect data for this measure; 
HAI process measure: Central line insertion practices[C]: State has 
decided to collect data for this measure; 
HAI process measure: Central line bundle[D]: [Empty]; 
HAI process measure: VAP prevention practices[E]: [Empty]; 
HAI process measure: Ventilator bundle[E]: [Empty].

State[A]: Connecticut; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
[Empty]; 
HAI process measure: Health care worker influenza vaccination: [Empty]; 
HAI process measure: Central line insertion practices[C]: [Empty]; 
HAI process measure: Central line bundle[D]: [Empty]; 
HAI process measure: VAP prevention practices[E]: [Empty]; 
HAI process measure: Ventilator bundle[E]: [Empty].

State[A]: Delaware; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
[Empty]; 
HAI process measure: Health care worker influenza vaccination: State is 
considering collection of data for this measure; 
HAI process measure: Central line insertion practices[C]: [Empty]; 
HAI process measure: Central line bundle[D]: [Empty]; 
HAI process measure: VAP prevention practices[E]: [Empty]; 
HAI process measure: Ventilator bundle[E]: [Empty].

State[A]: New Hampshire; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
State has decided to collect data for this measure; 
HAI process measure: Health care worker influenza vaccination: State 
has decided to collect data for this measure; 
HAI process measure: Central line insertion practices[C]: State has 
decided to collect data for this measure; 
HAI process measure: Central line bundle[D]: [Empty]; 
HAI process measure: VAP prevention practices[E]: [Empty]; 
HAI process measure: Ventilator bundle[E]: [Empty].

State[A]: Tennessee; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
[Empty]; 
HAI process measure: Health care worker influenza vaccination: [Empty]; 
HAI process measure: Central line insertion practices[C]: [Empty]; 
HAI process measure: Central line bundle[D]: [Empty]; 
HAI process measure: VAP prevention practices[E]: [Empty]; 
HAI process measure: Ventilator bundle[E]: [Empty].

State[A]: Maryland; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
State has decided to collect data for this measure; 
HAI process measure: Health care worker influenza vaccination: State 
has decided to collect data for this measure; 
HAI process measure: Central line insertion practices[C]: [Empty]; 
HAI process measure: Central line bundle[D]: [Empty]; 
HAI process measure: VAP prevention practices[E]: [Empty]; 
HAI process measure: Ventilator bundle[E]: State has decided to collect 
data for this measure.

State[A]: Massachusetts; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
[Empty]; 
HAI process measure: Health care worker influenza vaccination: State is 
considering collection of data for this measure; 
HAI process measure: Central line insertion practices[C]: [Empty]; 
HAI process measure: Central line bundle[D]: [Empty]; 
HAI process measure: VAP prevention practices[E]: State is considering 
collection of data for this measure; 
HAI process measure: Ventilator bundle[E]: [Empty].

State[A]: Oklahoma; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
[Empty]; 
HAI process measure: Health care worker influenza vaccination: [Empty]; 
HAI process measure: Central line insertion practices[C]: [Empty]; 
HAI process measure: Central line bundle[D]: [Empty]; 
HAI process measure: VAP prevention practices[E]: [Empty]; 
HAI process measure: Ventilator bundle[E]: [Empty].

State[A]: Virginia; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
[Empty]; 
HAI process measure: Health care worker influenza vaccination: [Empty]; 
HAI process measure: Central line insertion practices[C]: [Empty]; 
HAI process measure: Central line bundle[D]: [Empty]; 
HAI process measure: VAP prevention practices[E]: [Empty]; 
HAI process measure: Ventilator bundle[E]: [Empty].

State[A]: Washington; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
[Empty]; 
HAI process measure: Health care worker influenza vaccination: [Empty]; 
HAI process measure: Central line insertion practices[C]: [Empty]; 
HAI process measure: Central line bundle[D]: [Empty]; 
HAI process measure: VAP prevention practices[E]: [Empty]; 
HAI process measure: Ventilator bundle[E]: [Empty].

State[A]: Minnesota; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
State has decided to collect data for this measure[I]; 
HAI process measure: Health care worker influenza vaccination: [Empty]; 
HAI process measure: Central line insertion practices[C]: [Empty]; 
HAI process measure: Central line bundle[D]: [Empty]; 
HAI process measure: VAP prevention practices[E]: [Empty]; 
HAI process measure: Ventilator bundle[E]: [Empty].

State[A]: New Jersey; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
State has decided to collect data for this measure; 
HAI process measure: Health care worker influenza vaccination: [Empty]; 
HAI process measure: Central line insertion practices[C]: [Empty]; 
HAI process measure: Central line bundle[D]: [Empty]; 
HAI process measure: VAP prevention practices[E]: [Empty]; 
HAI process measure: Ventilator bundle[E]: [Empty].

State[A]: Oregon; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
State has decided to collect data for this measure; 
HAI process measure: Health care worker influenza vaccination: [Empty]; 
HAI process measure: Central line insertion practices[C]: [Empty]; 
HAI process measure: Central line bundle[D]: [Empty]; 
HAI process measure: VAP prevention practices[E]: [Empty]; 
HAI process measure: Ventilator bundle[E]: [Empty].

State[A]: Texas; 
HAI process measure: Antibiotics administered prior to surgery[B]: 
[Empty]; 
HAI process measure: Health care worker influenza vaccination: [Empty]; 
HAI process measure: Central line insertion practices[C]: [Empty]; 
HAI process measure: Central line bundle[D]: [Empty]; 
HAI process measure: VAP prevention practices[E]: [Empty]; 
HAI process measure: Ventilator bundle[E]: [Empty].

Sources: State documents and communication with state government and 
hospital association officials.

Notes:

[A] States listed in order of when they began collecting HAI data, as 
shown in table 1.

[B] Three measures, developed under the SCIP, are related to the 
routine administration of antibiotics to forestall SSIs: (1) the 
percentage of surgical patients who received an antibiotic within 1 
hour prior to surgery, (2) the percentage of surgical patients who 
received the antibiotic recommended for their procedure, and (3) the 
percentage of surgical patients whose antibiotics were discontinued 
within 24 hours after the procedure's end time.

[C] Central line insertion practices is a set of process measures 
developed by CDC to monitor compliance with recommended practices 
outlined in CDC's guidelines for the prevention of intravascular 
catheter-related infections. They include occupation of the inserter, 
hand hygiene, use of sterile barrier precautions, type of skin 
preparation, location of insertion site, and type of central line 
inserted.

[D] Central line bundle was developed by IHI. It consists of five 
components: hand hygiene, using maximal sterile barrier precautions, 
chlorhexidine skin antisepsis, optimal catheter site selection, and 
prompt removal of lines that are no longer necessary. The bundle 
measure represents the percentage of patients for whom all five 
components of the bundle were complied with.

[E] VAP prevention practices include head-of-bed elevation and daily 
assessments of readiness to discontinue mechanical ventilation. These 
are two of the four components of the IHI ventilator bundle, which 
represents the percentage of patients for whom all four components of 
the bundle were complied with. The other two components of the 
ventilator bundle are medication to prevent peptic ulcer disease and 
medication or mechanical stimulation to prevent blood clots.

[F] Pennsylvania collects information on VAP prevention practices as 
well as some, but not all, items included in two of the other process 
measures: antibiotics administered prior to surgery and the central 
line bundle. However, it only collects these data for patients who 
develop SSIs, central line-associated BSIs, and VAP. It also collects 
similar information on patients who develop urinary tract infections. 
So Pennsylvania uses these data to help explain the infections that 
occur, rather than assess the extent to which hospitals comply with 
recommended infection prevention practices.

[G] Missouri hospitals report one VAP prevention measure, head-of-bed 
elevation, voluntarily.

[H] Vermont has hospitals self-report which components of the central 
line bundle they have adopted and whether they train their staff to 
perform those selected components and ensure that staff use them.

[I] Minnesota will also collect data for two additional SCIP infection 
prevention measures, one on controlling postoperative blood glucose 
levels for cardiac surgery patients and one on appropriate hair 
removal. 

[End of table] 

For the most part, states have chosen to publicly report on a handful 
of measures relating to HAI outcomes and process that are well- 
established and clearly defined. For the states selecting HAI outcome 
measures, all but one have selected or are considering measures 
developed by CDC. Among the states that have selected process measures, 
most have emphasized the SCIP measures designed to prevent SSIs that 
both CDC and CMS helped develop.

The HAI outcome measures selected by the state reporting systems have 
largely focused on two types of infections as defined by CDC. Of the 18 
states that have selected HAI outcome measures, 17 have chosen to 
collect rates of central line-associated BSIs, as defined by CDC and in 
accordance with NHSN collection protocols (see table 2). Three other 
states are actively considering this measure. Twelve states have chosen 
to collect rates of SSIs for specified procedures, as defined by CDC 
and in accordance with NHSN collection protocols, while 3 other states 
are actively considering this measure. Surgical procedures that states 
have selected for this outcome measure include coronary artery bypass 
grafts, hip replacements, knee replacements, and hysterectomies. All 12 
states selecting the SSI measure were among the 17 that selected the 
central line-associated BSI measure. Both central line-associated BSIs 
and SSIs were recommended for use in public reporting by CDC's HICPAC 
and professional associations in infection control and epidemiology, 
and more recently by the National Quality Forum (NQF).[Footnote 20]

The states that have chosen to measure processes of care designed to 
prevent HAIs have focused on surgical measures (see table 3). 
Specifically, 10 states decided to track the routine administration of 
antibiotics to forestall SSIs. Three measures of this process were 
adopted under the SCIP program: antibiotic received within 1 hour of 
surgery, appropriate antibiotic selection, and antibiotics discontinued 
within 24 hours after the surgery end time. These are the same surgical 
measures that CMS reports on its Hospital Compare Web site, and they 
have also been recommended for use in public reporting by CDC's HICPAC 
committee.

A smaller number of states have selected HAI outcome and process 
measures for which there is less agreement in the infection control 
community. For example, among the outcome measures, VAP and catheter- 
associated UTI rates have not been recommended for public reporting by 
HICPAC or the professional associations, although both are among the 
HAI measures endorsed by NQF.[Footnote 21] Several states have also 
selected influenza vaccination for health care workers as a process 
measure. While not endorsed by NQF, this measure has been recommended 
for public reporting by HICPAC, and CDC plans to include it in the NHSN.

Of the 23 states we reviewed, only 2 have selected HAI outcome measures 
that substantially diverge from CDC definitions and protocols. Florida 
and Oklahoma selected two measures developed by the Agency for 
Healthcare Research and Quality (AHRQ) as part of its Patient Safety 
Indicators (PSI).[Footnote 22] One PSI measure identifies "selected 
infections due to medical care," which includes (but is not limited to) 
device-related infections such as central line-associated BSIs. In 
contrast to SSIs, which are infections at the site of the surgery, the 
second HAI-related PSI measure, postoperative sepsis, focuses on major, 
systemwide infections that occur following surgery. The two PSI 
measures are calculated by analyzing combinations of diagnosis and 
procedure codes in administrative billing records to identify certain 
adverse events using computer software. Both states have also selected 
at least one of the measures commonly selected by other states that 
accord with CDC definitions and protocols or guidance (see tables 2 and 
3).[Footnote 23]

Data collection systems:

With respect to setting up systems for collecting HAI data from 
hospitals, states have increasingly relied on CDC's NHSN (see table 4). 
In January 2007, New York became the first state to begin collecting 
data for public reporting using the NHSN, and by June 2007, CDC had 
completed its development of the NHSN sufficiently to open enrollment 
in the system to hospitals in every state. Prior to that date, 4 states 
developed their own data collection mechanisms, beginning with 
Pennsylvania in 2004. Since CDC opened enrollment in NHSN to all 
hospitals, no state has chosen not to use NHSN to collect at least some 
of its HAI data.[Footnote 24] In addition to New York, Colorado, South 
Carolina, and Vermont began collecting data through NHSN in 2007, and 
13 other states have decided to use NHSN for their HAI public reporting 
programs.[Footnote 25] Included in the latter group is Pennsylvania, 
which discontinued its original system in favor of NHSN starting in 
January 2008. Meanwhile Minnesota, New Jersey, and Texas are 
considering whether to use NHSN to collect HAI data for public 
reporting. Currently, only 3 states--Florida, Maine, and Missouri--use 
systems that do not rely on the NHSN to collect HAI data, though Maine 
and Missouri draw on CDC's definitions.

Table 4: Data Collection Systems, by States We Reviewed with HAI 
Reporting:

State[A]: Pennsylvania[B]; 
Data collection system: NHSN: Data collection system selected; 
Data collection system: State developed: [Empty].

State[A]: Florida; 
Data collection system: NHSN: [Empty]; 
Data collection system: State developed: Data collection system 
selected.

State[A]: Missouri; 
Data collection system: NHSN: [Empty]; 
Data collection system: State developed: Data collection system 
selected.

State[A]: Vermont; 
Data collection system: NHSN: Data collection system selected; 
Data collection system: State developed: [Empty].

State[A]: Maine; 
Data collection system: NHSN: [Empty]; 
Data collection system: State developed: Data collection system 
selected.

State[A]: New York; 
Data collection system: NHSN: Data collection system selected; 
Data collection system: State developed: [Empty].

State[A]: Colorado; 
Data collection system: NHSN: Data collection system selected; 
Data collection system: State developed: [Empty].

State[A]: Illinois; 
Data collection system: NHSN: Data collection system selected; 
Data collection system: State developed: [Empty].

State[A]: South Carolina; 
Data collection system: NHSN: Data collection system selected; 
Data collection system: State developed: [Empty].

State[A]: California; 
Data collection system: NHSN: Data collection system selected; 
Data collection system: State developed: [Empty].

State[A]: Connecticut; 
Data collection system: NHSN: Data collection system selected; 
Data collection system: State developed: [Empty].

State[A]: Delaware; 
Data collection system: NHSN: Data collection system selected; 
Data collection system: State developed: [Empty].

State[A]: New Hampshire; 
Data collection system: NHSN: Data collection system selected; 
Data collection system: State developed: [Empty].

State[A]: Tennessee; 
Data collection system: NHSN: Data collection system selected; 
Data collection system: State developed: [Empty].

State[A]: Maryland; 
Data collection system: NHSN: Data collection system selected; 
Data collection system: State developed: [Empty].

State[A]: Massachusetts; 
Data collection system: NHSN: Data collection system selected; 
Data collection system: State developed: [Empty].

State[A]: Oklahoma; 
Data collection system: NHSN: Data collection system selected; 
Data collection system: State developed: [Empty].

State[A]: Virginia; 
Data collection system: NHSN: Data collection system selected; 
Data collection system: State developed: [Empty].

State[A]: Washington; 
Data collection system: NHSN: Data collection system selected; 
Data collection system: State developed: [Empty].

State[A]: Minnesota; 
Data collection system: NHSN: Data collection system being considered; 
Data collection system: State developed: [Empty].

State[A]: New Jersey; 
Data collection system: NHSN: Data collection system being considered; 
Data collection system: State developed: [Empty].

State[A]: Oregon; 
Data collection system: NHSN: Data collection system selected; 
Data collection system: State developed: [Empty].

State[A]: Texas; 
Data collection system: NHSN: Data collection system being considered; 
Data collection system: State developed: [Empty].

Sources: GAO analysis of state documents and communication with state 
government and hospital association officials.

Notes:

A number of states that use the NHSN also use other data collection 
systems for measures that are not incorporated into the NHSN, such as 
those for antibiotics administered prior to surgery.

[A] States listed in order of when they began collecting HAI data, as 
shown in table 1.

[B] From 2004 through 2007 Pennsylvania used its own state data 
collection system. 

[End of table] 

Data validation:

Data collection systems may or may not incorporate procedures to 
independently verify the accuracy of the data submitted to them. 
However, according to infection control experts as well as state 
officials responsible for HAI reporting programs, unless such 
procedures are in place, there is a substantial risk that the data 
provided by hospitals in a mandatory public reporting system will be 
misleading because some hospitals will provide data that are more 
accurate and complete than others. This variation in reporting accuracy 
and completeness can occur for several reasons. First, as New York 
health department officials found, hospitals can provide inconsistent 
information because they interpret the relevant definitions 
differently. Second, some hospitals are likely to have infection 
control programs that are more effective than others in identifying 
HAIs, which means that they detect a higher proportion of the HAIs that 
occur in their facilities. Finally, the act of publicly reporting 
infection rates as a guide for patients to use in selecting a hospital 
may encourage hospitals to be less rigorous in seeking to detect HAIs, 
since the fewer they find the better they look compared to their 
competitors.

Because the HAI data collection systems developed by CDC, including 
NHSN, were based on a model of voluntary participation by hospitals for 
purposes of internal quality improvement without public disclosure of 
the results, CDC systems did not incorporate processes for independent 
data validation. Voluntary participation without public disclosure was 
presumed to minimize any incentive for hospitals to submit inaccurate 
data. Consequently, CDC has not conducted an ongoing or systematic 
validation study of the data currently being submitted to 
NHSN,[Footnote 26] though it has collaborated with states that adopt 
NHSN for mandatory public reporting to develop methods that the states 
can use to ensure the submitted data are accurate.

Of the 23 states we reviewed, 4 have plans to validate the accuracy of 
the data collected from hospitals, while several others indicated they 
may develop such plans in the future. New York has made the most 
progress on implementing a broad data validation process. It has hired 
five ICPs to review a systematic sample of infection reports submitted 
to the NHSN from each New York hospital and compare the reports with 
the hospitals' medical records. The ICPs review medical records of ICU 
patients with bloodstream infections from each hospital, as well as 
records of matched patients with similar surgeries for whom infections 
were and were not reported. After identifying which patient medical 
records showed HAIs that should have been reported, they compare them 
to the infection reports submitted by the hospitals. For any 
discrepancies, state officials meet with hospital staff to better 
ensure the accuracy of the data for the next reporting period.

Three other states--Pennsylvania, Missouri, and South Carolina--have 
undertaken less extensive efforts to validate data they receive from 
hospitals. Pennsylvania has conducted inspections of a limited number 
of hospitals selected on the basis of statistical anomalies in the HAI 
data that they submitted. However, Pennsylvania state officials have 
developed plans to emulate New York's approach and hire auditors to 
review a sample of patient medical records from each hospital. In 
addition, they plan to analyze utilization data obtained from insurance 
plans. In Missouri, health department officials conducting annual 
onsite inspections of licensed hospitals compare a hospital's HAI 
reports with a sample of patient medical records. This is one of many 
items covered during a licensing inspection and it is not designed to 
be a comprehensive data validation effort. South Carolina has initiated 
a pilot program with one hospital system to develop data validation 
methods based on linking NHSN data with hospital billing data from the 
state's hospital discharge data set.

Officials in other states have indicated similar concerns about the 
accuracy of data submitted to HAI public reporting programs, but have 
not yet acted on those concerns. Documents from seven states supported 
efforts to validate the data submitted by hospitals to ensure their 
accuracy.[Footnote 27] However, most of these states are just beginning 
to implement their public reporting systems and have not yet begun to 
develop data validation methods.

Most States Do Not Require Hospitals to Track MRSA HAIs, though Some 
States Collect Limited MRSA Data through Public Reporting or Other 
Systems:

States have generally not required MRSA-related outcome measures or 
process measures as a part of their public reporting programs, even 
though MRSA and other MDROs cause many HAIs. Three exceptions are 
Illinois, Maryland, and New Jersey. Illinois plans to collect data on 
the number of hospital patients with MRSA infections using diagnostic 
codes included in administrative data that hospitals routinely submit 
to the state. In January 2008, Illinois made two changes to its 
administrative data systems that will enhance its identification of 
hospital-associated MRSA infections. First, it required all hospitals 
to enter a code for each reported diagnosis to indicate if the 
condition was present when the patient was admitted.[Footnote 28] The 
state also expanded the number of diagnosis codes that hospitals report 
to the state, from a maximum of 9 to 25, which will reduce the chances 
of undercounting the number of patients with MRSA infections for 
patients with more than 9 diagnoses.

New Jersey is also requiring hospitals to report on MRSA cases acquired 
in hospitals. Rather than rely on administrative data, New Jersey plans 
to use an MDRO module for the NHSN that CDC is developing and expects 
to release in the fall of 2008. Maryland has taken yet another approach 
by deciding to collect data on a MRSA-related process measure instead 
of outcomes. It will collect information from hospitals on the 
proportion of patients in ICUs who undergo AST for MRSA.

States also are able to obtain some data on HAIs caused by MRSA from 
the existing NHSN modules. Seventeen states have decided to use the 
NHSN to collect outcome measures on one or more types of HAIs for which 
there are NHSN protocols.[Footnote 29] These protocols require 
hospitals to report available information about the pathogens causing 
the infections and the results of any antimicrobial susceptibility 
laboratory testing performed. However, these data are limited to the 
types of infections that the states require hospitals to report, and 
most states have opted not to require hospitals to report on all types 
of HAIs in hospitals for which NHSN has developed protocols. Moreover, 
the existing NHSN modules do not include community-associated MRSA, 
which can only be reported through NHSN as part of the MDRO module to 
be released in fall of 2008.

Although MRSA does not appear on CDC's list of nationally notifiable 
infectious diseases for 2008, we found 13 states that classify MRSA 
infections as a reportable disease under their state communicable 
disease programs[Footnote 30]. These programs require hospitals, 
laboratories, or other providers to report some or all MRSA cases to 
the state or local departments of health periodically. [Footnote 31] In 
all but one of these states, those reporting MRSA cases are not asked 
to distinguish between health-care-associated and community-associated 
infections.

Resource and Technological Challenges Influence How States Implement 
HAI Reporting Systems:

State and state hospital association officials we interviewed mentioned 
a variety of resource and technology challenges they faced in 
implementing their HAI reporting systems. These challenges often 
limited the scope of their reporting systems and the timing of their 
implementation. Regarding resource challenges, officials in one state 
reported that they needed to train and provide technical assistance for 
hospital staff, some of whom struggled to implement the clinically 
sophisticated NHSN protocols for data collection. A status report 
issued by another state noted that the state resources dedicated to 
training hospital staff to use the NHSN prevented the state from 
conducting other program activities such as data validation. Officials 
in several states reported trouble hiring and retaining the staff they 
needed to initiate their HAI reporting systems, sometimes due to a lack 
of financial resources. State officials underscored their need for 
highly trained personnel to effectively implement these reporting 
systems. Hospital association and state officials in several states 
noted that hospitals did not have enough qualified ICPs, which has 
exacerbated implementation challenges. One state official indicated 
that although the health department had financial resources to hire 
staff, it did not have enough office space.

States also confronted technological challenges when implementing HAI 
reporting systems, especially if they developed their own data 
collection systems. Missouri officials, for example, found the system 
they developed had to balance competing technological demands to (1) 
collect all the necessary data elements for proper risk adjustment, (2) 
allow hospitals to extract the data using their existing computer 
systems, and (3) be user-friendly for those collecting and entering 
data. Pennsylvania also experienced technological challenges. For 
example, when it began collecting HAI data from hospitals using a data 
system that was developed for hospitals to report administrative data, 
it generated strong criticisms from hospital officials and clinicians 
who argued that this system did not collect the information needed to 
risk adjust the reported results as recommended by CDC.[Footnote 32]

CDC had already dealt with such technological issues in developing the 
NHSN, building on its decades-long experience in operating the NNIS 
system. In June 2007, CDC opened enrollment in the NHSN to all U.S. 
hospitals. This made adoption of the NHSN an attractive option for 
state officials seeking to address these technological concerns. For 
example, New York officials reported to us that they considered 
developing their own data collection system tailored to the needs of 
the New York program before deciding to adopt the NHSN. Because New 
York's law required a reporting system that was functionally similar to 
the NHSN, these officials concluded that it made more sense to use the 
existing system than attempt to create a new system to perform the same 
functions.

These challenges, particularly with respect to resources, have affected 
the decisions states have made regarding timelines for implementation, 
measures to use, data collection mechanisms, and data validation 
processes. To ensure they have sufficient resources to adequately 
implement their reporting systems, some states have delayed the 
starting date for reporting or limited the number of measures to be 
collected. Frequently states restricted the measures that they selected 
to patients in certain units, such as ICUs, or those who underwent 
selected surgical procedures.

To avoid the resource and technological challenges of developing their 
own data collection systems, most states have decided to use the NHSN. 
State officials cited numerous reasons for adopting the NHSN, including 
that it is free to both the states and the hospitals, accessible on the 
Internet, requires no software development by the states or commercial 
software purchases by hospitals, uses professionally accepted 
definitions, and collects detailed data that hospitals can use for 
quality improvement. However, despite widespread recognition among 
state officials of the need to validate the data submitted by 
hospitals, only in a few states have officials determined how to 
accomplish data validation with the resources available to them.

Hospital MRSA-Reduction Initiatives Share Multiple Components, but Vary 
in Scope and Resource Requirements:

All the hospitals with MRSA-reduction initiatives that we reviewed use 
routine testing for MRSA as part of their initiative, although they 
chose different patient populations to test. These hospitals reported 
changing a number of general infection control policies or practices as 
part of their initiatives, and all included patient or health care 
staff decolonization as part of their initiative despite limited 
support for such practices among infection control experts. The 
hospitals we reviewed reported needing varying levels of funding and 
staff resources to operate their initiatives, but all hospitals that 
tracked MRSA infection rates reported a decline in MRSA infections as a 
result of their initiatives.

All Initiatives Use Routine Testing for MRSA but Vary in How Testing Is 
Targeted and Conducted:

All 14 hospitals we reviewed reported that they conduct AST as part of 
their MRSA-reduction initiative. However, these hospitals vary in the 
patient populations tested (see table 5). Three hospitals conduct 
universal AST, testing all patients admitted. The remaining hospitals 
conduct targeted AST, screening select patient populations deemed to be 
at risk for MRSA colonization. Of the hospitals that conduct targeted 
AST, all but one screen patients in adult or neonatal intensive care 
units and 5 screen surgical patients.

Table 5: Patient Populations Screened with Active Surveillance Testing, 
by Selected Hospital:

Evanston Northwestern Healthcare; 
All (Universal): Hospital screens patient population for MRSA; 
Targeted screening: Adult intensive care unit: Included in universal 
active surveillance testing where all admitted patients are tested; 
Targeted screening: Neonatal intensive care unit: Included in universal 
active surveillance testing where all admitted patients are tested; 
Targeted screening: Surgical: Included in universal active surveillance 
testing where all admitted patients are tested; 
Targeted screening: Long-term care facility admissions: Included in 
universal active surveillance testing where all admitted patients are 
tested; 
Targeted screening: Jail or prison admissions: Included in universal 
active surveillance testing where all admitted patients are tested; 
Targeted screening: Dialysis: Included in universal active surveillance 
testing where all admitted patients are tested; 
Targeted screening: Other: Included in universal active surveillance 
testing where all admitted patients are tested.

Medical University of South Carolina; 
All (Universal): Hospital screens patient population for MRSA; 
Targeted screening: Adult intensive care unit: Included in universal 
active surveillance testing where all admitted patients are tested; 
Targeted screening: Neonatal intensive care unit: Included in universal 
active surveillance testing where all admitted patients are tested; 
Targeted screening: Surgical: Included in universal active surveillance 
testing where all admitted patients are tested; 
Targeted screening: Long-term care facility admissions: Included in 
universal active surveillance testing where all admitted patients are 
tested; 
Targeted screening: Jail or prison admissions: Included in universal 
active surveillance testing where all admitted patients are tested; 
Targeted screening: Dialysis: Included in universal active surveillance 
testing where all admitted patients are tested; 
Targeted screening: Other: Included in universal active surveillance 
testing where all admitted patients are tested.

Pitt County Memorial Hospital; 
All (Universal): Hospital screens patient population for MRSA; 
Targeted screening: Adult intensive care unit: Included in universal 
active surveillance testing where all admitted patients are tested; 
Targeted screening: Neonatal intensive care unit: Included in universal 
active surveillance testing where all admitted patients are tested; 
Targeted screening: Surgical: Included in universal active surveillance 
testing where all admitted patients are tested; 
Targeted screening: Long-term care facility admissions: Included in 
universal active surveillance testing where all admitted patients are 
tested; 
Targeted screening: Jail or prison admissions: Included in universal 
active surveillance testing where all admitted patients are tested; 
Targeted screening: Dialysis: Included in universal active surveillance 
testing where all admitted patients are tested; 
Targeted screening: Other: Included in universal active surveillance 
testing where all admitted patients are tested.

Eastern Idaho Regional Medical Center; 
All (Universal): [Empty]; 
Targeted screening: Adult intensive care unit: Hospital screens patient 
population for MRSA; 
Targeted screening: Neonatal intensive care unit: Hospital screens 
patient population for MRSA; 
Targeted screening: Surgical: Hospital screens patient population for 
MRSA[A]; 
Targeted screening: Long-term care facility admissions: Hospital 
screens patient population for MRSA; 
Targeted screening: Jail or prison admissions: Hospital screens patient 
population for MRSA; 
Targeted screening: Dialysis: Hospital screens patient population for 
MRSA; 
Targeted screening: Other: Hospital screens patient population for 
MRSA[B].

Centra, Lynchburg General and Virginia Baptist Hospitals; 
All (Universal): [Empty]; 
Targeted screening: Adult intensive care unit: Hospital screens patient 
population for MRSA; 
Targeted screening: Neonatal intensive care unit: [Empty]; 
Targeted screening: Surgical: Hospital screens patient population for 
MRSA[C]; 
Targeted screening: Long-term care facility admissions: Hospital 
screens patient population for MRSA; 
Targeted screening: Jail or prison admissions: [Empty]; 
Targeted screening: Dialysis: Hospital screens patient population for 
MRSA; 
Targeted screening: Other: Hospital screens patient population for 
MRSA[D].

Wake Forest University Baptist Medical Center; 
All (Universal): [Empty]; 
Targeted screening: Adult intensive care unit: Hospital screens patient 
population for MRSA; 
Targeted screening: Neonatal intensive care unit: [Empty]; 
Targeted screening: Surgical: [Empty]; 
Targeted screening: Long-term care facility admissions: [Empty]; 
Targeted screening: Jail or prison admissions: [Empty]; 
Targeted screening: Dialysis: [Empty]; 
Targeted screening: Other: Hospital screens patient population for 
MRSA[E].

Mercy Medical Center; 
All (Universal): [Empty]; 
Targeted screening: Adult intensive care unit: [Empty]; 
Targeted screening: Neonatal intensive care unit: [Empty]; 
Targeted screening: Surgical: [Empty]; 
Targeted screening: Long-term care facility admissions: Hospital 
screens patient population for MRSA; 
Targeted screening: Jail or prison admissions: [Empty]; 
Targeted screening: Dialysis: [Empty]; 
Targeted screening: Other: Hospital screens patient population for 
MRSA[F].

Albany Medical Center; 
All (Universal): [Empty]; 
Targeted screening: Adult intensive care unit: [Empty]; 
Targeted screening: Neonatal intensive care unit: Hospital screens 
patient population for MRSA; 
Targeted screening: Surgical: Hospital screens patient population for 
MRSA; 
Targeted screening: Long-term care facility admissions: [Empty]; 
Targeted screening: Jail or prison admissions: [Empty]; 
Targeted screening: Dialysis: [Empty]; 
Targeted screening: Other: [Empty].

Newark Beth Israel Medical Center; 
All (Universal): [Empty]; 
Targeted screening: Adult intensive care unit: Hospital screens patient 
population for MRSA; 
Targeted screening: Neonatal intensive care unit: Hospital screens 
patient population for MRSA; 
Targeted screening: Surgical: [Empty]; 
Targeted screening: Long-term care facility admissions: [Empty]; 
Targeted screening: Jail or prison admissions: [Empty]; 
Targeted screening: Dialysis: [Empty]; 
Targeted screening: Other: [Empty].

Beth Israel Medical Center; 
All (Universal): [Empty]; 
Targeted screening: Adult intensive care unit: Hospital screens patient 
population for MRSA; 
Targeted screening: Neonatal intensive care unit: [Empty]; 
Targeted screening: Surgical: Hospital screens patient population for 
MRSA[G]; 
Targeted screening: Long-term care facility admissions: [Empty]; 
Targeted screening: Jail or prison admissions: [Empty]; 
Targeted screening: Dialysis: [Empty]; 
Targeted screening: Other: [Empty].

Rochester General Hospital; 
All (Universal): [Empty]; 
Targeted screening: Adult intensive care unit: Hospital screens patient 
population for MRSA; 
Targeted screening: Neonatal intensive care unit: [Empty]; 
Targeted screening: Surgical: Hospital screens patient population for 
MRSA[H]; 
Targeted screening: Long-term care facility admissions: [Empty]; 
Targeted screening: Jail or prison admissions: [Empty]; 
Targeted screening: Dialysis: [Empty]; 
Targeted screening: Other: [Empty].

University of Pittsburgh Medical Center; 
All (Universal): [Empty]; 
Targeted screening: Adult intensive care unit: Hospital screens patient 
population for MRSA; 
Targeted screening: Neonatal intensive care unit: [Empty]; 
Targeted screening: Surgical: [Empty]; 
Targeted screening: Long-term care facility admissions: [Empty]; 
Targeted screening: Jail or prison admissions: [Empty]; 
Targeted screening: Dialysis: [Empty]; 
Targeted screening: Other: [Empty].

Barnes-Jewish Hospital; 
All (Universal): [Empty]; 
Targeted screening: Adult intensive care unit: Hospital screens patient 
population for MRSA; 
Targeted screening: Neonatal intensive care unit: [Empty]; 
Targeted screening: Surgical: [Empty]; 
Targeted screening: Long-term care facility admissions: [Empty]; 
Targeted screening: Jail or prison admissions: [Empty]; 
Targeted screening: Dialysis: [Empty]; 
Targeted screening: Other: [Empty].

Pacific Hospital of Long Beach; 
All (Universal): [Empty]; 
Targeted screening: Adult intensive care unit: Hospital screens patient 
population for MRSA; 
Targeted screening: Neonatal intensive care unit: [Empty]; 
Targeted screening: Surgical: [Empty]; 
Targeted screening: Long-term care facility admissions: [Empty]; 
Targeted screening: Jail or prison admissions: [Empty]; 
Targeted screening: Dialysis: [Empty]; 
Targeted screening: Other: [Empty].

Source: GAO analysis of survey and site visit data.

[A] Screens patients admitted for open mediastinal procedures, total 
joint replacements, and open spine procedures.

[B] Screens patients admitted from another acute care hospital.

[C] Screens admissions to the surgical ICU.

[D] Screens patients who live in a household with a MRSA-positive 
individual or have been told in the past that they have an MDRO.

[E] Screens patients who have a length of stay in the hospital that is 
greater than 6 days and who have been given antibiotics; patients who 
have a length of stay greater than 21 days; patients known to have at 
least one MDRO; and patients transferred from other health care 
facilities.

[F] Screens patients with soft tissue or skin infections.

[G] Some surgical patients are screened.

[H] Screens cardiothoracic patients. 

[End of table]

The hospitals we reviewed divide fairly evenly in their choice of 
testing methods. Five of the hospitals conduct AST using selective 
media, which generally produces results in 24 hours at a cost of 
approximately $5 per test. All but one of the remaining hospitals 
reported using PCR testing, which provides results in only 2 to 4 hours 
but costs about $25 to $30 per test, and the one remaining hospital 
reported using routine culture media. Two hospitals reported using more 
than one testing method. One of these hospitals reported that PCR 
testing is used only when results are needed quickly because of limited 
staff availability to operate the equipment.

Hospitals Expanded Infection Control Activities and Information Systems 
to Reduce MRSA:

In implementing their MRSA-reduction initiatives, all the hospitals we 
reviewed reported changing general infection control policies or 
practices. CDC guidelines for managing MDROs include recommended 
practices relating to hand hygiene adherence, contact precautions, 
environmental cleaning, and judicious use of antibiotics. All 14 
hospitals made changes to their existing policies or practices for hand 
hygiene, while more than half of the hospitals made changes to their 
contact precautions or environmental cleaning policies (see table 6). 
[Footnote 33] Fewer hospitals reported making changes to their 
antibiotic stewardship policies.

Table 6: Policy or Practice Changes Implemented by Selected Hospitals 
as Part of MRSA-Reduction Initiatives:

Evanston Northwestern Healthcare; 
Hand hygiene: [Check]; 
Contact precautions: [Check]; 
Enhanced environmental cleaning: [Empty]; 
Antibiotic stewardship: [Check].

Medical University of South Carolina; 
Hand hygiene: [Check]; 
Contact precautions: [Empty]; 
Enhanced environmental cleaning: [Empty]; 
Antibiotic stewardship: [Empty].

Pitt County Memorial Hospital; 
Hand hygiene: [Check]; 
Contact precautions: [Empty]; 
Enhanced environmental cleaning: [Check]; 
Antibiotic stewardship: [Empty].

Eastern Idaho Regional Medical Center; 
Hand hygiene: [Check]; 
Contact precautions: [Check]; 
Enhanced environmental cleaning: [Check]; 
Antibiotic stewardship: [Check].

Centra, Lynchburg General and Virginia Baptist Hospitals; 
Hand hygiene: [Check]; 
Contact precautions: [Check]; 
Enhanced environmental cleaning: [Empty]; 
Antibiotic stewardship: [Empty].

Wake Forest University Baptist Medical Center; 
Hand hygiene: [Check]; 
Contact precautions: [Check]; 
Enhanced environmental cleaning: [Check]; 
Antibiotic stewardship: [Check].

Mercy Medical Center; 
Hand hygiene: [Check]; 
Contact precautions: [Empty]; 
Enhanced environmental cleaning: [Check]; 
Antibiotic stewardship: [Empty].

Albany Medical Center; 
Hand hygiene: [Check]; 
Contact precautions: [Check]; 
Enhanced environmental cleaning: [Check]; 
Antibiotic stewardship: [Check].

Newark Beth Israel Medical Center; 
Hand hygiene: [Check]; 
Contact precautions: [Empty]; 
Enhanced environmental cleaning: [Check]; 
Antibiotic stewardship: [Check].

Beth Israel Medical Center; 
Hand hygiene: [Check]; 
Contact precautions: [Check]; 
Enhanced environmental cleaning: [Check]; 
Antibiotic stewardship: [Empty].

Rochester General Hospital; 
Hand hygiene: [Check]; 
Contact precautions: [Check]; 
Enhanced environmental cleaning: [Check]; 
Antibiotic stewardship: [Check].

University of Pittsburgh Medical Center; 
Hand hygiene: [Check]; 
Contact precautions: [Check]; 
Enhanced environmental cleaning: [Check]; 
Antibiotic stewardship: [Empty].

Barnes-Jewish Hospital; 
Hand hygiene: [Check]; 
Contact precautions: [Check]; 
Enhanced environmental cleaning: [Empty]; 
Antibiotic stewardship: [Empty].

Pacific Hospital of Long Beach; 
Hand hygiene: [Check]; 
Contact precautions: [Check]; 
Enhanced environmental cleaning: [Check]; 
Antibiotic stewardship: [Check].

[End of table]

Source: GAO analysis of survey and site visit data.

* Hand hygiene--All of the hospitals we reviewed reported changing hand 
hygiene policies as part of their MRSA-reduction initiative. Eleven of 
the hospitals reported conducting observation audits to monitor 
compliance with hand hygiene protocols. Two of these hospitals noted 
that their audits are coupled with immediate feedback to staff who are 
noncompliant. More than half of the hospitals also reported increasing 
staff training or public awareness campaigns to increase compliance 
with hand hygiene among staff or hospital visitors, or both. Multiple 
hospitals have increased the use of alcohol-based gel hand sanitizers 
as part of their initiatives by providing more product dispensers in 
the hospital. In addition, 2 hospitals reported monitoring the 
consumption of hand hygiene products, such as hand sanitizer or soap, 
to gauge hand hygiene compliance. For more information on the changes 
hospitals made to hand hygiene polices, see appendix II, table 7.

* Contact precautions--Most hospitals reported making changes to their 
contact precautions as part of their MRSA-reduction initiatives, for 
example, by requiring health care workers to wear gowns and gloves when 
in contact with a MRSA-positive patient or with equipment used on a 
MRSA-positive patient. Two hospitals also began requiring health care 
workers to wear masks in addition to gowns and gloves when in contact 
with a MRSA-positive patient.[Footnote 34] Multiple hospitals use signs 
at room entrances of MRSA-positive patients to remind health care 
workers to follow contact precautions when entering those environments. 
Hospitals that changed their contact precautions also reported 
conducting audits to measure staff compliance with contact precaution 
procedures. For more information on the changes hospitals made to their 
contact precautions, see appendix II, table 8.

* Environmental cleaning--Most hospitals reported changing 
environmental cleaning procedures as part of their MRSA-reduction 
initiatives. Three hospitals reported that they disinfect patient 
equipment between uses or high-touch areas, such as keyboards and door 
knobs. Three hospitals implemented checklists for housekeeping staff to 
ensure that rooms are properly cleaned following the discharge of a 
MRSA-positive patient. One hospital began changing privacy curtains in 
patient rooms as part of its initiative because the curtains often 
become contaminated with MRSA. For more information on the changes 
hospitals made to environmental cleaning polices, see appendix II, 
table 9.

* Antibiotic stewardship--Half of the hospitals created new policies or 
revised their existing policies pertaining to antibiotic stewardship. 
These changes generally included tracking antibiotic prescriptions or 
restricting the use of certain antibiotics. For more information on the 
changes hospitals made to antibiotic stewardship policies, see appendix 
II, table 10.

In addition to changes in infection control practices, most of the 
hospitals we reviewed adapted their information systems to support 
their MRSA-reduction initiatives. All but 1 of the 14 hospitals has a 
mechanism to identify previously colonized patients readmitted to their 
hospital. Most of these hospitals reported that they track patients' 
MRSA status in electronic medical records, using flags to identify a 
patient as MRSA-positive each time the patient's electronic medical 
record is accessed. This enables the staff to immediately implement 
contact precautions, without the cost or time needed for additional 
screening.

All 14 Hospitals Included Decolonization in Their MRSA-Reduction 
Initiatives:

All the hospitals we reviewed included patient or health care staff 
decolonization as part of their MRSA-reduction initiatives, despite 
limited support for MRSA decolonization among infection control experts 
and in CDC's MDRO guidelines. Twelve hospitals reported decolonizing 
patients, with 6 of these hospitals decolonizing all MRSA-positive 
patients. Seven hospitals reported that they decolonize health care 
staff--6 hospitals test health care staff for MRSA colonization during 
outbreaks and decolonize those found to be positive while the other 
hospital decolonizes staff found to be MRSA-positive during voluntary 
testing. For more information on these hospitals' approaches to 
decolonization, see appendix II, table 11.

Hospital MRSA Initiatives Reported Needing Varying Levels of Funding 
and Staff Resources:

The hospitals we reviewed reported needing varying levels of funding 
and staff resources to implement and operate their MRSA-reduction 
initiatives. Half of the hospitals reported needing limited or no 
additional funding for these initiatives. However, the remaining 
hospitals reported that moderate to substantial additional funds were 
needed. Six of the seven hospitals that reported needing moderate to 
substantial additional funding use the more expensive PCR testing or 
screen all patients (see fig. 1). Several of the remaining hospitals 
that reported needing limited or no additional resources also use PCR 
testing, but all of them conduct AST on targeted patient populations. 
Eight hospitals reported needing additional staff to conduct patient 
testing, laboratory staff to process the tests, or both.

Figure 1: Selected Hospital-Reported Financial Resource Needs for MRSA- 
Reduction Initiative, by Type of Screening and Test Method:

[See PDF for image] 

This figure is a matrix of selected hospital-reported financial 
resource needs for MRSA-Reduction Initiative, by type of screening and 
test method, as follows: 

Targeted screening: 

Financial resources needed for initiative: Substantial; Testing 
methodology: Selective: 1 hospital; 

Financial resources needed for initiative: Substantial; Testing 
methodology: PCR: 2 hospitals; 

Financial resources needed for initiative: Moderate; Testing 
methodology: PCR: 1 hospital; 

Financial resources needed for initiative: Limited; Testing 
methodology: Routine: 1 hospital; 

Financial resources needed for initiative: Limited; Testing 
methodology: Selective: 1 hospital; 

Financial resources needed for initiative: Limited; Testing 
methodology: PCR: 2 hospitals; 

Financial resources needed for initiative: None; Testing methodology: 
Selective: 2 hospitals; 

Financial resources needed for initiative: None; Testing methodology: 
PCR: 1 hospital. 

Universal screening: 

Financial resources needed for initiative: Substantial; Testing 
methodology: PCR: 2 hospitals; 

Financial resources needed for initiative: Moderate; Testing 
methodology: Selective: 1 hospital. 

Source: GAO. 

Note: Reporting hospitals characterized the level of additional 
resources needed for their MRSA-reduction initiatives as none, limited, 
moderate, or substantial. 

[End of figure] 

Most hospitals reported that they place all or most MRSA-positive 
patients in private rooms as part of their initiative. However, several 
of these hospitals noted that the availability of single or semiprivate 
rooms was a factor in the approach or scope of their MRSA-reduction 
initiative. For example, at Newark Beth Israel, the first priority is 
to place all MRSA-positive patients in single rooms. However, when 
single rooms are not available, a MRSA-positive patient is placed with 
another MRSA-positive patient. Eight hospitals reported at least some 
cohorting of MRSA-positive patients.

Hospitals with MRSA Initiatives Consistently Reported Reductions in 
MRSA Infection Rates:

Of the 13 hospitals that tracked MRSA infection rates, all found a 
decline in MRSA infections as a result of their initiatives. Though 
some hospitals simply cited reductions or significant decreases in 
their MRSA infections, 5 hospitals provided estimates of the percentage 
by which their MRSA infection rates had declined. These estimates 
ranged from around 50 to 74 percent. Three hospitals assessed their 
reductions quantitatively, but in terms other than percentage or 
proportion. Two hospitals noted that infections from all organisms, not 
just MRSA, declined. Over half of the hospitals we reviewed reported 
that they have tracked MRSA colonization rates as part of their MRSA 
initiatives. Of the hospitals that reported tracking MRSA colonization 
rates, half reported an observed decrease in the incidence of MRSA 
colonization since implementing their initiatives.

Two Hospital Systems Addressed Similar Challenges in Implementing MRSA- 
Reduction Initiatives:

The two hospital systems that we visited overcame a similar set of 
challenges in implementing multifaceted MRSA-reduction programs. Both 
systems designed and executed processes to put the elements of their 
MRSA-reduction initiatives into effect and promote compliance with 
those processes by hospital staff. Both strove to facilitate the 
implementation of these processes by incorporating them as much as 
possible into the normal workflow of hospital staff. Both hospital 
systems promoted staff compliance with their MRSA-reduction initiatives 
through a combination of concerted leadership on the part of the 
physicians who led their infection control programs and specific 
procedures designed to facilitate staff compliance reinforced through 
detailed feedback on their performance. However, the two hospital 
systems took different approaches to marshalling resources for their 
initiatives. One directed substantial financial resources into its MRSA-
reduction initiative to implement the initiative simultaneously for all 
patients at all of its hospitals, while the other relied largely on 
existing resources and implemented its initiative more incrementally at 
selected hospitals and on selected units.

The Two Systems Faced Process, Compliance, and Resource Challenges in 
Implementing Their MRSA Reduction Initiatives:

The two hospital systems that we visited faced a similar set of 
challenges in implementing multifaceted MRSA-reduction programs over 
the past several years.[Footnote 35] Evanston Northwestern Healthcare 
(ENH) and the University of Pittsburgh Medical Center (UPMC)--both 
multihospital systems[Footnote 36]--each sought to reduce MRSA 
infections by instituting AST of patients for MRSA and ensuring 
consistent implementation of hospital procedures, such as hand hygiene 
procedures and contact precautions. To achieve these objectives, both 
systems had to overcome three challenges: (1) designing and executing 
processes to put the elements of their MRSA-reduction initiatives into 
effect, (2) promoting compliance with those processes by hospital 
staff, and (3) marshalling the required financial and staff resources 
to implement their initiatives.

The Two Systems Incorporated Processes to Implement Their MRSA- 
Reduction Initiatives into Routine Hospital Workflows:

The two systems put processes in place to ensure that all eligible 
patients were tested for MRSA and that any positive results were 
quickly communicated to the clinical staff to alert them to initiate 
contact precautions for those patients. Both strove to facilitate the 
implementation of these processes by incorporating them as much as 
possible into the normal workflow of hospital staff. At ENH, the 
implementation of universal AST at admission meant that collecting 
specimens and submitting them to the laboratory became part of the 
routine admission procedure for every patient. Because all patients 
were tested, there were no target populations to identify. Although 
UPMC did not adopt universal AST, its strategy of screening every 
patient in selected hospital units had a similar advantage in terms of 
clearly identifying the patients to be tested.[Footnote 37]

Both hospitals devised processes for easing access to the supplies that 
staff needed to conduct MRSA testing and to initiate contact 
precautions for the patients who tested positive. ENH developed a 
packet with all the supplies needed for testing a patient for MRSA. The 
housekeeping staff was responsible for leaving this packet on the bed 
as it finished preparing each room for the next patient. At ENH, 
supplies needed for contact precautions were stocked on isolation 
supply carts that were delivered to the room of each patient who tested 
positive for MRSA. To reduce the time of the arrival of that cart for 
patients undergoing contact precautions, ENH officials revised their 
procedure for ordering the carts. Instead of having the nursing staff 
order the cart once it had received notice of a patient's positive test 
result, ENH officials instructed the laboratory staff to order the cart 
directly for all patients with positive test results. According to ENH 
officials, this reduced the time from test result to initiation of 
isolation precautions by approximately 45 minutes. UPMC staff designed 
a special container to install at each patient room that was routinely 
kept stocked with the gloves, gowns, and other supplies needed whenever 
a patient was placed under contact precautions. Moreover, UPMC 
programmed its laboratory information system so that a positive MRSA 
test result automatically generated a notification by fax, e-mail, and 
pager to the clinical staff on that patient's hospital unit to initiate 
contact precautions.

Concerted Leadership and Monitoring of Staff Performance Fostered 
Compliance with MRSA-Reduction Initiatives:

Both hospital systems promoted staff compliance with their MRSA- 
reduction initiatives through a combination of concerted leadership on 
the part of the two physicians who led their respective infection 
control programs and specific procedures designed to facilitate staff 
compliance reinforced through detailed feedback on their performance. 
Much of the impetus for implementing MRSA-reduction programs at ENH and 
UPMC came from these two lead physicians, both of whom saw the 
potential to achieve substantial decreases in MRSA infection rates by 
putting a comprehensive program in place. These lead physicians worked 
extensively with hospital administrators and their fellow clinicians to 
build support for the MRSA-reduction initiative by documenting the 
extent of their existing problem with MRSA, laying out the steps that 
they could take to address the problem, and marshalling the evidence 
that the resulting initiative was producing positive results once 
implementation had begun. They also responded to any problems that 
arose during implementation or concerns expressed by the clinicians 
affected by the initiative by making adjustments in its operation. To 
identify emerging problems and find effective solutions, the lead 
physicians established internal working groups with representation 
across the affected hospital departments. At UPMC this group continued 
to meet regularly to review data on whether patients were being 
properly tested and isolated, to discuss any concerns raised by 
hospital staff, and to consider specific adjustments to the 
implementation of the initiative.

Both hospital systems relied heavily on information technology to 
facilitate compliance with the various components of the MRSA 
initiative. ENH made a number of specific adaptations to its electronic 
medical record (EMR) system.[Footnote 38] For example, it added an 
orange banner on the medical record screen that highlighted any patient 
who had been admitted until staff entered a confirmation that the MRSA 
test had been performed. ENH also created a prominent flag in its EMR 
for any patient who had been identified as MRSA-positive during a 
previous admission or outpatient encounter; all such patients were 
immediately placed under contact precautions. UPMC incorporated similar 
reminders into its EMR system and also implemented a flag to identify 
patients who had previously tested positive for MRSA so that they could 
be immediately placed under contact precautions at subsequent 
admissions.

In addition, ENH and UPMC monitored staff compliance with targeted 
hospital procedures. At ENH, hospital ICPs used their electronic record 
system to measure the length of time it took staff on various units to 
perform the MRSA test and to respond to positive test results by 
implementing contact precautions. They used these data to provide 
feedback to both units and individual staff members on their relative 
performance. At UPMC, the infection control department provided similar 
feedback at monthly meetings with staff in the individual hospital 
units, where they presented data on the proportion of patients who were 
tested at UPMC's designated time points.

UPMC also expanded its oversight of staff compliance with standard hand 
hygiene procedures in conjunction with its MRSA-reduction initiative. 
To obtain more accurate information on staff compliance with those 
procedures, UPMC implemented routine audits that used trained, 
anonymous observers to assess staff performance. UPMC officials sent 
formal letters to clinical staff, including physicians, who were 
observed not following hand hygiene procedures. Less formally, UPMC 
officials provided immediate, positive feedback to staff members who 
were observed complying with their hand hygiene procedures.

One Hospital System Marshalled Substantial Resources to Effect 
Systemwide Change While the Other Implemented Incremental Changes with 
Existing Resources:

ENH directed substantial financial resources into its MRSA-reduction 
initiative to implement the initiative simultaneously for all patients 
at all three of its hospitals, while UPMC relied largely on existing 
resources and implemented its initiative more incrementally at selected 
hospitals and on selected units. For both hospital systems, one key 
resource challenge was paying for an increased number of MRSA tests. 
Ultimately, both systems conducted analyses indicating that the 
increased costs of their initiatives were more than compensated for by 
the reduced cost of treating a smaller number of patients with MRSA 
infections.

ENH officials made a key strategic decision to move expeditiously to 
implement MRSA screening for all patients admitted to ENH's three 
hospitals. To do this, they developed an implementation plan based on 
an analysis of clinical and financial data. Beginning in 2003, ENH 
piloted MRSA AST in one ICU. In 2004, it conducted a one-time 
prevalence survey[Footnote 39] that determined that 8.5 percent of all 
patients were colonized with MRSA--most of them in units outside of the 
ICUs.[Footnote 40] Based on this information and the ICU pilot 
experience, ENH officials developed a plan to implement universal AST 
within a year and budgeted $1 million per year in additional costs, 
mostly for the increased number of MRSA tests performed and additional 
laboratory staff. ENH officials conducted a cost-benefit analysis that 
concluded that the hospital system would save more from having fewer 
patients with MRSA infections needing treatment than it would spend for 
increased testing. Because ENH had collected detailed information on 
patient costs and charges over a number of years, these officials were 
able to develop their own estimates for the additional costs associated 
with an MRSA infection in the ENH hospitals.[Footnote 41]

Administrators at ENH provisionally approved the MRSA-reduction 
initiative, pending confirmation during its first 2 years that it had 
the expected effect on the number of ENH patients who developed MRSA 
infections and had not increased overall costs. Ultimately, the number 
of MRSA cases at ENH decreased more rapidly than expected following 
implementation of the initiative, and the additional costs were less 
than expected--approximately $600,000 per year.

The cost-benefit analysis provided ENH officials with support for their 
choice of the more expensive PCR testing method. Under the plan, the 
projected cost savings from the anticipated reduction in MRSA 
infections were greater than the additional costs of the MRSA-reduction 
initiative, even using PCR to test every patient at admission. ENH 
officials were willing to pay approximately $25 per test to obtain two 
advantages offered by PCR testing--faster results and greater 
sensitivity in detecting patients with MRSA. Getting results for most 
patients no later than 15 hours after testing reduces the amount of 
time that MRSA-positive patients spend in the hospital without contact 
precautions in place, which in turn reduces the chances that they will 
infect other patients.[Footnote 42]

UMPC took a more incremental approach to implementing its MRSA- 
reduction initiative and, as a result, did not need additional 
resources. It began its initiative in 2002 in one ICU at Presbyterian 
Hospital, and expanded it over 4 years to other ICUs in that hospital 
and then to all adult ICUs in the 19 other hospitals in the UPMC 
system. This measured pace of expansion restricted the number of 
additional patients who needed to undergo contact precautions at any 
one time, which eased potential logistical problems that stem from the 
predominance of semiprivate rooms in UPMC hospitals. UPMC officials 
told us that they expect to continue making such incremental decisions 
on where and when to expand their MRSA-reduction initiative in the 
future. They stated that this could eventually lead to screening of all 
inpatient admissions.

UPMC officials have relied, as did their counterparts at ENH, on their 
analysis of clinical and financial data in developing and expanding 
their MRSA-reduction initiative. UPMC officials selected the initial 
hospital unit from those that had the largest number of MRSA infections 
and, therefore, the greatest potential for improvement, with additional 
consideration given to the readiness of staff on the unit to fully 
support the initiative. On that basis, they began with the 20-bed 
medical ICU at Presbyterian Hospital. Once the initiative was 
implemented and the ICU's MRSA infection rate declined, they made the 
case for expanding the initiative to other units within Presbyterian 
and to other UPMC hospitals. As with the initial selection of the first 
ICU, UPMC officials selected the units for expansion of the initiative 
based on those with the highest MRSA rates, and they plan to continue 
expanding participation in the initiative on that basis.

Because UPMC began its MRSA-reduction initiative with just one unit, 
and monitored its progress for 3 years before expanding to other units, 
UPMC officials could implement their initiative with a relatively small 
upfront investment of resources. They hired no new staff for the 
initiative. Instead, to meet the demand for increased MRSA testing, 
they reallocated existing laboratory staff and financial resources. 
Other additional costs, such as for increased use of gowns, gloves, and 
masks to maintain contact precautions, were relatively minor.[Footnote 
43] In selecting which test to use for screening patients, UPMC 
officials chose the relatively inexpensive selective media test, which 
costs approximately $5 and requires only about 40 seconds of laboratory 
technician time to perform. Although using selective media did not 
produce results as quickly as PCR would, UPMC officials found that they 
could nonetheless identify 81 percent of MRSA-positive patients within 
24 hours.

UPMC's MRSA-reduction initiative has achieved large reductions in the 
number of MRSA cases at a relatively low cost, resulting in a highly 
favorable ratio of benefits to costs. UPMC officials estimate that 
their savings in terms of the reduced costs to treat a smaller number 
of MRSA cases were 12 to 32 times greater than the costs they incurred 
to test patients for MRSA and implement contact precautions for those 
who test positive. To calculate those savings, they relied on estimates 
from the published literature for determining the difference in 
treatment costs for patients with and without MRSA infections,[Footnote 
44] and multiplied that figure by the reduction in the number of MRSA 
infections that have occurred in their targeted units. UPMC officials 
have used these estimates to build support for expanding the MRSA- 
reduction initiative into other units of the UPMC hospitals besides 
ICUs, including orthopedic units.

Concluding Observations:

Governmental initiatives to reduce HAIs involve a complicated mix of 
federal and state activities. The federal government, and in particular 
its lead agency for HAIs, CDC, have over the last few decades evolved a 
role that involves certain discrete activities. These include the 
development of guidelines that assess and recommend specific clinical 
practices for reducing HAIs. They also include the development and 
promulgation of procedures and definitions that enable ICPs to 
determine in a systematic and consistent way which patients have HAIs, 
and to measure their HAI rates over time. In addition, CDC has 
initiated and maintained data collection programs, such as NHSN, that 
provide a mechanism that hospitals can use to both collect information 
on their own HAIs and compare their experience with that of other 
hospitals using the same set of clinical definitions and data 
collection procedures. CDC provides these services to participating 
hospitals free of charge, and by law protects the confidentiality of 
the data that hospitals submit.

Meanwhile, at least 23 states have taken initiatives that seek to use 
comparable information about HAIs for a quite different purpose-- 
informing consumers about the relative performance of specific 
hospitals. As the states have set up these programs, and confronted the 
challenges of implementing them with limited resources, many have found 
compelling advantages in drawing on CDC's procedures and data 
collection systems. CDC protocols for identifying HAIs are widely 
respected for their clinical sophistication, and are well known to the 
ICPs in individual hospitals who will most likely be the ones to report 
the data. NHSN not only incorporates those widely accepted definitions 
and procedures, it is also available at no cost to the hospitals that 
use it. Thus many states have chosen to implement their public 
reporting programs by mandating that hospitals in their states enroll 
in NHSN. Although CDC itself may not publicly release HAI data on 
individual hospitals enrolled in NHSN, hospitals can give access to the 
state agencies to view and analyze their data using the group feature 
of NHSN. The state agencies can then use those data for their public 
reporting programs.

The increasing number of states opting to use information obtained from 
this federal data collection system to publicly report on the relative 
performance of individual hospitals raises concerns about the lack of 
established mechanisms to check the completeness and accuracy of the 
data submitted by hospitals. When the data are released to the public 
in order to influence consumers to choose hospitals with lower rates of 
HAIs, hospitals may have an incentive to minimize the number of HAI 
cases that they identify and report if they believe either that the 
hospitals with which they compete for patients could be minimizing the 
number of HAIs they reported or that those hospitals have actually 
achieved lower rates of HAIs than their own hospital. NHSN was created 
under a completely different paradigm, in which hospitals voluntarily 
collected the data on HAIs to inform their own internal efforts to 
reduce HAIs, with a legal protection from public release. Because the 
data were intended strictly for internal use, CDC officials assumed 
that hospitals had an incentive to generate the most accurate and 
complete data possible. Consequently, the NHSN did not develop any 
process or mechanism to audit the accuracy and completeness of the data 
that hospitals submitted.

Both CDC and state officials have noted that converting NHSN to a 
source for publicly reported data on HAIs fundamentally changes the 
incentives for participating hospitals, and thereby creates a need for 
procedures to independently validate the data that hospitals submit. 
Specifically, CDC has collaborated with states using NHSN for public 
reporting to develop and implement data validation as part of their 
programs. However, few states have so far acted on this advice. 
Specific procedures for validating HAI data need to be developed and 
tested, and resources allocated to implement them. To some extent, New 
York has done the most to accomplish these tasks, but its experience 
indicates that systematic data validation requires substantial staff 
resources. Unless other states can marshal the resources needed to 
ensure the accuracy and completeness of the HAI data submitted by their 
hospitals, they are unlikely to make substantial progress in addressing 
this issue.

Comments from HHS and the American Hospital Association and Our 
Evaluation:

We obtained written comments on our draft report from HHS, which were 
largely technical in nature. Overall, HHS commended GAO for developing 
a helpful report on an important topic. The department also highlighted 
the contributions that CDC has made, including its research into 
understanding the epidemiology of MRSA and HAIs. HHS noted that CDC's 
work in this area is reflected in a large number of scientific 
publications pertaining to the detection, measurement, and prevention 
of HAIs and MRSA. In addition, we incorporated the technical comments 
that HHS provided as appropriate.

The vice president of quality and patient safety policy for the 
American Hospital Association (AHA) provided oral comments on our draft 
report. The AHA appreciated that our report addressed state reporting 
programs for HAIs as a whole, along with a detailed review of hospital 
initiatives to reduce MRSA. It highlighted the technical and resource 
challenges described in our report that hospitals face in conducting 
HAI surveillance and prevention activities, which smaller hospitals in 
particular may have difficulty overcoming. Therefore, the AHA believes 
that it is important to link the collection of HAI data to achieving a 
reduction of HAIs including MRSA, and to acknowledge that different 
hospitals can use different approaches to accomplish this objective. In 
addition, the AHA expressed serious concern about public reporting of 
HAI data collected through NHSN. It noted that the NHSN data were not 
validated and that hospitals vary in how they collect the data 
submitted to NHSN. As a result, the AHA felt that the NHSN data do not 
provide a valid comparative assessment of hospital performance. The AHA 
also provided technical comments that we incorporated as appropriate.

We agree with HHS that CDC has played a central role in developing both 
the science and the data collection systems on which current efforts to 
assess and reduce HAIs rest. At the same time, we share AHA's concerns 
that to be viable in the long run, systems for collecting HAI data for 
public reporting need to produce data that are clinically accurate and 
that assist hospitals in their efforts to reduce HAIs. As evidenced by 
its widespread adoption, CDC's NHSN has made a substantial contribution 
in that direction, though questions remain regarding how best to ensure 
that the data it produces are accurate and complete.

As arranged with your office, unless you publicly announce the contents 
of this report earlier, we plan no further distribution until 30 days 
after its issuance date. At that time, we will send copies of this 
report to the Secretary of HHS and other interested parties. We will 
also make copies available to others on request. In addition, the 
report will be available at no charge on GAO's Web site at [hyperlink, 
http://www.gao.gov].

If you or your staff have any questions about this report, please 
contact me at (202) 512-7114 or bascettac@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff who made major contributions 
to this report are listed in appendix III.

Sincerely yours, 

Signed by: 

Cynthia A. Bascetta: 
Director, Health Care:

[End of section]

Appendix I: Characteristics of Selected Hospitals with MRSA-Reduction 
Initiatives:

Albany Medical Center; 
Location: Albany, NY; 
Beds: 599; 
Teaching hospital[A]: Yes; 
Size of Metropolitan Area[B]: 2; 
Census region: Middle Atlantic.

Barnes-Jewish Hospital; 
Location: Saint Louis, MO; 
Beds: 1,183; 
Teaching hospital[A]: Yes; 
Size of Metropolitan Area[B]: 1; 
Census region: West North Central.

Beth Israel Medical Center; 
Location: New York, NY; 
Beds: 794; 
Teaching hospital[A]: Yes; 
Size of Metropolitan Area[B]: 1; 
Census region: Middle Atlantic.

Centra, Lynchburg General and Virginia Baptist Hospitals; 
Location: Lynchburg, VA; 
Beds: 494; 
Teaching hospital[A]: No; 
Size of Metropolitan Area[B]: 3; 
Census region: South Atlantic.

Eastern Idaho Regional Medical Center; Location: Idaho Falls, ID; 
Beds: 289; 
Teaching hospital[A]: No; 
Size of Metropolitan Area[B]: 3; 
Census region: Mountain.

Evanston Northwestern Healthcare; 
Location: Evanston, IL; 
Beds: 629; 
Teaching hospital[A]: Yes; 
Size of Metropolitan Area[B]: 1; 
Census region: East North Central.

Pacific Hospital of Long Beach; 
Location: Long Beach, CA; 
Beds: 171; 
Teaching hospital[A]: No; 
Size of Metropolitan Area[B]: 1; 
Census region: Pacific.

Pitt County Memorial Hospital; 
Location: Greenville, NC; 
Beds: 761; 
Teaching hospital[A]: Yes; 
Size of Metropolitan Area[B]: 3; 
Census region: South Atlantic.

Medical University of South Carolina; 
Location: Charleston, SC; 
Beds: 596; 
Teaching hospital[A]: Yes; 
Size of Metropolitan Area[B]: 2; 
Census region: South Atlantic.

Mercy Medical Center; 
Location: Cedar Rapids, IA; 
Beds: 318; 
Teaching hospital[A]: No; 
Size of Metropolitan Area[B]: 3; 
Census region: West North Central.

Newark Beth Israel Medical Center; 
Location: Newark, NJ; 
Beds: 407; 
Teaching hospital[A]: Yes; 
Size of Metropolitan Area[B]: 1; 
Census region: Middle Atlantic.

Rochester General Hospital;
Location: Rochester, NY; 
Beds: 492; 
Teaching hospital[A]: No; 
Size of Metropolitan Area[B]: 1; 
Census region: Middle Atlantic.

Wake Forest University Baptist Medical Center; 
Location: Winston-Salem, NC; 
Beds: 953; 
Teaching hospital[A]: Yes; 
Size of Metropolitan Area[B]: 2; 
Census region: South Atlantic.

University of Pittsburgh Medical Center;
 Location: Pittsburgh, PA; 
Beds: 1,492; 
Teaching hospital[A]: Yes; 
Size of Metropolitan Area[B]: 1; 
Census region: Middle Atlantic.

Sources: American Hospital Association, U.S. Census Bureau, Association 
of American Medical Colleges, U.S. Department of Agriculture.

[A] Hospitals were designated as teaching hospitals if they were 
members of the Association of American Medical Colleges' Council of 
Teaching Hospitals and Health Systems.

[B] All hospitals were located in metropolitan counties according to 
the Economic Research Service of the U.S. Department of Agriculture, 
using the rural-urban continuum codes defined by the U.S. Census 
Bureau. The codes break down as follows: 1= Counties in metropolitan 
areas of 1 million population or more; 2= Counties in metropolitan 
areas of 250,000 to 1 million population; and 3= Counties in 
metropolitan areas of fewer than 250,000 population. 

[End of table] 

[End of section]

Appendix II: Changes Made by Selected Hospitals with MRSA-Reduction 
Initiatives:

Table 7: Hand Hygiene Changes by Selected Hospitals with MRSA-Reduction 
Initiatives:

Albany Medical Center; 
Hand hygiene compliance audits: [Check]; 
Enhanced staff training or public education campaigns: [Check]; 
Increased number of dispensers of alcohol-based hand sanitizer: 
[Check]; 
Monitor consumption of hand hygiene products: [Empty].

Barnes-Jewish Hospital; 
Hand hygiene compliance audits: [Check]; 
Enhanced staff training or public education campaigns: [Check]; 
Increased number of dispensers of alcohol-based hand sanitizer: 
[Empty]; 
Monitor consumption of hand hygiene products: [Empty].

Beth Israel Medical Center; 
Hand hygiene compliance audits: [Check]; 
Enhanced staff training or public education campaigns: [Check]; 
Increased number of dispensers of alcohol-based hand sanitizer: 
[Empty]; 
Monitor consumption of hand hygiene products: [Empty].

Centra, Lynchburg General and Virginia Baptist Hospitals; 
Hand hygiene compliance audits: [Check]; 
Enhanced staff training or public education campaigns: [Empty]; 
Increased number of dispensers of alcohol-based hand sanitizer: 
[Empty]; 
Monitor consumption of hand hygiene products: [Empty].

Eastern Idaho Regional Medical Center; 
Hand hygiene compliance audits: [Check]; 
Enhanced staff training or public education campaigns: [Check]; 
Increased number of dispensers of alcohol-based hand sanitizer: 
ò[Check]; 
Monitor consumption of hand hygiene products: [Check].

Evanston Northwestern Healthcare; 
Hand hygiene compliance audits: [Check]; 
Enhanced staff training or public education campaigns: [Empty]; 
Increased number of dispensers of alcohol-based hand sanitizer: 
[Empty]; 
Monitor consumption of hand hygiene products: [Empty].

Pacific Hospital of Long Beach; Hand hygiene compliance audits: 
[Empty]; 
Enhanced staff training or public education campaigns: [Check]; 
Increased number of dispensers of alcohol-based hand sanitizer: 
[Empty]; 
Monitor consumption of hand hygiene products: [Empty].

Pitt County Memorial Hospital; 
Hand hygiene compliance audits: [Check]; 
Enhanced staff training or public education campaigns: [Empty]; 
Increased number of dispensers of alcohol-based hand sanitizer: 
[Empty]; 
Monitor consumption of hand hygiene products: [Empty].

Medical University of South Carolina; Hand hygiene compliance audits: 
[Empty]; 
Enhanced staff training or public education campaigns: [Check]; 
Increased number of dispensers of alcohol-based hand sanitizer: 
[Empty]; 
Monitor consumption of hand hygiene products: [Empty].

Mercy Medical Center; Hand hygiene compliance audits: [Check]; 
Enhanced staff training or public education campaigns: [Empty]; 
Increased number of dispensers of alcohol-based hand sanitizer: 
[Empty]; 
Monitor consumption of hand hygiene products: [Empty].

Newark Beth Israel Medical Center; Hand hygiene compliance audits: 
[Check]; 
Enhanced staff training or public education campaigns: [Empty]; 
Increased number of dispensers of alcohol-based hand sanitizer: 
[Check]; 
Monitor consumption of hand hygiene products: [Check].

Rochester General Hospital; Hand hygiene compliance audits: [Empty]; 
Enhanced staff training or public education campaigns: [Check]; 
Increased number of dispensers of alcohol-based hand sanitizer: 
[Check]; 
Monitor consumption of hand hygiene products: [Empty].

Wake Forest University Baptist Medical Center; 
Hand hygiene compliance audits: [Check]; 
Enhanced staff training or public education campaigns: [Empty]; 
Increased number of dispensers of alcohol-based hand sanitizer: 
[Empty]; 
Monitor consumption of hand hygiene products: [Empty].

University of Pittsburgh Medical Center; 
Hand hygiene compliance audits: [Check]; 
Enhanced staff training or public education campaigns: [Check]; 
Increased number of dispensers of alcohol-based hand sanitizer: 
[Check]; 
Monitor consumption of hand hygiene products: [Empty].

[End of table]

Source: GAO analysis of survey and site visit data.

Table 8: Contact Precaution Changes by Selected Hospitals with MRSA- 
Reduction Initiatives:

Albany Medical Center; 
Required gown & gloves for contact with MRSA-positive patients and 
their environment: [Check]; 
Isolation cart/supply holder: [Empty]; 
Mask required when in contact with MRSA-positive patient: [Empty]; 
Room entrance signs or checklists to remind staff of MDRO patient: 
[Empty]; 
Enhanced staff training or public awareness campaigns: [Empty]; 
MRSA-positive patients in private rooms or cohorted: [Check]; 
Contact precaution compliance audits: [Empty].

Barnes-Jewish Hospital; 
Required gown & gloves for contact with MRSA-positive patients and 
their environment: [Empty]; 
Isolation cart/supply holder: [Check]; 
Mask required when in contact with MRSA-positive patient: [Empty]; 
Room entrance signs or checklists to remind staff of MDRO patient: 
[Empty]; 
Enhanced staff training or public awareness campaigns: [Check]; 
MRSA-positive patients in private rooms or cohorted: [Check]; 
Contact precaution compliance audits: [Check].

Beth-Israel Medical Center; 
Required gown & gloves for contact with MRSA-positive patients and 
their environment: [Empty]; 
Isolation cart/supply holder: [Empty]; 
Mask required when in contact with MRSA-positive patient: [Empty]; 
Room entrance signs or checklists to remind staff of MDRO patient: 
[Check]; Enhanced staff training or public awareness campaigns: 
[Check]; 
MRSA-positive patients in private rooms or cohorted: [Check]; 
Contact precaution compliance audits: [Check].

Centra, Lynchburg General and Virginia Baptist Hospitals; 
Required gown & gloves for contact with MRSA-positive patients and 
their environment: [Empty]; 
Isolation cart/supply holder: [Empty]; 
Mask required when in contact with MRSA-positive patient: [Empty]; 
Room entrance signs or checklists to remind staff of MDRO patient: 
[Empty]; 
Enhanced staff training or public awareness campaigns: [Empty]; 
MRSA-positive patients in private rooms or cohorted: [Check]; 
Contact precaution compliance audits: [Check].

Eastern Idaho Regional Medical Center; Required gown & gloves for 
contact with MRSA-positive patients and their environment: [Check]; 
Isolation cart/supply holder: [Empty]; 
Mask required when in contact with MRSA-positive patient: [Check]; 
Room entrance signs or checklists to remind staff of MDRO patient: 
[Empty]; 
Enhanced staff training or public awareness campaigns: [Check]; 
MRSA-positive patients in private rooms or cohorted: [Check]; 
Contact precaution compliance audits: [Empty].

Evanston Northwestern Healthcare; 
Required gown & gloves for contact with MRSA-positive patients and 
their environment: [Empty]; 
Isolation cart/supply holder: [Check]; 
Mask required when in contact with MRSA-positive patient: [Empty]; 
Room entrance signs or checklists to remind staff of MDRO patient: 
[Check]; 
Enhanced staff training or public awareness campaigns: [Empty]; 
MRSA-positive patients in private rooms or cohorted: [Check]; 
Contact precaution compliance audits: [Empty].

Pacific Hospital of Long Beach; 
Required gown & gloves for contact with MRSA-positive patients and 
their environment: [Empty]; 
Isolation cart/supply holder: [Empty]; 
Mask required when in contact with MRSA-positive patient: [Empty]; 
Room entrance signs or checklists to remind staff of MDRO patient: 
[Empty]; 
Enhanced staff training or public awareness campaigns: [Empty]; 
MRSA-positive patients in private rooms or cohorted: [Check]; 
Contact precaution compliance audits: [Empty].

Pitt County Memorial Hospital; 
Required gown & gloves for contact with MRSA-positive patients and 
their environment: [Empty]; 
Isolation cart/supply holder: [Empty]; 
Mask required when in contact with MRSA-positive patient: [Empty]; 
Room entrance signs or checklists to remind staff of MDRO patient: 
[Empty]; 
Enhanced staff training or public awareness campaigns: [Empty]; 
MRSA-positive patients in private rooms or cohorted: [Check]; 
Contact precaution compliance audits: [Empty].

Medical University of South Carolina; 
Required gown & gloves for contact with MRSA-positive patients and 
their environment: [Empty]; 
Isolation cart/supply holder: [Empty]; 
Mask required when in contact with MRSA-positive patient: [Empty]; 
Room entrance signs or checklists to remind staff of MDRO patient: 
[Empty]; 
Enhanced staff training or public awareness campaigns: [Empty]; 
MRSA-positive patients in private rooms or cohorted: [Check]; 
Contact precaution compliance audits: [Empty].

Mercy Medical Center; 
Required gown & gloves for contact with MRSA-positive patients and 
their environment: [Empty]; 
Isolation cart/supply holder: [Empty]; 
Mask required when in contact with MRSA-positive patient: [Empty]; 
Room entrance signs or checklists to remind staff of MDRO patient: 
[Empty]; 
Enhanced staff training or public awareness campaigns: [Empty]; 
MRSA-positive patients in private rooms or cohorted: [Check]; 
Contact precaution compliance audits: [Empty].

Newark Beth Israel Medical Center; 
Required gown & gloves for contact with MRSA-positive patients and 
their environment: [Empty]; 
Isolation cart/supply holder: [Empty]; 
Mask required when in contact with MRSA-positive patient: [Empty]; 
Room entrance signs or checklists to remind staff of MDRO patient: 
[Empty]; 
Enhanced staff training or public awareness campaigns: [Empty]; 
MRSA-positive patients in private rooms or cohorted: [Check]; 
Contact precaution compliance audits: [Empty].

Rochester General Hospital; 
Required gown & gloves for contact with MRSA-positive patients and 
their environment: [Empty]; 
Isolation cart/supply holder: [Empty]; 
Mask required when in contact with MRSA-positive patient: [Empty]; 
Room entrance signs or checklists to remind staff of MDRO patient: 
[Empty]; 
Enhanced staff training or public awareness campaigns: [Check]; 
MRSA-positive patients in private rooms or cohorted: [Check]; 
Contact precaution compliance audits: [Check].

Wake Forest University Baptist Medical Center; 
Required gown & gloves for contact with MRSA-positive patients and 
their environment: [Check]; 
Isolation cart/supply holder: [Empty]; 
Mask required when in contact with MRSA-positive patient: [Empty]; 
Room entrance signs or checklists to remind staff of MDRO patient: 
[Empty]; 
Enhanced staff training or public awareness campaigns: [Empty]; 
MRSA-positive patients in private rooms or cohorted: [Check]; 
Contact precaution compliance audits: [Check].

University of Pittsburgh Medical Center; 
Required gown & gloves for contact with MRSA-positive patients and 
their environment: [Check]; 
Isolation cart/supply holder: [Check]; 
Mask required when in contact with MRSA-positive patient: [Check]; 
Room entrance signs or checklists to remind staff of MDRO patient: 
[Check]; 
Enhanced staff training or public awareness campaigns: [Check]; 
MRSA-positive patients in private rooms or cohorted: [Check]; 
Contact precaution compliance audits: [Check].

[End of table]

Source: GAO analysis of survey and site visit data.

Table 9: Environmental Cleaning Changes by Selected Hospitals with MRSA-
Reduction Initiatives:

Albany Medical Center; 
Checklist or electronic notification system for housekeeping staff: 
[Check]; 
Environmental cleaning compliance audits: [Empty]; 
Enhanced training: [Empty]; Change curtains: [Empty]; 
Enhanced cleaning of hospital environment or patient equipment: 
[Empty]; 
Dedicated equipment for MRSA-positive patients: [Empty].

Barnes-Jewish Hospital; 
Checklist or electronic notification system for housekeeping staff: 
[Empty]; 
Environmental cleaning compliance audits: [Empty]; 
Enhanced training: [Empty]; Change curtains: [Empty]; 
Enhanced cleaning of hospital environment or patient equipment: 
[Empty]; 
Dedicated equipment for MRSA-positive patients: [Empty].

Beth Israel Medical Center; 
Checklist or electronic notification system for housekeeping staff: 
[Check]; 
Environmental cleaning compliance audits: [Check]; 
Enhanced training: [Check]; 
Change curtains: [Empty]; 
Enhanced cleaning of hospital environment or patient equipment: 
[Check]; 
Dedicated equipment for MRSA-positive patients: [Empty].

Centra, Lynchburg General and Virginia Baptist Hospitals; 
Checklist or electronic notification system for housekeeping staff: 
[Empty]; 
Environmental cleaning compliance audits: [Empty]; 
Enhanced training: [Empty]; 
Change curtains: [Empty]; 
Enhanced cleaning of hospital environment or patient equipment: 
[Empty]; 
Dedicated equipment for MRSA-positive patients: [Empty].

Eastern Idaho Regional Medical Center; 
Checklist or electronic notification system for housekeeping staff: 
[Empty]; 
Environmental cleaning compliance audits: [Check]; 
Enhanced training: [Check]; 
Change curtains: [Empty]; 
Enhanced cleaning of hospital environment or patient equipment: 
[Empty]; 
Dedicated equipment for MRSA-positive patients: [Empty].

Evanston Northwestern Healthcare; 
Checklist or electronic notification system for housekeeping staff: 
[Empty]; 
Environmental cleaning compliance audits: [Empty]; 
Enhanced training: [Empty]; 
Change curtains: [Empty]; 
Enhanced cleaning of hospital environment or patient equipment: 
[Empty]; 
Dedicated equipment for MRSA-positive patients: [Empty].

Pacific Hospital of Long Beach; 
Checklist or electronic notification system for housekeeping staff: 
[Empty]; 
Environmental cleaning compliance audits: [Empty]; 
Enhanced training: [Check]; 
Change curtains: [Empty]; 
Enhanced cleaning of hospital environment or patient equipment: 
[Empty]; 
Dedicated equipment for MRSA-positive patients: [Empty].

Pitt County Memorial Hospital; 
Checklist or electronic notification system for housekeeping staff: 
[Empty]; 
Environmental cleaning compliance audits: [Empty]; 
Enhanced training: [Empty]; 
Change curtains: [Empty]; 
Enhanced cleaning of hospital environment or patient equipment: 
[Empty]; 
Dedicated equipment for MRSA-positive patients: [Empty].

Medical University of South Carolina; 
Checklist or electronic notification system for housekeeping staff: 
[Empty]; 
Environmental cleaning compliance audits: [Empty]; 
Enhanced training: [Empty]; 
Change curtains: [Empty]; 
Enhanced cleaning of hospital environment or patient equipment: 
[Empty]; 
Dedicated equipment for MRSA-positive patients: [Empty].

Mercy Medical Center; 
Checklist or electronic notification system for housekeeping staff: 
[Empty]; 
Environmental cleaning compliance audits: [Check]; 
Enhanced training: [Empty]; 
Change curtains: [Empty]; 
Enhanced cleaning of hospital environment or patient equipment: 
[Empty]; 
Dedicated equipment for MRSA-positive patients: [Empty].

Newark Beth Israel Medical Center; 
Checklist or electronic notification system for housekeeping staff: 
[Empty]; 
Environmental cleaning compliance audits: [Empty]; 
Enhanced training: [Empty]; 
Change curtains: [Empty]; 
Enhanced cleaning of hospital environment or patient equipment: 
[Check]; 
Dedicated equipment for MRSA-positive patients: [Empty].

Rochester General Hospital; 
Checklist or electronic notification system for housekeeping staff: 
[Empty]; 
Environmental cleaning compliance audits: [Empty]; 
Enhanced training: [Empty]; 
Change curtains: [Empty]; 
Enhanced cleaning of hospital environment or patient equipment: 
[Check]; 
Dedicated equipment for MRSA-positive patients: [Check].

Wake Forest University Baptist Medical Center; 
Checklist or electronic notification system for housekeeping staff: 
[Empty]; 
Environmental cleaning compliance audits: [Check]; 
Enhanced training: [Empty]; 
Change curtains: [Empty]; 
Enhanced cleaning of hospital environment or patient equipment: 
[Check]; 
Dedicated equipment for MRSA-positive patients: [Empty].

University of Pittsburgh Medical Center; 
Checklist or electronic notification system for housekeeping staff: 
[Check]; 
Environmental cleaning compliance audits: [Empty]; 
Enhanced training: [Empty]; 
Change curtains: [Check]; 
Enhanced cleaning of hospital environment or patient equipment: 
[Check]; 
Dedicated equipment for MRSA-positive patients: [Empty].

Source: GAO analysis of survey and site visit data. 

[End of table] 

Table 10: Antibiotic Stewardship Changes by Selected Hospitals with 
MRSA-Reduction Initiatives:

Albany Medical Center; 
Description: 
* Antibiotic stewardship team; 
* Electronic system to track antibiotic usage and evaluate 
microorganism combinations; 
* Reduced usage of certain antibiotics.

Barnes-Jewish Hospital; 
Description: [Empty].

Beth Israel Medical Center; 
Description: [Empty].

Centra, Lynchburg General and Virginia Baptist Hospitals; 
Description: [Empty].

Eastern Idaho Regional Medical Center; 
Description: [Empty].

Evanston Northwestern Healthcare; 
Description: 
* Tracking of mupirocin resistance; 
* Removal by pharmacy of mupirocin ointment from authorized use for 
anything other than decolonization to keep resistance under control; 
* Tracking of utilization of vancomycin.

Pacific Hospital of Long Beach; 
Description: 
* Education; 
* Implementation of the hospital antibiogram, which tests for the 
sensitivity of isolated bacterial strains to different antibiotics.

Pitt County Memorial Hospital; 
Description: [Empty].

Medical University of South Carolina; 
Description: [Empty].

Mercy Medical Center; 
Description: [Empty]. 

Newark Beth Israel Medical Center; 
Description: 
* Development of an antibiotic deescalation program; 
* Introduction of an antibiotic substitution policy; 
* Institution of antibiotic restriction requiring approval by an 
infectious diseases specialist.

Rochester General Hospital; 
Description: 
* Monitor drug selection and duration and make recommendations based on 
this review; 
* In process of implementing an electronic surveillance system with 
antibiotic monitoring capabilities.

Wake Forest University Baptist Medical Center; 
Description: 
* Two pharmacy positions dedicated to antibiotic stewardship; 
* Physician dedicated to the prudent use of antibiotics.

University of Pittsburgh Medical Center; 
Description: [Empty].

Source: GAO analysis of survey and site visit data. 

[End of table]

Table 11: Decolonization Characteristics by Selected Hospitals with 
MRSA-Reduction Initiatives:

Albany Medical Center; 
All MRSA-positive patients identified through screening: Hospital 
decolonizes these individuals; 
Orthopedic surgery patients: Included within "All MRSA-positive 
patients" category; 
Cardiothoracic surgery patients: Included within "All MRSA-positive 
patients" category; 
Other: Included within "All MRSA-positive patients" category; 
Health care workers: [Empty].

Barnes-Jewish Hospital; 
All MRSA-positive patients identified through screening: [Empty]; 
Orthopedic surgery patients: [Empty]; 
Cardiothoracic surgery patients: [Empty]; 
Other: [Empty]; 
Health care workers: Hospital decolonizes these individuals[F].

Beth Israel Medical Center; 
All MRSA-positive patients identified through screening: [Empty]; 
Orthopedic surgery patients: Hospital decolonizes these individuals; 
Cardiothoracic surgery patients: Hospital decolonizes these 
individuals; 
Other: [Empty]; 
Health care workers: Hospital decolonizes these individuals[F].

Centra, Lynchburg General and Virginia Baptist Hospitals; 
All MRSA-positive patients identified through screening: [Empty]; 
Orthopedic surgery patients: [Empty]; 
Cardiothoracic surgery patients: [Empty]; 
Other: Hospital decolonizes these individuals[B]; 
Health care workers: [Empty].

Eastern Idaho Regional Medical Center; 
All MRSA-positive patients identified through screening: Hospital 
decolonizes these individuals; 
Orthopedic surgery patients: Included within "All MRSA-positive 
patients" category; 
Cardiothoracic surgery patients: Included within "All MRSA-positive 
patients" category; 
Other: Included within "All MRSA-positive patients" category; 
Health care workers: Hospital decolonizes these individuals[F,G].

Evanston Northwestern Healthcare; 
All MRSA-positive patients identified through screening: Hospital 
decolonizes these individuals; 
Orthopedic surgery patients: Included within "All MRSA-positive 
patients" category; 
Cardiothoracic surgery patients: Included within "All MRSA-positive 
patients" category; 
Other: Included within "All MRSA-positive patients" category; 
Health care workers: [Empty].

Medical University of South Carolina; 
All MRSA-positive patients identified through screening: [Empty]; 
Orthopedic surgery patients: [Empty]; 
Cardiothoracic surgery patients: [Empty]; 
Other: [Empty]; 
Health care workers: Hospital decolonizes these individuals[F].

Mercy Medical Center; 
All MRSA-positive patients identified through screening: [Empty]; 
Orthopedic surgery patients: Hospital decolonizes these individuals; 
Cardiothoracic surgery patients: [Empty]; 
Other: [Empty]; 
Health care workers: [Empty].

Newark Beth Israel Medical Center; 
All MRSA-positive patients identified through screening: Hospital 
decolonizes these individuals; 
Orthopedic surgery patients: Included within "All MRSA-positive 
patients" category; 
Cardiothoracic surgery patients: Included within "All MRSA-positive 
patients" category; 
Other: Included within "All MRSA-positive patients" category; 
Health care workers: Hospital decolonizes these individuals[F].

Pacific Hospital of Long Beach; 
All MRSA-positive patients identified through screening: Hospital 
decolonizes these individuals; 
Orthopedic surgery patients: Included within "All MRSA-positive 
patients" category; 
Cardiothoracic surgery patients: Included within "All MRSA-positive 
patients" category; 
Other: Included within "All MRSA-positive patients" category[C]; 
Health care workers: [Empty].

Pitt County Memorial Hospital; 
All MRSA-positive patients identified through screening: Hospital 
decolonizes these individuals; 
Orthopedic surgery patients: Included within "All MRSA-positive 
patients" category; 
Cardiothoracic surgery patients: Included within "All MRSA-positive 
patients" category; 
Other: Included within "All MRSA-positive patients" category; 
Health care workers: Hospital decolonizes these individuals[H].

Rochester General Hospital; 
All MRSA-positive patients identified through screening: [Empty]; 
Orthopedic surgery patients: [Empty]; 
Cardiothoracic surgery patients: Hospital decolonizes these 
individuals[A]; 
Other: [Empty]; 
Health care workers: [Empty].

Wake Forest University Baptist Medical Center; 
All MRSA-positive patients identified through screening: [Empty]; 
Orthopedic surgery patients: [Empty]; 
Cardiothoracic surgery patients: [Empty]; 
Other: Hospital decolonizes these individuals[D]; 
Health care workers: [Empty].

University of Pittsburgh Medical Center; 
All MRSA-positive patients identified through screening: [Empty]; 
Orthopedic surgery patients: [Empty]; 
Cardiothoracic surgery patients: [Empty]; 
Other: Hospital decolonizes these individuals[E]; 
Health care workers: Hospital decolonizes these individuals[F].

Source: GAO analysis of survey and site visit data.

Notes:

[A] All cardiothoracic surgery patients, including those who have not 
tested positive for MRSA, receive decolonization therapy. Mupirocin 
ointment is also applied to chest tube sites when removing chest tubes.

[B] MRSA-positive patients scheduled to undergo implant procedures are 
decolonized.

[C] All patients admitted to hospital undergo skin decolonization plus 
daily cleansing.

[D] Newly colonized patients are decolonized. Patients with a history 
of MRSA are decolonized at a physician's request.

[E] Patients are decolonized only if they request it and if the 
physician believes that decolonization is reasonable.

[F] Health care workers are decolonized if identified as MRSA-positive 
as part of an outbreak investigation.

[G] All newly hired health care workers are screened and decolonized if 
positive.

[H] Health care workers are provided voluntary MRSA screening at annual 
physical, and MRSA decolonization is offered at no charge for those who 
test positive. 

[End of table] 

[End of section]

Appendix III" GAO Contact and Staff Acknowledgments:

GAO Contact:

Cynthia A. Bascetta at (202) 512-7114 or bascettac@gao.gov:

Acknowledgments:

In addition to the contact named above, key contributors to this report 
were Nancy Edwards, Assistant Director; Donald Brown; Eric Peterson; 
Andrea E. Richardson; Shannon Slawter Legeer; and Timothy Walker.

[End of section]

Footnotes: 

[1] MDROs develop resistance to antimicrobial drugs when bacteria 
change or adapt in a way that allows them to survive in the presence of 
antibiotics designed to kill them. In some cases, bacteria become 
resistant to all available antibiotics. 

[2] Although named for its resistance to methicillin, MRSA is also 
resistant to a large group of commonly prescribed antibiotics.

[3] R.M. Klevens et al., "Changes in the Epidemiology of Methicillin- 
Resistant Staphylococcus aureus in Intensive Care Units in US 
Hospitals, 1992-2003," Clinical Infectious Diseases, 2006, 42:389-91. 
These trends are based on data from 1,268 ICUs in 337 U.S. hospitals.

[4] GAO, Health-Care-Associated Infections in Hospitals: Leadership 
Needed from HHS to Prioritize Prevention Practices and Improve Data on 
These Infections, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-
283] (Washington, D.C.: Mar. 31, 2008). 

[5] The HAI public reporting system in Arkansas does not require 
hospitals to report data to the state and will report only aggregate 
data on HAIs to the public. Nevada and Nebraska will not report any HAI 
data publicly. Utah has begun to collect HAI data from hospitals, but 
has not yet decided whether it will report these data to the public. 
Ohio requires hospitals to report quality data publicly, but did not 
include HAI measures in its initial set of measures. An advisory 
committee convened to consider and possibly recommend HAI measures for 
inclusion. Its final report was expected in August 2008. 

[6] In several instances, including the two site visits we conducted, 
the MRSA-reduction initiative applied to multiple hospitals that 
belonged to the same hospital system. Because our analysis of MRSA- 
reduction initiatives examined the variation across the different 
initiatives, we use the term hospital in the following discussion to 
refer to the single or multiple facilities that adopted a particular 
MRSA-reduction initiative.

[7] The term HAI is often used synonymously with hospital-acquired 
infection and nosocomial infection. HAIs are distinct from community- 
acquired infections, which are infections that were transmitted to 
patients prior to their admission to a hospital or other health care 
facility.

[8] Central lines are intravenous lines inserted into a large vein 
typically in the neck or near the heart.

[9] To be eligible for payment under the Medicare and Medicaid 
programs, hospitals must comply with HHS-established health and safety 
standards, known as conditions of participation (COP), which include a 
COP for infection control. Many hospitals meet this requirement through 
accreditation by the Joint Commission.

[10] IHI is an independent, nonprofit organization that works to 
improve the quality of health care.

[11] Hand hygiene is a general term that applies to handwashing, 
antiseptic handwash, antiseptic hand rub, or surgical hand antisepsis. 
Environmental cleaning refers to the disinfection of environmental 
surfaces and equipment for infection control efforts in hospitals.

[12] H.T. Stelfox et al., "Safety of Patients Isolated for Infection 
Control," Journal of the American Medical Association (Oct. 8, 2003) 
290:14, 1899-1905; see also K.B. Kirkland & J.M. Weinstein, "Adverse 
effects of contact isolation" (Oct. 2, 1999) The Lancet, 354, 1177- 
1178; S. Saint et al., "Do physicians examine patients in contact 
isolation less frequently? A brief report," American Journal of 
Infection Control, 31:6 (October 2003) 354-356.

[13] These costs do not include laboratory overhead and personnel costs.

[14] J.D. Siegel et al., Management of Multidrug-Resistant Organisms in 
Healthcare Settings, 2006, downloaded from [hyperlink, 
http://www.cdc.gov/ncidod/dhqp/guidelines.html] on Jun. 5, 2007.

[15] See, CDC/NHSN Surveillance Definition of Health Care-Associated 
Infection and Criteria for Specific Types of Infections in the Acute 
Care Setting [hyperlink, 
http://www.cdc.gov/ncidod/dhqp/nhsn_documents.html] and CDC, The 
National Healthcare Safety Network (NHSN) Manual: Patient Safety 
Component Protocol, Division of Healthcare Quality Promotion, National 
Center for Infectious Diseases (Atlanta, Ga.: updated January 2008).

[16] See [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-283] for 
a description of this process.

[17] The NHSN allows hospitals to identify and report HAIs that fall 
into any of the other 13 categories of HAIs for which CDC has developed 
definitions but without specific data collection protocols. 

[18] The CMS and CDC are represented on the SCIP steering committee, 
along with such groups as the American College of Surgeons, the 
American Hospital Association, the American Society of 
Anesthesiologists, the Institute for Healthcare Improvement, and the 
Joint Commission.

[19] This Web site can be accessed at [hyperlink, 
http://www.hospitalcompare.hhs.gov]. Since 2004, hospitals' submission 
of data for a series of process measures has been part of the Medicare 
hospital inpatient prospective payment system (IPPS). In addition, CMS 
issued a final rule stating that, effective October 1, 2008, hospitals 
would no longer receive higher payment under IPPS for eight preventable 
outcomes, including three HAIs. See 72 Fed. Reg. 47200, 47217-8 (Aug. 
22, 2007).

[20] NQF, "National Voluntary Consensus Standards for the Reporting of 
Healthcare-Associated Infection Data" (Washington, D.C.: 2008). NQF is 
a voluntary standard-setting, consensus-building organization 
representing providers, consumers, purchasers, and researchers.

[21] NQF recently requested that CDC consider revising its definitions 
for these two measures. See NQF, "National Voluntary Consensus 
Standards for the Reporting of Healthcare-Associated Infection Data," 
p. 12.

[22] AHRQ is an HHS agency that conducts and funds research to promote 
more effective and higher quality care.

[23] Florida selected the antibiotics administered prior to surgery 
process measures, and Oklahoma selected rates for central line- 
associated BSIs and VAP. 

[24] A number of these states use other systems to collect data for 
measures not incorporated into NHSN, such as the SCIP measures on 
antibiotics administered prior to surgery.

[25] Although participation in the NHSN is, from a federal perspective, 
voluntary on the part of hospitals, and the confidentiality of the data 
they submit is protected by law, the mandatory state reporting programs 
require hospitals in those states to enroll in the NHSN and to 
authorize access to their data by state officials through the group 
feature in NHSN. 

[26] CDC researchers did conduct one pilot study in the mid-1990s that 
examined the accuracy of HAI reporting at nine hospitals participating 
in the voluntary NNIS system that preceded NHSN. In general they found 
that the patients that the hospitals reported as having HAIs did have 
them, but that an additional number of patients had HAIs that were not 
reported to NNIS. The extent of underreporting varied by type of 
infection, lower for BSIs and higher for UTIs, for example. The 
researchers concluded that "Data integrity is essential and can be 
accomplished only when an ongoing and objective method to assess the 
quality of the data is included as an integral part of the surveillance 
system." See T.G. Emori et al., "Accuracy of Reporting Nosocomial 
Infections in Intensive-Care-Unit Patients to the National Nosocomial 
Infections Surveillance System: A Pilot Study," Infection Control and 
Hospital Epidemiology, 19 (May 1998) 308-316.

[27] The seven states are Colorado, Connecticut, Maryland, New 
Hampshire, Oregon, Texas, and Washington.

[28] CMS developed this "present on admission" (POA) indicator to 
identify hospital-acquired conditions. All hospitals paid under 
Medicare's IPPS must attach this indicator to the diagnosis codes that 
they submit with their claims. Certain hospitals that Medicare pays 
outside of the IPPS, such as critical access hospitals, are not subject 
to this CMS requirement, but Illinois requires all hospitals to report 
the POA code.

[29] There are NHSN protocols for central line-associated BSIs, VAP, 
catheter-associated UTIs, SSIs, and postprocedure pneumonia.

[30] Several other states require hospitals and other providers to 
report only suspected cases of community-associated MRSA.

[31] Some states focus their reporting requirement on cases of invasive 
MRSA. The frequency of reporting varies from within 12 hours of 
identification in Connecticut to semiannually in Maine.

[32] Pennsylvania's original data collection system recorded each 
instance where hospitals found a patient had an HAI. However, it did 
not collect information on the number of patients at risk of developing 
comparable HAIs, information which the NHSN collects in order to risk 
adjust its results. In 2007 the Pennsylvania legislature passed a law 
that mandated adoption of NHSN for HAI data collection.

[33] We do not know the extent to which hospitals already had in place 
extensive policies for contact precautions, environmental cleaning, or 
antibiotic stewardship. We asked hospitals to report changes they made 
to these policies for their MRSA-reduction initiatives. 

[34] One of these hospitals reported that it included the use of masks 
because their use may help prevent health care staff from being 
colonized with MRSA in their nasal passages, a common site of MRSA 
colonization. However, a hospital official noted that the use of masks 
has not been adequately studied. 

[35] UPMC and ENH began implementing their MRSA-reduction initiatives 
in January 2002 and February 2003, respectively.

[36] ENH is a 3-hospital system located on separate campuses in 
Chicago's northern suburbs. All 3 hospitals primarily function as 
community hospitals with many surgical and long-term care patients and 
relatively few ICU patients. UPMC is a 20-hospital system, largely 
located in the Pittsburgh metropolitan area but with some hospitals 
scattered across Western Pennsylvania. One of the UPMC hospitals is 
Presbyterian Hospital, a large academic medical center with a 
substantial number of ICUs and ICU patients. Some of the other 
hospitals in the UPMC system function more as community hospitals. 

[37] In addition to testing patients for MRSA on admission to the 
selected units, UPMC tested them again (unless they had already tested 
positive) once a week while on the unit and at the time of discharge 
from the unit. UPMC made it easier to ensure that patients were tested 
weekly by testing all patients in the unit on the same day of the week, 
rather than counting 7 days from each patient's admission date.

[38] In 2003, ENH converted all its patient medical records to an EMR 
system. Paper records received from other facilities were scanned and 
converted into electronic documents, allowing ENH to become a 
completely "paperless" facility.

[39] The prevalence survey determined the number of patients across all 
units of the three ENH hospitals who were colonized with MRSA at a 
particular point in time.

[40] This contrasted with a report published the previous year that 2.7 
percent of patients admitted to Emory University Hospital were MRSA- 
positive. J.A. Jernigan et al., "Prevalence of and Risk Factors for 
Colonization with Methicillin-Resistant Staphylococcus Aureus at the 
Time of Hospital Admission," Infection Control and Hospital 
Epidemiology, 24:6 (June 2003) 409-14.

[41] Financial experts at ENH constructed an internal database that 
recorded actual costs associated with individual chargable items and 
procedures going back to fiscal year 2005. They used these data to 
assess the net costs of treating patients with MRSA infections, after 
taking account of any higher payments received, compared to the costs 
of treating comparable patients who did not have MRSA infections. These 
analyses found that ENH absorbed a net cost of approximately $10,000 
for each patient with a MRSA-related respiratory infection and a net 
cost of $19,000 for each patient with a MRSA-related bloodstream 
infection.

[42] Individual PCR tests require only about 2 to 4 hours to produce a 
result, but it takes additional time to transport specimens to the 
laboratory site and it is more efficient to conduct the tests in 
batches. 

[43] UPMC officials estimated that the total cost, including testing, 
for the first year of the initiative was just over $62,000.

[44] P.W. Stone et al., "A Systematic Audit of Economic Evidence 
Linking Nosociomial Infections and Infection Control Interventions: 
1990-2000," American Journal of Infection Control, 30 (2002) 145-52.

[End of section] 

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