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Testimony: 

Before the Subcommittee on Health Care, Committee on Finance, U.S. 
Senate: 

United States Government Accountability Office: 
GAO: 

For Release on Delivery: 
Expected at 2:30 p.m. EDT:
Wednesday, March 18, 2009: 

Health-Care-Associated Infections in Hospitals: 

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

Statement of Dr. Marjorie Kanof, Managing Director: 
Health Care: 

GAO-09-516T: 

GAO Highlights: 

Highlights of GAO-09-516T, a testimony before the Subcommittee on 
Health Care, Committee on Finance, U.S. Senate. 

Why GAO Did This Study: 

According to the Centers for Disease Control and Prevention (CDC), 
health-care-associated infections (HAI)óinfections that patients 
acquire while receiving treatment for other conditionsóare estimated to 
be 1 of the top 10 causes of death in the nation. The statement GAO is 
issuing today summarizes a March 2008 report, Health-Care-Associated 
Infections in Hospitals: Leadership Needed from HHS to Prioritize 
Prevention Practices and Improve Data on These Infections (GAO-08-283). 
In this report, GAO examined (1) CDCís guidelines for hospitals to 
reduce or prevent HAIs and what HHS does to promote their 
implementation, (2) Centers for Medicare & Medicaid Servicesí (CMS) and 
hospital accrediting organizationsí required standards for hospitals to 
reduce or prevent HAIs, and (3) HHS programs that collect data related 
to HAIs and integration of the data across HHS. To conduct the work, 
GAO reviewed documents and interviewed HHS and accrediting organization 
officials. To update certain information for this statement, GAO 
reviewed relevant HHS documents released after GAOís March 2008 report. 

What GAO Found: 

In its March 2008 report, which is summarized in this statement, GAO 
found the following: 

* CDC has 13 guidelines for hospitals on infection control and 
prevention, which contain almost 1,200 recommended practices, but 
activities across HHS to promote implementation of these practices are 
not guided by a prioritization of the practices. Although most of the 
practices have been sorted into categories primarily on the basis of 
the strength of the scientific evidence for the practice, other factors 
to consider in prioritizing, such as costs or organizational obstacles, 
have not been taken into account. 

* While CDCís guidelines describe specific clinical practices 
recommended to reduce HAIs, the infection control standards that CMS 
and the accrediting organizations require describe the fundamental 
components of a hospitalís infection control program. The standards are 
far fewer in number than CDCís recommended practices and generally do 
not require that hospitals implement all recommended practices in CDCís 
guidelines. 

* Multiple HHS programs have databases that collect data on HAIs, but 
limitations in the scope of information collected and a lack of 
integration across the databases constrain the utility of the data. 

GAO concluded that the lack of department-level prioritization of CDCís 
large number of recommended practices had hindered efforts to promote 
their implementation. GAO noted that a few of CDCís strongly 
recommended practices were required by CMS or the accrediting 
organizations but that it was not reasonable to expect CMS or the 
accrediting organizations to require additional practices without 
prioritization. GAO also concluded that HHS had not effectively used 
the HAI-related data it had collected through multiple databases across 
the department to provide a complete picture of the extent of the 
problem. 

Subsequent to GAOís report, HHS established a steering committee, with 
senior-level representation of HHS offices and operating divisions, to 
develop the HHS Action Plan to Prevent Healthcare-Associated 
Infections. This plan includes strategies that are intended to address 
some of the reasons for the lack of effective actions to control HAIs, 
including some identification of priorities from among the 1,200 
recommended practices, and plans to coordinate HAI-related data 
collection activities across HHS. HHS released the Action Plan for 
comment in early January 2009, with the intent of revising it based on 
the public input it received. Following the transition to the new 
presidential administration, HHS has continued to solicit public 
comments. Consequently, it remains uncertain when or if the new 
administration will choose to implement this plan, and if so, with what 
modifications, to address GAOís recommendations and reduce the serious 
problem of HAIs. 

What GAO Recommends: 

In its report, GAO recommended that the Secretary of HHS identify 
priorities among the recommended practices in CDCís guidelines and 
establish greater consistency and compatibility of the data collected 
across HHS on HAIs. HHS generally agreed with GAOís recommendations. 

View [hyperlink, http://www.gao.gov/products/GAO-09-516T] or key 
components. For more information, contact Marjorie Kanof at (202) 512-
7114 or kanofm@gao.gov. 

[End of section] 

Mr. Chairman and Members of the Subcommittee: 

I am pleased to be here today to discuss our work on federal government 
efforts to address the problem of health-care-associated infections 
(HAI) in hospitals and to provide a summary of our March 2008 report 
entitled Health-Care-Associated Infections in Hospitals: Leadership 
Needed from HHS to Prioritize Prevention Practices and Improve Data on 
These Infections.[Footnote 1] According to the Centers for Disease 
Control and Prevention (CDC), HAIs are infections that patients acquire 
while receiving treatment for other conditions[Footnote 2] and are 
estimated to be 1 of the top 10 causes of death in the United States. 
HAIs can be acquired in several ways, such as from bacteria on a needle 
or tube used to deliver medicine, fluids, or blood to a patient. 
According to CDC, the most common HAIs are urinary tract infections, 
surgical site infections, pneumonia, and bloodstream infections. A 
reduction in the prevalence of HAIs through implementation of practices 
that are based on the best available scientific evidence would 
represent a substantial improvement in health care quality. 

HAIs can be expensive. In 2005 the average payment for a 
hospitalization in Pennsylvania was over six times higher for patients 
who contracted a hospital-acquired infection than for patients who did 
not acquire infections.[Footnote 3] A 2007 study of 1.69 million 
patients who were discharged from 77 hospitals found that the 
additional cost of treating a patient with an HAI averaged $8,832. 
[Footnote 4] The costs of HAIs are borne not only by the patients who 
suffer infections, but also by those who pay for care, such as the 
Centers for Medicare & Medicaid Services (CMS). According to the 
American Hospital Association, Medicare paid for over one-third of all 
hospital costs in 2007.[Footnote 5] 

Although not all HAIs are preventable, the federal government and 
private organizations have established standards and other activities 
aimed at controlling and preventing them. CMS has established health 
and safety standards--known as conditions of participation (COP)--with 
which hospitals must comply in order to be eligible for payment by 
Medicare and Medicaid and which include the COP for infection control. 
[Footnote 6] Hospitals may choose one of two ways to show that they 
have met these or equivalent standards: they may be certified by a 
state agency under agreement with CMS to survey the hospital's 
compliance with the COPs or they may be accredited by a CMS-approved 
private organization, including the Joint Commission or the Healthcare 
Facilities Accreditation Program of the American Osteopathic 
Association (AOA).[Footnote 7] Most hospitals are accredited by the 
Joint Commission.[Footnote 8] Other activities within the Department of 
Health and Human Services (HHS) aimed at addressing the problem of HAIs 
in hospitals include CDC's development of guidelines, which contain 
recommended practices that hospitals may adopt, and the management of 
several databases in different parts of HHS that contain information 
about HAIs in hospitals. According to the Institute of Medicine, 
prevention of HAIs through implementation of evidence-based guidelines 
can lead to improvements in quality of care.[Footnote 9] Furthermore, 
the collection of national data on these infections can provide a 
benchmark for individual hospitals to gauge their performance and 
design targeted interventions. In addition to these activities, in 
January 2009 HHS released for public comment the Action Plan to Prevent 
Healthcare-Associated Infections.[Footnote 10] This document is 
designed as a road map for how the department plans to address HAIs. 

Federal and state lawmakers are also concerned about HAIs and have 
taken action to reduce them. With the passage of the Deficit Reduction 
Act of 2005 (DRA),[Footnote 11] the Congress took steps to revise the 
way Medicare pays hospitals so that beginning on October 1, 2008, they 
would not receive higher payments for patients who acquire certain 
preventable conditions (including any of three HAIs) during their 
hospital stays.[Footnote 12] The HAI-related preventable conditions 
that CMS identified under subsection 5001(c) of the DRA were urinary 
tract infections caused by catheters, infections caused by vascular 
catheters, and surgical site infections following selected types of 
surgery.[Footnote 13] In addition, 23 states were designing or had 
implemented state-mandated public reporting of hospital HAI rates or 
HAI-related information as of February 2008.[Footnote 14] 

My statement today is based largely on our March 2008 report, and 
includes some updated information from the HHS Action Plan.[Footnote 
15] In the March 2008 report, we examined (1) CDC's guidelines for 
hospitals to reduce or prevent HAIs, and what HHS does to promote their 
implementation; (2) CMS's and the accrediting organizations' required 
standards for hospitals to reduce or prevent HAIs, and how compliance 
is assessed; and (3) HHS programs that collect data related to HAIs in 
hospitals, and the extent to which the data are integrated across HHS. 

In carrying out this work for our March 2008 report, we interviewed 
officials from CDC, CMS, the Agency for Healthcare Research and Quality 
(AHRQ), the Food and Drug Administration, the Joint Commission, and 
AOA. We also interviewed selected experts in the field of infection 
control. In addition, we reviewed and analyzed CDC's infection control 
and prevention guidelines issued from 1981 through 2007; minutes of 
HHS's Healthcare Infection Control Practices Advisory Committee 
(HICPAC); the World Health Organization's guideline on hand hygiene; 
[Footnote 16] CMS's COPs for hospitals and interpretive guidelines, 
[Footnote 17] which describe the COPs and provide survey procedures 
used to determine compliance with them; the Joint Commission's 2008 
standards for hospitals and its hospital standards manual; and AOA's 
2005 standards for hospitals and its hospital standards manual. We 
refer to the guidance that CMS provides about its COPs in the 
interpretive guidelines, and that the Joint Commission and AOA provide 
about their standards in their respective manuals, as "standards 
interpretations."[Footnote 18] We also reviewed manuals and other 
documents that explain the HHS programs that collect HAI-related data, 
and related publications and data analyses conducted by the agencies 
based on the data collected. We conducted the performance audit for the 
March 2008 report from January 2007 to March 2008, and updated certain 
information from the report for this testimony in March 2009 by 
reviewing the HHS Action Plan and other relevant HHS documents, 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. A detailed explanation of 
our methodology is included in our March 2008 report. 

In brief, we found that federal authorities and private organizations 
had undertaken a number of activities to address the problem of HAIs. 
We reported that CDC had 13 guidelines for hospitals on infection 
control and prevention, which contained almost 1,200 recommended 
practices. However, activities across HHS to promote implementation of 
these practices were not guided by a prioritization of the practices. 
Although most of the practices have been sorted into categories 
primarily on the basis of the strength of the scientific evidence for 
the practice, there were other factors to consider in prioritizing, 
such as costs or organizational obstacles. We concluded that a lack of 
department-level prioritization of CDC's large number of recommended 
practices had hindered efforts to promote their implementation. While 
CDC's guidelines describe specific clinical practices recommended to 
reduce HAIs, the infection control standards that CMS and the 
accrediting organizations require of hospitals describe the fundamental 
components of a hospital's infection control program. We found that the 
standards were far fewer in number than CDC's recommended practices and 
generally did not require that hospitals implement all recommended 
practices in CDC's guidelines. We noted that a few of CDC's strongly 
recommended practices were required by CMS or the accrediting 
organizations but that it was not reasonable to expect CMS or the 
accrediting organizations to require additional practices without 
prioritization. Other HAI-related federal efforts included multiple HHS 
programs that collect data on HAIs, but we found that limitations in 
the scope of information collected and a lack of integration across the 
programs' databases constrained the utility of the data. We concluded 
that HHS had not effectively used the HAI-related data it had collected 
through multiple databases across the department to provide a complete 
picture of the extent of the problem and make progress in reducing 
HAIs. 

In order to help reduce HAIs in hospitals, we recommended that the 
Secretary of HHS take the following two actions: (1) identify 
priorities among CDC's recommended practices and determine how to 
promote implementation of the prioritized practices, including whether 
to incorporate selected practices into CMS's conditions of 
participation (COP) for hospitals, and (2) establish greater 
consistency and compatibility of the data collected across HHS on HAIs 
to increase information available about HAIs, including reliable 
national estimates of the major types of HAIs. In commenting on a draft 
of our report, HHS generally agreed with our recommendations. HHS's 
Action Plan includes a number of strategies, some of which are intended 
to address our recommendations. HHS released the Action Plan for 
comment in early January 2009, with the intent of revising it based on 
the public input it received. Following the transition to the new 
presidential administration, HHS has continued to solicit public 
comments on the plan with no designated deadline for submissions. 
Consequently, it remains uncertain when or if the new administration 
will choose to implement this plan, and if so, with what modifications. 

CDC Had 13 Infection Control and Prevention Guidelines Containing 
Almost 1,200 Recommended Practices, and HHS's Action Plan Includes Some 
Prioritized Practices to Promote Implementation: 

In March 2008, we reported that CDC had 13 guidelines for hospitals on 
infection control and prevention, and in these guidelines CDC 
recommended almost 1,200 practices for implementation to prevent HAIs 
and related adverse events.[Footnote 19] (See table 1.) CDC's infection 
control and prevention guidelines set forth recommended practices, 
summarize the applicable scientific evidence and research, and contain 
contextual information and citations for relevant studies and 
literature. Most of CDC's infection control and prevention guidelines 
are developed in conjunction with HICPAC, an advisory body created in 
1992 by the Secretary of HHS. CDC publishes the final guidelines in its 
Morbidity and Mortality Weekly Report, on its Web site, or through a 
professional journal. 

Table 1: CDC's Infection Control and Prevention Guidelines, with Number 
of Recommended Practices, Issued between 1981 and 2007: 

1; 
Guideline (issue date): Guideline for Prevention of Catheter- 
associated Urinary Tract Infections (1981); 
Total number of recommended practices: 24. 

2; 
Guideline (issue date): Guideline for Infection Control in Health Care 
Personnel (1998); 
Total number of recommended practices: 183. 

3; 
Guideline (issue date): Guideline for Prevention of Surgical Site 
Infection (1999); 
Total number of recommended practices: 63. 

4; 
Guideline (issue date): Guidelines for Preventing Opportunistic 
Infections among Hematopoietic Stem Cell Transplant Recipients (2000); 
Total number of recommended practices: [A]. 

5; 
Guideline (issue date): Guidelines for the Prevention of Intravascular 
Catheter-Related Infections (2002); 
Total number of recommended practices: 111. 

6; 
Guideline (issue date): Guideline for Hand Hygiene in Health-Care 
Settings (2002); 
Total number of recommended practices: 42. 

7; 
Guideline (issue date): Recommendations for Using Smallpox Vaccine in a 
Pre-Event Vaccination Program (2003); 
Total number of recommended practices: [B]. 

8; 
Guideline (issue date): Guidelines for Environmental Infection Control 
in Health-Care Facilities (2003); 
Total number of recommended practices: 329. 

9; 
Guideline (issue date): Guidelines for Preventing Health-Care- 
Associated Pneumonia (2003); 
Total number of recommended practices: 208. 

10; 
Guideline (issue date): Guidelines for Preventing the Transmission of 
Mycobacterium Tuberculosis in Health-Care Settings (2005); 
Total number of recommended practices: [B]. 

11; 
Guideline (issue date): Influenza Vaccination of Health-Care Personnel 
(2006); 
Total number of recommended practices: [6]. 

12; 
Guideline (issue date): Management of Multidrug-Resistant Organisms in 
Healthcare Settings (2006); 
Total number of recommended practices: 80. 

13; 
Guideline (issue date): Guideline for Isolation Precautions: Preventing 
Transmission of Infectious Agents in Healthcare Settings (2007); 
Total number of recommended practices: 152. 

Total: 
Total number of recommended practices: 1,198. 

Source: [hyperlink, http://www.gao.gov/products/GAO-08-283]. 

[A] For the purpose of this table, we do not include a count of the 
recommended practices in this guideline because the guideline is 
targeted to a specific patient population that not all hospitals treat. 
However, for the hospitals that do treat such patients, this guideline 
provides at least another 164 recommended practices. 

[B] The practices in these guidelines are not organized in a way that 
supports counting the total number of practices. 

[End of table] 

We found that CDC's guidelines covered such topics as prevention of 
catheter-associated urinary tract infections, prevention of surgical 
site infections, and hand hygiene. An example of a recommended practice 
in the hand hygiene guideline is the recommendation that health care 
workers decontaminate their hands before having direct contact with 
patients. Most of the practices were sorted into five categories--from 
strongly recommended for implementation to not recommended--primarily 
on the basis of the strength of the scientific evidence for each 
practice. Over 500 practices were strongly recommended. 

We also found that CDC and AHRQ had conducted some activities to 
promote implementation of recommended practices, such as disseminating 
the guidelines and providing research funds. However, these steps were 
not guided by a prioritization of recommended practices. Our March 2008 
report noted that one factor to consider in prioritization is strength 
of evidence, as CDC had done. In addition to strength of evidence, an 
AHRQ study identified other factors to consider in prioritizing 
recommended practices, such as costs and organizational obstacles. 
Furthermore, the efforts of the two agencies had not been coordinated. 
For example, we found that CDC and AHRQ independently examined various 
aspects of the evidence related to improving hand hygiene compliance, 
such as the selection of hand hygiene products and health care worker 
education. This could have been an opportunity for coordination. We 
found that no one in the HHS Office of the Secretary was responsible 
for coordinating infection control activities across HHS. The 
department subsequently established the Steering Committee for the 
Prevention of Healthcare-Associated Infections, with senior-level 
representation of HHS offices and operating divisions, to develop the 
HHS Action Plan. To facilitate implementation of recommended practices 
among health care organizations, the plan prioritized some recommended 
practices to address four of its six targeted HAIs.[Footnote 20] 

CMS's and Accrediting Organizations' Required Hospital Standards 
Described Components of Infection Control Programs, and Compliance with 
These Standards Was Assessed through On-Site Surveys: 

In March 2008, we reported that while CDC's infection control 
guidelines described specific clinical practices recommended to reduce 
HAIs, the infection control standards that CMS and accrediting 
organizations require as part of the hospital certification and 
accreditation processes described the fundamental components of a 
hospital's infection control program. These components included the 
active prevention, control, and investigation of infections. Examples 
of standards and corresponding standards interpretations that hospitals 
must follow included educating hospital personnel about infection 
control and having infection control policies in place. The standards 
were far fewer in number than the recommended practices in CDC's 
guidelines--for example, CMS's infection control COP contained two 
standards. 

We also found that as a whole, the CMS, Joint Commission, and AOA 
standards and their interpretations described similar required elements 
of hospital infection programs. For example, all required that the 
hospital designate a person or persons to be responsible for the 
infection control program. However, there were differences, including 
the extent to which the standards and their interpretations required 
implementation of practices recommended in CDC's infection control 
guidelines. Although CMS and the accrediting organizations generally 
did not require that hospitals implement all recommended practices in 
CDC's infection control and prevention guidelines, we reported that the 
Joint Commission and AOA had standards that required the implementation 
of certain practices recommended in CDC's infection control guidelines. 
For example, we reported that the Joint Commission and AOA required 
hospitals to annually offer influenza vaccinations to health care 
workers, whereas CMS's interpretive guidelines, or standards 
interpretations, were more general, stating that hospitals should adopt 
policies and procedures based as much as possible on national 
guidelines that address hospital-staff-related issues, such as 
evaluating hospital staff immunization status for designated infectious 
diseases. In our March 2008 report, we proposed that HHS determine how 
to promote implementation of prioritized practices, including whether 
to incorporate selected practices into CMS's hospital standards. In its 
Action Plan, HHS indicates its preference not to include specific 
infection control practices in its hospital standards in order to keep 
its standards flexible and broad. 

In our March 2008 report, we also discussed how compliance with 
hospital standards is assessed. CMS, the Joint Commission, and AOA 
assessed compliance with their infection control standards during on- 
site surveys through direct observation of hospital activities and 
review of hospital policy documents. Among the surveys conducted in the 
first quarter of 2007, 12.6 percent of CMS-surveyed hospitals, 17.6 
percent of Joint Commission-surveyed hospitals, and 22.2 percent of AOA-
surveyed hospitals were cited as noncompliant with one of the 
respective organizations' standards on infection control. 

Multiple HHS Programs Collected Data on HAIs, but Lack of Integration 
of Available Data and Other Problems Limited Utility of the Data: 

In March 2008, we reported that multiple HHS programs collected data on 
HAIs but that limitations in the scope of information they collected 
and the lack of integration across the databases maintained by these 
separate programs constrained the utility of the data. Three agencies 
within HHS--CDC, CMS, and AHRQ--collect HAI-related data for a variety 
of purposes in databases maintained by four separate programs: CDC's 
National Healthcare Safety Network (NHSN) program, CMS's Medicare 
Patient Safety Monitoring System (MPSMS), CMS's Annual Payment Update 
(APU) program, and AHRQ's Healthcare Cost and Utilization Project 
(HCUP). (See table 2.) We found that the most detailed source of 
information on HAIs in HHS was the NHSN database. It began as a 
voluntary program in the 1970s to assist hospitals that wanted to 
monitor their HAI rates. CDC has drawn on these data to publicly report 
aggregate trends in selected HAIs, and we found that it was working 
with a number of states that were implementing mandatory programs for 
hospitals to submit HAI-related data through NHSN. We reported that the 
MPSMS database provided CMS with information on national trends in the 
incidence of selected adverse events among hospitalized Medicare 
beneficiaries, including a number of different types of HAIs. These 
data were collected from medical records selected for annual random 
samples of approximately 25,000 Medicare inpatients. We also reported 
that the APU program implemented a financial incentive for hospitals to 
submit to CMS data that were used to calculate hospital performance on 
measures of quality of care. The program received quality-related data 
quarterly for a range of medical conditions, including data on three 
surgical infection prevention measures. We noted that CMS reported the 
results of its analyses of these data on its Hospital Compare Web site. 
Finally, we reported that AHRQ sponsored the development of the HCUP 
databases to create a national information resource of patient-level 
health care data. Two of the 20 Patient Safety Indicators that AHRQ 
derived from these data were related to HAIs, one involving infections 
caused by intravenous lines and catheters, and the other postoperative 
sepsis. 

Table 2: Selected Characteristics of HHS Databases That Contain HAI- 
Related Information, 2008: 

Responsible agency and database: CDC's National Healthcare Safety 
Network (NHSN); 
HAI-related data collected: Infection types; 
* central-line-associated BSI; 
* catheter-associated UTI; 
* VAP; 
* postprocedure pneumonia; 
* SSI; 
* MDRO[A]; 
* other[B]; 
Population for which data are collected: Most hospitals report on 
patients in selected critical care units and those undergoing selected 
procedures such as coronary bypass surgery and colon surgery. 

Responsible agency and database: CMS's Medicare Patient Safety 
Monitoring System (MPSMS); 
HAI-related data collected: Infection types[C]; 
* central-line-associated BSI; 
* catheter-associated UTI; 
* postoperative pneumonia; 
* antibiotic-associated C. difficile; 
* MRSA; 
* VRE; 
Population for which data are collected: National sample of 
hospitalized Medicare patients. 

Responsible agency and database: CMS's Annual Payment Update (APU) 
database; 
HAI-related data collected: Practices to prevent or reduce SSIs; 
* providing antibiotics within 1 hour of surgery; 
* selecting appropriate antibiotics to prevent surgical infections; 
* stopping the administration of the antibiotics within 24 hours of end 
of surgery; 
Population for which data are collected: National inpatient population 
for selected surgical procedures.[D] 

Responsible agency and database: AHRQ's Healthcare Cost and Utilization 
Project (HCUP) database, Nationwide Inpatient Sample; 
HAI-related data collected: Infection types; 
* postoperative sepsis[E]; 
* "infection due to medical care" (focused on intravenous and catheter 
infections); 
Population for which data are collected: A sample of inpatients in 
hospitals in 37 states. 

Source: [hyperlink, http://www.gao.gov/products/GAO-08-283]. 

Notes: BSI is bloodstream infection; C. difficile is Clostridium 
difficile; MDRO is multidrug-resistant organism; MRSA is methicillin- 
resistant Staphylococcus aureus; SSI is surgical site infection; UTI is 
urinary tract infection; VAP is ventilator-associated pneumonia; and 
VRE is vancomycin-resistant enterococci. 

[A] For patients whose infections are laboratory-confirmed, NHSN 
collects data on the pathogens identified, and for specified pathogens 
(including those responsible for MRSA and VRE), the result of any 
testing of their resistance to specific antibiotics. Participating 
hospitals have the option to report separately the number of times in a 
given month that they tested specimens of any of eight specified 
organisms for resistance to selected antibiotics, as well as the 
results of those tests. From these data, NHSN produces rates of 
antimicrobial resistance relative to the number of nonduplicative 
specimens tested (i.e., excluding multiple tests for the same organism 
in the same patient). This part of NHSN does not distinguish between 
MDRO infections acquired in the hospital and community-acquired 
infections present at admission. 

[B] Hospitals can choose to submit to NHSN data on other types of HAIs, 
such as skin and soft tissue infections, cardiovascular system 
infections, and gastrointestinal system infections. CDC does not 
provide data collection protocols for these types of infections, but 
they can be entered into NHSN as "custom events" using definitions 
provided separately by CDC. 

[C] In 2007, CMS added catheter-associated UTIs, VAP, MRSA, and VRE to 
MPSMS and dropped insertion-site infections associated with central 
vascular catheters, BSIs, and postoperative-associated UTIs. 

[D] The three practice measures are assessed for certain categories of 
surgeries: coronary artery bypass graft; other cardiac surgery; colon 
surgery; hip arthroplasty; knee arthroplasty; abdominal hysterectomy; 
vaginal hysterectomy; and vascular surgery. 

[E] The rate of postoperative sepsis is computed only for patients 
undergoing elective surgeries. 

[End of table] 

We found that each of these databases presented only a partial view of 
the extent of the HAI problem because each focused its data collection 
on selected types of HAIs and collected data from a different subset of 
hospital patients across the country. Although two databases--NHSN and 
MPSMS--addressed many of the same types of HAIs, the former provided 
information only from selected units of hospitals that participated in 
the NHSN program (which did not represent hospitals nationwide), while 
the latter provided information only on a representative sample of 
Medicare inpatients (i.e., MPSMS did not provide information on non- 
Medicare patients). In addition, the data collection methods employed 
by the NHSN, MPSMS, and HCUP databases ranged from concurrent review of 
patient care as patients were being treated in the hospital, to 
retrospective review of patient medical records after patients had been 
discharged, to analyses of diagnostic codes recorded electronically in 
patient billing data. 

Although we noted that officials from the various HHS agencies 
discussed HAI data collection with each other, we found that the 
agencies were not taking steps to integrate any of the existing data 
from the four databases. This integration could involve creating 
linkages across the databases by, for example, creating common patient 
identifiers so that data from the same individuals in multiple 
databases could be pulled together. Creating linkages across the HAI- 
related databases could enhance the availability of information to 
better understand where and how HAIs occur. For example, data on 
surgical infection rates and data on surgical processes of care were 
collected for some of the same patients in two different databases that 
were not linked. In our March 2008 report, we concluded that, as a 
consequence, the potential benefit of using the existing data to 
monitor the extent to which compliance with the recommended surgical 
care processes led to actual improvements in surgical infection rates 
had not been realized. In its January 2009 Action Plan, HHS proposes 
remedying this situation by undertaking a series of short-and longer- 
term initiatives to coordinate and align its various HAI-related data 
collection activities, under the guidance of a new interagency working 
group. 

In our March 2008 report, we reported concerns with the use of HAI data 
for providing a national picture of HAIs. Although none of the 
databases collected data on the incidence of HAIs for a nationally 
representative sample of hospital patients, CDC officials had produced 
national estimates of HAIs. However, those estimates derived from 
assumptions and extrapolations that raised questions about the 
reliability of those estimates. In its Action Plan, HHS proposes to 
draw on some of the same data sources--primarily NHSN--to track 
progress in reducing the incidence of five of its six targeted HAIs. 

Concluding Observations: 

HAIs in hospitals can cause needless suffering and death. Federal 
authorities and private organizations have undertaken a number of 
activities to address this serious problem; however, to date, these 
activities have not gained sufficient traction to be effective. 

In our March 2008 report, we identified two possible reasons for the 
lack of effective actions to control HAIs. First, although CDC's 
guidelines are an important source for its recommended practices on how 
to reduce HAIs, the large number of recommended practices and lack of 
department-level prioritization hinder efforts to promote their 
implementation. The guidelines we reviewed contain almost 1,200 
recommended practices for hospitals, including over 500 that are 
strongly recommended--a large number for a hospital trying to implement 
them. A few of these are required by CMS's or accrediting 
organizations' standards or their standards interpretations, but it is 
not reasonable to expect CMS or accrediting organizations to require 
additional practices without prioritization. Although CDC has 
categorized the practices on the basis of the strength of the 
scientific evidence, there are other factors to consider in developing 
priorities. For example, work by AHRQ suggests factors such as costs or 
organizational obstacles that could be considered. The lack of 
coordinated prioritization may have resulted in duplication of effort 
by CDC and AHRQ in their reviews of scientific evidence on HAI-related 
practices. 

Second, we reported that HHS had not effectively used the HAI-related 
data it had collected through multiple databases across the department 
to provide a complete picture of the extent of the problem. Limitations 
in the databases, such as nonrepresentative samples, hinder HHS's 
ability to produce reliable national estimates on the frequency of 
different types of HAIs. In addition, data collected on HAIs are not 
being combined to maximize their utility. HHS has made efforts to use 
the currently collected data to understand the extent of the problem of 
HAIs, but the lack of linkages across the various databases results in 
a lost opportunity to gain a better grasp of the problem of HAIs. 

HHS has multiple methods to influence hospitals to take more aggressive 
action to control or prevent HAIs, including issuing guidelines with 
recommended practices, requiring hospitals to comply with certain 
standards, releasing data to the public to expand information about the 
nature of the problem, and using hospital payment methods to encourage 
the reduction of HAIs. Prioritization of CDC's many recommended 
practices can help guide their implementation, and better use of 
currently collected data on HAIs could help HHS--and hospitals 
themselves--monitor efforts to reduce HAIs. In our March 2008 report, 
we concluded that leadership from the Secretary of HHS was lacking to 
do this and that without such leadership, the department would not be 
able to effectively leverage its various methods to have a significant 
effect on the suffering and death caused by HAIs. 

The recently released HHS Action Plan identifies strategies that are 
intended to address some of the reasons for the lack of effective 
actions to control HAIs, including some identification of priorities 
from among the 1,200 recommended practices, and plans to coordinate HAI-
related data collection activities across HHS. HHS released the Action 
Plan for comment in early January 2009, with the intent of revising it 
based on the public input it received. Following the transition to the 
new presidential administration, HHS has continued to solicit public 
comments on the plan with no designated deadline for submissions. 
Consequently, it remains uncertain when or if the new administration 
will choose to implement this plan, and if so, with what modifications, 
to address our recommendations and reduce the serious problem of HAIs. 

Mr. Chairman, this completes my prepared remarks. I would be happy to 
respond to any questions you or other members of the subcommittee may 
have at this time. 

Contacts and Acknowledgments: 

For further information about this statement, please contact Marjorie 
Kanof at (202) 512-7114 or kanofm@gao.gov or Cynthia A. Bascetta 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 statement. Key contributors to this statement were William 
Simerl, Assistant Director; Mary Giffin; Shannon Slawter Legeer; Eric 
Peterson; and Roseanne Price. 

[End of section] 

Footnotes: 

[1] 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/products/GAO-08-283] 
(Washington, D.C.: Mar. 31, 2008). 

[2] In general, HAIs are distinct from community-acquired infections, 
that is, infections that patients may have acquired before entering the 
hospital. 

[3] See Pennsylvania Health Care Cost Containment Council, Hospital- 
Acquired Infections in Pennsylvania (Harrisburg, Pa., November 2006). 

[4] See D. Murphy et al., Dispelling the Myths: The True Cost of 
Healthcare-Associated Infections (Washington, D.C.: Association for 
Professionals in Infection Control and Epidemiology, February 2007). 

[5] Medicare is a federal health insurance program that serves over 42 
million elderly and certain disabled beneficiaries and pays for health 
care needs, such as inpatient hospital stays and physician visits. 

[6] See 42 C.F.R. ß 482.1 (2007). 

[7] Section 1865(b)(1) of the Social Security Act also provides that 
any other national accreditation body that meets certain requirements 
as determined by the Department of Health and Human Services may 
accredit hospitals. CMS approved Det Norske Veritas Healthcare as a 
hospital accrediting organization in September 2008. 

[8] In fiscal year 2008, 81 percent of hospitals were accredited by the 
Joint Commission, state survey agencies certified approximately 16 
percent of hospitals, less than 2 percent were accredited by AOA, and 1 
percent of hospitals were accredited by both the Joint Commission and 
AOA. 

[9] See K. Adams et al., Priority Areas for National Action: 
Transforming Health Care Quality, Institute of Medicine of the National 
Academies (Washington, D.C.: The National Academies Press, 2003). 

[10] See Department of Health and Human Services, HHS Action Plan to 
Prevent Healthcare-Associated Infections, [hyperlink, 
http://www.hhs.gov/ophs/initiatives/hai/index.html] (accessed Mar. 14, 
2009). 

[11] Pub. L. No. 109-171, ß 5001(c), 120 Stat. 4, 30. 

[12] Under Medicare, hospitals generally receive fixed payments for 
inpatient stays based on diagnosis-related groups (DRG), a system that 
classifies stays by patient diagnoses and procedures. Some DRGs take 
account of certain comorbidities or complications associated with a 
diagnosis or procedure and pay at a higher rate than would otherwise be 
paid for the diagnosis or procedure. In a final regulation implementing 
section 5001(c) of the DRA, CMS identified certain preventable 
conditions that it would not consider as a comorbidity or complication 
that would lead to the higher payment. See 72 Fed. Reg. 47130, 47200- 
217 (Aug. 22, 2007). The DRA also requires hospitals to indicate the 
diagnoses that were present in patients at the time of admission in 
order for CMS to determine if a preventable condition developed during 
a patient's hospital stay. 

[13] The selected surgeries are certain orthopedic procedures, 
bariatric surgery for obesity, and coronary artery bypass graft. 
Additional preventable conditions that will no longer result in higher 
payments to hospitals include hospital-acquired injuries, such as 
fractures, pressure ulcers, objects left in the body during surgery, 
air embolisms, and blood incompatibility. See 73 Fed. Reg. 48434, 48477-
79; 72 Fed. Reg. at 47200-217. 

[14] See GAO, Health-Care-Associated Infections in Hospitals: An 
Overview of State Reporting Programs and Individual Hospital 
Initiatives to Reduce Certain Infections, [hyperlink, 
http://www.gao.gov/products/GAO-08-808] (Washington, D.C.: Sept. 5, 
2008). 

[15] [hyperlink, http://www.gao.gov/products/GAO-08-283]. 

[16] See World Health Organization, WHO Guidelines on Hand Hygiene in 
Healthcare (Advanced Draft): Global Patient Safety Challenge 2005-2006: 
Clean Care Is Safer Care (Geneva, Switzerland, 2006). 

[17] In addition to reviewing CMS's interpretive guidelines that can be 
found in CMS's State Operations Manual, we reviewed CMS's revised 
interpretive guidelines for the infection control COP, which were 
published in November 2007. Throughout this report, where we refer to 
the interpretive guidelines for infection control we are referring to 
the November 2007 revision. 

[18] Standards interpretations are given by CMS primarily in its State 
Operations Manual, which is arranged by COP (Appendix A of the State 
Operations Manual contains the COPs for hospitals); by the Joint 
Commission in its Comprehensive Accreditation Manual for Hospitals: The 
Official Handbook, which identifies rationales and performance 
expectations that are used to measure each standard and is organized 
into 11 chapters of safety and quality standards, such as "Medication 
Management" and "Leadership"; and by AOA's standards manual, 
Accreditation Requirements for Healthcare Facilities, which provides 
explanations for surveyors and the scoring procedures along with its 
standards and is organized into 32 chapters. 

[19] This total does not include the practices recommended in CDC's 
Guideline for Disinfection and Sterilization in Healthcare Facilities, 
which was issued in November 2008. 

[20] The Action Plan identified six targeted HAIs: central-line- 
associated bloodstream infections, catheter-associated urinary tract 
infections, surgical site infections, ventilator-associated pneumonia, 
Clostridium difficile infections, and methicillin-resistant 
Staphylococcus aureus infections. It identified prioritized recommended 
practices for all but Clostridium difficile infections and methicillin-
resistant Staphylococcus aureus infections. 

[End of section] 

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