Summary
According to the Centers for Disease Control and Prevention (CDC), health-care-associated infections (HAI) are estimated to be 1 of the top 10 causes of death in the United States. HAIs are infections that patients acquire while receiving treatment for other conditions. GAO was asked to examine (1) CDC's guidelines for hospitals to reduce or prevent HAIs and what the Department of Health and Human Services (HHS) does to promote their implementation, (2) Centers for Medicare & Medicaid Services' (CMS) and hospital accrediting organizations' required standards for hospitals to reduce or prevent HAIs and how compliance is assessed, and (3) HHS programs that collect data related to HAIs and integration of the data across HHS. GAO reviewed documents and interviewed officials from CDC, CMS, the Agency for Healthcare Research and Quality (AHRQ), and accrediting organizations.
CDC has 13 guidelines for hospitals on infection control and prevention, which cover a variety of topics, and in these guidelines CDC recommends almost 1,200 practices for implementation to prevent HAIs and related adverse events. Most of the practices are sorted into five categories--from strongly recommended for implementation to not recommended--primarily on the basis of the strength of the scientific evidence for each practice. Over 500 practices are strongly recommended. CDC and AHRQ have conducted some activities to promote implementation of recommended practices, but these activities are not based on a clear prioritization of the practices. Prioritization may consider not only the strength of the evidence, but also other factors that can affect implementation, such as cost and organizational obstacles. In addition to CDC, AHRQ has reviewed scientific evidence for certain HAI-related practices, but the efforts of the two agencies have not been coordinated. The infection control standards required by CMS and hospital-accrediting organizations--the Joint Commission and the Healthcare Facilities Accreditation Program of the American Osteopathic Association (AOA)--describe the fundamental components of a hospital's infection control program. These components include the active prevention, control, and investigation of infections. The standards are far fewer in number than the recommended practices in CDC's guidelines and generally do not require that hospitals implement all recommended practices in CDC's infection control and prevention guidelines. CMS, the Joint Commission, and AOA assess compliance with their infection control standards through direct observation of hospital activities and review hospital policy documents during on-site surveys. Multiple HHS programs collect data on HAIs, but limitations in the scope of information they collect and a lack of integration across the databases maintained by these separate programs constrain the utility of the data. Three agencies within HHS currently collect HAI-related data for a variety of purposes in databases maintained by four separate programs: CDC's National Healthcare Safety Network program, CMS's Medicare Patient Safety Monitoring System, CMS's Annual Payment Update program, and AHRQ's Healthcare Cost and Utilization Project. Each of the four databases presents only a partial view of the extent of the HAI problem because each focuses its data collection on selected types of HAIs and collects data from a different subset of hospital patients across the country. GAO did not find that the agencies were taking steps to integrate data across the four databases by creating linkages across the databases, such as creating common patient identifiers. Creating linkages across the HAI-related databases could enhance the availability of information to better understand where and how HAIs occur. Although CDC officials have produced national estimates of HAIs, those estimates derive from assumptions and extrapolations that raise questions about the reliability of those estimates.
Recommendations
Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director:
Team:
Phone:
Cynthia A. Bascetta
Government Accountability Office: Health Care
(202) 512-7207
Recommendations for Executive Action
Recommendation: In order to help reduce HAIs in hospitals, the Secretary of HHS should identify priorities among CDC's recommended practices and determine how to promote implementation of the prioritized practices, including whether to incorporate selected practices into CMS's conditions of participation (COP) for hospitals.
Agency Affected: Department of Health and Human Services
Status: Closed - implemented
Comments: In 2009, HHS established a Steering Committee for the Prevention of Healthcare-Associated Infections which developed a department-wide action plan to reduce HAIs and established a framework for prioritizing the recommended practices in four CDC guidelines. As a result, the Steering Committee identified a subset of priority recommendations related to the prevention of four HAIs: catheter-associated urinary tract infections, intravascular catheter-associated infections, surgical site infections, and ventilator-associated pneumonia. CDC is also in the process of identifying prioritized practices related to the prevention of Clostridium difficile and Methicillin Resistant Staphylococcus Aureus-related HAIs. HHS plans to take additional actions to promote implementation by hospitals of the prioritized practices by, for example, developing a national media campaign to elicit support for the implementation of the prioritized practices and by funding an initiative in 10 states to reduce central line-associated bloodstream infections. By establishing the Steering Committee and prioritizing recommended practices, HHS has taken steps to help reduce HAIs in hospitals which addressed our recommendation. However, HHS does not plan to incorporate any of the prioritized practices into Medicare's infection control Conditions of Participation for hospitals.
Recommendation: In order to help reduce HAIs in hospitals, the Secretary of HHS should establish greater consistency and compatibility of the data collected across HHS on HAIs to increase information available about HAIs, including reliable national estimates of the major types of HAIs.
Agency Affected: Department of Health and Human Services
Status: Open
Comments: In 2009, the Department of Health and Human Services (HHS) established a Steering Committee for the Prevention of Healthcare-Associated Infections which undertook several activities, including developing an interagency working group, called the "Healthcare-Associated Infections and Information Systems Technology Working Group" in order to collaborate HAI data collection and integration efforts across the Department of Health and Human Services. The goals of this group include establishing definitional alignment and identifying standardized data elements needed to measure HAIs across HHS agencies, provide guidance to enable integration of HAI data from multiple HHS databases, develop health information systems to reinforce clinical practices, and seek opportunities to make HHS data systems interoperable. HHS and this Technology Work Group plan to take several actions, which, if implemented could address our recommendation. For example, they have plans to organize and commission a HAI data and database resources inventory; they have started discussing how to integrate data across HHS, and they plan to implement a national HAI point prevalence survey. HHS launched pilot testing of the prevalence survey in August 2009 in preparation for conducting a national-level point prevalence survey in FY 2011.
