Health-Care-Associated Infections in Hospitals:
An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections
GAO-08-808, Sep 5, 2008
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.
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.