Health-Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on These Infections
Published: 2008-04-16T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: According to the Centers for Disease Control and Prevention (CDC), health-care-associated infections (HAI)--infections that patients acquire while receiving treatment for other conditions--are estimated to be 1 of the top 10 causes of death in the nation. This statement summarizes a report issued in March and released today, 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) CDC's guidelines for hospitals to reduce or prevent HAIs and what 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 (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 agency and accrediting organization officials.
section_title: What GAO Found
paragraphs: In its March report, which is summarized in this statement, GAO found 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 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. The standards are far fewer in number than CDC's recommended practices and generally do not require that hospitals implement all recommended practices in CDC's 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 CDC's large number of recommended practices has hindered efforts to promote their implementation. GAO 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. GAO also concluded that HHS has not effectively used the HAI-related data it has collected through multiple databases across the department to provide a complete picture of the extent of the problem.

section_title: Letter
paragraphs: 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 report, which you are  releasing today, entitled Health-Care-Associated Infections in Hospitals:  Leadership Needed from HHS to Prioritize Prevention Practices and  Improve Data on These Infections. According to the Centers for Disease  Control and Prevention (CDC), HAIs are infections that patients acquire  while receiving treatment for other conditions and are estimated to be 1  of the top 10 causes of death in the United States. For example, a patient  may acquire an infection from bacteria on a device used to treat them,  such as a needle or tube to deliver medicine, fluids, or blood. According to  CDC, the most common HAIs are urinary tract infections, surgical site  infections, pneumonia, and bloodstream infections.
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, according to a report by the Pennsylvania Health Care Cost  Containment Council. 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. 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 2005.
Although not all HAIs are preventable, public 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. 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 one  of two private organizations—the Joint Commission or the Healthcare  Facilities Accreditation Program of the American Osteopathic Association  (AOA). Most hospitals are accredited by the Joint Commission. Other  activities within the Department of Health and Human Services (HHS)  aimed at addressing the problem of HAIs in hospitals include the  development of guidelines by CDC, 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. Furthermore, the collection of national data on these  infections can provide a benchmark for individual hospitals to gauge their  performance and design targeted interventions.
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), 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 that acquire certain preventable conditions  (including any of three HAIs) during their hospital stays. The HAI-related  preventable conditions that CMS identified in the final regulation  implementing subsection 5001(c) of the DRA were urinary tract infections  caused by catheters, infections caused by vascular catheters, and  mediastinitis following coronary artery bypass graft surgery. According  to Consumers Union—a nonprofit organization that has a campaign to  stop HAIs—23 state legislatures have enacted laws that require public  reporting of hospital HAI rates or HAI-related information.
My statement today is based on the report that you are releasing today. In  that 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 the report you are releasing today, 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 the Healthcare Infection Control Practices Advisory Committee; the  World Health Organization’s guideline on hand hygiene; CMS’s COPs for  hospitals and interpretive guidelines, which describe the COPs and  provide survey procedures used to determine compliance with them; the  Joint Commission’s standards for hospitals and its hospital standards  manual; and AOA’s 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.” 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 report you are  releasing today from January 2007 to March 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. A detailed explanation of our methodology is included in  our report.
In brief, we found that federal authorities and private organizations have  undertaken a number of activities to address the problem of HAIs. CDC  has 13 guidelines for hospitals on infection control and prevention, which  contain almost 1,200 recommended practices. However, 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. We concluded that a lack of department-level prioritization  of CDC’s large number of recommended practices has 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. The standards are far fewer in number than CDC’s recommended  practices and generally do 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 federal efforts include multiple HHS programs that  collect data on HAIs, but limitations in the scope of information collected  and a lack of integration across the programs’ databases constrain the  utility of the data. We concluded that HHS has not effectively used the  HAI-related data it has collected through multiple databases across the  department to provide a complete picture about the extent of the problem.
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. (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. It indicated that CMS would consider whether to  incorporate some of CDC’s recommended practices into CMS’s hospital  COPs, and it identified some steps CMS would take to achieve greater  consistency and compatibility of the data collected on HAIs. In response to  comments from the Joint Commission, we clarified our discussion of Joint  Commission activities; in addition, we incorporated technical comments  from the Joint Commission and AOA.
subsections: section_title: CDC Has 13 Infection Control and Prevention Guidelines Containing Almost 1,200 Recommended Practices, but Activities across HHS to Promote Implementation Are Not Guided by Prioritization of Practices
paragraphs: CDC has 13 guidelines for hospitals on infection control and prevention,  and in these guidelines CDC recommends almost 1,200 practices for  implementation to prevent HAIs and related adverse events. (See table 1.)  The guidelines cover 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 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, such as  disseminating the guidelines and providing research funds. However, these  steps have not been guided by a prioritization of recommended practices.  One factor to consider in prioritization is strength of evidence, as CDC has  done. In addition to strength of evidence, an AHRQ study identified other  factors to consider in prioritizing recommended practices, such as costs or  organizational obstacles. Furthermore, the efforts of the two agencies  have 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. Although this could have been  an opportunity for coordination, an official from the HHS Office of the  Secretary told us that no one within the office is responsible for  coordinating infection control activities across HHS.
section_title: CMS’s and Accrediting Organizations’ Required Hospital Standards Describe Components of Infection Control Programs, and Compliance with These Standards Is Assessed through On- Site Surveys
paragraphs: While CDC’s infection control guidelines describe specific clinical  practices recommended to reduce HAIs, the infection control standards  that CMS and the accrediting organizations require as part of the hospital  certification and accreditation processes describe the fundamental  components of a hospital’s infection control program. These components  include the active prevention, control, and investigation of infections.  Examples of standards and corresponding standards interpretations that  hospitals must follow include educating hospital personnel about infection  control and having infection control policies in place. The standards are  far fewer in number than the recommended practices in CDC’s  guidelines—for example, CMS’s infection control COP contains two  standards. Furthermore, CMS and the accrediting organizations generally  do not require that hospitals implement all recommended practices in  CDC’s infection control and prevention guidelines. Only the Joint  Commission and AOA have standards that require the implementation of  certain practices recommended in CDC’s infection control guidelines. For  example, the Joint Commission and AOA require hospitals to annually  offer influenza vaccinations to health care workers, whereas CMS’s  interpretive guidelines, or standards interpretations, are 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. CMS, the Joint Commission, and AOA assess  compliance with their infection control standards through direct  observation of hospital activities and review of hospital policy documents  during on-site surveys.
section_title: Multiple HHS Programs Collect Data on HAIs, but Lack of Integration of Available Data and Other Problems Limit Utility of the Data
paragraphs: Multiple HHS programs collect data on HAIs, but limitations in the scope  of information they collect and the lack of integration across the databases  maintained by these separate programs constrain the utility of the data.  Three agencies within HHS—CDC, CMS, and AHRQ—currently 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). Each of these 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. (See table 2.)  Although officials from the various HHS agencies discuss HAI data  collection with each other, we did not find that the agencies were taking  steps to integrate any of the existing data 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. For  example, data on surgical infection rates and data on surgical processes of  care are collected for some of the same patients in two different databases  that are not linked. As a consequence, the potential benefit of using the  existing data to monitor the extent to which compliance with the  recommended surgical care processes leads to actual improvements in  surgical infection rates has not been realized. Although none of the  databases collect data on the incidence of HAIs for a nationally  representative sample of hospital patients, CDC officials have produced  national estimates of HAIs. However, those estimates derive from  assumptions and extrapolations that raise questions about the reliability of  those estimates.
section_title: Concluding Observations
paragraphs: 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.
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 have  hindered 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, HHS has not effectively used the HAI-related data it has 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,  currently collected data 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 expand information about the nature of the  problem, and soon, 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. We concluded that leadership from the Secretary of HHS  is currently lacking to do this. Without such leadership, the department is  unlikely to be able to effectively leverage its various methods to have a  significant effect on the suffering and death caused by HAIs.
Mr. Chairman, this completes my prepared remarks. I would be happy to  respond to any questions you or other members of the committee may  have at this time.
section_title: Contact and Acknowledgments
paragraphs: For further information about this statement, please contact   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 Linda T. Kohn, Assistant Director; Shaunessye Curry;  Shannon Slawter Legeer; Eric Peterson; and Roseanne Price.
section_title: Appendix I: Abbreviations
paragraphs: This is a work of the U.S. government and is not subject to copyright protection in the  United States. It may be reproduced and distributed in its entirety without further  permission from GAO. However, because this work may contain copyrighted images or  other material, permission from the copyright holder may be necessary if you wish to  reproduce this material separately.