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

Letter

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

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.

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

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.

Multiple HHS Programs Collect Data on HAIs, but Lack of Integration of Available Data and Other Problems Limit Utility of the Data

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.

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.

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.

Contact and Acknowledgments

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.

Appendix I: Abbreviations

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