Sandra Yin

July 07, 2011

July 7, 2011 (Baltimore, Maryland) — Legislation and public policies related to infection prevention are affecting hospitals in unintended ways, according to findings from 2 studies presented here at the Association for Professionals in Infection Control and Epidemiology (APIC) 2011 Annual Meeting.

In a December 2010 survey of infection preventionists, more than half of respondents said that their hospitals spend more time improving documentation in medical records since the Centers for Medicare and Medicaid Services (CMS) stopped paying extra for certain hospital-acquired conditions that occur after patients are hospitalized, and nearly half (49%) said that their hospitals take more time to improve the accuracy of coding.

The 49% is "perhaps not where you want to be when you want to focus on prevention," said Grace Lee, MD, MPH, assistant professor of population medicine and pediatrics at Harvard Pilgrim Health Care Institute, Harvard Medical School, and Children's Hospital Boston, Massachusetts, after revealing the findings from the survey of 500 infection preventionists.

The survey was designed to explore the perceived impact of the CMS policy that stopped paying hospitals more for specific hospital-acquired complications, including catheter-associated urinary tract infections, central line-associated bloodstream infections, and surgical-site infections after certain surgeries.

Among the intended effects, Dr. Lee noted, is the fact that 81% of infection preventionists surveyed said that they've seen a greater focus on hospital-acquired conditions targeted by CMS policy. However, one third said their hospitals devote less time to preventing healthcare-associated infections (HAI) not targeted by CMS policy. "It's really shifting resources in their perspective," she said.

The shift away from nontargeted HAIs and toward improving documentation of billing codes "is not where we want to be," Dr. Lee said.

Although funding for infection control programs stayed the same for the majority (77%), more than half of infection preventionists surveyed said Medicare's policy, which went into effect in October 2008, spurred more efficient use of existing resources and prompted greater collaboration by interdisciplinary teams to prevent HAIs.

Most of those surveyed said that more time was being spent on surveillance for catheter-associated urinary tract infections (CAUTIs) and being devoted to educating staff on best practices for CAUTIs and catheter-associated bloodstream infections (CLABSIs). The education apparently had an impact. Seven of 10 surveyed said that front-line staff remove urinary catheters more quickly than before, and 6 of 10 said that front-line staff increasingly use antiseptic dressings for central venous catheters.

Although the CMS no-payment policy appears to have had a positive impact on hospital infection prevention and control efforts, the survey did not look at whether the policy actually led to a reduction in infections.

At the same APIC panel on public policies and their implications, Patricia Stone, PhD, FAAN, professor of nursing and director of the Center for Health Policy at Columbia University's School of Nursing in New York City, reported that findings from the first statewide study of mandatory reporting reached many similar conclusions about unintended consequences. Specifically, infection preventionists are spending more time on surveillance and are frustrated that they're not able to address more local issues at their hospitals.

Her study, which looked at the impact of mandatory reporting of infections in California, involved 2 surveys — one in 2008, before state mandatory reporting kicked in for California in 2009, and another in 2010. It also included interviews with infection control staff and intensive care unit (ICU) administrators.

In the later survey, more hospitals reported the existence of evidence-based policies related to CLABSIs and CAUTIs, and more hospitals reported CAUTI policies related to condom catheters, reminder/stop orders, and discontinuation by nurses. Everything is moving in the right direction, said Dr. Stone. "But do people actually do it?"

In some cases, the answer is "yes." Although compliance with evidence-based policies was better in 2010 than in 2008 in California, HAI rates decreased significantly only for CLABSIs and ventilator-associated pneumonia in medical/surgical ICUs. "We're seeing some good things about the practice at the bedside," said Dr. Stone, "but not enough."

California has mandated that 26 surgical-site infections be reported, Dr. Stone said, eliciting a mixture of low groans and hisses from the audience of infection preventionists.

But all the attention on mandatory reporting in California has raised awareness of infection preventionists, Dr. Stone said. "I encourage you people to embrace this increased visibility and get the leadership skills that are needed," she said, "because you might be reporting more to the C suite." She also suggested that infection preventionists style themselves more as coaches and leaders as they educate staff at the bedside and get them to improve compliance with infection control practices.

The study was funded by the National Institute of Allergy and Infectious Diseases. Dr. Lee and Dr. Stone have disclosed no relevant financial relationships.

Association for Professionals in Infection Control and Epidemiology (APIC) 2011 Annual Meeting. Presented June 29, 2011.

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