Press Briefing Transcripts

Media Telebriefing on State Healthcare—Associated Infection Data

May 27, 2010, 12 PM

• Audio recording (MP3)
  

Operator: Welcome and thank you for standing by.  At this time all parties have been placed in a listen and only mode.  During the question and answer session please press star one on your touch tone phone. This call is being recorded, if you have any objections, please disconnect at this time.   I'd now like to introduce Mr. Joe Quimby.  Thank you, sir, you may begin.  

Joe Quimby: Good afternoon, everyone.  I'm Joe Quimby, a senior press officer here at the CDC in Atlanta, and welcome to a telebriefing on state healthcare-associated infection data.  We have a number of speakers that will be with you today to talk about this important news, but first of all I’d like to introduce Dr. Don Wright, who is the deputy assistant secretary for Healthcare Quality at the U.S. Department of Health and Human Services, Office of the Secretary, Office of the Public Health and Science.  And Dr. Wright will introduce our other speakers.  Dr. Wright?  

Don Wright: Thank you, Mr. Quimby.  We all understand that healthcare-associated infections are a significant medical and public health problem in the United States.  It's been estimated there are approximately 1.7 million healthcare-associated infections in hospitals alone each and every year resulting in 100,000 lives lost and an additional $30 billion in healthcare cost.  Responding to this significant public health issue, the U.S. Department of Health and Human Services has initiated a comprehensive strategy to reduce, prevent and ultimately eliminate healthcare-associated infections.  The strategy I mention is outlined in the HHS action plan to prevent healthcare-associated infections that was initially released in January 2009.  There was a team of senior level representatives from across the HHS agencies that drafted the action plan.  Currently, this same group is implementing the action plan in conjunction with our partners, the state, healthcare facilities, healthcare providers and patients.  The action plan provides the coordinated approach to healthcare-associated infection and elimination.  It also includes five-year goals to benchmark national progress; including a 50 percent reduction in central line-associated bloodstream infections by the end of 2013.  Today, we are releasing the first state-specific healthcare-associated infections summary data report that provides us with national and for the first time ever, state-specific data on central line-associated bloodstream infections, from the Center for Disease Control's National Healthcare Safety Network.  The report's findings are indeed encouraging and reflect the diligent efforts of clinicians, facilities, local state and federal governments and partnership groups that have accelerated central line-associated bloodstream infection prevention efforts.  At this time I want to ask Dr. Arjun Srinivasan of the CDC to discuss the report in greater detail.  Dr. Srinivasan currently serves as director for associated for Healthcare-Associated Infections Prevention Program within the CDC’s Division of Healthcare Quality Promotion.  Dr. Srinivasan?  

Arjun Srinivasan: Thank you Dr. Wright and thanks to everyone who is joining us to discuss this very important topic today.  I'm here to cover the major points of the state summary report, the purpose, methodology, findings and implications.  But first I’d like to say a few words by way of brief background on central line-associated bloodstream infections.  Bloodstream infections occur when bacteria enter a patient’s bloodstream, either from their skin or from the environment surrounding them.  These are serious infections that can cause deaths.  Studies have shown that the use of a central line is an important risk factor for getting a bloodstream infection.  Central lines are catheters that are generally placed into the large blood vessels of the neck to give medications and monitor the status of patients.  They are most commonly used in seriously ill patients.  Most importantly, extensive experience has shown us that the majority of central line-associated bloodstream infections are preventable.  So what is the report and why are we publishing it today?  To put it as simply as possible, this report gives us a snapshot of where the country stands in our efforts to prevent central line-associated bloodstream infections.  Data from this report gives us two key pieces of information, it tells us for the first time how we are performing nationally against central line-associated bloodstream infection prevention goals outlined in the U.S. Health and Human Services action plan to prevent healthcare-associated infection, and it will serve as the baseline from which states can assess their own progress towards eliminating these infections.  Today's report includes national data as well as state-specific information from 17 states.  Before I go any further, I think it's critical to emphasize the true value of this report.  While I certainly agree that it’s helpful to know the burden of specific healthcare-associated infections at any point in time, nationally or locally, this single report is only the first step especially for state reporting.  The real test will be comparing the data, the data in future reports which will be published every six months.  At that point we can judge progress over time and determine whether or not central line-associated bloodstream infection prevention efforts are driving infections down.  As such I encourage us all to avoid comparing states but rather focus on enhancing prevention efforts to ensure the next report shows a continued decline in central line-associated bloodstream infections.  

Moving on to the report itself to most accurately summarizes  the central line-associated bloodstream infection experience at national and state levels, the report uses a measurement called the standardized infection ratio.  The calculation is simple.  It's the number of central line-associated bloodstream infections observed in any group, compared to the predicted number of central line-associated bloodstream infections.  This predicted number is based on the number of central line-associated bloodstream infections reported by healthcare facilities to the CDC’s National Healthcare Safety Networkfrom 2006 through 2008.  A standardized infection ratio of greater than one means that there were more infections observed than predicted, whereas a standardized infection ratio of less than one means that there were fewer infections observed than predicted.  However, I should note that a standardized infection ratio of one is not our ultimate goal.  As experience has shown us that central line-associated bloodstream infections can be reduced much farther.  

So what were the key findings?  The national standardized infection ratio calculation showed an 18 percent national decrease in central line-associated bloodstream infections during the first six months of 2009, compared to the previous three years.  We believe this decrease reflects broader implementation of CDC guidelines, enhanced tracking and measurement and improved practices at the local level by thousands of dedicated healthcare professionals.  This is a significant step forward in meeting the HHS prevention goals of a 50 percent five-year reduction in central line-associated bloodstream infections.  And reflects the work of facilities, local, state and federal government, and cross-cutting partnership groups that have taken on central line-associated bloodstream infection prevention efforts.  Indeed, CDC is working with state health departments, federal agencies such as the Agency for Healthcare Research and Quality, and the centers for Medicare and Medicaid services, professional organizations, consumer advocates, and partnership groups, including the “On-the-cusp, Stop VSI” collaborative to enhance national participation in central line-associated bloodstream infection prevention efforts.  The bottom line here is that this 18 percent reduction shows that care in hospitals is getting safer but we know there is more work to be done.  

On the state level, the predicted number is the same number used in the national calculation, but the observed number only includes infections reported from a certain state.  By June 30th of 2009, 17 states had mandates to report central line-associated bloodstream infections to CDC through the National Healthcare Safety Network.  Data from those 17 states are included in this first report.  Future reports will include all states.  You'll find specific information in tables one through three of the report, but in general, the majority of the states had a standardized infection ratio below one.  This is encouraging, and we look forward to even lower rates for all states and future reports.  I'd especially like to recognize those states that are participating in validation efforts, in essence, double-checking their data to ensure all appropriate infections are reported, funding provided to states through the American Recovery and Reinvestment Act is supporting efforts in several states to enhance validation of healthcare-associated infection data.  CDC looks forward to the day when data validation becomes a standard practice in all facilities participating in the National Healthcare Safety Network.  

In summary, this report is helping paint a picture of where things are going well, where we can do better, and where federal and state and local health agencies should direct prevention efforts.  While we are encouraged by the 18 percent national reduction, we know that the number of infections can be lower.  The good news is that the healthcare-associated infection prevention landscape is changing.  Today we have stronger momentum than ever in the form of political will, funding, use of existing prevention tools, public engagement, and surveillance to perform this work.  Investments from Recovery Act, federal requirements for state healthcare-associated infection prevention plans, which are now posted to CDC’s website and reporting elements of the Patient Protection and Affordable Care Act have made the prevention of healthcare-associated infections a high national priority.  We also know that it is going to take a team of federal and local public health of infection preventionists of epidemiologists of facility leadership, of providers and of consumers to reach our ultimate goal of eliminating healthcare-associated infections and making the healthcare system safer for patients and providers alike.  Thank you.  With that I’ll turn the call back to you, Dr. Wright.  

Don Wright: Thank you, Dr. Srinivasan.  Let me say we are honored to have four distinguished experts in the field of infection control and prevention with us today to make some additional remarks.  These individuals represent a few of our external partners that have been crucial to the overall effort to date.  Our first contributor is Dr. Neil Fishman.  Dr. Fishman is associate professor of medicine at the University of Pennsylvania Medical Center.  He serves as director of the Department of Healthcare Epidemiology Infection Prevention and Control, and currently serves as the president of the Society of Healthcare Epidemiologists of America.  Dr. Fishman?  

Neil Fishman: Dr. Wright, thanks for inviting me.  The information presented in the first state-specific report of healthcare-associated infections is an encouraging step in providing accurate and timely data to drive progress toward the elimination of healthcare-associated infections.  The benefits of using the National Healthcare Safety Network include the application of both standard definitions and standard data collection methods.  This standardization is critical for ensuring consistent and comparable information that gives all stakeholders an accurate representation of the national landscape of healthcare-associated infections.  Although we also recognize that it is important to ensure that this data is validated, the reported reduction in central line-associated bloodstream infections stands as a testimony to the return on investment that dedicated infection prevention teams can have for our healthcare systems.  Measuring the problem and our progress is not enough, however.  This data should inform and sharpen our focus on implementing the best infection prevention practices, but it is vigorous research that leads to better understanding of what works to prevent infections.  The Society for Healthcare Epidemiology, the Society for Healthcare Epidemiology of America, and its members, produced the science that informs effective interventions, and drives the checklists of the future.  The cycle of prevention is not complete without rapid translation of this evidence into action at every level within our healthcare institutions.  The Society for Healthcare Epidemiology of America is encouraged by the findings of this state report that clearly demonstrate positive progress.  We honor the decades of dedicated service by our members to achieve this goal, and look ahead to continued partnership with the Centers for Disease Control and Prevention, and groups like the Association of Professionals in Infection Control and Epidemiology to further the advancement toward our ultimate goal of eliminating healthcare-associated infections from our healthcare system.  Thank you.  

Don Wright: Thank you, Dr. Fishman.  Our next contributor is Dr. Peter Pronovost.  Dr. Pronovost is a practicing physician and researchers at Johns Hopkins University School of Medicine.  Dr. Pronovost is perhaps best known for his research, the Michigan Keystone Study which showed the utilization of a checklist markedly reduced the rates of bloodstream infection.  Dr. Pronovost?  

Peter Pronovost: Thank you very much, Dr. Wright.  31,000 people die annually from bloodstream infections in the U.S. And most can be prevented.  We've shown that initially at Johns Hopkins and then with funding from the Agency for Healthcare Research and Quality, our research team nearly eliminated these infections from over 100 Michigan intensive care units.  The intervention was cheap, involving a checklist of evidence-based practices developed by the CDC, robust measuring of infections, and improving teamwork among doctors and nurses.  The results have now persisted for over four years.  And others have achieved similar results.  With funding from the Agency for Healthcare Research and Quality, we are working now the American Hospital Association and the Michigan Health and Hospital Association to implement the Michigan program state by state across all 50 states.  The program is called "On-the-cusp, Stop Bloodstream Infections."  Thus far, 33 states have committed to participate and over 600 hospitals are actively engaged, and we are seeing amazing results.  All of the hospitals in Rhode Island, 94 percent in Hawaii, and approximately half of New Jersey and Georgia have virtually replicated these Michigan results.

Today marks a turning point in transparency and accountability for healthcare.  We now must begin to be responsible for our outcomes and no doubt these data will make some uncomfortable.  We need to learn how to be accountable, to make progress we will need to collaborate and coordinated by the Health and Human Services, we now have federal and state agencies.  We have professional societies and individual hospitals.  We have consumer groups and employers, and we have regulators and insurers all working together to ultimately eliminate these infections.  Yet in the end, it's clinicians who must use the best practices and healthcare leaders who must be accountable for their infections.  So here is a simple checklist for what you can do.  Join your statewide efforts to reduce these infections, if you haven't done so.  Create an interdisciplinary team in each area that uses catheters, monitor and report your infection rates, ensure that supplies to comply with the checklist are readily available, empower nurses to stop the placement of a catheter if the physicians don't comply with the checklist.  Audit your catheter maintenance and investigate every infection as if it's a defect.  Central line-associated bloodstream infections are the polio campaign for the 21st century.  Working together, following this checklist, we can substantially reduce these infections.  We've seen what is possible.  We have prevented infections and we've saved lives.  Now we must spread it across our great country and now we must begin to be accountable for our outcomes.  

Don Wright: Thank you, Dr. Pronovost.  Our next contributor is Mr. Russell Olmsted.  Mr. Olmsted is an epidemiologist at St. Joseph's Mercy Hospital in Ann Arbor, Michigan, who is an active member of the Association of Professionals in Infection Control, and serves as associate editor of the American Journal of Infection Control. Mr. Olmsted?  

Russell Olmsted: Thank you, Dr. Wright, and Dr. Srinivasan for this opportunity to participate in this press briefing.  On behalf of president Catherine Murphy, the board of directors and the members of the Association for Professionals in Infection Control and Epidemiology or APIC, I am very pleased to acknowledge and thank the CDC, Centers for Disease Control and Prevention and Health and Human Services on the release of this important report on state-specific healthcare-associated infection data.  The Association for Professionals and Infection Control and Epidemiology's 13,000 infection preventionists are healthcare professionals with primary responsibility for protecting patients from healthcare-associated infections.  Our members rely on accurate data to guide prevention efforts, and educate front line teams on best practices.  The foundation for criteria to identify healthcare-associated infection and methods of surveillance are based on valid and reproducible standards developed by the Centers for Disease Control and Prevention's National Healthcare Safety Network or NHSN.  National Healthcare Safety Network is recognized as the benchmark not only here in the U.S. but worldwide for developing surveillance methods for identification and reporting of healthcare-associated infections.  

The positive findings from this initial report are gratifying and reflect the collaboration between infection preventionists and their direct care colleagues at their affiliated facilities who bring evidence-based infection prevention interventions to the patient's bedside, where central lines are placed.  These interventions are drawn from scientific evidence and recommendations that are published by the Centers for Disease Control and Prevention's Healthcare Infection Control Practices Advisory Committee.  The Association for Professionals and Infection Control and Epidemiology and its members believe this is a landmark report that demonstrates infection preventionists, healthcare epidemiologists and direct care providers can join forces to improve patient safety.  We welcome the release of the important findings contained in this report as well as commend the leadership of Dr. Donald Wright at HHS, or Health and Human Services, and Denise E. Cardo and the Division for Healthcare Quality and Promotion at the Centers for Disease Control and Prevention.  We feel this report furthers our goal for greater transparency within healthcare and ultimately lead us toward the elimination of healthcare-associated infections and prevention.  Thank you very much.  

Don Wright: Thank you, Mr. Olmsted.  Our last contributor is Miss Rachel Stricof, epidemiologist of the New York State Department of Health.  She serves as assistant professor at the state university of New York where she directs courses in infection disease epidemiology.  Miss Stricof?  

Rachel Stricof: Thank you, Dr. Wright.  This report is the first to provide a transparent view of one type of healthcare-associated infection by state.  Previous estimates of the incidence of healthcare-associated infections were to be relied on by administrative data obtained for another purpose and not using validated methods or having used the National Healthcare Safety Network data, but derived from a relatively small, select group of hospitals, those first using the National Healthcare Safety Network, and it was a predominantly comprised of academic medical centers and large community hospitals.  For the first time, the states, the public, and federal partners are able to review data from a much more representative group of hospitals within states and across the country.  And the representativeness of the data is growing exponentially as more states elect to use the National Healthcare Safety Network for public reporting purposes.  With the National Healthcare Safety Network, hospitals are using the same standard definitions, surveillance methods, and system to report.  For state reporting, that was not always the case.  At the time, New York state healthcare-associated infection reporting legislation was passed, seven other states had passed legislation, three were already collecting data, and all three were using different definitions and reporting system.  One state had published their data and clearly provided or misrepresented the incidence of healthcare-associated infections by using administrative data, where, upon further evaluation by infection preventionists, it was found only 10 percent to 20 percent of the reported infections actually met the criteria confirming healthcare-associated.  

New York state was the first to elect to use the National Healthcare Safety Network for mandatory public reporting of healthcare-associated infections for the reasons stated above, but also because the National Healthcare Safety Network had a reputation and history of providing credible data, the definitions and surveillance methods had been used across the country and internationally.  The system could be used by healthcare networks that cross state lines and very importantly, it provides by directional flow of information that can immediately be used by the hospitals themselves for monitoring interventions and for quality improvement purposes.  Because the National Healthcare Safety Network is an established national system, it makes the best use of limited state and local resources.  The New York state legislation was also very clear and prescribed an audit process to ensure that the data we reported to the public would be accurate and reliable.  The Department of Health was given not only the responsibility but the resources to ensure the completeness and accuracy of self-reported hospital data, experienced infection preventionists were hired and dedicated to monitor compliance, to audit the hospital data, but also to evaluate risk factors for infection, and conducted surveys for prevention activities.  It would not be surprising to find that states with strong auditing and validation programs have higher reported infection rates, at least in the short term.  We need to keep in mind, though, that it is not enough to count infections.  Through the American Recovery and Reinvestment Act funding, many states have been given the tools and dedicated resources to work with individual facilities and multidisciplinary groups to prevent infections, to improve the quality of care, and to enhance patient safety.  So as we systematically embark on this public health effort to monitor and reduce healthcare-associated infections with this first step, this first report focusing on central line-associated bloodstream infections, we all realize that there is so much more that needs to be done to address the full spectrum of healthcare-associated infection.  Thank you.  

Don Wright: Thank you, Miss Stricof.  I want to take just a moment to thank all four of our presenters for their remarks, for their participation in today's media briefing and most of all for their partnership in this important effort.  We believe that in order to be successful, a coordinated, complimentary effort is required.  In reality, a national coalition to reduce the burden attributed to healthcare-associated infections and to achieve the action plan elimination goals.  We are grateful for efforts across the country to address this issue so decisively and look forward to future iterations of this report showing additional progress.  As part of my role as the deputy assistant secretary for healthcare quality, we intend to use a coordinated data driven approach to prevent healthcare-associated infections as a model for addressing other preventable harms.  Our intent is to spur improvements in patient safety and in the broader realm of health quality.  Without question, reliable validated data is needed to track progress and inform ongoing efforts.  We need data for continued action.  Let me also say the states should specifically be commended today for their efforts to device and implement state-specific strategies to eliminate healthcare-associated infections.  

Earlier this year, state action plans from all 50 states from the District of Columbia and from Puerto rice were submitted to the secretary.  Each state completed a plan despite enumerable competing priorities.  Clearly this is a testament to the importance of this issue.  As was reported today, we've seen gains made in reducing healthcare-associated infections in acute care hospitals, and as we continue to implement the initial action plan focused on hospitals, the department is moving forward and is targeting improvements in other settings.  We are drafting strategies to improve infection control practices and reduce healthcare-associated infections in ambulatory surgical centers and in dialysis centers.  These reports will be released later this summer, after a public comment period.  While the data presented today represents a great step forward in our overall efforts, we acknowledge that more work needs to be done.  We urge all states, healthcare facilities and individuals, to strengthen efforts to prevent central line-associated bloodstream infections as well as all healthcare-associated infections.  It's through effective partnerships that we can accelerate national progress to achieving the action plan goal of a 50 percent reduction in central line-associated bloodstream infections that is a .50 standardized infection ratio by the end of 2013.  Thank you very much and at this point I’ll turn the, turn over to Mr. Quimby from the CDC.  

Joe Quimby: Thank you very much, doctor.  Joe Quimby again.  Before we get into questions, I would like to explain to reporters that due to the nature and the volume of subject matter experts, we will allow a primary question, if you would, from reporters, and a follow-up each.  Operator, over to you.  

Operator: Thank you.  At this time if you would like to ask a question, please press star followed by one on your touch tone phone.  Will you be prompted to record your name.  To withdraw a request press star followed by two.  Our first question from Mike Stobbe with Associated Press.  Your line is now open.  

Mike Stobbe: Hi, thank you all.  Thank you for taking the question.  I do have a follow-up coming in a minute.  The first one, though, is Arjun talked about the 18 percent national decrease.  I was wondering if you all could put that in context with the Burton JAMA study last year and others that have shown a decrease, this 18 percent, are we seeing an acceleration of the decrease or is the decrease kind of trending steadily?  What's going on there?  

Joe Quimby: I’d like to -- this is Joe Quimby.  I'd like to introduce one of the authors of the study to go into the details of that question with you, Mike.  I'll let him introduce himself.  

Scott Fridkin: This is Dr. Scott Fridkin, F, as in Frank, R-I-D-K-I-N.  Deputy Chief of the surveillance branch in the Division of Healthcare Quality Promotion here at CDC.  That 18 percent decrease represents a very comprehensive view of the reduction in central line-associated BSI’s from all facilities reporting data to NHSN.  It is consistent with some of the previous historical looks over the past decade at reduction of these types of infections from facilities that have been reporting to the National Healthcare Safety Network.  And that is very reassuring.  The unique aspect of this perspective is as Rachel Stricof mentioned earlier, these data involve a much larger number of facilities of much larger and diverse types than had been included in previous estimates looking at trends over time, because of the different nature of facilities reporting to the National Healthcare Safety Network, because of state-based mandates and other increased and awareness and participation.  

Joe Quimby: Thank you very much.  Mike, what's your second question?  

Mike Stobbe: It was about transparency.  I just wanted to make sure I understood a couple of speakers that talked about this report's importance in terms of turning point and transparency and accountability.  But the report's not actually naming specific hospitals and what their rates are.  I'm thinking many readers would think of transparent as naming the hospital so they can hospital shop so to speak.  When you talked about transparency, what do you mean exactly and is that data hospital-specific data available somewhere else or is that one of the reports that's coming this summer?  

Joe Quimby: Rachel, is that a question that is best for you?  

Rachel Stricof: Well, I can say that those states that do mandate reporting are publishing the hospital-specific rates.  I will say that in New York, I don't think you'll ever be seeing that data in as small an interval as a six-month interval.  In order for us to have any stability or any assurance in the validity of the data by hospital, we need at least a year's worth of data to be able to provide that, so our reports are put out on an annual basis and we do publish the reports and we will be putting out an annual report each year, so we can compare and trend the hospital data over time and give you the hospital specific rates.  I believe only a handful of the states thus far have published their rates, but you will see more and more doing so as we collect a sufficient amount of data to make the information reliable.  

Joe Quimby: Rachel, thank you.  Arjun has something he'd like to add.  

Arjun Srinivasan: Just to reiterate the point Rachel just made that several states are moving in this direction, and on the websites for several states that have these reporting mandates, some of them are now beginning to include the facility-specific information as Rachel is describing.  

Joe Quimby: Thank you, Arjun.  Next question, please.  

Operator: Our next question is from Daniel DeNoon with WebMD.  Your line is now open.  

Daniel DeNoon: Thank you very much.  I have two related questions and give them both to you at the same time.  Earlier this year we saw a report in Annals of Internal Medicine based on administrative data that there were 48,000 Americans dying of hospital-acquired infections each year.  Is this a closer look, nearly 100,000 number twice as many cases a more accurate reading of the number of deaths overall we're seeing, and my second related question is, aren't we just getting a rosy picture from the hospital as they're choosing to report once we drill down, are the problem hospitals the ones that are not reporting?  Thank you.  

Arjun Srinivasan: Those are good questions.  I think it's important to note that these estimates of the number of healthcare-associated infections provide a range of estimates, and so the actual number falls somewhere along a range.  You'll see information reported from a variety of different sources on what that range is.  It's important, though, to look at the source of the information, as we've heard during this call, there are some important differences between the different sources of information that people use to gather information on healthcare-associated infections, and as has been pointed out on this call, administrative discharge data was not developed for the purpose of monitoring and tracking healthcare-associated infections, and so fundamentally, we believe that the gold standard for monitoring and tracking healthcare-associated infections are system-centered designs specifically to do that.  To your other question about whether or not these are sort of selected hospitals, I think the answer is no, that in the states with mandates, the different states have different mandates but the mandates broadly cover healthcare facilities, so in these, in this information on the state-specific reports, those are states that have mandates, there's not an option for whether or not facilities are going to contribute information there.  So specifically, especially in those states, you can see that there is no ability to be selected.  These decreases that we're seeing are across the board, and they represent all the facilities that are covered under these mandates very broadly.  

Joe Quimby: And for clarification for reporters out there, that was Dr. Arjun Srinivasan speaking.  Next question, please.  

Operator: Next question Judith Graham with the Chicago Tribune. Your line is now open.  

 

Judith Graham: Given the importance of hospital-acquired infections which you all have stressed repeatedly, why are these infections still not -- why is mandatory reporting of infections not required by the government?  Even in this case you only have 17 states.  The vast majority of the states are not reporting.  Is there any movement along these lines on the part of the government to make reporting mandatory as it is for many other medical conditions that are of concern?  

Joe Quimby: Dr. Wright, do you have something you might want to add on that?  

Don Wright: Thank you, Mr. Quimby.  What I will point out is that there is an increasing trend towards public reporting.  Over the last two years, we've seen the number of states requiring mandatory reporting move from 13 to 20 to 27 states requiring mandatory reporting.  Not all states require the use of National Healthcare Safety Network, but certainly there is an increasing trend and we expect that trend will continue to encourage public reporting at the state level.  

Judith Graham: A technical follow-up question.  For the state numbers, is the SRI calculated, sorry, I didn't quite get this one, you said using the state experience only as the expected number or is that the, is the expected number based on the national experience?  

Don Wright:  I’m sorry; you're referring to the state-specific information?  

Judith Graham: Yes, exactly.  

Don Wright:  Yes, it's based on the predicted number within that individual state.  

Judith Graham: Okay, thank you.  

Joe Quimby: Arjun had something to add to the first question.  

Arjun Srinivasan: To clarify the predicted number of infections based upon the reference period, 2006 to 2008 information, and in follow-up to what Dr. Wright was saying, you know, CDC does believe that increased transparency, public reporting of healthcare-associated infections is an important part of a comprehensive effort to prevent healthcare-associated infections and eliminate these infections and we are working very closely with states that either have laws or are considering laws to help them implement these.  

Joe Quimby:  Thank you, doctor.  Next question, please.  

Operator: Thank you as a reminder for any further questions or comments, please press star one.  Our next question is from Rebecca Volker with JAMA.  Your line is open.  

Rebecca Volker: Yes I’m looking at your state specific data here and it looks like at the top of the pack and doing best according to the SIR is Vermont and at the opposite end of the pole is Maryland.  I'm wondering if you could talk about maybe a few specifics on what those two states are doing that put them in that position, and as a second question, central line infections are not kind of newly known as a big healthcare problem, and so why do you think it has taken this long to get to this point?  

Arjun Srinivasan: So to your first question, you know, we view this information most importantly as being data for action and this information has been, of course, shared with public health officials, in all of the states, in states that have lower SIR’s, we're encouraging them to look at their facilities and try to understand how those facilities have gotten there.  In states that have higher SIR’s, we're encouraging them to go to their facilities, try to figure out why the SIR’s are higher.  The specifics on what the different states are doing is I think the next step for people, how people will use this report.  The other factor there, of course, is also to mention that some of the states in Maryland included does conduct validation and so it's possible that they have efforts that are more comprehensive in terms of looking for these types of infections, so that's an important factor to keep in mind as well.  In terms of, you know, why we've seen so much of these decreases recently it's important to note and this was something that was demonstrated in a paper that was published in the Journal of the American Medical Association a couple of years ago that we have been seeing decreases in central line-associated bloodstream infections for several years.  So I think we've seen a lot more effort and more involvement in efforts to prevent central line-associated bloodstream infections in the last couple of years and there's been more attention to this issue, but it is important to note that healthcare providers and other groups have been working on this issue for quite some time, and we have been seeing decreases for quite some time.  

Joe Quimby: We have time for one more question, please.  

Operator: Thank you our final question is from Maureen McKinney with Modern Healthcare magazine.  Your line is now open.  

Maureen McKinney: Thanks so much for taking my question.  I just wanted to know a little bit more about the states that are doing validation, what that entails and if there's move from other states to go in that direction as well.  

Joe Quimby: Rachel, do you want to offer something at this point?  

Rachel Stricof: Well, yes.  We actually have multiple stages in our validation process, and I do know that Tennessee and Maryland have been, and South Carolina to some extent have been following what we've been doing.  They've asked for all of our protocols.  So we, one, check the data that comes in to make sure that things, that the information that has been reported looks accurate, but then we go out and visit hospitals and randomly select records to review.  If we identify any problems, we intensively look, more intensively look in the facility and continue to review records.  We may ask facilities if it appears to be a systematic error that they're making, they may have to go back and re-review all their data for a year and we may be right in there with them, so we take a very aggressive role in ensuring that hospitals are completely and accurately reporting.  

Arjun Srinivasan:  This is Arjun Srinivasan.  At the national level, we indeed are seeing an expansion of efforts to validate data being submitted to the National Healthcare Safety Network, and in fact, a number of states submitted requests for and were provided funding through the American Recovery and Reinvestment Act specifically to enhance their ability to validate data they're submitting to the National Healthcare Safety Network.  

Joe Quimby: Great.  At this point I’d like to thank all of our participants who spoke today, and for everyone's time and attention to this very important issue, who have joined us on the telephone call.  As a reminder, we will have an audio mp3 available along with a written transcript at the CDC press office site at www.cdc.gov, and in the press room you'll find that.  That will be available in about two to three hours, and thank you all very much for calling in, and be safe.  Have a good day.  

Operator: Thank you; this does conclude today's conference.  Thank you for participating.  You may disconnect at this time.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES