CDC Advisory Committee Offers Guidance to States on Developing
Systems for Public Reporting of Healthcare-Associated Infections
February 28, 2005
MS. COFFIN: Good afternoon, everyone. My name is Nicole Coffin, I'm with
the Centers for Disease Control and Prevention. Thank you for joining us
On this call we're going to discuss CDC's Healthcare Infection Control
Practices Advisory Committee's guidance to states on public reporting of
The full copy of the guidance document is going to be able to be found at
CDC's website. The URL specifically can be found at the bottom of the press
The embargo on this document lifted at the start of this telebriefing and
also let me add that after the telebriefing, if you want any additional
information or if you have additional follow-up questions, please feel free
to contact our Office of Communications. That number is (404)639-3286. One
more time, that number is (404)639-3286.
And now before we begin discussing the guidance, I'd like to take a moment
and introduce our speakers.
Dr. Denise Cardo is the director of CDC's Division of Healthcare Quality
Promotion and she will be speaking about CDC's role on this issue.
Dr. Patrick J. Brennan is the chair of CDC's Healthcare Infection Control
Practices Advisory Committee, also known as HICPAC. And he will be talking
about the recommendation of the committee itself.
Kathleen Meehan Arias is the president-elect of the Association for
Professionals in Infection Control and Epidemiology, and she'll be talking
about a meeting that occurred two weeks ago in Atlanta on this issue as well
as explaining a little bit about the role of infection control professionals
related to this issue.
With that, let us begin. Dr. Cardo.
DR. CARDO: Good afternoon. CDC believes that preventing
healthcare-associated infections is a critical component of patient safety
and an important public health issue. CDC has been a national leader for
surveillance and prevention of healthcare-associated infections for many
Some states that were considering the public release of
healthcare-associated infection data have contacted CDC for guidance.
As a result, CDC asked the Healthcare Infection Control Practices Advisory
Committee, or HICPAC, to look at this issue and provide guidance to states
interested in making information on healthcare-associated infections
available to the public.
We, at CDC, applaud HICPAC for taking on this issue and for working so
quickly to put together this very important guidance document.
We also want to thank the professional organizations that have contributed
to and endorsed this document -- The Association for Professionals in
Infection Control and Epidemiology, or APIC, the Council of State and
Territorial Epidemiologists, or CSTE, and the Society for Healthcare
Epidemiology of America, or SHEA.
DR. BRENNAN: Good afternoon. My name is Patrick J. Brennan and I'm the
chair of HICPAC. HICPAC began to explore this issue just about one year ago
and went through the process that is HICPAC's norm, which is to explore the
evidence in an area of interest and then taking that evidence, produce the
most useful guidance available.
In the exploration of this topic, we discovered that there is insufficient
evidence to recommend for or against public reporting of
healthcare-associated infections. Nonetheless, we realize that this is a
process that is going forward. While we have not made a recommendation for or
against these processes, we are providing our consensus opinion on the best
way to pursue the public disclosure of healthcare-associated infections.
This document then is a guide to best practices. It is the consensus
opinion of HICPAC and we believe it is a starting point in the process of
public disclosure for healthcare-associated infections. We have not put
forward this document as model legislation.
Our intended audience is the policy makers, program planners and consumer
advocacy organizations who are tasked with planning and implementing the
public reporting systems for healthcare-associated infections.
As background on the document, I will tell you that we advocate the
specification of goals, objectives and priorities as a starting point in
developing these systems, the selection of measurable outcomes and the use of
The reports that are generated should identify the endorsers of the
indicators that are chosen and the sources of data, and we believe that tools
such as public disclosure report cards should be useful processes for quality
improvement and that that can be accomplished through feedback to the
providers who really generate this data.
There are four major recommendations in the document and they are as
First, use established public health surveillance methods when designing
and implementing mandatory reporting of healthcare-associated infections.
This means the selection of appropriate patient populations to monitor, the
use of standardized case-finding methods and data validity checks, and
importantly, the provision of adequate support and resources within
organizations so that these processes can be carefully carried out. We do not
advocate the use of hospital discharge diagnostic codes as a primary data
source for healthcare-associated public reporting systems.
Our second recommendation is to create a multidisciplinary advisory panel
and include persons with expertise in prevention and control of
healthcare-associated infections in the planning and oversight of these
public reporting systems.
We believe that there are many stakeholders in these processes.
Controversies have existed over the methods but the methods are important in
determining the outcomes of these processes. Since there are many
stakeholders, the development process should be a multidisciplinary one.
The third recommendation is to choose appropriate process and outcome
measures based on facility type.
We believe these indicators should be phased in over time and this will
maximize the usefulness of these indicators to consumers and the
acceptability to providers.
We have recommended three process measures and two outcome measures. The
process measures include the practices used to insert central venous
catheters that can lead to bloodstream infections, antimicrobial prophylaxis
for surgical procedures, and influenza vaccination coverage for both
healthcare workers and for patients.
The outcome measures that we are recommending include central line
associated laboratory-confirmed bloodstream infections and surgical site
infections, though there is a synergy or a linkage between the process
measures and the outcome measures and those are the major points in the
MS. MEEHAN ARIAS: The consensus conference that the Association for
Professionals in Infection Control and Epidemiology convened earlier this
month, was set up to provide a forum for various key stakeholders so that
they could present their perspectives on public reporting of
The goal of the conference was to create a foundation for developing a
system of measurement that's accurate, meaningful and consistent nationwide
and the conference provided an opportunity to explore the essential elements
that are needed to develop an effective public reporting system and these are
basically the elements that are discussed in the new HICPAC guidelines.
The consensus conference allowed the attendees to gain insight from the
lessons learned from our colleagues in the four states that have passed
legislation already, that require public reporting on hospital infection
This issue is important for APIC because our goal is to reduce
healthcare-associated infections to an irreducible minimum. APIC is an
organization that represents more than 10,000 infection control professionals
and infection control professionals manage the infection prevention programs
in hospitals and other healthcare facilities. And one of their
responsibilities is to collect data on healthcare-associated infections. So
they have expertise in doing this and are well aware that
healthcare-associated infections are difficult to manage.
Because many states have introduced legislation already requiring public
reporting of healthcare-associated infections, infection control
professionals have been working with legislators, hospital associations,
health departments and others at the state level to develop public reporting
programs that will provide meaningful information.
MS. COFFIN: We can open it up for questions at this time.
OPERATOR: Thank you, and at this time, if you would like to ask a question
please press star one on your touchtone phone. To withdraw your request, you
may press star two. Once again, to ask a question, please press star one.
Thank you. Our first question comes from Gary Evans, editor of Hospital
QUESTION: Hi. Dr. Brennan, you may have already answered this when you
said this was not a template for legislation. I just wanted to know, to
clarify though, is there any effort underway to take this to a national or
federal regulatory agency, so there would be standardized national
requirements rather than individual state laws that may vary?
DR. BRENNAN: Gary, there is a desire to have a national standard on this
and there was a great deal of discussion about that at the APIC conference in
Atlanta earlier this month.
At that conference, there was an expression of interest from the National
Quality Forum to help establish such a standard, and I think the professional
societies, including APIC and the Society for Healthcare Epidemiology of
America as well as HICPAC and DHQP have a strong desire to see that go
forward and a willingness to work with any appropriate agencies in that
QUESTION: I had one quick follow-up question, if I could. I'm still
wondering if this effort doesn't create some kind of disincentives, though,
to track and report every infection.
For example, would a hospital that does not aggressively track its
post-discharge surgical infections appear to be better quality-wise than a
hospital that made every effort to find every infection?
DR. BRENNAN: We acknowledge the potential adverse consequences of public
reporting systems in the document. The possibility exists that there could be
adverse selection of patients as a result of public disclosure. We would
certainly hope that that would not happen and that there would be appropriate
prohibitions and consequences for such actions. But I think that this process
is no different than any other public disclosure process in that regard.
Adverse selection could be a consequence of report cards on heart bypass
surgery, for example.
MS. COFFIN: Could you explain what you mean by adverse selection to the
DR. BRENNAN: Adverse selection would be the selection of less complex and
lower-risk patients for the purpose of ensuring that better outcomes would be
reported in the public disclosure process.
OPERATOR: Thank you. Our next question comes from Robyn Shelton with the
QUESTION: Hi. Could you please explain again the outcome-based measures
that you are recommending? I didn't quite understand that.
DR. BRENNAN: Sure. The outcome-based measures are linked to the process
measures and the outcome measures that we're advocating are central venous
catheter-associated laboratory-confirmed bloodstream infections, and surgical
Central venous catheters are plastic tubes that are inserted into the
large veins in a patient, usually in the chest or neck, for the purpose of
infusing drugs and nutrition and they provide a conduit from the external
environment to the internal environment of the patient, whereby bacteria can
infect the bloodstream.
These are recognized as perhaps the most common cause of bloodstream
infections in hospitalized patients, and so we are advocating that that--and
by the way, these have very high associated morbidity, mortality and cost. So
we're advocating that this be one of the outcome measures. It is easily
confirmed by a blood culture, so we're recommending that there be a
laboratory confirmation component to this outcome measure.
The linkage into the process measure is in central line insertion
practices. Central line insertion practices have been identified, that can
reduce the incidence of these infections, and they include the use of proper
skin antiseptics and the proper draping of the patient.
The second outcome measure is surgical site infection. That requires the
monitoring of the patient after surgery to determine, using appropriate
definitions, whether an infection has developed at the surgical site and
there are well-established practices and process measures that are known to
reduce the incidence of surgical site infections.
We're not advocating for the monitoring of all surgical sites,
post-operatively. This is a challenging outcome measure because at least half
of all surgical site infections occur after the patient has been discharged
from the hospital.
So in developing these systems, careful thought will have to be given to
which types of surgery can be adequately tracked by the means currently
OPERATOR: Thank you. Our next question comes from Martin Sipkoff with
Drugs Topics Magazine.
QUESTION: Yes. My question is a fairly general one. What is the proper
role of health system pharmacists in the guidelines that you've been
describing? What can they do to make this process that you described more
DR. BRENNAN: Well, in the process measure on surgical antimicrobial
prophylaxis, I think that health system pharmacists could play an important
role in identifying whether the proper drug has been selected, whether the
drug has been administered in a timely fashion, which should be within an
hour of the skin incision that starts the surgery, and whether the drug is
stopped in a timely fashion, which ought to be 24 hours at the latest after
the completion of the surgery.
So I think pharmacists can play an important role in establishing that as
a standard within an organization and monitoring the appropriate use of the
drug within the parameters that I described.
OPERATOR: Thank you. Our next question comes from David Wahlberg with the
QUESTION: Hi; thank you very much. I think one of you said that four
states have passed laws requiring this kind of disclosure. Could you confirm
that and tell me which states those are and do you have any rough idea, how
many states have introduced this kind of legislation?
And again, these are guidelines but they're not sort of a national
guideline. Can you explain that again?
DR. CARDO: To date, four states have passed laws requiring hospitals to
publicly report healthcare-associated infections and they are Illinois,
Pennsylvania, Missouri and Florida.
And we also are aware of an additional 30 states who are moving toward
mandatory public release of this information.
MS. COFFIN: Could you repeat your follow-up question?
QUESTION: Yeah. I guess I'm just trying to better understand the weight of
these guidelines. They are not to be taken as a national policy yet but
they're suggestions for hospitals as they implement their own guidelines? Is
DR. BRENNAN: Well, what we're hoping is that the--this guideline has
been--this guidance document has been written in a different way than the
others that HICPAC has written in the past.
The intended audience for past guidelines has been the professional
community, physicians, epidemiologists, infection control professionals and
clinicians. The intended audience for this document are those who are tasked
with designing and implementing these systems.
We hope that the professional community will serve as the conduit for this
information as states and regulators attempt to design and implement these
systems. But it does not establish a national policy on it. HICPAC's guidance
documents in the past have been highly regarded and have been relied upon as
a standard in the industry and we're hoping that this one can be adopted in
the same way.
DR. CARDO: I think it's important to note that this is the first step in
the process to really work together to collect information that can lead not
just to release to the public, for the public to make decisions, but also to
the healthcare institutions to prevent infection.
OPERATOR: Thank you. Our next question comes from Tom Corwin with the
QUESTION: Thanks for taking this. I notice in the process indicators that
you want to include vaccination levels and the antibiotic prophylaxis for
surgery, and I know that those levels are fairly low for compliance. I think
healthcare workers have been rated around 40 to 60 percent and get the
influenza vaccination and the surgical prophylaxis has been found to be about
55 percent. Was that the reason for including those in these recommendations?
DR. BRENNAN: Well, we considered a number of different indicators and
these were chosen, in part, for their significance, that's correct, and in
part because the guidelines are very clear in these areas and unambiguous.
But, you know, I think your point is right on target. These are very
important in terms of prevention activities, and, after all, that's what we
want to get to, prevention. So your point is right on target.
OPERATOR: Thank you. Once again, as a reminder, if you would like to ask a
question, please press star followed by one.
Thank you. Our next question comes from Gary Evans. You may ask your
QUESTION: Yeah. This is a question for Ms. Arias. Can you give me some
information on what you're hearing from infection control professionals about
the resources they have to do these reporting requirements in the states that
have enacted laws or are considering them?
MS. MEEHAN ARIAS: Yes. Some of the states have actually conducted studies
of infection control programs in hospitals, specifically, and they have found
that some of the hospitals are going to have a hard time collecting some of
the data that's currently proposed, just because the resources may be not
The resources aren't necessarily just personnel resources, some of the
resources that we need are technology, hardware and software programs that
allow the data to be collected and accurately reported to the public.
OPERATOR: At this time we have no further questions.
MS. COFFIN: Dr. Brennan was about to say something.
DR. BRENNAN: Well I wanted to follow up on Gary Evans' question and say
that we don't, in a very specific way, address resources in the guidance
document but that is clearly a very important issue.
We do indicate that the right resources need to be in place if public
disclosure is to be carried out properly but the resources may include
additional full-time equivalent employees in the infection control
professional category or the proper information system resources.
But resources are essential, and in fact I think the states that have
implemented so far have really done this with the intention of raising the
profile of this issue, raising the profile of infection control and
prevention in hospitals and are really sending a challenge out to
organizations and to their leadership to step forward and meet this
OPERATOR: Thank you. We have no further questions at this time.
MS. COFFIN: Okay. I'm going to turn it over to Dr. Cardo for some closing
DR. CARDO: I want to thank you for joining us this afternoon. As I said
before, CDC believes that information about healthcare-associated infections
can lead to increased focus on infection control and prevention. We believe
that tracking the processes that lead to infections, in addition to infection
rates, can improve patient safety, and we're very pleased with the HICPAC
guidelines and the fact that the professional organizations have joined us in
And we want to remind that the information that we recommend to be
collected has to be useful for the public but also be useful for the facility
in order to improve the quality of health they are providing to all the
patients in the healthcare systems in United States.
MS. COFFIN: All right. Thank you for joining us. If you have any
additional questions or follow-up, you can call the CDC's Office of
Communications. Also if you'd like to take some more time to look at the
document, it can be found through the URL at the end of the press release.
Thank you for joining us.
OPERATOR: Thank you. This concludes the CDC media conference. We thank you
for your participation.
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