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Telebriefing Transcript
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 today.

On this call we're going to discuss CDC's Healthcare Infection Control Practices Advisory Committee's guidance to states on public reporting of healthcare-associated infections.

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 release.

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 years.

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 established methods.

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 follows:

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 document.

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 healthcare-associated infections.

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 data.

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 Infection Control.

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 regard.

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 listeners?

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 Orlando Sentinel.

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 site infections.

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 available.

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 efficient?

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 Atlanta Journal-Constitution.

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 that correct?

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 Augusta Chronicle.

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.

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 there.

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 challenge.

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 remarks.

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 this effort.

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.

Listen to the telebriefing

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