Ambitious HHS action plan may be a landmark development for hospital infection prevention
Sets stage for CMS to put 'teeth'into CDC guidelines
The U.S. Department of Health and Human Services (HHS) has developed a sweeping national "Action Plan to Prevent Healthcare-Associated Infections" that not only brings its considerable influence to bear on a longstanding problem, but also calls on hospital leadership, infection preventionists, clinicians, and even patients to help solve it.
"We want to create a culture of safety within hospitals that is just the normal way of doing business," says Don Wright, MD, MPH, principal deputy assistant secretary for health at the HHS. "Hospital employees have a huge role to play but also hospital patients do as well."
In a time of competing priorities and political transition it's a fair question to ask whether the HHS plan will be sufficiently funded and implemented to the degree necessary to have a major impact on HAIs. They are an entrenched, complex problem that results in some 2 million infections and 100,000 patient deaths annually. But in dire economic times, nothing may speak louder than money. "In addition to the substantial human suffering exacted by HAIs, the financial burden attributable to these infections is staggering," the HHS plan states.1 In that regard, the HHS estimates that HAIs incur nearly $20 billion in excess health care costs each year. Health care charges for Staphylococcus aureus bloodstream infections for Medicare patients exceeded $2.5 billion in 2005, the HHS adds.
At any rate, combining the vast resources and expertise of the HHS member agencies — which include the Centers for Disease Control and Prevention, the National Institutes of Health (NIH), the Agency for Healthcare Research and Quality (AHRQ), the Food and Drug Administration, and the Centers for Medicare & Medicaid Services (CMS) — into a single infection prevention plan is completely unprecedented.
"The various operating divisions in the HHS all have significant roles to play in the reduction of HAIs, from CDC and their prevention guidelines to AHRQ and the research that they bring to the table, to the NIH, to FDA and those of us here in the office of public health and science, Wright says. "This was an opportunity to bring all the important HHS stakeholders to the table and really attempt to coordinate our activities in a way that would maximize the impact."
Infection preventionists and hospital epidemiologists must play key roles, of course, but the scope of the plan underscores the "shared responsibility" of preventing HAIs, says Wright, who chairs the HHS Steering Commission for Prevention of Healthcare Associated Infections, which produced the action plan.
"The readers of your periodical have a very important role to play," he tells Hospital Infection Control & Prevention. "We also think the consumers have a role to play as well. There are some great prevention guidelines out there but it is going to be important that those recommendations are actually translated into bedside care. We firmly believe for us to be successful in reducing health care-associated infections on a nationwide basis that it is going to have to be a shared responsibility."
The plan establishes five-year goals and metrics to determine progress in reducing four categories of infection and two specific organisms: Clostridium difficile and methicillin-resistant S. aureus (MRSA). (See chart, plan highlights.) Concerning the latter, the goals include reducing MRSA by 50% in five years. While that would be a monumental accomplishment, the HHS will no doubt draw fire for returning to benchmark ranges in an age of "zero tolerance" for infections and dramatic results by some programs who have undertaken such approaches.
"All infection preventionists have as their ultimate goal eliminating HAIs," Wright says. "We do believe they are largely preventable. What we wanted to do by establishing the goals was to set some benchmarks that would grade our progress. We felt the benchmarks that we set are going to be a challenge but are doable over the next five years. It's what we are going to look at to judge our success on an ongoing basis."
The four categories of infections — which account for approximately three-quarters of HAIs in the acute care hospital setting — are surgical site infections; central line-associated bloodstream infections; ventilator-associated pneumonia, and catheter-associated urinary tract infections. The HHS has rounded up the "usual suspects" often targeted in HAI reduction efforts, but this plan has the potential to elevate infection prevention to a new level, observes Kathy Warye, CEO of the Association for Professionals in Infection Control and Prevention (APIC).
"It's hard to add new things without putting greater demands on already limited resources," she concedes. "However, APIC has struggled for 30 years to elevate the issue of HAIs. While many institutions are doing great work, many are not able to get the traction from leadership, clinicians, or others that really need to commit to this. So, we really welcome this. We think a more concerted focus at the federal level and the creation of targets is going to increase awareness and accelerate progress. I really think it is going to empower the infection prevention professional."
The HHS plan comes as a direct response to a highly critical report last year by the U.S. Government Accountability Office (GAO).1 The GAO report specifically cited a failure of leadership at the HHS on the issue of health care infections. The GAO is now involved in a study of infections in ambulatory care, but will review the HHS plan to determine if its findings were addressed, says Cynthia Bascetta, MA, MPH, director of health care for the GAO. "It's a pretty broad campaign to get HHS'act together — [involving] all of the agencies that have a hand in looking at this problem," she tells HIC. "The fact that they acted so quickly is a really good sign. We have continued on our other segments of work for Congress, and have not circled back to look at their overall plan, but we will do that."
Specifically, the GAO report called for the HHS to identify priorities among CDC's recommended infection control recommendations. The GAO emphasized that there are 1,200 such recommendations, accompanied by limited guidance on implementation or prioritization. Some work already has been done in this area, as The Joint Commission and all the major infection prevention associations created a compendium that essentially is a synthesis of established prevention guidelines to prevent the major HAIs. However, in specific response to the GAO, the HHS worked with the CDC's Healthcare Infection Control Practices Advisory Committee (HICPAC) to evaluate and prioritize recommendations from four key CDC guidelines. Prioritized recommendations come from guidelines for CAUTIs, SSIs, BSIs, and VAP. The four infection types account for more than 80% of all HAIs. "We made every effort to make sure that there is alignment in what we are recommending along with very valued external stakeholders," Wright says. "There is close alliance with the compendium."
In addition, the GAO report suggested the HHS determine how to promote implementation of its prioritized practices, including "whether to incorporate selected practices into CMS Conditions of Participation for hospitals." Indeed, the resulting HHS plan calls for improving "regulatory oversight of hospitals and CMS oversight of the hospital accreditation program by refining the current method of measuring Accreditation Organization performance, enhancing surveyor training and tools, and adding sources and uses of infection control data." The HHS will continue to "incorporate measures of infection prevention and outcomes into Hospital Value-Based Purchasing (VBP) Plan methodology through implementing performance-based payment for hospitals, including measures of infection prevention and outcomes as a basis for payment," the HHS plan states. The plan also calls for expanding measures included in "CMS Hospital Compare [to improve] the quality and transparency of hospital care by increasing public accountability."
CMS used to enforce CDC
As a result, the HHS appears to be setting the stage to use the CMS to "codify" the CDC guidelines, putting the power of the purse behind recommendations that have always been voluntary. The compelling question is whether that approach will empower infection prevention programs or saddle them with another unfunded mandate.
"If the action plan is implemented and there is a coordinated federal effort in HAI prevention, I think there will be an impact on hospital infection prevention programs," says Patrick J. Brennan, MD, HICPAC chairman. "The metrics and the incentives tied to them will influence hospitals and infection prevention programs by virtue of their tie back to guidance documents and implementation strategies. It should put 'teeth'into the efforts of HICPAC, accreditation and payer organizations."
While Wright quickly rejected any notion of "unfunded mandates," he concedes HHS wants "to send a strong message to hospitals that we want them to do everything that they possibly can to prevent HAIs. I know that CMS will be looking at hospitals through an infection control lens when they do their accreditation process. Our goal was to see how we could coordinate the rather large activities across the department in a manner to leverage our resources to really reduce these infections."
The HHS plan calls for hospital to "pursue a more proactive and innovative approach to infection control" suggesting a higher priority for IP programs within the organization's quality improvement agenda. "They are tasking management with providing the resources and the assistance and the infrastructure to make this happen," Warye says. "It doesn't specifically say that, but I think it is implicit in that statement. I also think that it is going to open the door to better integration between quality and infection prevention."
Astute IPs will no doubt use the HHS plan to leverage resources for their programs and strengthen the priority of infection prevention throughout their institution. "I can't imagine that would not be one of the outcomes to this," Warye says.
The comment period for the plan ran through Feb. 6, 2009, but Wright emphasized that the HHS is going to attend and hold meetings, seeking ongoing input from the infection prevention community and other stakeholders.
"We consider this a living document," he says. "We will be updating and revising our plan based on stakeholder input, as well as the evolution of the science on prevention of health care associated infections."
In that regard, the last thing Warye wants to see is this plan get swept into one of the many HAI prevention laws under some stage of discussion.
"I think some federal regulation — whether it focuses primarily on reporting or reduction of HAIs — is likely forthcoming," she says. "I would like to thing that this initiative on the part of HHS will be viewed as adequate, and federal legislators will allow this process to unfold. This can be a more flexible process. We look at the targets and the measures and they appear to be reasonable. We certainly know of institutions that have met these targets or even done better."
Reference
- U.S. Department of Health and Human Services. Action Plan to Prevent Healthcare-Associated Infections. 2009; Washington, DC. Available at: http://www.hhs.gov/ophs
- Government Accountability Office." Health Care-Associated Infections in Hospitals: Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on these Infections." GAO-08-673T; April 16, 2008. Available at: http://www.gao.gov/products/GAO-08-673T.
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