U.S. may require hospitals to disclose infection rates, nursing staff mix
Patient Safety Act would let the public judge’
A controversial but potentially landmark bill that would require hospitals to disclose both nursing staffing levels and nosocomial infection rates has been reintroduced in the U.S. Congress.
Proposed March 20, 1997, by Rep. Maurice Hinchey (D-NY), The Patient Safety Act of 1997 (H.R. 1165) calls for any health care provider to make information regarding nurse staffing and patient outcomes publicly available as a condition of continued participation in the Medicare program.
Staffing data made available to patients would include the number of registered nurses, licensed practical nurses, licensed vocational nurses, and unlicensed personnel providing direct patient care at the facility. The staffing data would include total hours of nursing care per patient for each type of nurse on all units and work shifts. Outcome data required to be made publicly available would include patient mortality rates and incidence of adverse patient care incidents, including medication errors, patient injuries, decubitus ulcers, and nosocomial infections, the bill states.
"What we’re trying to do in this bill is give people more information about health care and hospital care," Hinchey says. "We in Congress know that the people we represent are deeply concerned about the changes occurring in health care delivery because of cost-control pressures. Getting good information about the things that matter to them would start to give people back some of the power they have lost to manage their own care."
The bill, however, threatens to further divide an economically troubled health care community particularly hospital and nursing associations facing their own pressures to control spending and preserve jobs, respectively. The American Hospital Association strongly opposes the legislation as nothing more than a "jobs bill," while the American Nurses Association helped frame the bill and is lobbying for its enactment to preserve quality nursing care for patients.
Complicating the mix, infection control professionals have long fought against releasing infection rates as quality outcome measures because a host of variables, such as patient severity of illness, must be taken into account to make the data meaningful and comparable between facilities. In that regard, the Association for Professionals in Infection Control and Epidemiology in Washington, DC, reiterated such concerns and warned that the bill would not provide "valid quality data" to patients. (See related story, p. 67.)
Indeed, just the process of collecting nosocomial infection data is fraught with enough variables to profoundly affect rates, notes Eddie Hedrick, BS, MT(ASCP), CIC, infection control manager at the University of Missouri Hospital and Clinics in Columbia.
"This data is not risk-adjusted," he says. "The frequency of collection of the data, the training of the person collecting data, how many hours they work, access to patient charts, how often people do cultures a thousand things can make that [infection rate] number go up or down that have nothing to do with staffing."
Studies find staffing-outcomes link
The bill cites a growing public concern regarding the quality and safety of health care facilities that have instituted "aggressive efforts to reduce levels of staff who provide direct patient care services as a principal means of decreasing expenses. A growing body of data suggests a linkage between the number and mix of nursing staff and positive patient care outcomes, including the avoidance of patient death and injury."
The Centers for Disease Control and Prevention has linked nosocomial infections and staffing patterns in several recent investigations, essentially finding that reducing nursing staff or drawing from nursing "pools" can lead to increased infection rates in intensive care units.1,2 (See related stories in Hospital Infection Control, November 1996, pp. 137-140; June 1996, pp. 69-72.)
Nevertheless, trying to develop a ratio or formula addressing staffing and infection rates would be futile, Hedrick notes. An increase in urinary tract infections, for example, may be traced to inappropriate handling of catheters due to understaffing. On the other hand, an increase in surgical wound infections may be due to the technique of an individual surgeon and have nothing to do with staffing, he says.
"I clearly believe that there is a point to where things can get unsafe, but for each facility that is going to be different," Hedrick says. "If a hospital is overstaffed and then downsizes, for example, that doesn’t necessarily mean an [infection control] problem will result. A lot of it will depend on the severity of illness of the patient and other factors. I support concern about staffing, but I don’t think there is anything that should be done about it right now in terms of legislation. "
ICPs should be acutely aware of the possibility that staffing reductions or changes may compromise patient safety by increasing infection rates and make any concerns known to hospital administration, Hedrick says. Nonetheless, the bill’s requirement to release infection rate data is inappropriate and cannot be supported, he adds.
Let the public judge’
The argument that the hospital infection rate data could be misleading without risk adjustments is not immediately convincing to Christopher Arthur, PhD, legislative director in Hinchey’s office.
"That kind of argument has been used to argue against release of virtually any information about any subject by any agency at any time for any reason, " he says. "As with any information that is released, there is always room for misinterpretation, and there are also different but accurate interpretations of the same information. All we are saying with the bill is, let the information out. Let the public judge."
The bill was first introduced last year, but never developed enough political momentum to get serious consideration in a Republican-majority Congress, Arthur notes. The bill is thought to have a better chance this session, particularly if it can be attached to a larger "Christmas tree" health care bill with a mix of provisions, he adds.
"It’s still a Republican Congress so it’s got the same problems," he says. "If they do a health bill that involves a lot of different things, I think there is actually a real possibility that it would be attached in some form."
As principal lobbyist behind the bill, the ANA applauded its introduction as an assurance that patients would receive safe, high-quality nursing care. The ANA claims hospitals and other health care institutions are employing fewer registered nurses to provide direct patient care, choosing instead to replace nurses with minimally trained, unlicensed personnel. As a result, the nursing work force is being "de-skilled" even as patient care duties are being "sped up." In the ANA’s view, this combination of factors has resulted in less experienced nurses delivering care to sicker patients at a pace that increases the risk of nosocomial infections and other adverse events.
The ANA especially supports the bill’s provision of "whistleblower" job protection for RNs who speak out about patient care issues. The ANA also noted that the bill calls for health care facility mergers and acquisitions to be reviewed by the U.S. Department of Health and Human Services. The HHS would look at long-range issues related to the health and safety of patients, the community, and employees, and have the authority to block any transaction deemed to have a negative impact on health and safety.
"Health care decisions are increasingly driven more by a quest for short-term cost savings and profit than by a commitment to safe, quality patient care," says ANA President Beverly L. Malone, PhD, RN, FAAN. "This legislation lifts the veil of secrecy that keeps hospitals’ staffing and outcomes a mystery to patients, gives consumers access to information they need to make informed decisions, and protects nurses who speak out on behalf of safe patient care."
In addition to federal-level lobbying efforts, ANA state chapters are lobbying for the introduction of state legislation to address the issues. Variations of the Patient Safety Act are being submitted to state legislatures in Kentucky, Massachusetts, New Jersey, Oregon, Pennsylvania, Tennessee, and Washington, the ANA reports.
The American Hospital Association in Washington, DC, dismissed the proposed federal legislation, noting that the number of RNs employed by hospitals has actually increased slightly in recent years, even though more nurses are moving to outpatient settings.
"We feel that the bill has only one goal, and only one: to preserve existing [nursing] jobs," says Alicia Mitchell, AHA spokeswoman. "It is a jobs protection bill masquerading as pro-patient legislation. There really is no single approach to determining staffing levels in hospitals. There are a lot of things that depends on restructuring is tailored to meet the needs of the patients and the communities that are served. What makes sense at one hospital may not make sense at another hospital."
The AHA expressed its concerns in a meeting with Hinchey and his staff regarding the bill, which is not meant to be anti-hospital, Arthur says.
"We do not see the problem as the big, bad hospitals’ in any way, shape, or form," he says. "We know that hospitals are under a lot of pressure from both public and private insurers, and we think it would help make the case for hospitals if the public had more information about the consequences of that pressure."
That pressure is often characterized as hospital budget reductions and staffing cuts resulting from the economic restructuring of health care, so the bill ultimately addresses the managed care phenomenon in health care, Arthur concedes.
"We are not opposed to managed care per se, but we see a lot of potential problems with it," Arthur says. "The insurer, the employer, and the hospital are controlling what happens. Getting information out there will not only give [information] to the patient, but I think it will really boost the hospital’s case."
Infection rates may become quality measure
Yet, by the same token, pressure on hospitals to release such data as infection rates may translate to pressure on those doing the surveillance not to gather it with full vigor. That is already a concern as hospitals shift to the managed care environment, where infection rates may be increasingly viewed as a quality measure to be used in marketing contracts. ICPs may be pressured "not to look too hard" to find and document nosocomial infections.3
While the specific reporting provisions would be detailed by the HHS secretary after passage of the bill, hospitals that inaccurately report staffing or attempt to minimize adverse outcome data would risk being out of compliance with the law and losing their Medicare business, Arthur says.
"The [HHS] secretary would prescribe specific reporting standards for the regulation," he says. "A uniform reporting system is part of the idea. The secretary has the authority to take sanctions against them up to and including the point of suspending them from Medicare if they violate the regulations. They are out of business if they are out of Medicare."
[Editor’s note: For more information on the Patient Safety Act, contact Rep. Hinchey’s office at 1524 Longworth HOB, Washington, DC 20515. Telephone: (202) 225-6335; fax: (202) 226-0774. Co-sponsors of the legislation are Rep. Gary L. Ackerman (D-NY); Rep. William Delahunt (D-MA); Rep. Ronald V. Dellums (D-CA); Rep. Lane Evans (D-IL); Rep. Tim Holden (D-PA); Rep. Frank R. Mascara (D-PA); Rep. John W. Oliver (D-MA); Rep. Lynn Rivers (D-MI); and Rep. Bennie G. Thompson (D-MS).]
References
1. Fridkin SK, Pear SM, Williamson TH, et al. The role of under staffing in central venous catheter-associated bloodstream infections. Infect Control Hosp Epidemiol 1996; 17:150-158.
2. Haley RP, Bregman DA. The role of under staffing and over-crowding in recurrent outbreaks of staphylococcal infection in a neonatal special-care unit. J Infect Dis 1982; 145:875-885.
3. Jackson MM. Infection prevention and control in the managed care era: Dinosaur, dragon, or dark horse? Am J Infect Control 1997; 25:38-43.
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