CDC, state health building a bridge
States on the cutting edge of HAI prevention
State health departments are becoming vital partners with the Centers for Disease Control and Prevention in an increasing national effort to eradicate healthcare associated infections (HAIs).
Many state health departments initially became engaged in HAI prevention as state infection reporting laws spread across the map. There is the potential for considerably more than data collection, however, as state health departments are uniquely positioned to help the CDC move surveillance and prevention measures beyond the hospital and into a wide variety of settings like dialysis centers and long-term care.
"We are very focused on increasing the role of state health departments," says Michael Bell, MD, associate director for infection control in the CDC′s Division of Healthcare Quality Promotion. "The reason for that is [for example] the world of dialysis organizations is completely detached from many of the hospitals. Similarly, if I am Kaiser [Permanente, managed care consortium] I may not be able to see anything happening outside of the Kaiser world — even though I have a great network. The one place that has access to and authority over all of that is the state health department."
The traditional line between public health and infection control is disappearing, as patients move across the continuum and take the full panoply of HAIs with them. As state collaboratives emerge linking the CDC, health departments, hospitals and outpatient settings, infection preventionists and their new-found allies may finally be in a fair fight with elusive HAIs.
"We are helping [state health departments] — funding them, giving them people, training them," Bell tells Hospital Infection Control & Prevention. "We are working as well as we can with them so we have a partner that can say, "I'm watching all of this, and that problem you're seeing in the hospital is actually related to this long-term care facility or that dialysis center.' It's a very important piece."
The future of these critical collaboratives will inevitably depend on continued state and federal funding, with likely emphasis on the latter. With HAIs targeted early in the health care reform debate as "low-hanging fruit" for investment and action, there has been considerable federal allocation toward collaborations with state health departments. According to a report recently issued by the CDC and the Association of State and Territorial Health Officials (ASTHO), many "state stakeholders" participating in HAI collaborative projects benefited from the American Recovery and Reinvestment Act of 2009 funding. (See editor's note below.)
"Stakeholders expressed concern about the long-term sustainability of their programs," the report states. "In cases where enduring funding streams are not available, stakeholders indicated that seed money, bonus payments, or facility improvement grants from third-party private payers may enable HAI efforts and support the implementation of cost-saving, self-sustaining programs."
The challenge to prove prevention
It's a dilemma familiar to the IP, proving the power of prevention to secure continued and increased funding. However, state HAI policies are relatively new, with most originating since 2006. Beyond the data generated by mandatory public reporting, little published information is available regarding the effect of HAI-related policies on infection rates, the report notes. While it may be too early for outcome data that link specific policies to HAI reduction, other indicators can help to describe best practices, the CDC and ASTHO concluded, citing such examples as:
• New York: Adult and pediatric central line-associated bloodstream infection (CLABSI) rates have decreased by 18% in the state since 2007 after adjusting for type of intensive care unit. Numerous participants attributed the success of disclosure policies in New York to the auditing of reported data and the initial pilot reporting program, that allowed the state to refine requirements and educate facilities on reporting.
• Tennessee: According to state health agency representatives, the 2010 reduction in CLABSI rates in facilities can be attributed in part to public reporting of validated facility-specific rates.
• Colorado: Participants observed that the mandatory reporting requirements have yielded benefits by elevating infection prevention to the attention of facility leadership; but they expressed reservations about the quality of the data due to the need for clear, consistent definitions for measurement.
Most stakeholders agreed that public reporting is an important component of HAI programs, but many are not confident that reporting alone will affect infection rates without other interventions, the report found.
"While many individuals acknowledged that reporting alone does not change behavior, stakeholders indicated that the requirement raised the awareness of facility leadership, elevating the importance of HAI reduction and elimination to priority status for senior executives," the report states. "Many stakeholders asserted —despite doubting that members of the general public regularly used or accurately interpreted the reported data — that no facility wanted to be reported as having the 'worst HAI numbers in the state,'" the report found.
Culture change
Beyond the reporting issue, there are signs of an overall culture change. Stakeholders frequently cited culture and leadership awareness as enabling factors to the success of HAI policies, including the following:
• California: The creation and implementation of the state's HAI policies have elevated the importance of infection control and prevention professionals and environmental services within healthcare facilities.
• Massachusetts: The state has maintained strong communication, from the leadership to the front line, which has contributed to the effectiveness of the state's HAI policies.
• Pennsylvania: The state's success is due in part to several leaders, from various state organizations to facilities, who foster a culture that supports HAI reduction.
• Tennessee: Leadership, collaboration, and public reporting have exercised a strong, positive influence on HAI reduction in the state. The foundation for successful HAI policy interventions was laid through the state's early involvement of key stakeholders in deliberations to inform the policy-making process, including payers, consumers, medical associations, and infection control and prevention professionals. One participant noted that while training helps to establish a basic understanding of needed practices, institutional and professional culture change is imperative to successful implementation.
Editor's note: The CDC/ASTHO report: "Policies for Eliminating Healthcare-Associated Infections: Lessons from State Stakeholder Engagement" is available at: http://1.usa.gov/AtXTKf
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