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Hospitals appear to be heeding mandates to reduce and report preventable infections, but long-term impact still to be determined
NEW YORK, NY (November 2, 2011) – Hospitals, at least those in California, seem to be taking to heart federal and state policies designed to reduce preventable infections. But the policies’ long-term impact on healthcare delivery, staff workload and long-term patient safety remain unclear, two new studies say.
The studies, by researchers at the Columbia University School of Nursing (CUSON), the Association for Professionals in Infection Control and Epidemiology (APIC), and the New York University College of Dentistry, were published online in the quarterly journal Policy, Politics and Nursing Practice.
Healthcare-associated infections, or HAIs, are a serious public health problem affecting an estimated 1.7 million patients in U.S. hospitals each year, causing some 90,000 deaths and costing these facilities an estimated $25 billion, according to the U.S. Centers for Disease Control and Prevention. Four categories of infections account for about 75% of HAIs in the acute care hospital setting: surgical site infections; central line–associated bloodstream infections; ventilator-associated pneumonia; and catheter-associated urinary tract infections. Many of these problems are preventable.
In an effort to control such infections, the U.S. Centers for Medicare and Medicaid Services (CMS) in 2008 began denying higher Medicare payments for treatment of 10 preventable hospital-acquired conditions including select HAIs. In January 2009, California enacted mandatory reporting of infection prevention processes and HAI rates. Thirty other states have some type of HAI reporting laws.
Despite support for public release of hospital performance measures and quality improvement initiatives, “there has been little research examining the effect of these policy changes on the delivery of health care and even less research has assessed whether reporting actually improves the public’s safety,” Patricia W. Stone, PhD, FAAN, Centennial Professor in Health Policy at CUSON, director of the school’s Center for Health Policy, and colleagues say in the first study. The two new reports are the first statewide assessments of the changes in infection prevention and control structures, processes and outcomes before and after mandatory reporting requirements were implemented.
“Clearly, the goal of both the CMS policy change and state reporting is to give incentives to hospitals to improve hospital practices and decrease HAIs,” Stone and colleagues report. “Our results provide some evidence that the policy changes are working.” But the new regulations could be having unintended consequences as well, the authors suggest.
The two studies used quantitative and qualitative methods to look at the impact of these policy changes on California hospitals. The first study, by Stone and co-authors Monika Pogorzelska, PhD, MPH; Haomiao Jia, PhD; Mayuko Uchida, MSN, GNP-BC; and Elaine L. Larson, PhD, RN, FAAN, CIC, all of CUSON, and Denise Graham of APIC, employed web-based surveys and interviews with hospital staff to gather information on more than 200 hospitals. The second study, by Uchida, Stone, Pogorzleska, Larson and CUSON’s Laurie Conway, along with Victoria H. Raveis, PhD, of NYU, involved interviews with personnel at six hospitals across the state.
The first study found significant increases in adoption of and adherence to evidence-based practices and decreased HAI rates at the hospitals studied, particularly related to central line-associated bloodstream and catheter-associated urinary tract infections, both of which were targeted by different policy initiatives. It also reports changes in the role of the “infection preventionist (IP),” the bedside clinician who oversees infection control day-to-day. IPs, most of them nurses, spent more time on surveillance and in their offices, less time on education and in other locations, and generally saw their workloads increase. In addition, it found a need for greater information technology support for the new IT tools increasingly being utilized in enhanced infection control practices.
The second study echoed the finding of an increased workload related to reporting regulations and data entry and reported staff frustration over these issues. “Unless clinicians clearly understand why they are following these mandated requirements, or any other infection prevention process, compliance is likely to be variable,” Uchida and colleagues write. “Increasing interdisciplinary collaboration and education may facilitate information sharing and reduce barriers for promoting infection prevention.”
The authors say it’s not yet clear whether the laudable goal of public reporting of HAIs might have unintended consequences, such as hospitals becoming less likely to admit patients at high risk for HAIs, increased use of screening tools or antibiotics, underreported infection rates, over reported adherence rates, or staffing shifts that could affect other aspects of patient care. As a result, the authors of both studies urge ongoing monitoring of how these policy changes are implemented.
The authors note several limitations to their work: the studies were conducted in California and therefore may not represent hospitals nationally; data in the first study were collected through a selfreport survey and as such might not represent actual changes in structures, processes and outcomes; and the personnel interviewed may not represent all staff directly involved in infection prevention and control.
Still, as the authors of the second study conclude, this work “contributes to the understanding of infection prevention and control in light of new legislative and technological changes and explores how these changes are affecting the everyday activities of many health care professionals.”
Stone PW, Pogorzelska M, Graham D, Jia H, Uchida M, Larson EL. California Hospitals’ Response to State and Federal Policies Related to Health Care-Associated Infections. Policy Polit Nurs Pract. 2011. Vol. 12, No. 2; 73-81. Published online before print October 30, 2011, doi:10.1177/1527154411416129.
Uchida M, Stone PW, Conway LJ, Pogorzelska M, Larson EL, Raveis VH. Exploring Infection Prevention: Policy Implications from a Quantitative Study. Policy Polit Nurs Pract. 2011. Vol. 12, No. 2. PP. 82-89. doi: 10.1177/1527154411417721.Editors’ note: These articles will be available on the journal web site in open access for 30 days.
About the Columbia University School of Nursing
Since its founding in 1892, the Columbia University School of Nursing (CUSON) has been dedicated to preparing clinically excellent nurses, nurse practitioners, clinical nurse specialists, and scholars. As nursing educators and clinical professionals, CUSON faculty focus on addressing the needs of underserved and vulnerable populations, both in practice and research. Today, CUSON has clinical partnerships at more than 200 clinical practice sites throughout New York City and affiliations with three major medical centers. CUSON has a long history of “firsts,” including awarding a master’s degree in a clinical nursing specialty, developing the Doctor of Nursing Practice degree, having its faculty gain full admitting privileges to a major teaching hospital, and being designated a World Health Organization Collaborating Center for Advanced Practice Nursing. CUSON also is among the highest-ranked nursing schools in federal research grants awarded per faculty. Visit CUSON at www.nursing.columbia.edu.
About the Association for Professionals in Infection Control and Epidemiology
The mission of the Association for Professionals in Infection Control and Epidemiology (APIC) is to improve health and patient safety by reducing risks of infection and other adverse outcomes. The association’s more than 14,000 members direct infection prevention programs that save lives and improve the bottom line for hospitals and other healthcare facilities around the globe. APIC advances its mission through education, research, collaboration, practice guidance, public policy and credentialing. Visit APIC online at www.apic.org. For consumer-related information, visit www.preventinfection.org. Follow APIC on Twitter at http://twitter.com/apic.
About the NYU College of Dentistry
The NYU College of Dentistry (NYUCD) is the largest comprehensive oral healthcare center in the United States, graduating more than eight percent of U.S. dentists annually. NYUCD is widely recognized as a leading source for dental care in New York City and a leader in national research rankings and national policy issues in dentistry. Visit NYUCD at http://www.nyu.edu/dental.
About Policy, Politics and Nursing Practice
Policy, Politics & Nursing Practice is a quarterly, peer-reviewed journal that explores the multiple relationships between nursing and health policy. It serves as a major source of data-based study, policy analysis and discussion on timely, relevant policy issues for nurses in a broad variety of roles and settings, and for others who are interested in nursing-related policy issues. http://ppn.sagepub.com.
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