By Christopher Guadagnino, Ph.D.

Published January 2008

• React to this article in the Discussion Forum.

AH: The law requires the reporting of hospital-acquired infections rates, and the Department of Health and Senior Services’ Quality Improvement Advisory Council will determine which infections hospitals will need to report. Those rates will be become part of a statewide hospital performance report that is already being issued for core measures. The department convened a task force to work with them and the Council to look at which infections would be reported initially and which would be phased in. They want to use infection rates where definitions are clear and endorsed by the National Quality Forum (NQF) – looking mainly at surgical site infections and probably central-line bloodstream infections – but they haven’t made a specific list yet of which ones they will require to report, at least initially. Other categories that have been in discussion are ventilator-associated pneumonia and catheter-associated urinary tract infections, but those are being put off because the NQF has not yet endorsed definitions of those, and has asked for clarification from the CDC of them.

AH: The department is going to use the CDC’s system, which is called the National Healthcare Safety Network (NHSN) as the vehicle – an online tool where hospitals can enter their data and benchmark themselves against other hospitals across the country. I think New Jersey hospitals could be entering the data on a monthly basis or so, but the report will only come out on an annual basis, along with the hospital performance report, which tends to come out in the fall every year.

AH: It’s going to be very labor-intensive for infection control practitioners. For central-line bloodstream infections, for example, the definition is the number of such infections as a numerator and device days – the number of central-line days – as a denominator, one that routinely is not collected on a hospital-wide basis. It might require beefing up resources in the infection control department to get that data. It will probably get easier to enter the data once they’ve had more practice with it, but infection control practitioners are saying it does take a bit of time. Under current regulations you need to have one infection control practitioner for every 150 beds, and hospitals are probably going to have to hire more infection control practitioners, if they can find them, or they are going to have to train other personnel to be able to manage the new infection reporting requirement, as well as the MRSA bill that was also passed this year. In order to comply with this law and be able to report this data, they’re going to have to figure out a way of doing it.

AH: There aren’t any enforcement provisions other than to say the Commissioner can take measures. The department may address that issue in the development of rules and regulations for the bill, which they are working on now. There may also be language in the regulations that will address what measures the hospital should have in place to monitor these rates, reduce as indicated, and so on. The department may be more specific in its direction once they draft these rules, but we will have to wait and see.

AH: Rules and regulations are required by this law and the department hopes to present them to the Quality Improvement Advisory Council some time in February. Given New Jersey’s rulemaking process, they have to be published, put out for comment and then republished. They’re being very aggressive to have final adoption, which probably would not occur until the end of 2008. Their plan would be for hospitals to start reporting data in 2009 using NHSN, and the first public report would appear in the fall of 2010.

AH: We do support transparency in public reporting, and we did actually support this bill. I think that it will cause hospital administration and boards of trustees to start focusing more attention on what they can do to reduce their infections. We have seen in other instances where we have public reporting, like for the core measures, that people pay more attention and start discussions on why does hospital "A" have a higher or lower infection rate in a certain category than other hospitals. We ran a collaborative of 35 hospitals in New Jersey from 2004 to 2006 to improve care in the intensive care unit and focused on ventilator-associated pneumonia and central-line bloodstream infections. Even though they weren’t publicly reporting data, those 35 hospitals did share their rates for both of those categories of infections among themselves, and saw tremendous improvement just by sharing best practices and looking at how other organizations were achieving zero rates. They actually had a 73 percent reduction in central-line bloodstream infections and a 55 percent reduction in ventilator-associated pneumonia over those two years just by virtue of hospitals coming together and having the resources devoted to work on this.

AH: The Quality Improvement Advisory Council of the Department of Health has representatives from hospitals, payors, unions and other organizations. Our position is that whatever infections are reported have to have definitions and a methodology for acquiring the information that is standardized and endorsed by the NQF. The rates should be risk-adjusted the same way for everybody, to account for comorbid conditions and differences in patient populations. I think that’s one of the reasons the department has decided to use CDC’s methodology for benchmarking against other states and other hospitals: everyone who’s using it will be using the same risk adjustment and the same definitions. When some other states first started reporting hospital-acquired infections, they used administrative billing data, and there were concerns that inappropriate things were being counted as hospital-acquired infections, and that infection control people sometimes had not been involved. Using CDC and NHSN, all the data methodology is defined by infection control practitioners, so you don’t have that issue of using administrative data. People felt that using CDC’s methodology, even though it was very resource intensive, at least is in the purview of the infection control practitioners.

AH: The department hasn’t determined how they’re going to do it but it is going to have to provide a lot of information, and I’m sure a lot of consumers don’t read the small print at the bottom of the page. But my understanding is that they’re just going to be reporting the rates – which is the number of infections over the device days. That’s how CDC reports the data now, but it was health care professionals who could understand it and knew how those rates were determined. My concern, which we’ve addressed to the department, is that with device-related infections – for instance, Foley catheter infections, ventilator-associated infections, central-line bloodstream infections – you start to look at ways of getting those devices out of patients faster. We saw this in our ICU collaborative: one of the things we stressed with ventilator-associated pneumonia was to get the patient off the ventilator as soon as possible. There are ways of evaluating whether the patient could breathe on his own and didn’t need to have ventilator support, and hospitals worked to standardize care and implement evidence-based practices to prevent ventilator-associated pneumonia while also concurrently getting patients off the ventilator faster. Since the way infections are reported is a ratio of the number of infections over the device days, the numerator was falling but the denominator was falling also, so we started seeing hospitals’ infection rates going up even though they had fewer infections – because the denominator was falling faster and disproportionate to that numerator. That is an area of some concern because hospitals may actually improve on, say, central-line bloodstream infections, but their rates may actually go up as they get the central lines out as soon as they can and put a peripheral line in. We did see that happen with a number of hospitals, and we had to start focusing on how many months they could go with zero central-line bloodstream infections, because the rates will be difficult to explain to the public.

AH: The department is going to have to put together the reporting format and its explanation, and we’re going to have to work with all of our member hospitals to do some more education of the public, perhaps developing explanatory brochures.