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Policy Innovation Profile

State-Mandated Tracking and Public Reporting Reduce Incidence and Costs of Common Hospital-Acquired Infections


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Snapshot

Summary

The New York legislature passed a law in 2005 requiring hospitals in New York to track and regularly report infection rates for select types of hospital-acquired infections to the State Department of Health, which then analyzes the information and publishes a publicly available report each year providing hospital-specific performance, along with comparisons to regional, state, and (if available) national averages. As part of the program, the Department also funds multihospital quality improvement projects targeted at reducing specific types of infections. Since the program began, the incidence of targeted infections has fallen markedly, generating significant cost savings. In addition, several department-supported projects have improved adherence to preventive strategies and reduced infection rates.

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of pre- and post-implementation comparisons of statewide infection rates for targeted HAIs, along with estimates of the cost savings generated as a result of reductions in specific HAIs. Additional evidence includes post-implementation adherence to prevention strategies and trends in infection rates at hospitals receiving program funding to support QI projects.
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Developing Organizations

New York State Department of Health
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Use By Other Organizations

Currently, 28 states have passed some sort of legislation related to HAI reporting, 21 of which use NHSN. More information is available at: http://www.cdc.gov/hai/QA_stateSummary.html.

Date First Implemented

2005
Passed in July 2005 by the New York State legislature, the authorizing legislation required hospitals to begin submitting data to the Department of Health in 2007. The first public report—with de-identified data from 2007—was released in 2008, while the first report with hospital-specific data was released a year later.

Problem Addressed

A common, costly problem, hospital-acquired infections (HAIs) pose severe health risks to patients. Infection control practices can reduce the risk of infection, but adherence to these measures remains suboptimal in many facilities, as key stakeholders (providers and patients) remain largely unaware of the problem.
  • A common, growing problem: An estimated 1.7 million HAIs occur in the United States each year,1 and the prevalence of common infections has increased in recent years.2
  • Severe health risks, high costs, prolonged stays: Numerous studies show that HAIs lead to longer hospital stays, greater use of later-generation antibiotics, higher costs, and increased risk of death.2 Roughly 99,000 people die each year due to HAIs.1
  • Unrealized potential of preventive strategies: Up to 70 percent of HAIs can be prevented through strategies such as proper hand hygiene and use of protective gowns and gloves.3 Yet adherence to these strategies remains suboptimal, in large part because many stakeholders—including patients and providers—remain unaware of the problem.4 Regular tracking and public reporting on the frequency of such infections can serve to educate key stakeholders and encourage patients and providers to take the steps needed to prevent infections. Yet relatively few such tracking and reporting programs exist.

What They Did

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Description of the Innovative Activity

New York State requires hospitals to track and regularly report infection rates for select types of HAIs to the State Department of Health, which analyzes the information and publishes a publicly available report each year providing hospital-specific performance, along with comparisons to regional, state, and (if available) national averages. The Department also funds multihospital quality improvement (QI) projects targeted at reducing HAIs. Key program elements include the following:

  • Mandatory tracking and reporting to Department of Health: Passed in July 2005, the legislation requires hospitals to identify, track, and report select HAIs to the New York State Department of Health based on established standards, as outlined below:
    • Identification and tracking: The legislation requires every New York hospital to identify and track select HAIs, as determined by the State Department of Health. Hospitals must track the specific agent or toxin responsible for the infection; infection site; clinical department or unit where the patient first became infected; the patient’s diagnoses; and relevant surgical, medical, or diagnostic procedures performed during the stay. The Department of Health currently requires tracking of the following:
      • Surgical-site infections (SSIs): Since the program's inception, the Department has required tracking of several types of SSIs, including for colon surgery and coronary artery bypass graft (CABG) surgery. The Department later added requirements to report SSIs related to hip replacement surgery (2008) and abdominal hysterectomy procedures (2012).
      • Central line-associated blood stream infections (CLABSIs): Also from the program's onset, the Department has required tracking of CLABSIs in intensive care units (ICUs), including umbilical catheter-associated infections in neonates.
      • Gastrointestinal infections: Beginning in July 2009, the Department began requiring reporting of gastrointestinal infections due to Clostridium difficile, with performance first reported publicly in 2010 (after a 6-month pilot to validate the reporting protocol).
      • Laboratory-identified carbapenem-resistant Enterobacteriaceae (CRE): Information provided in August 2013 indicates that as of July 2013, hospitals are required to report Escherichia Coli and CRE-Klebsiella infections from all specimen types for inpatients facility-wide, using the NHSN. The period between July 1, 2013 and December 31, 2013 is considered a 6-month pilot reporting period.
      • Data use agreement (DUA): Information provided in August 2013 indicates that as of July 2013 the New York State Department of Health entered into a DUA with the Centers for Disease Control and Prevention (CDC). This gives the New York State Department of Health the ability to use non-mandated NHSN data (e.g., catheter-associated urinary tract infections (CAUTI) and methicillin-resistant Staphylococcus aureus infections) for quality improvement purposes.
      • Additional infections to be determined: The Department may begin requiring the tracking of additional HAIs in the future.
    • Regular reporting using established, standards-based system: The Department requires hospitals to report data on a monthly basis, with information submitted within 60 days of the end of the reporting period (e.g., by the end of March for infections in January, by the end of April for infections in February, etc.). Hospitals submit the information electronically using an established, standards-based system known as the National Healthcare Safety Network (NHSN), a secure, internet-based surveillance system developed and operated by the CDC.
    • State auditing: After receiving data from the hospitals, the Department audits the information to ensure that hospitals have entered it appropriately. Initially, staff visited every hospital to compare entered information to that found in medical records. In more recent years, program staff have been able to audit some hospitals remotely by comparing NHSN data to that found in electronic medical records.
    • Ongoing technical assistance: Department-based infection preventionists and other program staff provide ongoing technical assistance to hospitals, including inperson and telephone-based support related to monitoring, reporting, and QI activities (see bullet below for more information on the QI projects).
  • Annual public report: Around September 1 of each year, the Department of Health releases a publicly available report on its Web site that provides hospital-specific infection rates, along with comparisons to regional, state, and (if available) national averages. Hospitals receive an embargoed copy a few days before the public release, giving them a chance to review the information, alert the Department about any discrepancies with their own data, and prepare for the release. The Commissioner of Health typically issues a press release in conjunction with the report’s posting, and in some cases may hold a public event to announce the release (e.g., at a hospital).
  • Electronic database: The Department of Health maintains an electronic version of the hospital-specific infection rates presented in the annual report. This spreadsheet is available upon request.
  • Department-funded, collaborative QI projects: The legislation authorized funding for QI initiatives through the State budget, which is distributed to select health care organizations through the Department of Health. In August 2007, the Department issued a request for applications (RFA) for funding to support multihospital QI projects designed to reduce HAIs. To participate, applicants had to obtain the commitment of at least five hospitals. The Department initially funded 5 projects, for a period of up to 5 years. Each year, the Department decides whether to renew funding for the subsequent year based on the progress made to date. The four Department-funded collaborative projects ended in February 2013. A new RFA was issued in October 2012. Below is a summary for each project, each of which received around $130,625 in fiscal year 2012-2013 (updated in August 2013): 
    • Continuum Health Partners: This project focused on the continued reduction of CLABSIs in patients with a specific type of central line referred to as a peripherally inserted central catheter (PICC). Patients often leave the hospital with these catheters in place. Strategies tested to prevent this included an instructional video in multiple languages for patients and staff on proper care and maintenance of the PICC line; a PICC insertion checklist; and a PICC maintenance bundle. This infection prevention collaborative was conducted in four acute care hospitals in New York City.
    • North Shore University Hospital: This hospital collaborative focused on the impact of chlorhexidine glutonate (CHG) bathing on methicillin-resistant Staphylococcus aureus (MRSA) in the ICU at three community hospitals. The project evaluated MRSA transmission and the impact of prevention measures, rapid detection technology, and strain typing of isolates.
    • University of Rochester School of Medicine Dentistry: This collaborative focuses on reducing CLABSIs outside the ICU through use of evidence-based protocols for central line insertion and care.
    • Westchester County Healthcare Corporation: This collaborative focused on reducing hospital-associated bloodstream infections in ICU and respiratory care patients. The project tested the effectiveness of one particular strategy—daily bath with a wash cloth soaked in CHG, an antibacterial agent. 

Context of the Innovation

Headed by the Health Commissioner, the New York State Department of Health takes responsibility for public health in the state of New York. The impetus for the legislation came from Department leaders, hospital representatives, consumer advocates, and legislators who recognized that HAIs were a problem both nationally and in New York. These stakeholders worked together to draft legislation that would provide New Yorkers and other stakeholders with fair, accurate, and reliable data to guide decisions on where to receive care. The end result was Public Health Law 2819, passed in July 2005. The legislation called for the first year of reporting (based on 2007 data) to be a pilot phase of the project.

Did It Work?

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Results

Infection rates for targeted HAIs have fallen markedly since the program began, generating significant cost savings. In addition, several Department-supported QI initiatives have improved adherence to preventive strategies and reduced infection rates.

  • Fewer infections in targeted areas: Between 2007 and 2010, the statewide SSI rate fell by 15 percent, primarily due to reductions in SSIs related to colon and CABG surgery.5 Over the same time period, the infection rate for adult/pediatric and neonatal ICU CLABSIs fell by 37 percent.5 Additional details are provided below:
    • Colon SSIs: Between 2007 and 2010, the SSI rate for colon surgery procedures in the 173 hospitals performing them fell by 16.1 percent, from 5.9 to 5.0 infections per 100 procedures.5
    • CABG SSIs: Between 2007 and 2010, the SSI rate for CABG surgery in the 39 hospitals performing such procedures fell by 17.3 percent, from 2.7 to 2.2 infections per 100 surgeries.5
    • CLABSIs: Between 2007 and 2010, adult/pediatric and neonatal ICU CLABSI rates fell by 37 percent in the 173 hospitals that reported information from 394 ICUs.5 In 2010, 31 percent of ICUs reported having experienced no CLABSIs.
    • Total hip replacement SSIs: Between 2008 and 2010, no change occurred in the rate for infections related to hip replacement surgery in the 167 hospitals performing this procedure.5
  • Significant cost savings: Using CDC-developed methodologies, the Department of Health estimates that the decline in SSIs between 2007 and 2010 has generated between $7.9 and $23.1 million in cost savings, while the decline in CLABSIs in adult, pediatric, and neonatal ICUs has generated an additional $7.3 to $29.4 million in savings.5
  • Project-specific improvements: Several projects supported by Department of Health grants have yielded improvements in adherence to prevention strategies and/or reductions in infection rates, as outlined below:5
    • Continuum Health Partners: Information provided in August 2013 indicates that the implementation of the PICC checklist and maintenance bundle led to significant improvements in a variety of areas.
      • Decreased PICC infection rates: In 2012, PICC infection rates decreased by 54 percent, from the 2009 baseline of 2.8 to 1.2 per 1000 PICC line days, resulting in a cost savings of approximately $564,000. 
      • Decreased length of stay: From 2010-2012, the median length of stay for patients with PICC lines without infection decreased from 16 to 12 days. In 2012, the median length of stay among patients with a PICC infection was 46 days.
      • Reduced readmissions rate: Patient readmission due to PICC line infections decreased from 8.5 percent in 2010 to 5.8 percent in 2012.
      • Standardization of indications for PICC lines: Indication for PICC lines have been standardized between participating hospitals. Compliance with using the PICC insertion and maintenance bundle checklists remained at 95 percent or greater.
      • Use of PICC instructional DVD: Utilization of a PICC instructional DVD developed for patients and staff in calendar year 2012 increased from 55 to 75 percent and remains an important educational tool in reducing PICC CLABSIs.
    • The North Shore University Hospital: Information provided in August 2013 shows that MRSA transmission was reduced through the use of CHG baths, using 2 percent CHG impregnated washcloths.
    • University of Rochester School of Medicine Dentistry: Information provided in August 2013 indicates that the use of evidence-based protocols had a positive effect on the central line insertion and care.
      • CLABSI rates decreased: CLABSI rates outside the ICU decreased from pre-intervention rates of 2.6 to 1.3 per 1,000 line days post-intervention.
      • Cost savings: A retrospective medical record review estimated the excess cost of a CLABSI at $45,560. Using this estimate, an overall cost savings of $13,713,560 was achieved during the three year post-intervention period.
    • Westchester County Healthcare Corporation: The use of CHG has shown a positive impact on infection rates.
      • CHG bathing: CHG bathing was associated with significant and sustained reductions in ICU CLABSIs. Three years after the CHG intervention began, the combined CLABSI rate at the five hospitals was 1.05 per 1,000 catheter days, compared to 8.7 pre-intervention. 
      • Randomized double-blind study: Data was collected from a randomized double-blind study of CHG baths in an adult oncology unit and the analysis will soon be completed.

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of pre- and post-implementation comparisons of statewide infection rates for targeted HAIs, along with estimates of the cost savings generated as a result of reductions in specific HAIs. Additional evidence includes post-implementation adherence to prevention strategies and trends in infection rates at hospitals receiving program funding to support QI projects.

How They Did It

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Planning and Development Process

Several key planning activities occurred between passage of the legislation and release of the first report, as outlined below:
  • Decision to use NHSN: Program leaders decided to use CDC’s NHSN system, an existing Web-based system based on established, standardized definitions, guidelines, criteria, and coding.
  • Minor modifications based on input from workgroup: The NHSN required a few minor modifications to incorporate a handful of state-specific rules. A technical advisory workgroup provided input on these modifications.
  • Staff hiring and training: During the summer of 2006, program leaders wrote job descriptions and interviewed and hired staff, including six infection prevention specialists and a data manager. New staff received training on the public reporting initiative and the NHSN system.
  • Letter to hospital chief executives: The Department sent a letter to hospital chief executive officers informing them of the requirements of the new program.
  • Training hospital-based staff: During the fall of 2006, the newly hired program staff trained hospital-based infection preventionists on the NHSN system, making sure they understood and could follow the standardized definitions, criteria, and coding. CDC staff assisted with this effort by providing training materials and attending some of the early sessions at the hospitals. For the most part, program staff provided inperson training and support, although some activities, such as help in acquiring digital certificates, took place remotely.
  • Initial report with de-identified data: The first public report was released in the summer of 2008, with 2007 data. Consistent with the legislation, this report did not provide hospital-specific data, although individual hospitals did receive access to their own information, thus allowing them to compare their performance to statewide averages. As noted, all subsequent reports have contained hospital-specific data.

Resources Used and Skills Needed

  • Staffing: The program creates work for staff within the Department of Health and at New York hospitals, as outlined below:
    • Department of Health: The program requires a full-time program coordinator, 6 infection preventionists (each supporting roughly 35 hospitals), a full-time data manager, a half-time data analyst, and administrative staff. These staff work as part of the Department’s Bureau of Healthcare-Associated Infections, which was created after the pilot phase of the program. Program staff work in the central office (in Albany) and in five regional offices that cover the New York City metropolitan area, Western New York, and Central New York.
    • Participating hospitals: The program creates an added burden for hospital-based infection preventionists. A recent Department of Health survey suggests that hospitals have not hired additional staff to meet this burden. However, program requirements likely leave less time for other activities, including direct patient care.
  • Costs: The program required roughly $500,000 in startup costs for staff (partial year), space, furniture, supplies, and equipment (e.g., computers, copiers, fax machines). Annual operating expenses average roughly $800,000 a year.
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Funding Sources

New York State Department of Health
The New York State Department of Health covers the costs of program operations, including the QI collaboratives, using funds from the State. Money for routine program operations comes out of the State general fund, while funds to support the QI collaboratives are included as a line item in the State budget.end fs

Tools and Other Resources

Background information on the law mandating public reporting of HAIs can be found at: http://www.health.ny.gov/statistics/facilities/hospital/hospital_acquired_infections/.

Older public reports can be accessed through the following links:

More information on NHSN is available at: http://www.cdc.gov/nhsn/.

Adoption Considerations

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Getting Started with This Innovation

  • Find champion in health department and legislature: HAI champions throughout New York State, including program-level employees within the Department of Health, the Commissioner and Deputy Commissioner, legislators, and representatives from hospital associations and consumer groups, worked together to pass the legislation and quickly secure startup funding. As a result, the program was able to begin operations quickly; between June and December of 2006, program leaders secured needed equipment, hired and trained staff, and trained all hospitals.
  • Work with NHSN system: This system already has standard surveillance definitions, and many hospitals already use it as part of other reporting programs. Because so many hospitals use it, they can easily share knowledge, experiences, and lessons learned. As noted, CDC staff may be available to assist with training.
  • Expect initial data-related challenges: Hospitals will inevitably face data-related challenges early in the process, and getting them “up to speed” will likely require a major, one-time training effort in addition to ongoing training as reporting requirements change. Over time, the system will run more smoothly, with most reports generated automatically based on standard input.

Sustaining This Innovation

  • Align requirements with other initiatives: To avoid overburdening hospitals, choose HAIs that hospitals already report as part of other initiatives. For example, the Centers for Medicare and Medicaid Services has a program in which hospitals report CLABSIs.
  • Consider funding QI projects: While not a core element of the program, department support of QI projects provides an opportunity for hospitals to test innovations that they likely could not develop and evaluate on their own.
  • Offer ongoing support: To keep hospitals engaged, offer ongoing technical support related to reporting requirements and assistance with QI initiatives.

Use By Other Organizations

Currently, 28 states have passed some sort of legislation related to HAI reporting, 21 of which use NHSN. More information is available at: http://www.cdc.gov/hai/QA_stateSummary.html.

More Information

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Contact the Innovator

Cindi Dubner
State HAI Plan Coordinator
New York State Department of Health
Bureau of Healthcare-Associated Infections
ESP Corning Tower, Room 2580
Albany, NY 12237
Phone: (518) 474-3343
Fax: (518) 473-4090
E-mail: clk01@health.state.ny.us

Emily Lutterloh, MD, MPH
Bureau Director
New York State Department of Health
Bureau of Healthcare-Associated Infections
ESP Corning Tower, Room 523
Albany, NY 12237
E-mail: ecl02@health.ny.gov

Valerie Haley, MS
Data Manager
New York State Department of Health
Bureau of Healthcare-Associated Infections
ESP Corning Tower, Room 2580
Albany, NY 12237
E-mail: vbh03@health.state.ny.us

Innovator Disclosures

Ms. Dubner, Dr. Lutterloh, and Ms. Haley reported that the New York State Department of Health received a grant from the CDC that helped to cover travel and administrative costs related to this program.

References/Related Articles

New York State Department of Health. Hospital-Acquired Infections. New York State, 2010. Available at: http://www.health.ny.gov/statistics/facilities/hospital/hospital_acquired_infections/2010/docs
/hospital_acquired_infection.pdf
.

Footnotes

1 Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122(2):160-6. [PubMed] Available at: http://www.cdc.gov/ncidod/dhqp/pdf/hicpac/infections_deaths.pdf.
2 Siegel JD, Rhinehart E, Jackson M, et al. The Healthcare Infection Control Practices Advisory Committee. U.S. Centers for Disease Control and Prevention. Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006. December 29, 2009. Available at: http://www.cdc.gov/hicpac/mdro/mdro_3.html.
3 Scott RD. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention. Centers for Disease Control and Prevention. March 2009. Available via link provided at: http://www.cdc.gov/HAI/burden.html.
4 U.S. Department of Health and Human Services. HHS Action Plan to Prevent Healthcare-Associated Infections: Research. (No date provided.)
5 New York State Department of Health. Hospital-Acquired Infections. New York State, 2010. Available at: http://www.health.ny.gov/statistics/facilities/hospital/hospital_acquired_infections/2010/docs
/hospital_acquired_infection.pdf
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Original publication: September 26, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.