CUSON Researchers Release Important New Findings
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 self-report 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."
Citations:
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.