Public reporting of healthcare-associated infections (HAIs) could become mandatory in the USA if a proposed major health care legislation gets approved by the House of Representatives. In a joint letter to members of Congress, five public-health organisations have voiced their support for the requirement, saying it will help to cut down on potentially deadly hospital infections.

 

“Patients have a right to know how well they are protected from healthcare-associated infections and this level of openness will encourage healthcare facilities to improve their outcomes,” said Jeffrey Levi, Executive Director of Trust for America’s Health, in a press release.

 

The statement of support was made together with experts from the Association for Professionals in Infection Control and Epidemiology (APIC), the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Council of State and Territorial Epidemiologists (CSTE).

 

US government estimates suggest that in 2002 alone, 1.7 million infections were picked up by patients while in hospital, at a cost of 28–33 billion dollars. Nearly 100,000 deaths were associated with these infections that year, making this one of the top 10 leading causes of death in the country.

 

HAIs come from various sources including the use of medical devices, transmission of pathogens from other patients or health workers, and overuse of antibiotics that promotes resistance to available drugs. Pathogens find an easy target in hospitalised people already weakened by existing medical conditions.

 

According to the US Centers for Disease Control and Prevention (CDC), there are signs of improvement for certain infections at some hospitals. But for others, including methicillin-resistant Staphylococcus aureus (MRSA), more cases are being recorded with each passing year. “This legislation will assure accountability and transparency as the nation moves to address this growing public health problem,” says Levi.

 

America's Affordable Health Choices Act of 2009 was introduced in the House of Representatives on 14 July, and is due for a vote in coming weeks after finding approval by a third House committee on 31 July. The bill states that hospitals and ambulatory surgical centres will be required to make public their data on HAIs as a condition for participating in Medicare and Medicaid, government-funded programmes providing health insurance to millions of people who are disabled, older than 65 years, or have low income.

 

The data will be deposited in the National Healthcare Safety Network, an internet-based CDC surveillance programme already in place. Setting up this system means that infections associated with health care will be reported in the same way across the country, according to public health experts supporting the bill, making it easier to compare infection rates and trends across regions. “This will give us the science base we need to better prevent HAIs,” says Mark Rupp, president of SHEA.

 

The system proposed under the new bill can allow people and agencies to assess progress in controlling HAIs over time, but only for those infections where reporting criteria are reliable and accepted by the public health community, comments Donald Goldmann, Professor at the Department of Epidemiology at the Harvard School of Public Health, Senior Physician at Children’s Hospital Boston, and Senior Vice President at the Institute for Healthcare Improvement in Massachusetts, USA.

 

“For the most robust measures, it may be possible to determine that some [healthcare] organizations have exemplary performance that should be emulated,” says Goldmann. But he sees some practical obstacles in getting this done, pointing out that “collecting data for most of the measures is burdensome and not yet automated”.

 

Under the current system, data on hospital-specific rates of infection reported to the CDC are not released to the public, and participation in the surveillance system is voluntary. But the tide towards public reporting began to turn in 2002, when some US states began to pass legislation requiring healthcare organisations to put HAI data in the public domain. Proponents of this approach believe this will improve the quality of care and give people the information they need to make informed choices about their health care.

 

But a public reporting system is not without drawbacks, cautions the European Centre for Disease Prevention and Control (ECDC). “In order not to be blamed hospitals may underreport their infection rates,” ECDC experts tell EHTF News. A comparison of infection rates across different hospitals will be “scientifically inadmissible” if different HAI definitions are used, or validation of the surveillance system has not been done.

 

In Europe, each country is responsible for setting a legal requirement for HAI surveillance. More than half of EU member states have national surveillance systems in place, says the ECDC — all confidential, except the system operating in the UK. “Gradually more and more MS [member states] are implementing (confidential) surveillance according to the ECDC protocols.”

 

There are no controlled trials available to assess the impact of mandatory reporting, with or without public disclosure of the information, adds the ECDC. A public system such as the one that operates in the UK, and as is now proposed in the USA, “may influence the sensitivity of reporting so that the changes in rates might not reflect a true change of practices.” But Goldmann believes the country’s example should be followed elsewhere. “The UK did a great job tracking MRSA bloodstream infection, and the transparency and simplicity of what was done merits study by other countries.”

 

The UK Health Protection Agency was not available to comment on the success of the reporting strategy. Data released last June suggest a decrease in the number of MRSA bloodstream infections compared to the same quarter of last year, but a small increase compared to the previous quarter. A similar trend was seen for the number of Clostridium difficile infections.

 

Last June the EU commission approved a Council Recommendation on patient safety, which aims to complement national policies for preventing and controlling HAIs. This is a political agreement but is legally non-binding, says the ECDC. “There is no suggestion for mandatory reporting with public disclosure, like for instance [that] performed in the UK for surgical site infections and MRSA bloodstream infections.”

 

Rather than using “outcome indicators”, which ECDC says are more prone to “underreporting and misinterpretation”, European countries are advised to use “structure and process” indicators of how well healthcare organisations are doing in reducing HAIs. Structure indicators might refer to resources and staffing, while process indicators would include factors such as hand hygiene. Compliance with agreed surveillance strategies is one of the process indicators that can help to evaluate infection control programmes, explains the ECDC.