[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
HEALTHCARE-ASSOCIATED INFECTIONS: A PREVENTABLE EPIDEMIC
=======================================================================
HEARING
before the
COMMITTEE ON OVERSIGHT
AND GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
APRIL 16, 2008
__________
Serial No. 110-122
__________
Printed for the use of the Committee on Oversight and Government Reform
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
index.html
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COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM
HENRY A. WAXMAN, California, Chairman
EDOLPHUS TOWNS, New York TOM DAVIS, Virginia
PAUL E. KANJORSKI, Pennsylvania DAN BURTON, Indiana
CAROLYN B. MALONEY, New York CHRISTOPHER SHAYS, Connecticut
ELIJAH E. CUMMINGS, Maryland JOHN M. McHUGH, New York
DENNIS J. KUCINICH, Ohio JOHN L. MICA, Florida
DANNY K. DAVIS, Illinois MARK E. SOUDER, Indiana
JOHN F. TIERNEY, Massachusetts TODD RUSSELL PLATTS, Pennsylvania
WM. LACY CLAY, Missouri CHRIS CANNON, Utah
DIANE E. WATSON, California JOHN J. DUNCAN, Jr., Tennessee
STEPHEN F. LYNCH, Massachusetts MICHAEL R. TURNER, Ohio
BRIAN HIGGINS, New York DARRELL E. ISSA, California
JOHN A. YARMUTH, Kentucky KENNY MARCHANT, Texas
BRUCE L. BRALEY, Iowa LYNN A. WESTMORELAND, Georgia
ELEANOR HOLMES NORTON, District of PATRICK T. McHENRY, North Carolina
Columbia VIRGINIA FOXX, North Carolina
BETTY McCOLLUM, Minnesota BRIAN P. BILBRAY, California
JIM COOPER, Tennessee BILL SALI, Idaho
CHRIS VAN HOLLEN, Maryland JIM JORDAN, Ohio
PAUL W. HODES, New Hampshire
CHRISTOPHER S. MURPHY, Connecticut
JOHN P. SARBANES, Maryland
PETER WELCH, Vermont
------ ------
Phil Schiliro, Chief of Staff
Phil Barnett, Staff Director
Earley Green, Chief Clerk
Lawrence Halloran, Minority Staff Director
C O N T E N T S
----------
Page
Hearing held on April 16, 2008................................... 1
Statement of:
Lawton, Edward, a survivor of hospital-acquired infections;
Cynthia Bascetta, Director for Healthcare Issues,
Government Accountability Office; Peter Pronovost, M.D.,
Ph.D., medical director, Center for Innovation in Quality
Patient Care and assistant professor, Department of
Anesthesiology and Critical Care Medicine, Johns Hopkins
University, School of Medicine; John Labriola, senior vice
president and hospital director, William Beaumont Hospital-
Royal Oak; Leah Binder, chief executive officer, the
Leapfrog Group; and Don Wright, M.D., MPH, Principal Deputy
Assistant Secretary for Health, U.S. Department of Health
and Human Services......................................... 12
Bascetta, Cynthia........................................ 32
Binder, Leah............................................. 49
Labriola, John........................................... 40
Lawton, Edward........................................... 12
Pronovost, Peter......................................... 33
Wright, Don.............................................. 56
McCaughey, Betsey, Ph.D., founder and chairman, Committee to
Reduce Infection Deaths.................................... 114
Letters, statements, etc., submitted for the record by:
Binder, Leah, chief executive officer, the Leapfrog Group,
prepared statement of...................................... 52
Cummings, Hon. Elijah E., a Representative in Congress from
the State of Maryland, prepared statement of............... 123
Davis, Hon. Tom, a Representative in Congress from the State
of Virginia, prepared statement of......................... 8
Hodes, Hon. Paul W., a Representative in Congress from the
State of New Hampshire, the New Yorker article............. 92
Labriola, John, senior vice president and hospital director,
William Beaumont Hospital-Royal Oak, prepared statement of. 42
Lawton, Edward, a survivor of hospital-acquired infections,
prepared statement of...................................... 14
McCaughey, Betsey, Ph.D., founder and chairman, Committee to
Reduce Infection Deaths, prepared statement of............. 117
McCollum, Hon. Betty, a Representative in Congress from the
State of Minnesota, article on patient safety and quality.. 104
Pronovost, Peter, M.D., Ph.D., medical director, Center for
Innovation in Quality Patient Care and assistant professor,
Department of Anesthesiology and Critical Care Medicine,
Johns Hopkins University, School of Medicine, prepared
statement of............................................... 36
Waxman, Chairman Henry A., a Representative in Congress from
the State of California, prepared statement of............. 4
Wright, Don, M.D., MPH, Principal Deputy Assistant Secretary
for Health, U.S. Department of Health and Human Services,
prepared statement of...................................... 59
HEALTHCARE-ASSOCIATED INFECTIONS: A PREVENTABLE EPIDEMIC
----------
WEDNESDAY, APRIL 16, 2008
House of Representatives,
Committee on Oversight and Government Reform,
Washington, DC.
The committee met, pursuant to notice, at 11:09 a.m., in
room 2154, Rayburn House Office Building, Hon. Henry A. Waxman
(chairman of the committee) presiding.
Present: Representatives Waxman, Kucinich, Davis of
Illinois, Watson, Yarmuth, McCollum, Hodes, Sarbanes, Davis of
Virginia, Burton, Shays, and Platts.
Also present: Representative Murphy of Pennsylvania.
Staff present: Andy Schneider, chief health counsel; Sarah
Despres, senior health counsel; Steve Cha, professional staff
member, Earley Green, chief clerk, Teresa Coufal, deputy clerk;
Jesseca Boyers, special assistant; Ella Hoffman, press
assistant; Leneal Scott, information systems manager; Kerry
Gutknecht and Miriam Edel, staff assistants; Larry Halloran,
minority staff director; Jennifer Safavian, minority chief
counsel for oversight and investigations; Ashley Callen,
minority counsel; Jill Schmaltz and Benjamin Chance, minority
professional staff members; Patrick Lyden, minority
parliamentarian and member services coordinator; and John Ohly,
minority staff assistant.
Chairman Waxman. The meeting of the committee will come to
order. Today we will examine an epidemic that causes about 2
million infections and 100,000 deaths each year and costs the
Nation billions of dollars. This epidemic ranks sixth among the
leading causes of death. It is largely preventable, and the sad
fact is we are not doing nearly enough to prevent it.
The epidemic I am referring to is healthcare-associated
infections. These are the infections that patients get when
they are in the hospital, clinic, or even their doctor's
office, receiving treatment for other illnesses.
Today's discussion will be limited to the infections
patients get in the hospital. There are several types of
healthcare-associated infections. Patients often need large
catheters placed into their bloodstream. Improper procedures by
physicians and nurses can contaminate these lines and cause
bloodstream infections. When patients need surgery, improper
procedures can lead to unnecessary infections of the surgical
site.
Today's hearing will focus on what the Department of Health
and Human Services is doing to address this epidemic. According
to new findings by the Government Accountability Office, the
Department is not providing the necessary leadership. It has
not identified for hospitals the most important infection-
control practices, and it is not coordinating the collection of
data from hospitals in order to avoid duplication and
unnecessary burden.
The failure of HHS leadership is particularly regrettable
because these illnesses, deaths, and costs are preventable.
Moreover, the preventive measures don't require new
technologies or large investments.
Thanks to the work of one of our witnesses, Dr. Peter
Pronovost, and the efforts of Michigan hospitals, we know that
by taking simple steps hospitals can significantly reduce the
number of patients who become infected when they are receiving
treatment for another condition. These steps are not expensive.
Healthcare workers should wash their hands before inserting the
catheter into a blood vessel. If a patient is going to undergo
a surgical procedure, the hair around the surgical site should
be removed with clippers, not a razor, so as to avoid nicks and
cuts that can be routes of infection. Catheters should be
withdrawn as soon as they are no longer necessary.
We are going to hear this morning from a hospital
administrator whose hospital has taken these simple infection-
control measures. He will explain that his hospital's infection
rate dropped precipitously.
How many deaths could be prevented if all the hospitals
took these simple steps? I asked the Society of Healthcare
Epidemiologists to prepare an estimate of the number of deaths
from healthcare-associated infections that could be prevented
by using proven interventions. They noted that data was
limited, and analyzed just four kinds of healthcare-associated
infections. According to their analysis, we could prevent tens
of thousands of deaths each year just by doing what we already
know how to do.
Earlier this week the Institute of Medicine [IOM] reported
that there would be a large cost savings if we simply put our
knowledge into action. The IOM conservatively estimated that
healthcare-associated infections result in extra costs of about
$5 billion with a ``B,'' billion per year to society as a
whole.
Other infection-control measures may be promising, but are
less well understood. For instance, two articles recently
appeared in the top medical journals about screening for the
drug resistant bacteria known as MRSA. One concluded that MRSA
screening did work. One concluded it did not.
HHS needs to help hospitals understand which strategies do
work. But hospitals should not wait while HHS sorts out all the
evidence. They should adopt the simple measures that are
already proven and give their patients the benefit of the
lowest achievable risk of infection.
It is not too often that a prevention strategy comes along
that is simple, inexpensive to implement, and proven to be
effective in reducing the number of patients' deaths. The
experience of the Michigan hospitals demonstrates clearly that
this prevention strategy works.
Today we will try to understand why the Department of
Health and Human Services is not doing more to lead in the
dissemination and adoption of this strategy nationwide.
[The prepared statement of Chairman Henry A. Waxman
follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman Waxman. Before we call on the witnesses, I want to
recognize Mr. Tom Davis for an opening statement.
Mr. Davis of Virginia. Thank you, Mr. Chairman.
A century and a half ago, Hungarian physician Ignaz
Semmelweis noted that one in three women died from fever after
giving birth in hospitals. He was the first to make the
connection between basic hygiene practices by doctors and the
deadly trend. When he instructed his students to wash their
hands before examining patients, the maternal death rate fell
to less than 1 percent.
Today we think of our healthcare system as highly advanced
and technologically sophisticated. But hospital infection rates
remain stubbornly and unacceptably high. The very complexity of
modern healthcare delivery can give persistent microbes many
more places to hide. Distracted by all the costly gadgets,
effective and cheap low-tech solutions like basic hand hygiene
can be overlooked and undervalued.
This year, in this country, 1.7 million patients will
contract an infection in a healthcare facility; 98,000 of those
patients will not survive. Those who do may face degraded
health, unnecessary time away from work and family, and the
additional costs of treating a preventable complication of
their original care.
Ed Lawton is one of those survivors. Facing surgery in
1998, Mr. Lawton could not have foreseen the most dangerous
threat to his health would be antibiotic-resistant infections
acquired in the hospital. That contamination put his life in
danger, and needlessly added years to the course of his
recovery. Mr. Lawton is a constituent of mine and a victim of
the painful, costly, and too often deadly epidemic of hospital-
acquired infections. His sad saga brings meaning to the often
lifeless statistics about our healthcare system's dirty
secrets. We are grateful he could be here to testify today on
the impact and implications of this intractable public health
threat.
On top of the human suffering, treatment of hospital-
acquired infections adds $5 billion to healthcare spending
annually. In a system already strained to meet urgent needs,
the $5 billion is wasted fixing preventable mistakes. Those
resources could be used to treat vulnerable children, research
or a cure for debilitating disease. Reducing the instance of
infection would improve the quality of care, prevent needless
suffering and death, and reduce waste.
It is a problem with known solutions, but the healthcare
system has been largely ineffective at making progress. Why?
One answer seems to be pervasive financial incentives that
simply pay the bill for care-induced infections rather than
reward prevention or punish carelessness.
In an effort to reverse that flow, the Department of Health
and Human Services recently engaged the powerful fiscal tool
available to the Federal Government in the healthcare
marketplace: Medicare repayments. By withholding reimbursements
for certain hospital infections, the Federal Government sends a
powerful signal that healthcare spending should align more
closely with quality outcomes, and the signal is being heard.
That change in Medicare policy helped pave the way for
similar changes in private insurance reimbursement. At the
request of the Minority, the Leapfrog Group will testify this
morning. They represent large private purchasers of healthcare,
and will discuss the importance of incentives to focus spending
on the quality, not just the quantity of care. We appreciate
the chairman's willingness to include their testimony in
today's hearing. It is still too early to know the impact of
these reforms, and the opportunities for change have not been
exhausted.
HHS has yet to maximize the use of various health
surveillance data bases, expand the type of infections Medicare
will no longer pay for, and partner with hospitals and payers
to make infectious-control activities a priority. Health
facility boards and CEOs need to be clear that infection
prevention is an indispensable element in the standard of care.
Cultural behavioral norms will have to change and money may
have to be invested to implement infection-control guidelines.
And hospital accreditation standards should reflect stronger
anti-infection requirements, demanding more than just a plan,
but an actual program that produces measurable outcomes to
reduce contamination.
We do know that there are significant opportunities to
effect change in hospital infection rates. The Centers for
Disease Control and Prevention has developed detailed
guidelines for infection control. We will also hear about
private research into healthcareinterventions that have
dramatically lowered infection rates. The answer may seem
simple--a little soap, a drop of bleach--but the broad-scale
changes needed to clean up healthcare institutions won't be
easy. Hearings like this shine the disinfecting light of public
discourse on a critical public health problem, and we look
forward to today's testimony. Thank you.
[The prepared statement of Hon. Tom Davis follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman Waxman. Thank you very much, Mr. Davis.
I want to call forward our panel 1: Edward Lawton a
survivor of hospital-acquired infections; Cynthia Bascetta,
Director for Healthcare Issues, Government Accountability
Office; Peter Pronovost, medical director, Center for
Innovation in Quality Patient Care and Assistant Professor,
Department of Anesthesiology and Critical Care Medicine at
Johns Hopkins University School of Medicine; John Labriola,
senior vice president and hospital director, William Beaumont
Hospital, Royal Oak; Leah Binder, chief executive officer of
the Leapfrog Group; Don Wright, M.D., Principal Deputy
Assistant Secretary for Health, U.S. Department of Health and
Human Services.
As you come forward to take your seat, why don't you remain
standing, because it is the practice of this committee that all
witnesses that testify do so under oath. So I would like you to
please raise your right hands.
Mr. Davis of Virginia. Mr. Chairman, could I ask unanimous
consent to let Mr. Murphy of Pennsylvania, Mr. Tim Murphy,
participate in the hearing?
Chairman Waxman. Without objection, we would welcome his
participation. We are pleased to welcome you today.
[Witnesses sworn.]
Chairman Waxman. The Chair wants to note for the record all
the witnesses answered in the affirmative. So you are properly
under oath. And we want to welcome you to give your testimony.
Your written statements that have been submitted in advance
will be part of the record in full.
We would like to ask each of you to limit your oral
presentation to around 5 minutes. We will have a clock, a
buzzer over there that doesn't ring, but it does have a light.
And when the green light is on it means your time is still
going. For the last minute it will turn yellow. And then when
the time is up, it will turn red. And when you see it red, I
would hope you would conclude your remarks or summarize them
very quickly.
Mr. Lawton, thank you so much for being here. I want to
welcome you, and particularly note you are a constituent of Mr.
Davis', and for being willing to share the unfortunate
circumstances that befell you, which are going to be helpful to
us to learn.
There is a button on the base of the mic, and be sure to
pull it close enough so that it will all be picked up.
STATEMENTS OF EDWARD LAWTON, A SURVIVOR OF HOSPITAL-ACQUIRED
INFECTIONS; CYNTHIA BASCETTA, DIRECTOR FOR HEALTHCARE ISSUES,
GOVERNMENT ACCOUNTABILITY OFFICE; PETER PRONOVOST, M.D., Ph.D.,
MEDICAL DIRECTOR, CENTER FOR INNOVATION IN QUALITY PATIENT CARE
AND ASSISTANT PROFESSOR, DEPARTMENT OF ANESTHESIOLOGY AND
CRITICAL CARE MEDICINE, JOHNS HOPKINS UNIVERSITY, SCHOOL OF
MEDICINE; JOHN LABRIOLA, SENIOR VICE PRESIDENT AND HOSPITAL
DIRECTOR, WILLIAM BEAUMONT HOSPITAL-ROYAL OAK; LEAH BINDER,
CHIEF EXECUTIVE OFFICER, THE LEAPFROG GROUP; AND DON WRIGHT,
M.D., MPH, PRINCIPAL DEPUTY ASSISTANT SECRETARY FOR HEALTH,
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
STATEMENT OF EDWARD LAWTON
Mr. Lawton. Chairman Waxman, Ranking Member Davis, members
of the House Committee on Oversight and Government Reform,
distinguished and honored guests, my name is Edward Lawton, and
today I sit before you, a survivor of healthcare-acquired MRSA,
VRE, osteomyelitis, and klebsiella.
Today is very special not only because of the privilege of
speaking before you, but because it is the 10th anniversary of
my survival of the two most serious aforementioned healthcare-
acquired infections. Ten years ago today, following two
scheduled back surgeries, I lay in a hospital bed diagnosed
with MRSA. Later, VRE and osteomyelitis would also be
identified.
Ultimately, in 1998 I spent 9 months surviving what I
characterize as the fog of survival. I had five back surgeries,
many smaller procedures, injections too numerous to count, and
more prescribed drugs than I can recall. Three of those
surgeries necessitated debridement. My doctor was required to
open me up three times over a period of 90 days and surgically
remove contaminated tissue and foreign matter. Consequences of
the infections had broader implications relating to nerve and
skeletal damage and other health consequences, most of which
you cannot see.
Returning home in late 1998, I spent the next 5\1/2\ years
reconstituting my life, despite the fact that I could no longer
independently stand or walk. Five open back wounds also
diminished my homecoming. They never healed. A wound specialist
advised me the wounds couldn't heal due to osteomyelitis. He
said I could only be treated by more surgery, without
assurances of resolution. I felt trapped, facing an inevitable
consequence.
I survived, but according to CDC estimates approximately
99,000 others among the population of nearly 2 million patients
nationwide, all diagnosed with healthcare-acquired infections,
died that same year in America. In the past decade of my
survival, approximately 20 million people were diagnosed with
avoidable healthcare-acquired infections, with more than 1
million patients dying. Those are staggering statistics.
In 2004, I was rehospitalized. I had the surgery, and
afterwards my doctor told me I would require additional
surgeries to remove substantial infectious fluids in my body,
along with the remaining rods and screws, all contaminated by
klebsiella. I had two additional surgeries among other
specialized care. My 6-1/2-year infection saga finally seemed
over, along with the open back wounds.
In 2004, unlike my earlier hospitalizations, I insisted
upon certain protective measures during my hospital stay. I had
educated myself since 1998, and I refused to die because of
someone's dirty hands or complacent attitude. This time I
didn't contract a hospital infection. I have detailed my
initiatives in my accompanying written statement.
In 1998, I witnessed and experienced unconscionable acts of
hospital staff. If these well-trained, well-educated medical
professionals had complied with their own standards and
protocols, I probably would have walked into this hearing as a
spectator rather than entering in a wheelchair as a witness.
Past years' testimony to Congress by former secretaries and
assistant secretaries of the Department of Health and Human
Services all consistently acknowledged the crisis of
healthcare-acquired infections, yet well-educated and well-
trained medical practitioners continued perpetuating the
culture of complacency, ignoring the same rules we teach our
children to follow before they sit at a dinner table.
Medical practitioners routinely claim that due to the
inherent dangers of their work environment, healthcare
infection-related deaths are unavoidable. Is that the
interpretation of friendly fire? Consider that for 42 years,
police officers in America have carried what is called the
``rights card'' so any interview with a suspect is preceded by
the reading of the person's constitutional rights. Eight years
ago Chief Justice William Rehnquist stated the advisement of
rights was part of the national culture.
Why shouldn't medical practitioners carry anti-infection
cards to protect the survival rights of patients by explaining
fundamental hygienic protocols? I have created a sample for
your review and consideration. Sadly, during my presentation
today, someone died in America due to an infection they
contracted in the hospital they trusted.
Finally, Americans ought to know what is occurring in their
hospitals. We can research nearly anything on the Internet. Why
don't we have the same right to check out a hospital before we
risk our lives entering it?
Thank you for your courtesy. I hope my comments contribute
to converting HHS sound bites into meaningful, proactive
workplace attitudes, ending the scourge of healthcare-acquired
infections.
Chairman Waxman. Thank you very much, Mr. Lawton.
Mr. Lawton. Thank you, sir.
[The prepared statement of Mr. Lawton follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman Waxman. Ms. Bascetta.
STATEMENT OF CYNTHIA BASCETTA
Ms. Bascetta. Mr. Chairman, Mr. Davis, and other members of
the committee, thank you for the opportunity to discuss our
report, completed at your request----
Chairman Waxman. There is a button on the base of the mic.
Ms. Bascetta. It is on. It is probably not close enough.
Chairman Waxman. Pull it a little closer.
Ms. Bascetta [continuing]. To discuss our report, completed
at your request, on healthcare-associated infections in
hospitals.
Common HAIs, such as bloodstream, surgical site, and
urinary tract infections can be deadly. And evidence is
mounting that they also take an economic toll on our healthcare
system and on the hospitals in which they occur.
But patients should not have to accept HAIs as a necessary
risk of medical treatment. In fact, some hospitals have
dramatically lowered their HAI rates by using new infection-
control techniques and by enforcing others, like hand washing,
which was proven to save patients' lives more than 100 years
ago.
Our report identified ongoing HHS activities that could
help reduce HAIs. CDC has issued 13 guidelines for hospitals
that contain almost 1,200 recommended practices. And 500 of
them are strongly recommended. However, only a few of them are
incorporated by CMS and accrediting organizations in the
required standards for hospitals.
Second, HHS has multiple HAI data bases, but none provide a
complete picture about the magnitude of the problem. Some of
the data bases are limited by nonrepresentative sampling, and
reporting differences impede combining the data to better
understand the extent of HAIs and to measure progress in
reducing rates.
A good example is the lack of linkage between one data base
on surgical infection rates and another on surgical processes
of care, even though these data bases cover some of the same
patients.
Third, both AHRQ and CDC fund research aimed at reducing
HAIs. However, there is little evidence of their collaboration
to maximize the return on research dollars and avoid
duplication.
And finally, CMS has included some HAI-related measures in
its pay-for-performance program for hospitals and has targeted
three preventable HAIs for which it will eliminate Medicare
patients beginning this October. But it is too early to tell
how effective this will be and how many conditions can be
tackled through the payment system.
Despite these actions, we believe that HHS is not
exploiting its leverage to reduce or eliminate HAIs. We
concluded that leadership from the Secretary is required for
HHS to bring to bear the multiple ways for influencing
hospitals to tackle the HAI problem. However, an official from
HHS told us that no one within the Office of the Secretary is
responsible for coordinating infection-control activities
across the Department.
In light of the prevalence and the serious consequences of
HAIs, this lack of leadership has already resulted in lost
opportunities to take concerted action to reduce the suffering
and death caused by these infections. We made two
recommendations that, if implemented, could help HHS gain
sufficient traction to be more effective.
First, we recommended that the Secretary identify
priorities among CDC's recommended practices and determine how
to promote their implementation. This would include whether to
incorporate selected practices into CMS's conditions of
participation for hospitals. In its comments on our draft
report, CMS said that it welcomed the opportunity to work with
CDC on this matter. CDC has categorized the practices on the
basis of the strength of scientific evidence, but work by AHRQ
suggests that cost, complexity, organizational obstacles, and
other factors are necessary in considering how to set
priorities.
Making headway is important because the large number of
practices and the lack of departmental-level prioritization has
hindered efforts to promote their implementation. Clear
priorities could assist CMS and the hospital accrediting
organizations in determining whether additional recommended
practices ought to become part of the required infection-
control standards for hospitals. And it could also help
hospitals themselves monitor their own efforts to reduce HAIs.
Our second recommendation was for the Secretary to
establish greater consistency and compatibility of HAI data
collected across HHS to increase information available,
including reliable national estimates. HHS's comments
acknowledged the need for greater consistency and compatibility
and identified actions that CMS would take, as well as noted
that CDC has recently begun working toward greater alignment
with CMS. We encourage HHS to act quickly so it can draw a more
complete picture of the HAI problem.
Although we found CDC, CMS, and AHRQ officials discussed
HAI data collection with each other, they were not taking steps
to integrate any of the existing data bases by, for example,
creating linkages or standardizing patient identifiers. We
believe this would enable HHS to do a better job connecting the
dots regarding how hospitals can reduce these often preventable
infections. That concludes my comments.
Chairman Waxman. Thank you very much for the report and for
your testimony today.
[Note.--The Government Accountability Office report
entitled, ``Health-Care-Associated Infections in Hospitals,
Leadership Needed from HHS to Prioritize Prevention Practices
and Improve Data on These Infections,'' GAO-08-283, March 2008,
may be found in committee files.]
Chairman Waxman. Dr. Pronovost.
STATEMENT OF PETER PRONOVOST
Dr. Pronovost. Mr. Chairman, Mr. Davis, and members of the
committee, thank you for having me here today.
The suffering that Mr. Lawton incurred ought never happen,
nor should the excess costs that he incurred because of that.
I would like to share my reflections on why I think it
happened and what we might do about it. There was a promising
violinist who was a mother of two who woke up one night with
tingling in her hand and slurred speech. She had a CAT scan
that showed a large brain tumor. The surgeons did a very
technical test to measure her blood flow, that showed that
where they planned on cutting was the part of her brain that
actually allowed her to play the violin. And based on that
technical test, they changed how they were going to cut, and
she woke up with no deficit and is playing the violin now.
That case is one example of the dramatic benefits we have
had, as the U.S. public, from investments in biomedical
research. And that is one of many. Our life expectancy since
1955 is up from 69 to 78 years. AIDS is now virtually a chronic
disease. Many cancers, including childhood cancers, are
curable. And, indeed, a recent report said the United States is
more productive in research than the entire European Union. And
yet that same healthcare system infects Mr. Lawton, leaves
surgical equipment in patients, overdoses children with
heparin, and kills 98,000 people a year. And when we hear this,
how could we possibly explain this discrepancy?
And perhaps most concerning is the recent Commonwealth
report that showed that the United States ranks dead last in
measures of quality and access and efficiency among the 29
other countries in the Organization for Economic Cooperation
and Development. And when I think about this, how could it
happen, without trivializing it, the basic issue is that we
have failed to view the delivery of healthcare as a science.
That science or traditional biomedical science has funded
looking at genes and finding new therapies, but once we find
them or at least have a hunch, knowing whether they really work
in the real world or whether patients get them hasn't been a
priority.
Indeed, we spend a dollar for biomedical research for every
penny that we spend on research into safety and healthcare
delivery. And so it is entirely predictable and understandable
that we are ranked as the world's preeminent biomedical
sciences and yet are dead last in outcomes and quality.
Now, the public has seen the benefits when we do make some
small investments. I was fortunate enough to lead a project
funded by the Agency for Healthcare Research and Quality,
which, by the way, the direct costs were about 350,000 a year
for 2 years. We summarized the CDC guidelines and made a
checklist to reduce those infections and pilot-tested it at my
hospital, Johns Hopkins.
We then partnered with the Michigan Hospital Association
Safety Center at 127 ICUs in Michigan to put it in. We didn't
know that we could move all these infections from the
``inevitable'' bucket to the ``preventable,'' but we thought we
needed to try. The results were, frankly, breathtaking and were
published in the New England Journal of Medicine and
subsequently in the New Yorker. We virtually eliminated those
infections.
The median rate of infections was zero in those hospitals;
the overall rate was reduced by 66 percent. And those rates now
have stayed that low for 4 years after this infection. The
estimates are that annually it was saving somewhere around
1,800 lives and nearly $200 million in costs, all for an
investment of 350,000.
Unfortunately, though, there is far too few of those
programs that exist. We don't have a funding mechanism to
develop those programs, nor do we have funding to train people
who can lead them. But what it showed for us is when they are
done well, there is a hunger for it.
The hospitals in Michigan are saying, what is the next
program we can put in? They want one for surgical-site
infections or surgical safety, to tackle MRSA and VRE in a
meaningful way. And other States, including Oregon and
California, Arizona, and Ohio are asking, Could we come and do
this? So we really need HHS leadership.
Importantly, though, there seems to be barriers for this,
that indeed OHRP charged that this study violated the
protection of human subjects and that the study ought not
continue. They subsequently allowed us to continue in Michigan,
but there is not at all clarity about what is going to be
required to prevent these infections in Ohio and California or
for the myriad of other quality improvement programs that the
country so desperately needs.
And so I would ask the committee to consider four concrete
things that I think can make the difference.
The first is, I think, supplying some support for AHRQ to
make this program national, and to develop a pipeline of other
programs that the country is hungry for, to do in a
scientifically sound way. I think you could urge HHS to clarify
from OHRP what are the requirements to do these so that we
don't risk running afoul of regulations.
I think we need to increase funding for biomedical
research, and especially alter that ratio of a dollar to a
penny. It is appalling. Imagine what would happen if it was a
dollar to a dime or a dollar to a quarter.
And finally, we need to have programs to treat more people;
so there are many more people, like myself or my colleagues,
who can do these in a more robust way.
Your committee through this has the opportunity to save
more lives this year than we have in the last decade. And it is
going to take courageous leaders who are going to do this. And
I hope your committee can move us beyond the far too common
rhetoric of high-quality, low-cost care to make that a reality.
We have a program that works, that the return on investment
is almost ridiculous, and we need leadership to make that
happen--so that Mr. Lawton becomes a rare, rare exception.
Thank you.
Chairman Waxman. Thank you very much.
[The prepared statement of Dr. Pronovost follows:]
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Chairman Waxman. Mr. Labriola.
STATEMENT OF JOHN LABRIOLA
Mr. Labriola. Good morning, Chairman Waxman and committee
members. My name is John Labriola. I am the hospital director
of William Beaumont Hospital in Royal Oak, MI. And thank you
for the opportunity to offer comments on this most important
subject.
You had asked us to prepare and respond to some questions
about healthcare-associated infections dealing with
implications, barriers, costs and benefits. And, hopefully, our
written testimony has done that.
I just show you we had prepared a book last year. This book
really represents a compendium of all of the different
initiatives that we do at the hospital. The purpose of the book
was to show to our staff and our board and leadership what is
being done. But I think, more importantly, it was prepared to
demonstrate our commitment to this culture of safety that
exists in our hospital.
It is interesting that the mention of culture was brought
up earlier by Mr. Lawton. So in our case, it is the combination
of all of these activities, and more to develop, that will
improve care.
We are a very large hospital. We have a very high patient
census, both in terms of inpatient admissions and surgeries. We
are one of the largest hospitals in the country. The culture of
safety that I mentioned is a result of decisions that were made
by our hospital and medical leadership and supported by our
board many, many years ago. They established as an expectation,
as a core belief, the importance of safety for each and every
patient in our hospital. To create this culture has required
will and courage. It represents a commitment to challenge and
change, when necessary, the traditional beliefs and approaches
to care that are found in our hospital, and really throughout
the healthcare system.
We feel that at its core, patient safety is about the
dignity and respect of our patients. There are no alternatives.
It is difficult for me to isolate a cost for patient safety. To
us it is not a program or an approach, it is embedded in the
way we deliver care. It is how we hire our staff. It is how we
train our staff. It is part of our expectation of our staff. We
take words like ``teamwork'' and ``collaboration'' very
seriously. We ensure that all of our staff, from our very
skilled intensivists and nurses, our house staff, our support
staff, work together in a prescriptive manner that defines and
ensures that all treatments and care for our patients is
appropriate.
We have conducted over 40,000 briefings, done before every
surgery, to go over checklists so that everyone on the surgical
team confirms the patient, the site, what is to be done by all
the team members.
Behaviors of engagement and empowerment are emphasized and
supported by all members of our leadership team so that anyone
can stop a procedure if they feel something is not being done
correctly.
The Institute of Medicine's compelling reports have been a
call to action for all of us in healthcare. There is so much
more to do and improve in all of our systems and processes. So
for us, the adoption of the principles that surround Keystone,
which is what Dr. Pronovost was referring to, were very easy
for us to support and embrace; we, along with all the other
hospitals in Michigan.
The Keystone Michigan project has been a tremendous benefit
to us. Our patients are someone's family member, their loved
ones. When they are in our care they are to be protected. That
is why we have taken this so seriously, and why we need to do
what we have done.
Thank you for giving me the opportunity to talk about
Beaumont and its wonderful staff.
Chairman Waxman. Thank you very much, Mr. Labriola.
[The prepared statement of Mr. Labriola follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman Waxman. Is it Binder or Binder?
Ms. Binder. Binder.
Chairman Waxman. Binder. Ms. Binder, we are pleased to have
you with us. And there is a button on the base. Yes.
STATEMENT OF LEAH BINDER
Ms. Binder. Thank you. Thank you, Chairman Waxman,
Representative Davis, and members of the committee for the
opportunity to testify today on the problem of hospital-
acquired infections.
I am the CEO of the Leapfrog Group, which is a member-
supported nonprofit organization representing a consortium of
major companies and other private and public purchasers of
healthcare benefits for more than 37 million Americans in all
50 States. As our founders envisioned it, Leapfrog triggers
giant leaps forward in safety, quality, and affordability of
healthcare; hence, our name.
And we have two key business principles underlying our work
and underlying what I will talk about today in terms of our
perspective on hospital-acquired infections.
One is transparency. Healthcare quality data should be made
public, understandable, and accessible, supporting informed
decisionmaking by those who use and pay for healthcare.
And two, common sense alignment of payment with patient
outcomes. Financial incentives and rewards should be used to
promote high-quality, high-value healthcare that produces the
best possible outcomes for patients. We call this value-based
purchasing.
Leapfrog conducts an annual survey of hospitals, called the
Leapfrog Hospital Survey. It is completed by about 1,300
hospitals, which represent more than 60 percent of the
inpatient beds in the country. Several items on the Leapfrog
survey address whether hospitals have deployed proven methods
to reduce hospital-acquired infections. Unfortunately, last
year we found that 87 percent of the hospitals completing the
Leapfrog survey do not take the recommended steps to prevent
avoidable infections.
Leapfrog also applies our principles of transparency to
call for changes in the way hospitals handle medical errors and
infections. We call for hospitals to apologize to victims,
something Mr. Lawton did not receive and deserved.
We also call for hospitals to conduct root-cause analyses,
publicly report these events, and waive all charges related to
them. Many health plans now ask hospitals to adhere to these
principles, and we are confident they will soon be standard
practice.
The statistics, as we have discussed today, are
breathtaking. Infections kill almost twice as many people as
breast cancer and HIV/AIDS put together. Despite the
overwhelming impact of these preventable infections on U.S.
citizens, eradication has not been prioritized to the same
extent as other very important issues.
We believe that hospital-acquired infections are emblematic
of a larger problem in our healthcare system. We as
governmental and private sector payers have not traditionally
aligned financial incentives with patient well-being, and
unfortunately in some ways we get what we pay for. We pay for
this surgery, that medication, this x-ray, without tying the
payment to quality outcomes for the patient. We pay the same
even when errors occur that jeopardize the patient's health or
life. Indeed, we pay more for poor performance.
On average, hospital-acquired infections add over $15,000
to the patient's hospital bill, amounting to over $30 billion a
year wasted on avoidable costs. We must assume that money is
concentrated on hospitals with the worst record of hospital-
acquired infections.
As a former executive in a hospital network, I can say I
know firsthand the pressure to direct resources within the
hospital system toward the high-profit, new surgical suite, and
not toward the unreimbursed infection-control program. We as
purchasers have an obligation to take some of that pressure
off.
Leapfrog has been pleased to support HHS Secretary
Leavitt's efforts to foster increased healthcare transparency
and promote a healthcare market that recognizes and rewards
quality. We have worked with some very dedicated and visionary
colleagues throughout HHS, from AHRQ to CMS and CDC.
Unfortunately, many of their efforts and many of the components
of Secretary Leavitt's vision are not being prioritized and
coordinated effectively enough at this point. We offer the
following recommendations.
Federal agencies must view this problem as a priority. We
must measure the right things. We must be measuring patient
outcome. We do not have enough measures to actually tell us if
a particular procedure or a particular protocol we are
measuring leads to the outcomes we seek.
We must tie payments with outcomes. And that is something
that we have been working with CMS jointly on in many ways.
We would like to see much more aggressive actions, as
outlined in my written testimony. We must work together to
improve transparency. Hospital Compare is an excellent Web
site, but we believe it needs more outcomes-oriented measures,
and would like to work more closely with the Department to see
that happen.
We also need to acknowledge and support voluntary efforts
by hospitals across the country, such as Mr. Labriola's. They
are very impressive efforts. They are very powerful. And they
are not supported in terms of payment or in terms of the kind
of recognition that good hospitals deserve. The recognition is
money in the bank, too, because hospitals are often in
competitive marketplaces, and people deserve to know if one
hospital is really putting the effort out to achieve the right
outcomes for patients.
And finally, we would like to grant HHS more authority
around value-based purchasing. We, among private sector
employers, would like to commend Congress for your bold step in
the Deficit Reduction Act of 2005 toward redressing the current
perverse payment system.
In November 2007, HHS submitted a plan for the
implementation of value-based healthcare purchasing as
requested in section 5001(b). Our employer members
unequivocally support CMS's plan to replace the current payment
structure with this new program that includes both public
reporting and financial incentives for better performance as
tools to drive improvements in clinical quality, patient-
centeredness, and efficiency.
The proposed rule change would implement payment reforms,
strongly recommended by both the IOM and MedPac. We would like
to see if there is anything that could come out of today's
work; and your work as the committee would be more support for
this proposed rule change. Thank you.
Chairman Waxman. Thank you, very much, Ms. Binder.
[The prepared statement of Ms. Binder follows:]
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Chairman Waxman. Dr. Wright.
STATEMENT OF DON WRIGHT
Dr. Wright. Good morning, Chairman Waxman, Ranking Member
Davis, and other distinguished members of the committee. I am
Don Wright the Principal Deputy Assistant Secretary for Health
in the U.S. Department of Health and Human Services, Office of
Public Health and Science. Thank you for this opportunity to
appear before you on behalf of HHS to discuss our efforts to
reduce the rates of healthcare-associated infections.
There are several operating divisions within the Department
that have taken lead roles in addressing this important public
health challenge. These include the Center for Disease Control
and Prevention, the Agency for Healthcare Research and Quality,
and the Centers for Medicare and Medicaid Services. There are
also a number of examples of how these agencies have worked
collaboratively on this important issue.
We do recognize that there has been significant progress
made in several areas. However, HHS also recognizes more work
and leadership are necessary to enhance patient safety.
I want to take this opportunity to highlight some of our
activities within the Department that relate to or address
healthcare-associated infections. The CDC leads and supports a
range of infection-prevention activities on behalf of HHS. For
example, the agency produces evidence-based guidelines that
serve as the standard of care in U.S. hospitals, and guides to
clinical practices of healthcare providers.
The Healthcare Infection Control Practices Advisory Board,
an advisory committee to HHS and CDC, has provided
recommendations for the development of evidence-based
guidelines for the prevention of healthcare-associated
infections. And most recently, the CDC published guidelines to
prevent the emergence of antimicrobial resistance and stop
transmission of methicillin-resistant staphylococcus aureus
[MRSA], and other antimicrobial-resistant pathogens in
healthcare settings.
A second way the Department works to prevent healthcare-
associated infections is through the Agency for Healthcare
Research and Quality, the lead agency for patient safety. In
2007, AHRQ invested nearly 2 million in reducing HAIs through
its program, Accelerating Change and Transformation in
Organizations and Networks, a field-based research mechanism
designed to promote innovation in healthcare delivery.
AHRQ awarded five task orders to ACTION partners to support
infection mitigation activities at 72 hospitals. For 12 months,
teams at each participating hospital will implement clinical
training using AHRQ-supported evidence-based tools for
improving infection safety. The findings from the HAI
initiative will provide information on the barriers and
challenges to improving and sustaining infection safety.
In addition to these activities, there are interagency
initiatives that have recently been launched to reduce the
rates of healthcare-associated infections. For instance, in
fiscal year 2008, AHRQ was awarded 5 million to implement a new
initiative, in collaboration with both the CDC and CMS. To
identify gaps in prevention, diagnosis, and treatment of MRSA-
related infections across the healthcare system.
CDC plans to use this new knowledge and findings to update
multidrug resistant organism prevention, Healthcare Infection
Control Practices Advisory Committee recommendations, to modify
MRSA clinical management recommendations as appropriate, and to
advise prevention implementation campaigns on how best to
prevent MRSA infections. CMSexpects that the MRSA Initiative
project results will enhance the quality of care for Medicare
beneficiaries and, in general, public health.
Although we have a number of interagency activities in
place, we also know that there is a need to establish greater
consistency and compatibility of healthcare-associated
infection data. That is why the CDC and other HHS agencies have
made a concerted effort to establish compatibility of
healthcare-associated infection data across the Department. CDC
and CMS are working collaboratively toward a common set of data
requirements for monitoring both healthcare-associated
infections and adherence to their prevention guidelines.
Presently, they are working together on data requirements for
measurement of MRSA and toward an agreement on the surgical
procedures that should be monitored as part of public reporting
of surgical-site infection rates.
Before I close, I wanted to also mention the novel approach
to reducing healthcare-associated infection through payment
policy incentives. This is commonly referred to as value-based
purchasing, and is currently being undertaken by CMS. The
Deficit Reduction Act required CMS to select certain conditions
for which Medicare will no longer pay an additional amount when
that condition is acquired during a hospitalization.
CMS has collaborated closely with CDC on the selection of
these conditions, with particular attention to identifying
evidence-based guidelines that are consistent with CDC's
recommended practice. Thus, the Medicare payment provision is
closely tied to CDC's prioritized practices.
On Monday of this week, CMS announced additional steps to
strengthen the tie between the quality of care provided to
Medicare beneficiaries and payment for those services provided
when they are in the hospital by proposing to expand the list
of conditions. The proposed regulation builds on efforts across
Medicare to transform the program to a prudent purchaser of
healthcare services, paying based on quality of care, not just
quantity of service.
You have just heard me discuss activities related to the
prevention of HAIs, payment policy incentives, and also
surveillance and monitoring of healthcare-associated
infections. However, I think it is also important to note that
we recognize that the implementation of healthcare institutions
of quality improvement protocols can significantly reduce the
number of healthcare-associated infections. I know you join me
in saying that quality improvement research needs to continue
to improve patient safety for all Americans. What I hope to
convey during today's testimony is that the reduction of
healthcare-associated infections to enhance patient safety and
reduce unnecessary cost is a top priority for HHS. HHS looks
forward to working with all stakeholders, public and private,
in meeting its shared responsibility to reduce healthcare-
associated infections. I will be pleased to answer any
questions that you might have.
Chairman Waxman. Thank you very much for your testimony.
[The prepared statement of Dr. Wright follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman Waxman. And I want to thank all of you for your
presentation to us. You seem to be of one mind that there is
something we can do about a problem that is an extraordinary
one in costing lives and money, that could be prevented.
Maybe I will start off the questions. You might have heard
bells. We are being called to the House floor for some votes.
We will break in a minute. But let's see how far we can get.
Let me try to understand the scope of this problem.
According to the Centers for Disease Control's best estimates,
there are 1.7 million hospital-associated infections which lead
to 100,000 deaths each year. And these are largely preventable
infections. And they come at a price. They come at a price not
only to the person infected, who may lose his or her life, they
come at a price to the government, to employers, to members of
the family. The Institute of Medicine said we could save $5
billion. Now, most people who die of these infections don't
have it on their death certificate that they died of a hospital
infection. They usually have something else reported typically
as the cause of death.
But if we were able to look at this chart that I am going
to put up on the screen, or one that is already standing on the
pedestal there, what we have seen is that if you look at
hospital-associated infections, it would be the sixth leading
cause of death, higher than even diabetes. But unlike other
causes of death, this is one we know how to reduce.
Dr. Pronovost, you now have several years of experience
working with the hospitals in Michigan. You have a checklist
for these hospitals to follow. If all hospital ICUs in every
State were to use the same checklist, how many lives do you
estimate we could be saving?
Dr. Pronovost. Mr. Chairman, the number of deaths from this
particular type of infection is 28,000 a year. And the costs
are somewhere between $2 and $3 billion a year for these
catheter-related infections. I would add, though, that our
knowledge of both how to measure and the extent to which we
could actually prevent these infections for other infections is
less mature. For these, though, there is no doubt that we used
to think they were all inevitable. Now we know they are
virtually all preventable. The others, though, I think the
science still has to mature to say how much of them--certainly
some, but I don't know that we are comfortable in saying what
percentage are.
Chairman Waxman. Now, the GAO did an evaluation of our
efforts in that regard. And Ms. Bascetta, you found that we
just seem to have a very haphazard way of approaching the
problem from the government's perspective. What would allow us
to make sure that all the hospitals are doing the same thing
that Dr. Pronovost and the hospitals say they want to be able
to do?
Ms. Bascetta. Well, I think there are some basic infection-
control measures that are known that should be taken by all
hospitals. And then another important point to remember is that
it is important for hospitals to assess their own particular
risks. Some of them may need to prioritize things differently
than others. So we don't necessarily want them to all be
tackling exactly the same problem, although there are certainly
common approaches that they should take.
And our belief is that HHS could be doing a much better job
bringing to bear its collective expertise from CDC and AHRQ and
CMS to use these various leverage points to influence hospitals
to take the measures that they need to take.
Chairman Waxman. What is the problem? Three separate
agencies at HHS are not talking to each other, or are they
taking too long at each of these agencies to figure out what
recommendations to make, and make sure that the hospitals are
following them?
Ms. Bascetta. Well, although they all seem to have a sense
of urgency about the problem, collectively they haven't
achieved what we call ``traction'' in our report. And we think
it is because, although they talk to one another, most of their
discussions are so far in the nature of updating one another
about their independent actions or their independent data
bases. There isn't the synergy that is needed to ratchet up the
attention to how they can strategically attack the problem and
how they can get the word out to hospitals about their
expectations and about what hospitals can do.
Chairman Waxman. We want this hearing to be a constructive
hearing, because after this hearing is over we want to see
action, using low-cost technology in proven ways to reduce
these infections to save lives.
Dr. Pronovost, you developed a checklist. It looks like the
government is giving a very long list of things for hospitals
to do, but you had a simple checklist. Why aren't hospitals
just following your checklist?
Dr. Pronovost. Well, in part, because as you alluded to,
the typical way of summarizing guidelines is to make these
often elegant but 200 to 300-page documents that clinicians
don't read. They are too busy. And so we summarized the very
detailed CDC guidelines into five key points and packaged them
in a way. But what we were lucky enough to do, with some
funding from AHRQ, was to find the science. And it is really
almost social science of how do you get behavior change. How do
we make something in a way that clinicians buy into? And part
of it is having rigorous measurements so they believe the
results.
In this case we measured infections quite robustly, having
good evidence on which to act on, and then using some internal
levers--payment system is one of them--that they are encouraged
to say, I have to do the right thing. And we have made it easy
for them.
Chairman Waxman. Thank you. My time has expired. Mr. Davis.
Mr. Davis of Virginia. We have a quick vote coming up. Let
me ask Mr. Lawton--thank you for being here. The Leapfrog Group
recommends that when a patient is a victim of a medical error
or an infection, hospitals should apologize to the victims,
conduct root-cause analysis, publicly report events, and waive
all charges related to them. Did the hospital that treated you
take any of those steps after your infection in 1998?
Mr. Lawton. Not that I can recall.
Mr. Davis of Virginia. Would those steps have impacted your
experience at the hospital?
Mr. Lawton. Well, it would have helped me. The experiences
I went through, from what I remember--and I try not to
remember--were fairly traumatic. And I kind of suffered through
all of them. But I mean, the folks were nice. I know everybody
was busy trying to help people in the hospital. But I really
didn't feel that a lot of attention was given to that. It was
just part of the process. They were going through their day-to-
day activities and my situation----
Mr. Davis of Virginia. Just mailing it in. Thank you.
Ms. Binder, one of the outcomes that must be avoided is
that in good-faith attempts to reduce infections, the Federal
Government and the payers overburden hospitals with bureaucracy
to the point that energy is spent fulfilling requirements
versus improving care. That is also the balance.
Are there opportunities for the private sector and the
Federal Government to collaborate to avoid overburdening
hospitals?
Ms. Binder. Yes. And we have been working on collaborating
on exactly that issue for some time now, and continue to do so.
The key issue, as I stated in my testimony for the Leapfrog
Group, is that we are measuring--whatever measures we ask
hospitals to report--are measuring outcomes of care. Our focus
is on whether or not the patient improves or how the patient
does. The patient outcomes should be preeminent.
Ms. Bascetta. The patient outcome should be preeminent.
Now, it is very difficult sometimes to find a measure that
will address patient outcomes. But if a measure will looked at,
for example, a procedure in a hospital setting, then we ought
to have evidence that procedure leads to positive patient
outcome. So one of the issues that we have been working with
our colleagues on the Federal Government with and our employer
members, is to identify measures that are outcome-oriented and
to apply those in the public setting in a transparent way so
people are aware of how patients do when they go to one
hospital versus another. And I think we do have more work to be
done. Hospital Compare, as stated, the employers are not
comfortable that it has enough outcome-oriented measures. We
would like to see more of that.
Mr. Davis of Virginia. Dr. Pronovost, part of the
frustration with infection controls, that in some areas there
is evidence of effective interventions that reduce infection
rates, but those interventions just aren't widely implemented.
How do you explain this gap, where we have the knowledge but it
is just not happening on the ground?
Dr. Pronovost. That is absolutely the case. And if you
listen to this testimony, it is remarkable; that must be one of
the few things that everyone on the panel agrees with. We all
are acknowledging there is a problem. We want to help it. I
think, as an industry, we have been talking past each other,
and we really need some strategic leadership.
What I would say is, because we viewed getting doctors and
nurses to change these things as seen as an AHRQ. Yet, medicine
can go around the way it wants to. And what we have learned is
that there is as rigorous a science of measuring these things
and of implementing change as there is in finding the human
genome. It takes different skills, but we have invested in
learning how to do that. And I think, with some investments, we
can dramatically ratchet up how effective and efficient we are
in implementing these programs.
Mr. Davis of Virginia. Behavioral change is one of the most
difficult obstacles in a case like this. What are some of the
challenges in achieving behavioral change, even when someone
isn't watching?
Dr. Pronovost. And payment policies have to be part of it,
but payment policies that run ahead of science aren't going to
get us where we need to be. So even if you prefer, one of the
things we are not going to pay for is ventilator-associated
pneumonia. With our current ability to diagnose that, ensuring
we will have 30 false positives, that is patients who don't
really have it, for every one that we diagnose correctly. And
certainly we need to allow for policy, but we also need to
invest in how to diagnose the darned thing right so that--and
how much we can really prevent it, so that we are paving a way
to create a wise and just payment system.
The behavioral change has to be multi-factorial. Aligning
the payment system is a component. Measurement and giving
feedback is another component in making sure that the evidence
is sound and is packaged in a way that is practical for busy
clinicians, such things as a checklist and not a 200-page
guideline, are all things that seem to work.
Chairman Waxman. Thank you very much, Mr. Davis.
We are going to have to respond to the vote on the House
floor, and it will probably take 20 minutes because there are
four separate votes that will be reduced to 5 minutes after the
first.
But I do want to recognize Ms. Norton, because while we
tried to make it otherwise, she still does not have a vote as a
full Member of the House of Representatives. So I want to
recognize her for 5 minutes. And when she has completed her 5
minutes, maybe witnesses can take a break themselves and grab a
quick bite in a very, very short period of time.
And we will get back hereby 12:30. Thank you.
Ms. Norton. Thank you very much, Mr. Chairman.
Occasionally you gain something from not having a vote on
the House floor. I do get to vote on the Committee of the
Whole. This is not a Committee of the Whole vote. And I am
pleased that I vote in this committee. It is a very important
committee to our country.
I am going to ask you about the rather, for me, frightening
notion of infections that appear possible to be spread in
hospitals and may be brought into hospitals. It has been
brought to my attention, and I am going to try to pronounce
this without knowing if it is correct, that a highly resistant
bacteria that apparently has ravaged soldiers in Iraq and
Afghanistan called Acinetobacter. And, for some, the bacteria
can mean the loss of limbs that are otherwise saved, and lives.
The reason I bring this question to you is that, for
example, at Bethesda, they said they found hundreds of positive
cultures. And I was particularly concerned that, of those who
have died, the seven who have died, or that the Defense
Department acknowledges have died, from this particular
bacteria, five were non-active-duty patients being treated in
the same hospitals as infected service patients.
This is an apparently highly resistant bacteria. And
according to the experts, the only drugs they found--they don't
know--and they believe that this particular bacteria quickly
colonizes in such a way to make it resistant to even other
pharmaceuticals which are found, but one was found at Walter
Reed here in our District. Some of these have been at Walter
Reed here in our District. And one of the doctors said that one
of the antibiotics that he has not used in recent years that
could be used here is called Colistin. But he hasn't used it
because it causes or could cause nerve damage and kidney
damage, which is also what this particular bacteria sometimes
causes.
Now, they don't know where this came from. I do not believe
this originated in hospitals, and they are trying to find out.
They don't think it originated in the soil in Iraq. They think,
however, that it lies dormant in open wounds. As quick as the
paramedics, and they have been miracle workers, have been, that
this may be the cause for it.
Well, these soldiers are coming back in large numbers. They
are going all over the country. Some of them go to military
hospitals, most of them probably would not unless--well,
sometimes I suppose if they have a wound. And here we are
concerned about kind of low-cost, easy ways to deal with
infections that we are well aware of, we know how to combat.
My question really goes to whether hospitals are prepared
to deal with the introduction of new infections. People come in
the hospital sick. They can be infected with things. And if we
can't deal with infections that arise in the hospital, what
chance do we have of dealing with what amounts to a global
health system as well, where people come with whatever they
bring from other countries, including our own American
soldiers?
One, do you know anything about this particular bacterium?
And, two, what should hospitals do now that soldiers are coming
back, and some of them may be treated in ordinary hospitals and
by ordinary physicians, about the introduction of bacteria such
as this? And is this a rare case? It certainly isn't rare in
the Armed Services. Perhaps it hasn't killed large numbers of
people. But the possibility of it spreading, and particularly
in hospitals, and then being carried heaven knows where exists
when people come back.
Quite apart from the important work you have done and
commented upon here, are hospitals prepared to deal with the
introduction of new kinds of bacteria that they in turn spread
to others in the hospital and elsewhere? Don't all of you speak
at once.
What would you do if, in fact, maybe as a law school
hypothetical, if you knew that there was a patient who had
tested positive for this bacteria but was ill of something
else? What would you, or what would your hospital do in that
case?
Dr. Pronovost. These micro-organisms are in some sense the
most brilliant scientists, because no matter how clever we
think we are with getting drugs, biology or evolution seems to
make them resistant to many things. So this Acinetobacter is
like a number of other infections, others including pseudomonas
that you may have heard. And, by the way, your medical
knowledge is impressive. We will give you a degree from Johns
Hopkins.
And we struggle with this all the time of having these
organisms that are resistant. And, indeed, on many patients, I
use Colistin because it is the only drug that works and the
risk-benefit ratio is, without a drug, they will most likely
die, so we accept some risk of harm.
The strategies that we do are, one would be a surveillance.
First, we have to make sure we identify when patients have
them. And, if they do, we put that----
Ms. Norton. Can we test for this? Apparently, we know how
to test for it. Will we test for it? Should we be alerting--I
guess military hospitals may test for it. But if this bacteria
is spread, perhaps it spreads through hospitals. Should we try
to get us more tests?
Dr. Pronovost. Right now it is probably tested for if
someone has some other infections.
Ms. Norton. If they are tested for some other infections.
Dr. Pronovost. It would come up. Right. And typically
hospitals, and almost all hospitals, have the ability to say
what antibiotics might be effective in treating that infection,
and that patient would be isolated. In other words, they would
be put in a separate room, and clinicians would have to have
what is called contact precautions. So, they would not be
allowed to go in the room without having a special gown on to
prevent them from spreading it to other patients. There
typically would be some environmental surveillance and
cleaning, so that we don't have our stethoscopes or the
computers or the beds harbor this infection. And maybe we try
to treat it with other antibiotics that we could, fully
acknowledging that we may induce some harm in trying to save a
life or limb.
Ms. Norton. Ms. Bascetta, do you have a comment?
Ms. Bascetta. Yes. Your comment brings to light that we are
focused on HHS, but as you point out DOD and VA as well have
their own Federal hospital system. And I know that the military
has a way of tracking global emerging infectious disease, as
does CDC. So perhaps Dr. Wright would like to comment on
whether HHS, or--I am sure they are--to what extent HHS and DOD
and VA are working together on these kinds of issues.
Ms. Norton. For example, do you think at least the ordinary
civilian hospitals ought to be alerted to this infection as
something they ought to look for?
Dr. Wright. Yes, Congresswoman.
Acinetobacter really is a problem that has been in
intensive care units and has been a problem among soldiers
returning from Iraq, as you said. But I think it is important
to note that it is not a rare case, and it has actually been a
problem in the United States, here locally as well.
As far as the problem with our soldiers, let me assure you
that the CDC is working very collaboratively with Walter Reed,
looking at that issue, trying to better understand this
particular problem and how we can prevent it in the future.
Along that same line, I would like to say that the CDC has
done an excellent job in recently releasing guidelines that
deal with multi-drug-resistant organisms in hospitals.
Certainly MRSA has been an issue that received a great deal of
media attention, but it clearly is not the only bacteria that
has achieved resistant status. And their approach is to look
from a holistic standpoint: What is it that we can do to
eliminate these infections from bacteria that have developed
resistance?
Ms. Norton. Thank you.
You are dealing often with infections which do not resist,
and yet we still have them. So I am just moving the trajectory
up somewhat to say that there is likely to be more and more of
these resistant infections that you encounter.
Thank you very much for your testimony. The hearing is
recessed. They will return.
[Recess.]
Chairman Waxman. Yarmuth.
Mr. Yarmuth. Thank you, Mr. Chairman.
Dr. Wright, in your testimony, you considered that the
hospital-associated infections are an important public health
challenge. I think that is the way you phrased it. And you also
said that more work and leadership is necessary to enhance
patient safety. You also detailed various activities that
different agencies within the Department are undertaking. That
is helpful as far as it goes. But given the stakes involved, it
doesn't seem to me that it goes nearly far enough.
We apparently have an epidemic of hospital-associated
infections in this country if we are talking about virtually
100,000 people dying a year, resulting in all those deaths and
avoidable costs of billions of dollars. And I think every
hospital patient and family member has a right to expect more
from our government and from the Department. At a minimum, they
have a right to expect leadership in this area. And today's GAO
report states that no one within the Office of the Secretary is
responsible for coordinating infection control activities
across HHS. Your testimony does not really address this point,
so I would like to have a response to that specific issue.
So, why hasn't there been a coordinated response to this
epidemic within the Department?
Dr. Wright. Thank you, Congressman.
The Office of Public Health and Science is in the Office of
the Secretary at HHS. I serve as the principal Deputy Assistant
Secretary. That particular office is headed by the Assistant
Secretary for Health. And the Assistant Secretary for Health is
very frequently asked to serve in a coordinating role on issues
that involve many of our agencies or operating divisions, and
coordinate activities across those.
In the area of healthcare-associated infections, there is a
good example of where this office has had a key role in
coordination, and it relates to immunizations for seasonal flu
for healthcare workers. You are probably well aware that the
Center for Disease Control has long stated that healthcare
workers are a top priority for receiving this vaccine, and yet
the numbers of healthcare workers that actually receive the
vaccine is somewhat disappointing. It is only about 40 percent.
Now, this is an issue that has both occupational health
concerns as well as patient safety concerns. Certainly a
healthcare worker who is exposed on the job by taking care of
an influenza patient has a risk of workplace transmission. But,
also, there is the concern that a healthcare worker could
inadvertently infect patients that they come in contact on a
ward. As a result of that, the Assistant Secretary for Health
coordinated--led and coordinated an interagency working group
that involved all the major operating divisions of the HHS to
address this particular healthcare concern.
The first goal of this particular task force was to see
what we could do within the HHS family. There are numerous
healthcare workers within HHS and the Indian Health Service and
the National Institutes of Health and CDC and Federal
Occupational Health. What is it that we can do to set the
example? And then, more importantly, what is it that we can do
with our other Federal partners and the Veterans Administration
and Department of Defense, as well as private sector hospitals,
to increase the immunization rate for seasonal influenza. So
there is a coordination role. There is a leadership role within
the Office of Public Health to work across operating divisions
as it relates to issues of healthcare-associated infections.
Mr. Yarmuth. But that doesn't deal specifically with these
situations in the hospital. That is a different example. So my
question would be, do you think this approach is working?
Because apparently, from the data that we have, this type of
approach is not working, and there does seem to be a lack of a
coordinated effort within the Department.
Dr. Wright. Congressman, there is some good news with
healthcare-associated infections. We are seeing improvement in
bloodstream infections, partly done by Dr. Pronovost's work and
work that was done in Pittsburgh. We are also seeing
improvement as it relates to surgical site infections.
That said, clearly there is a great deal of work to be
done. And we at the Department do have opportunities to
collaborate, and there are examples where we collaborate across
operating divisions or agencies in a very effective way.
Another great example----
Mr. Yarmuth. I just want to ask Ms. Bascetta whose report
this was, if this is the type of cooperation that GAO
envisioned when it issued its report and the recommendations
that agency made.
Ms. Bascetta. No, it isn't. And I would like to point out
that, and HHS had an opportunity to comment on our report, and
they did not bring up that they were in fact coordinating or
collaborating at the level that we would have expected. I think
they certainly have the potential to do that. And an example of
what we would expect to see is some sort of strategy that takes
the offense in dealing with HAIs at a much higher level than
having their components do their very good but relatively
independent activities so far.
Mr. Yarmuth. Thank you for that. I think that is an
approach that we all would prefer to see.
Thank you, Mr. Chairman.
Chairman Waxman. Thank you, Mr. Yarmuth.
Mr. Burton.
Mr. Burton. Thank you, Mr. Chairman.
First of all, I want to apologize. I had several other
meetings going on, so I haven't been here to hear all of your
testimony, but I will read it, and my staff and I will go over
it.
I have a couple of questions, and Ms. McCaughey is here,
and I appreciate you being here on such short notice. She is
the head of the Committee to Reduce Infection Deaths, and she
is a former Lieutenant Governor of New York.
And in her article, I would like to read this to you, she
says: Restaurants and cruise ships are inspected for
cleanliness. Food processing plants are tested for bacterial
content on cutting boards and equipment. But hospitals, even
operating rooms, are exempt. The Joint Commission which
inspects and accredits U.S. hospitals doesn't measure
cleanliness, neither do most State Health Departments nor the
Federal Centers for Disease Control and Prevention.
Now, I am going to ask her when she gets before the
committee if that is true. But if that is true, that is
criminal. That is absolutely criminal.
I also found in this little brochure, it says, ``things
that you should ask a doctor and say to hospitals to reduce
your risk of getting an infection.'' And there are 15 things on
here. And it says: Ask the hospital staff to clean their hands
before treating you. Before your doctor uses a stethoscope to
listen to your chest, ask him to put some alcohol on it to
clean it. If you need a central line catheter, ask your doctor
about the benefits of one that is antibiotic impregnated or
antiseptic coated to reduce infections. If you need surgery,
choose a surgeon with a low infection rate. Beginning 3 to 5
days before surgery, shower or bathe daily with chlorhexidine
soap.
And it goes on and on and on. And all this ought to be
academic to a hospital. The patient should not have to ask
these questions.
I mean, when I went into a hospital, I had a shoulder
injury, and my doctor was supposed to be the best. I won't go
into his name now, but he was pretty negligent. And after about
3 or 4 weeks after the surgery, I had trouble in my shoulder
and he said, ``well, see how you are working with it.'' And I
raised my arm. He says, ``well, you don't have any problem.''
He says, ``you are doing well.'' And I said, ``but I am telling
you, something is wrong.''
I came back to Washington, and I kept telling myself. I
flew back. When I flew back, I said, ``I am telling you
something is wrong.'' And he said, ``well, you can get an MRI,
and it will cost about $1,000, but you don't need it.'' I went
to get the MRI at 8:30 at night. He called me and said, can you
be at the hospital tomorrow at 7:00? I was at the hospital at 7
the next morning. He had to operate on me four more times. They
had to cut into the bone and the muscle, and he said I might
have arthritis and never be able to use the arm again. But we
worked real hard, so it is OK.
But the point is, it was an infection that I got either
through the surgery or the hospital, and he wouldn't even
acknowledge it without testing it. And it was just lucky that I
found out about it. And I talked to the surgeon here at the
Capitol, our doctor, when he came in, and he said he had a
person with a similar problem who had an infection and dropped
dead right after he met with him because the infection had
spread so much.
I guess the question I would like to ask you generally, and
I don't know which one of you to address this to, is, why
aren't we, across the country and the States and the HHS and
FDA, why aren't we insisting that these 15 steps be implemented
in every single hospital across this country? And if what Ms.
McCaughey says, that restaurants and cruise ships and food
processing plants are tested for bacteria, if they are doing it
there, why aren't we doing it in the hospitals? I mean, I just
don't understand it. And if they are handing out this brochure
for me to ask my doctor of things to do, and most people aren't
going to see this thing. They are never going to see this
thing. And so they are going to go in, and they are going to
rely on the nurses to wash their hands and do all the things
that this thing says. Why isn't that standard operating
procedure? And, why isn't there a requirement to make sure
these things are done in every hospital in this country? Now,
with that, any one of you can answer.
Ms. Binder. I couldn't agree with you more. As I talked
about earlier, the Leapfrog survey last year of covering about
60 percent of the in-patient beds in this country we found that
87 percent of those responding to our voluntary survey did not
undertake the required practices for safe practices for a
hospital, which was astounding to us, even though we came into
this realizing this was a problem.
Fundamentally, I worked in a hospital. I know it is
extremely difficult to make the kinds of changes that are
needed to have safe practices. You have to educate every staff
person, not just the physician and not just the nurses; but the
person who admits the patient, the janitor, everybody has to
understand and comply completely with safe practices to prevent
infection. To get to that point----
Mr. Burton. I am running out of time, if the chairman will
give me one more second here. This is probably the most
important thing that people deal with regarding their health,
and you just said that it is very difficult. Even if it is
difficult, it should be done.
Ms. Binder. Absolutely.
Mr. Burton. And there ought to be penalties imposed by FDA,
HHS, or State health agencies to make sure that this stuff is
done. And if a nurse or a doctor doesn't comply with the
requirements, they ought to be penalized severely. Severely.
Because people are dying because of that.
With that, Mr. Chairman, I am sorry I took so much time.
Chairman Waxman. Thank you, Mr. Burton.
Mr. Hodes.
Mr. Hodes. Thank you, Mr. Chairman.
The testimony from Dr. Pronovost and Mr. Labriola is very
convincing about the results in Michigan, and I think you have
made a convincing case for replicating the Michigan project in
every State in the country. Every ICU patient should have the
benefit of reductions of risk of infection that come from the
application of a checklist regardless of what State they are
in. And, frankly, not just in ICUs, but in all other areas of
care in the hospitals where there is a risk of infection.
Now, the Michigan project was made possible by $1 million
from Merck, and estimates apparently vary as to the benefits.
Dr. Pronovost pointed out in his testimony that, for every
dollar we spend on biomedical research, we spend only a penny
on research. So there we have, I don't know, a 100 to 1 ratio.
But it looks like we saved about $200 million for the $1
million investment in Michigan.
Now, the Department's budget for fiscal year 2009 heads in
the opposite direction. AHRQ's fiscal year 2008 budget for
general patient safety research is $34 million. For the next
year, the Department proposes to cut this amount by $2 million.
I find it incomprehensible. In a New Yorker article, which with
the permission of the chair, I will submit for the record.
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Chairman Waxman. Without objection, we will make it part of
the record.
Mr. Hodes. Thank you, Mr. Chairman.
The interviewer asked Mr. Pronovost how much it would cost
him to do for the whole country what he did for Michigan. About
$2 million, he said, maybe $3 million, mostly for the technical
work of signing up hospitals to participate State By State and
coordinating a data base to track the results. He has already
devised a plan to do it in all of Spain for less. ``We could
get ICU checklists in use throughout the United States within 2
years, if the country wanted it,'' he said. Well, I think the
country wants it. I think the country needs it.
So, Dr. Pronovost, how are we able to fund the replication
of what you did in Michigan if it cuts its budget by the $2
million that you say we need to spend to move this nationwide?
Dr. Pronovost. Congressman, I completely agree with the
sentiment that I don't understand the logic of saying these are
national problems while we need to make wise investments,
because the return on them in lives saved and in dollars to the
health care system are real. For example, yesterday I was in
Pennsylvania. Tonight I am flying to California to try to get
them to sign up for that, for this program. But what that
screams to me is, where is the leadership? Because I am happy
to do it, but it certainly should be a much more integrated
program with AHRQ, with CDC, perhaps with NIH of saying, what
don't we know that we need to also learn for CMS with payment
policy, with consumer groups and this public-private
partnership to work together to do this.
Infections needs the equivalent of what we did in Polio.
Polio used to kill 350,000 people a year in the 1980's. We
collaborated and worked together, and now it is less than a
thousand--none in the United States--and in one small part of
Africa. And we need that collaborative effort.
Mr. Hodes. It strikes me that dealing with infections with
the simple use of a checklist is really pretty low-hanging
fruit in terms of expenditures of health care dollars in terms
of the savings of lives and money. Is that correct?
Dr. Pronovost. Absolutely.
Mr. Hodes. Let me ask the panel. Would any of you fly in an
airplane today if you knew that the pilot was not completing a
pre-flight checklist? Would any of you fly? The answer is, no,
of course not. So why should anybody go into a hospital in the
United States, given what we now know about what checklists do,
and go into an ICU or other area of the hospital where
infections are possible and be subject to care without having a
checklist there? I can't understand why we are not making that
investment.
And Dr. Wright, I just ask you this. You have heard Ms.
Bascetta's testimony. Have you not?
Dr. Wright. Yes.
Mr. Hodes. Did you read the GAO report?
Dr. Wright. I did.
Mr. Hodes. Are you willing to go back to HHS and produce
the synergy, which frankly seems pretty simple given all the
good work you are doing, the synergy among the different silos
in HHS to create the momentum that we need to follow the GAO
recommendations and get on this in a very coordinated way?
Because you are doing lots of work, but it sounds like there
are some simple things the GAO has pointed out your agency
needs to do to get it better. Are you willing to do it?
Dr. Wright. As I said in my initial testimony, we think
that there are great opportunities for enhanced collaboration
and cooperation at HHS and will make efforts to carry that out,
and in the area of healthcare-associated infections and in
other areas as well.
Mr. Hodes. I appreciate the opportunities, and I don't want
to belabor the point. My question is, will you follow the
recommendations that the GAO has set out as a path for you to
collaborate in the area of reducing infections?
Dr. Wright. This is a top priority for HHS, to lower
healthcare-associated infections. And certainly we need to
collaborate. We must collaborate. We must do better working
across the very important operating divisions, from NIH to CDC
to AHRQ, etc.
Mr. Hodes. Thank you for that answer. I understand it is a
priority. My question was, will you follow the GAO
recommendations, yes or no?
Dr. Wright. We will make every effort to move forward with
the recommendations as made by the GAO.
Mr. Hodes. I will take that as a yes. Thank you.
Chairman Waxman. Thank you, Mr. Hodes.
Ms. McCollum.
Ms. McCollum. Thank you, Mr. Chairman. I am going to read
from something, and then, Mr. Chairman, I have two articles I
would like to submit for the record.
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Ms. McCollum. Patient Safety: In 2003, Minnesota passed
groundbreaking legislation, the Adverse Health Events Reporting
Law. Minnesota hospitals report adverse health events, 28 types
of events defined by the National Quality Forum. The Minnesota
Department of Health publishes an annual report of these events
which includes the number and types of events of each hospital
in the State. And you can go on a Web site to see the report.
And our hospitals are complying with this. Minnesota in fact
has been consistently recognized for overall health quality
performance. In 2006, it was ranked No. 2 by the Agency for
Health Care Research and Quality for Overall Health Care,
Quality Performance, and was recognized by the Center for
Medicaid and Medicare as a high-quality, low-cost State. Also,
10 hospitals were recognized by Health Grades to an elite list
of 2007 distinguished hospitals for patient safety, a
designation which goes to hospitals scoring in the top 15
percent of national patient safety indicators.
Minnesota hospitals credit their success to their ability
to share information across facilities through the Minnesota
Hospital Association's Web-based information Patient Registry.
Under this initiative, hospitals not only report events, but
they also openly--openly--exchange lessons learned.
GAO has reported the need for improvement and coordination
for sharing. The three agencies, CDC, CMS, and the Agency for
Health Care Quality Research, need to be sharing.
Are there any plans underway at HHS to improve the sharing
about best practices? That is one question I have.
And, how will this information get to hospitals and
providers?
So, for three of you, I have three specific questions.
Ms. Bascetta, what level of cooperation did GAO really find
using these different data bases? And, is there any meaningful
effort at the Department level to coordinate the data
collection among different agencies?
Dr. Pronovost, is there research physicians working on
quality improvement? And, does it make sense to you that the
Department data bases are not linked?
And then, finally, Mr. Wright, President Bush has talked
about the four cornerstones of the better health care system.
The first is information and technology interoperability. How
is it even possible then that your own internal data bases
aren't linked? And, can you show us the plan, show this
committee the plan that you just alluded to, to Mr. Hodes, that
you have to make this a reality? Where is the plan? And is that
plan 2011? And if it is 2011, how do we make that plan 2009,
2010? Thank you.
Ms. Bascetta. You asked about the level of cooperation that
we have seen, and whether there is evidence of a meaningful
effort to coordinate. And we would have to say that, so far, we
have not seen a meaningful effort to coordinate or collaborate
at the level that is necessary to really make headway on this
problem.
HHS has 60 days from the release of the report to respond
in writing to our recommendations as to how they plan to
implement them, and we will be looking very closely at what
they tell us.
Ms. McCollum. And what is 60 days?
Ms. Bascetta. Sixty days from today.
Dr. Pronovost. Congresswoman McCollum, the need to improve
quality and safety is going to require skilled workers who know
how to measure, how to do improvement and how to lead these
efforts. And there are virtually no programs in this country to
train doctors or nurses in public health to get these degrees.
We have quite robust training if you want as to basic research.
Now we have programs if you want to do clinical trials and find
drug therapies. And I think this is a glaring oversight. We
need to do improve those programs so that people can do
scholarly work like that has been going on in Minnesota or our
Michigan project.
From a research perspective or just from a public
perspective, I think it is completely unacceptable that we
can't link these data bases, because at the end of the day, the
public, like Mr. Lawton, want to know, am I safer? And I think
we deserve to give them a credible answer, and it is only going
to happen with data.
Dr. Wright. First of all, let me say that we at HHS fully
realize that health information technology is a crucial link
moving forward in all areas of patient safety, not only in the
area of reducing healthcare-acquired infections. And we are
making efforts to move along that, in that direction.
Secretary Leavitt has asked AHRQ to provide common formats
for new patient safety organizations. CMS and CDC are working
very closely toward a common set of data requirements. As far
as our surveillance system, we certainly believe that what gets
measured gets improved. In the National Health Care Safety
Network, which is the CDC surveillance tool, I think was
reported in the GAO report only had 500 participants. That has
grown exponentially. We are now up to 1,400 less than a year
later, and we expect that to be 2,000 by the end of next year.
Ms. McCollum. Mr. Wright, I asked you the plan. And your
time is up, and I would like to hear where the plan is.
Dr. Wright. Our efforts to work with software vendors to
make sure that, for hospitals, that they will be able to--that
the systems are interoperable and can be released into the
National Health Care Safety Network, which will provide us
additional information in a more timely fashion.
Ms. McCollum. Mr. Chair, I asked where the plan was. I
heard goals. I heard dreams. I didn't hear clear sets of
objectives. Is the committee planning on being able to resubmit
a question to ask for a definite plan in a timeline?
Chairman Waxman. We will certainly have the record open if
a Member wishes to ask a question and get a written response.
But I think the purpose of this hearing is to make sure that
something gets done. And it doesn't have to be this second, but
we want to impress on HHS that we want them to act. And I think
Mr. Hodes' question was very, very targeted. I don't think Dr.
Wright is in a position to tell us his plan at this moment. But
we will check with him next week.
Ms. McCollum. Thank you, Mr. Chairman.
Chairman Waxman. Thank you very much.
We are pleased to have Congressman Murphy with us today,
and I want to recognize him for 5 minutes to ask questions.
Mr. Murphy. Thank you, Mr. Chairman. It is good to be back.
I used to be a member of this committee. And also I have a bill
sitting out there for a couple of years, called The Healthy
Hospitals Act, which would require hospitals to report
infection rates; and ask HHS to devise a system to do that; and
also, recognizing a lot of savings comes from that, establish a
grant program for those hospital that dramatically lower their
rate or maintain a very low level of infections.
A couple things first, and then I am going to ask you all
one question, if you can answer that.
It amazes me that I can go online and find out if any
airline I want to take is going to depart on time. I cannot go
online and find out if I am going to depart from a hospital.
Many States have laws on this. Pennsylvania has a law of things
that require reporting; you are able to go and compare and find
out different infection rates for different hospitals. And I
also know that when hospitals, such as the VA system in
Pittsburgh, worked toward identification and eradication as
much as possible of nosocomial infections, they were able to
drop the rate by some 60 percent of one type. And actually
paying attention to one type helped them reduce all others.
I also note the number of people per day that die from
healthcare-acquired infections, 270 or so, give or take,
roughly the population you would see on an airplane. And if an
airplane went down today and 270 people were killed, it would
be a huge national tragedy. If tomorrow a plane crashed where
270 people were killed, you would have lots of questions being
asked, lots of Federal agencies would begin to investigate. If,
on the third day, a plane went down, crashed, killed 270
people, my guess is every airline in America would stop flying.
But we have been putting up with this for years.
A few years ago, when I first introduced my bill, it still
has been part of this every day; even while this committee has
been holding hearings, people have died.
Given that scenario, I would like to ask each one of you,
just answer yes or no, do you believe the Federal Government
should mandate a uniform reporting system for healthcare-
acquired infections with the results available to the public
online?
Mr. Lawton.
Mr. Lawton. Yes, sir.
Mr. Murphy. Ms. Bascetta.
Ms. Bascetta. Yes.
Mr. Murphy. Dr. Pronovost.
Dr. Pronovost. Yes. And I would like to see it coupled with
efforts to reduce those infections.
Mr. Murphy. Mr. Labriola.
Mr. Labriola. Yes, sir.
Mr. Murphy. Ms. Binder.
Ms. Binder. Yes.
Mr. Murphy. Dr. Wright.
Dr. Wright. Certainly we support transparency in health
care. It is one of the Secretary's top priorities, and States
are really taking the lead in this area. There are 25 States
now that mandate reporting back to State agencies of
healthcare-associated infections on a hospital basis. Two
States in particular, Vermont and North or South Carolina, are
now making that information available. Certainly we in the
Federal system will be looking to those States as a laboratory
to see what next steps the Federal Government should do.
Mr. Murphy. I appreciate that. And many States have made
some changes. One of my points was, if you got sick today in
Washington, DC, and you needed to choose a hospital, would you
know which one to choose? I think the answer is no. And if you
weren't in Vermont or Pennsylvania, where the information is
available online, the answer is no. And given 100,000 deaths a
year, I agree--and I certainly commend Secretary Leavitt. He
has been a champ in pushing for transparency, and he and I have
had many conversations. I appreciate that.
But this is my final question to the panel: Should we move
quickly in terms of a Federal standard to move forward in
reporting that is available to the public? Go down the line
again. Mr. Lawton.
Mr. Lawton. Absolutely. Yes.
Mr. Murphy. Ms. Bascetta.
Ms. Bascetta. Yes, urgency is very important.
Mr. Murphy. Dr. Pronovost.
Dr. Pronovost. My mother is having an operation in a week
from now. I sure hope she would have some of these tools
available.
Mr. Murphy. Mr. Labriola.
Mr. Labriola. Clearly the magnitude of the problem requires
urgency. I would just ask, from the other side of it, that it
be very, very thoughtful in terms of what and how and the
method in which it is done. More requirements may not
necessarily just make it better for the patients. It has to be
thoughtfully done.
Mr. Murphy. I appreciate that.
Ms. Binder.
Ms. Binder. We 100 percent agree there needs to be much
more urgency. And I will point out that the Leapfrog Group does
publish some of the results on infections for various hospitals
that respond to our survey. And we stand ready to help in any
way in working Federal agencies to do similar work.
Mr. Murphy. Dr. Wright.
Dr. Wright. Yes, we need to move.
Mr. Murphy. I appreciate that. Because I also think that if
we move quickly and called upon HHS to at least have some
standards--and I recognize we don't want to burden hospitals
with paperwork. But I also know, when I have spoken to
hospitals, they do pay attention. They do reduce infection
rates, and they find they save a lot of money for each patient.
Mr. Chairman, I thank you for indulging me and allowing me
to sit on this committee hearing. I appreciate that.
Chairman Waxman. Thank you very much, Mr. Murphy, for being
here. I wish you were back on our committee. I appreciate the
leadership you have given to this and other health issues. I
know, at this time, the Energy and Commerce Committee is
considering a bill that you have co-sponsored that I have
joined you on to make sure that we have the adequate funds for
the most vulnerable in our population for healthcare services.
So I very much appreciate your being here. Thank you.
Mr. Sarbanes.
Mr. Sarbanes. Thank you, Mr. Chairman.
I apologize for not being here for the whole hearing, and
welcome the witnesses.
I am intrigued by the sort of payment dimension of this,
how you used payment as a carrot and stick. And there was a
comment that we are all familiar with this adage, that what
gets measured gets done. But in health care, what gets paid for
often is what gets done.
So, Dr. Pronovost, I would be interested in, I was reading
your testimony, maybe you speaking a little bit more directly
with respect to the reimbursement regime. What particular
things do you see us using increased reimbursement for, new
reimbursement for to enhance; and then I know you also talked
about in effect penalties where people don't take steps to
address complications that could be avoided. Although you did
point out that there is not sufficient research yet, maybe to
put that kind of approach into play. So if you could just kind
of talk about the carrot and stick from the funding and
reimbursement side.
Dr. Pronovost. Sure. Congressman Sarbanes, for far too
long, the healthcare community has labeled all these
complications in the inevitable bucket. And we know that was a
mistake, and patients like Mr. Lawton suffered for that. What
we have done now is labeled them at the other extreme, all in
the preventable bucket, and are trying to align payment
policies with that. And we certainly need to align payment with
high quality. The problem is they are not all preventable. And
truth is, probably somewhere in the middle, and so we have to
do things wisely.
What I believe we should do is those where CMS's
complications that they are not going to pay for, I quite
frankly think the only two that the science is robust enough--
and what I mean by that is that we know how to measure them and
we have good evidence that most, not all, but the majority are
preventable are catheter-related bloodstream infections and
retained foreign bodies after surgery; we leave things in that
we shouldn't.
The others, we are not even clear how to measure accurately
let alone to have any idea how many are preventable. We need
to. And so I think the leadership ought to be, let's learn how
to tackle, let's make a national goal to eliminated these
catheter-related bloodstream infections, and find out what does
it take to get all the different agencies CMF with policy, CDC
with measurement, AHRQ implementing these programs, to really
lick a problem well and, in the meantime, support efforts so we
do learn how to measure more outcomes and estimate that they
are preventable, we can have more Michigan projects so the
public has a group of outcome measures that they could believe
that hospitals aren't paying for things but that we are not
holding them liable for things that really aren't preventable,
because that is going to be gamesmanship, and we are going to
be in the same place 10 years from now where we have data but
harm continues unabated.
Mr. Sarbanes. What about on the sort of front-end side of
it? Should there be more funding in the form of reimbursement
targeted to training and other things that are going on in
hospital settings or other provider settings?
Dr. Pronovost. Absolutely. Right now, there are two medical
schools, maybe three, one including Johns Hopkins, that has a
required course for patient safety for medical students. And
you say, well, why aren't there teachers? Because most don't
have people who know this stuff well enough to teach it. They
have geneticists and physiologists, but they don't have safety
experts. And we need absolutely to invest in training that we
are producing doctors and nurses who, at a minimum, are skilled
in the basics of this, and that we have populated it with
people who have formal training like myself who know how to
measure it in a scholarly way, who know how to lead health
systems and do the quality improvement efforts that can really
realize the benefits that the public so dramatically wants.
Mr. Sarbanes. One last question, which is a completely
different question. To what degree have we seen, or do you
predict we will see going forward, actual implications for the
design of--physical design and layout and so forth of hospitals
and different provider venues in response to this healthcare-
acquired infection issue?
Dr. Pronovost. I think the science of how do you design a
safe hospital is immature, but we are doing that. And I have
worked with five different hospitals, including my own, who,
for the first time, built mock shelves of what they are doing
to simulate how easy it is to do hand hygiene? How easy it is
to prevent these infections? What the physical layout should
be? And I think those requirements ought to be built into the
design as they are planning new hospitals. I think a big
limitation of that is most hospitals don't have people with
those skills, and so what we need to continue to do--we set up
a program for the World Health Organization to train leaders in
patient safety, and several countries around the world are
supporting those people to get public health degrees at the
Johns Hopkins School of Public Health. And they work with us to
be trained and go back to their country. There is no support
for a U.S. person on there, and I think there needs to be.
Mr. Sarbanes. Thank you.
Chairman Waxman. Thank you, Mr. Sarbanes.
You have been a terrific panel. We raised this question
with the GAO, and we asked them to give us a report, because we
are aware of the work that Dr. Pronovost and many others have
been doing. We have heard about the successes in Michigan and
elsewhere. We asked the Secretary to come in, and the Secretary
wasn't able to make it. The first suggestion of the Department
was have the Centers for Disease Control come in. Well, Centers
for Disease Controls are one of three agencies that have been
mentioned that deal in this area. What the GAO report has told
us is that we need stronger leadership and coordination at the
Departmental level, and that is why I am glad Dr. Wright is
here representing the full Department.
This is a classic example of a national problem, and we
ought to find an easy way to use techniques that are available
and have been successful. I know that no hospital, and I am
sure that Mr. Labriola will tell me this, wants to be inundated
with all sorts of checklists of this and that and the other.
Let's coordinate what is essential, what is successful, and
what is doable, and make sure the job gets done. We can
criticize each other. We can say things haven't been
successful, and there is a lot of justification for it. But
what we wanted from this hearing is not just to criticize but
to urge that the Department take the leadership. And we are
willing to work with the Department to give them any assistance
that they need, but we are going to have a period of time, a
short period of time in which we want to make sure something
gets done.
So we will be checking in with the Secretary and Dr.
Wright. And in the meantime, if we don't see aggressive action
from HHS, this committee is going to ask each of the State
hospitals associations what their plans are to adopt these
proven measures we discussed today. I would prefer that we use
all the tools that we have at the Federal level, because all
hospitals take patients for which the taxpayers in this country
pay them compensation for, at least the Medicare and the
Medicaid population, and through that, we want to make sure
that the hospitals are doing what they need.
But this is not to be punitive. This is to be constructive.
And we all need to work together to use our best guidance as to
how we can accomplish those goals.
I want to thank GAO for the report that you have done and
all of the witnesses for your presentations.
Mr. Lawton, I am sorry you had to go through what you did,
but at least you are here to tell us that we don't want others,
to happen to them what happened to you. And it is preventable.
Mr. Burton. Mr. Chairman, if I may make one comment.
Chairman Waxman. Yes, Mr. Burton.
Mr. Burton. I agree with you that we shouldn't be overly
critical of many of the people who are trying to do the right
thing, but I do think that punitive action sometimes is
necessary. If we have a food processing plant that is letting
salmonella come out of their plants on a regular basis, we
would close it down or we would penalize them severely. And I
think if hospitals across this country are letting 100,000
people a year die a because of bacterial infections, then there
ought to be penalties involved. And those who are responsible
should have punitive action taken against them. We are talking
about American lives here, and I think there ought to be
penalties for people who don't do the job properly.
With that, thank you very much, Mr. Chairman.
Chairman Waxman. I appreciate that. And we want to use all
the tools that we have available to us. Penalties is obviously
one tool, but guidance and coordination and successfully
setting out what needs to be done along with recommendations of
the GAO I think will get us there. We want to prevent the
infections, and we want to prevent the penalties, because we
want to make sure that not each individual has to check just
the hospital but that the hospital systems are working so that
each individual who goes to a hospital is going to get the best
possible care.
I want to thank you very much for your presentation. We
have one other witness, and I want to ask her to come forward
as this panel leaves. Thank you.
Our last witness is Dr. Betsy McCaughey, who is the former
Lieutenant Governor of New York. She is testifying today as the
founder and chair of the Committee to Reduce Infection Deaths,
a nonprofit group dedicated to reducing deaths from hospital
infections. We are pleased to welcome you to our hearing today.
It is the committee's policy to swear in all witnesses
before they testify, so I would like to ask you, if you would,
to rise and raise your hand.
[Witness sworn.]
Ms. McCaughey. The question is, is the Federal Government--
--
Chairman Waxman. Just a minute. If you have a prepared
statement, we are going to put it in the record. So I am going
to----
Ms. McCaughey. I am just going to tell you what I think.
Chairman Waxman. We are going to give you 5 minutes to say
what you are going to say. Since you were here for the first
panel, you can give us your comments on what they had to say
and your thoughts on how to get this job done.
There is a button on the base of the mic. Is it on?
STATEMENT OF BETSEY MCCAUGHEY, PH.D., FOUNDER AND CHAIRMAN,
COMMITTEE TO REDUCE INFECTION DEATHS
Ms. McCaughey. Is the Federal Government doing everything
it should to prevent hospital infections? The answer is ``no.''
And actually, the Centers for Disease Control and Prevention is
largely to blame. The CDC has consistently understated the size
of this problem and the cost of the problem. And their lax
guidelines give hospitals an excuse to do too little.
So I am going to provide you with four kinds of information
in these 5 minutes: the size of the problem, the cost of the
problem, and the CDC's two most serious or deadly mistakes.
First, the size of the problem. The CDC claims that 1.7
million people contract infections in the hospital each year,
but the truth is several times that number. And the data prove
it.
I am going to hold up this chart to show you. Methicillin-
resistant staphylococcus aureus [MRSA], is one of the fast-
growing hospital infection problems in the United States. In
1993, there were 2,000 hospital-acquired MRSA infections,
according to the AHRQ. Last year 880,000--the largest-ever
survey of hospital infections in U.S. hospitals, published in
December in the American Journal of Infection Control, showed
that 2.4 percent of all hospital patients acquired healthcare-
related MRSA infections--880,000 during the course of a year.
That is from one bacterium. Imagine how many infections there
are from Acinetobacter, Pseudomonas, klebsiellas, vancomycin-
resistant enterococcus, Clostridium difficile, and the other
bacteria contained within the hospital.
Dr. Julie Gerberding testified to this committee in
November that MRSA hospital-acquired infections are only 8
percent of the total. All right. So clearly these facts
discredit the CDC estimate of 1.7 million infections. That
guesstimate, that irresponsible guesstimate is based on a
sliver of evidence that is 6 years old, from 2002.
The Centers for Disease Control and Prevention also
understates the cost of this problem. The average hospital
infection adds $15,275 to the medical costs of caring for a
patient in the hospital. That means that 2 million hospital
infections a year would add 30.5 billion a year to the Nation's
health tab. So you do the arithmetic. What that really means is
that the United States is spending as much treating hospital
infections as the entire Medicare Part D drug benefit. We could
be paying for drugs for all seniors for what we are spending on
treating these hospital infections.
But the problem doesn't end there. What causes these
infections? Unclean hands, inadequately cleaned equipment and
rooms, and lax procedures in the hospital. The Centers for
Disease Control and Prevention has for many years now advocated
rigorous hand hygiene. That is a start, but it is not enough,
because as long as hospitals are heavily contaminated with
these bacteria on all the surfaces, doctors' and nurses' hands
are going to be recontaminated seconds after they wash and
glove, when they touch a computer keyboard, a bed rail, a
privacy curtain, any surface or tool within the hospital.
How dirty are hospitals? Research shows that three-quarters
of surfaces in hospitals are contaminated with vancomycin-
resistant enterococcus and methicillin-resistant staphylococcus
and other bacteria. A recent study done by Boston University of
49 operating rooms in four New England hospitals found that
over half the surfaces in the operating room that are supposed
to be disinfected were left untouched by the cleaners. And a
followup study of over 1,100 patient rooms, all the way from
Washington, DC, to Boston, found that over half the surfaces in
patient rooms were also overlooked by the cleaners. Numerous
studies link contaminated blood pressure cuffs, unclean EKG
wires, and other equipment with hospital infections.
A recent study done right down the street at the University
of Maryland showed that 65 percent of doctors and other medical
professionals admit they change their white lab coat less than
once a week, even though they know it is contaminated; 15
percent admitted they changed it less than once a month.
The Centers for Disease Control and Prevention's standards
of hospital hygiene are so vague as to be meaningless. They are
mind-numbing. And as you pointed out, Congressman Burton,
restaurants are inspected for cleanliness in this country but
not hospitals.
An accreditation by the Joint Commission is no guarantee
that a hospital is clean. In fact, last year a study done
showed that 25 percent of hospitals deemed unsanitary in the
State of California by State health department inspectors
responding to complaints had been accredited within the
previous 12 months.
Hospitals in the United States used to inspect surfaces,
test surfaces for bacteria levels. In 1970, the CDC and the
American Hospital Association jointly announced that hospitals
should stop doing that testing because they considered it a
waste of money. And since that time, as late as this year right
now, the Centers for Disease Control and Prevention adheres to
that position against bacterial testing of surfaces in
hospitals.
Bacterial testing of surfaces is so simple and so
inexpensive that it is routine in the food processing industry.
And I would like to ask you, Congressman Burton, whether you
think that it is more necessary to test for bacteria at a hot
dog factory than in an operating room.
Finally, the Centers for Disease Control and Prevention has
also failed to call for screening for MRSA. You cannot control
the spread of this deadly bacteria in hospitals if you don't
know the source. People are carrying this bacteria on their
skin and enter the hospital shed it everywhere, on wheelchairs,
on bed rails, on stethoscopes, on the floor, on literally every
surface. It doesn't make them sick until it gets inside their
body via a ventilator, an IV, a urinary tract catheter, or a
surgical incision.
But testing, which is a simple noninvasive nasal swab or
skin swab, enables the hospital to take the precautions to
prevent that bacteria from spreading to all the other patients
in the hospital.
A new study just out from Case Western Reserve 2 weeks ago,
shows that people who are unknowing carriers of MRSA are just
as contagious as those who are infected and currently isolated
in hospitals. Denmark, Holland, and Finland virtually
eradicated these bugs in their hospitals through screening and
cleaning, and the British National Health Service is now making
screening universal. Some 50 studies in the United States prove
that it is effective and that it has reduced MRSA infections,
where it has been tried here, by 60 to 90 percent. And yet--and
the entire Veterans Administration is now launching universal
screening.
The CDC continues to delay recommending universal
screening. And every year of delay is costing millions--
billions of dollars and thousands of lives. And that is my
statement. Thank you.
Chairman Waxman. Thank you very much.
[The prepared statement of Ms. McCaughey follows:]
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Chairman Waxman. I am going to recognize Mr. Burton to ask
questions.
Mr. Burton. First of all, I want to thank you for coming on
such short notice. And I want to thank you for your dedication
to investigating all these things. What do you think ought to
be done? I mean you have expressed very clearly the problem.
Ms. McCaughey. First of all, let me say what ought to be
done.
Mr. Burton. And the chairman has indicated you have had a
GAO study that is being conducted right now on the hospitals.
What do you think should be done by the FDA and CDC and HHS to
correct these problems? And is there a timeframe within which
you think it can be done?
Ms. McCaughey. No. 1, American people deserve clean
hospitals. Clean them or close them. That is what they are
doing in Britain now. Now, they don't have a better healthcare
system than we do, but there the political leaders are very,
very engaged in affording the public clean hospitals. And that
is the least we can do.
We cannot cure every major illness in the United States,
but we can guarantee that patients have a clean hospital. And
it is not rocket science to inspect a hospital for cleanliness.
Yet when I called the Joint Commission and asked them if they
inspect for cleanliness when they go to accredit a hospital,
they say no.
The CDC has reams of paper, hundreds of pages devoted to
the issue of hospital hygiene. It is mumbo-jumbo. You can say
in two or three pages how to inspect a hospital for
cleanliness, how to test the surfaces for bacteria, as was done
routinely before 1970. You can say that doctors should change
their lab coat every day to avoid their own clothing becoming
vectors for disease. So the least we can expect is rigorous
hygiene in our hospitals. And it is highly cost-effective.
Mr. Burton. You think that within a relatively short period
of time, with the proper instructions, that they could clean up
most of the hospitals?
Ms. McCaughey. Yes. Let me give you an example. In Los
Angeles, restaurants are inspected three times a year for
cleanliness and the results are posted in the restaurant
window. But not hospitals. You don't have to go to a
restaurant. You can go home and make your own lunch.
Mr. Burton. Yeah. What kind of penalties do you think
should be imposed if hospitals would not adhere to the
requirements of keeping the place clean?
Ms. McCaughey. You are the lawmakers, but it seems to me
there should be substantial penalties. The greatest, of course,
is adverse publicity. Hospitals are advertising for our
business. You hear their ads on the radio, Come to our
hospital. We have the best doctors, the latest technology. They
are not telling you how many patients get an infection under
their care.
But now in Britain and Ireland and Scotland, hospitals are
routinely inspected every year for cleanliness. And the red,
yellow or green ratings are posted and publicized. And you can
bet that the newspapers in the United States would carry those
results as well.
Mr. Burton. I can't understand why--I mean, Health and
Human Services and the FDA are charged with the responsibility
of making sure that we have the best healthcare in the world.
And I can't understand why they would not take the kind of
advice you are giving to heart and actually do this. Can you
give me a reason why you think this isn't happening? Because, I
mean----
Ms. McCaughey. I can.
Mr. Burton. We have had these people before the committee
many times, the chairman--and when I was chairman--and they
seem like they are dedicated. And I can't figure out why they
wouldn't do this.
Ms. McCaughey. Yes. I must say I am amazed. When I spoke
with the Joint Commission about it, the Vice President for
Quality said, we can only ask hospitals to do so much. But is
asking for a clean room too much? So much of this is about
hygiene.
Mr. Burton. Well, I appreciate your being here. I think
this is something, Mr. Chairman, we ought to pursue as
diligently as possible. I know you feel the same way. And if
there is any way we can urge or force the health agencies to be
more diligent in this regard, I would really appreciate it.
And as a person who suffered infections that darn near cost
me mobility in my left arm, and possibly my life, and I had to
spend 6 or 7 weeks with a bag full of antibiotics hanging from
a stand to keep me from having an infection that would kill me,
I can attest to the fact that I know this stuff goes on.
And there ought to be some way that the hospitals and FDA
and CDC and HHS can implement a program that will make sure--
that will minimize the possibility of these infections. And I
would like to have your statistical data.
Ms. McCaughey. Of course. With all the footnotes, I am
submitting the entire thing in evidence. Let me just add this.
I am not asking the hospitals to do something they cannot
afford to do. Numerous studies illustrate that the more
rigorous cleaning that I have discussed actually yields a very
handsome financial return without a capital outlay. It can be
done in the first year.
In Rush Medical College in Chicago, the researchers who
identified the frequently overlooked areas of the operating
rooms and patients' rooms that were not cleaned worked with the
cleaning staff, showed them how to clean properly, drench and
wait, not just a quick spray and wipe, and how important it was
to get certain surfaces that were always overlooked. They
reduced the spread of another nasty bug, VRE, vancomycin-
resistant enterococcus by two-thirds simply working with the
cleaning staff.
Another hospital experienced a 350 percent return the first
year by adding cleaning staff and working with them to identify
the often overlooked areas. So cleaning is a highly effective
strategy to reduce the spread of most bacteria.
Chairman Waxman. Thank you very much. Did you read the GAO
report?
Ms. McCaughey. I haven't gotten it yet. I requested it, but
I am looking forward to reading it very soon.
Chairman Waxman. I would be interested in your response to
it. What GAO had to say was that they are not as harsh on CDC
as you seem to be. They point out that the CDC and the other
agencies within Department of Health and Human Services--and
there is no one giving guidance when you have three different
agencies promoting different data base, different rules, and so
on and so forth. But we need rules and we need to approach this
as a Federal responsibility.
Ms. McCaughey. I would like to add one other thing.
Chairman Waxman. Let me finish.
What was recommended to us in that first panel were some
things that I think are doable. And when they are done, they
have been very successful. What you are advocating goes beyond
that. And I think you are--from what I understand your analysis
of the possibility of infection from a lot of the cleaning
problems is accurate, but there seems to be some controversy as
to whether all of that is necessary.
I don't know the accuracy of it, but that is what we have
been told by some of the scientists. What we want to have done
is, first of all, what can be done now to reduce infections get
done; get the best science on what else needs to be done; and
then make sure that the best science is implemented.
And you have come before us and given us a broader
perspective. And you are right in pointing out that it is not
just a hospital infection. MRSA is a problem beyond the
hospitals themselves. And we want to recognize that fact and
make sure we get strategies in place to approach that.
So I appreciate your passion on this issue and the work you
have done. And I want you to give us your comments on that GAO
report. Because what we want to do is make sure that we do what
can be done, do what must be done, and prevent these diseases.
And I thank you very much for being here.
I am going to have to end the hearing because there is
another group that is going to be coming into the meeting room.
But thank you so much. And this committee hearing stands
adjourned.
[Whereupon, at 1:44 p.m., the committee was adjourned.]
[The prepared statement of Hon. Elijah E. Cummings and
additional information submitted for the hearing record
follow:]
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