Health-Care-Associated Infections in Hospitals: Leadership Needed
from HHS to Prioritize Prevention Practices and Improve Data on  
These Infections (16-APR-08, GAO-08-673T).			 
                                                                 
According to the Centers for Disease Control and Prevention	 
(CDC), health-care-associated infections (HAI)--infections that  
patients acquire while receiving treatment for other		 
conditions--are estimated to be 1 of the top 10 causes of death  
in the nation. This statement summarizes a report issued in March
and released today, Health-Care-Associated Infections in	 
Hospitals: Leadership Needed from HHS to Prioritize Prevention	 
Practices and Improve Data on These Infections (GAO-08-283). In  
this report, GAO examined (1) CDC's guidelines for hospitals to  
reduce or prevent HAIs and what HHS does to promote their	 
implementation, (2) Centers for Medicare & Medicaid Services'	 
(CMS) and hospital accrediting organizations' required standards 
for hospitals to reduce or prevent HAIs, and (3) HHS programs	 
that collect data related to HAIs and integration of the data	 
across HHS. To conduct the work, GAO reviewed documents and	 
interviewed HHS agency and accrediting organization officials.	 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-673T					        
    ACCNO:   A81696						        
  TITLE:     Health-Care-Associated Infections in Hospitals:	      
Leadership Needed from HHS to Prioritize Prevention Practices and
Improve Data on These Infections				 
     DATE:   04/16/2008 
  SUBJECT:   Avoidable hospital conditions			 
	     Best practices					 
	     Data collection					 
	     Data integrity					 
	     Disease control					 
	     Disease detection or diagnosis			 
	     Disease surveillance				 
	     Emerging infectious diseases			 
	     Health and behavioral care standards		 
	     Health care facilities				 
	     Health care policies				 
	     Health care programs				 
	     Health data repository				 
	     Health hazards					 
	     Health services administration			 
	     Hospital care services				 
	     Hospitals						 
	     Infectious diseases				 
	     Internal controls					 
	     Practice guidelines				 
	     Program evaluation 				 
	     Public health					 
	     Standards						 
	     Standards evaluation				 
	     Systems integration				 
	     Program implementation				 
	     Annual Payment Update Program			 

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GAO-08-673T

   

     * [1]CDC Has 13 Infection Control and Prevention Guidelines Conta
     * [2]CMS's and Accrediting Organizations' Required Hospital Stand
     * [3]Multiple HHS Programs Collect Data on HAIs, but Lack of Inte
     * [4]Concluding Observations
     * [5]Contact and Acknowledgments
     * [6]Appendix I: Abbreviations

          * [7]Order by Mail or Phone

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Testimony: 

Before the Committee on Oversight and Government Reform, House of 
Representatives: 

United States Government Accountability Office: 
GAO: 

For Release on Delivery: 
Expected at 11:00 a.m. EDT:
Wednesday, April 16, 2008: 

Health-Care-Associated Infections in Hospitals: 

Leadership Needed from HHS to Prioritize Prevention Practices and 
Improve Data on These Infections: 

Statement of Cynthia A. Bascetta:
Director, Health Care: 

GAO-08-673T: 

GAO Highlights: 

Highlights of GAO-08-673T, a testimony before the Committee on 
Oversight and Government Reform, House of Representatives. 

Why GAO Did This Study: 

According to the Centers for Disease Control and Prevention (CDC), 
health-care-associated infections (HAI)ï¿½infections that patients 
acquire while receiving treatment for other conditionsï¿½are estimated to 
be 1 of the top 10 causes of death in the nation. This statement 
summarizes a report issued in March and released today, Health-Care-
Associated Infections in Hospitals: Leadership Needed from HHS to 
Prioritize Prevention Practices and Improve Data on These Infections 
(GAO-08-283). In this report, GAO examined (1) CDCï¿½s guidelines for 
hospitals to reduce or prevent HAIs and what HHS does to promote their 
implementation, (2) Centers for Medicare & Medicaid Servicesï¿½ (CMS) and 
hospital accrediting organizationsï¿½ required standards for hospitals to 
reduce or prevent HAIs, and (3) HHS programs that collect data related 
to HAIs and integration of the data across HHS. To conduct the work, 
GAO reviewed documents and interviewed HHS agency and accrediting 
organization officials. 

What GAO Found: 

In its March report, which is summarized in this statement, GAO found 
the following: 

* CDC has 13 guidelines for hospitals on infection control and 
prevention, which contain almost 1,200 recommended practices, but 
activities across HHS to promote implementation of these practices are 
not guided by a prioritization of the practices. Although most of the 
practices have been sorted into categories primarily on the basis of 
the strength of the scientific evidence for the practice, other factors 
to consider in prioritizing, such as costs or organizational obstacles, 
have not been taken into account. 

* While CDCï¿½s guidelines describe specific clinical practices 
recommended to reduce HAIs, the infection control standards that CMS 
and the accrediting organizations require of hospitals describe the 
fundamental components of a hospitalï¿½s infection control program. The 
standards are far fewer in number than CDCï¿½s recommended practices and 
generally do not require that hospitals implement all recommended 
practices in CDCï¿½s guidelines. 

* Multiple HHS programs have databases that collect data on HAIs, but 
limitations in the scope of information collected and a lack of 
integration across the databases constrain the utility of the data. 

GAO concluded that the lack of department-level prioritization of CDCï¿½s 
large number of recommended practices has hindered efforts to promote 
their implementation. GAO noted that a few of CDCï¿½s strongly 
recommended practices were required by CMS or the accrediting 
organizations but that it was not reasonable to expect CMS or the 
accrediting organizations to require additional practices without 
prioritization. GAO also concluded that HHS has not effectively used 
the HAI-related data it has collected through multiple databases across 
the department to provide a complete picture of the extent of the 
problem. 

What GAO Recommends: 

In its report, GAO recommended that the Secretary of HHS identify 
priorities among the recommended practices in CDCï¿½s guidelines and 
establish greater consistency and compatibility of the data collected 
across HHS on HAIs. HHS generally agreed with GAOï¿½s recommendations. 
GAO also incorporated comments from the accrediting organizations as 
appropriate. 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-673T]. For more 
information, contact Cynthia A. Bascetta at (202) 512-7114 or 
[email protected]. 

[End of section] 

Mr. Chairman and Members of the Committee: 

I am pleased to be here today to discuss our work on federal government 
efforts to address the problem of health-care-associated infections 
(HAI)[Footnote 1] in hospitals and to provide a summary of our report, 
which you are releasing today, entitled Health-Care-Associated 
Infections in Hospitals: Leadership Needed from HHS to Prioritize 
Prevention Practices and Improve Data on These Infections.[Footnote 2] 
According to the Centers for Disease Control and Prevention (CDC), HAIs 
are infections that patients acquire while receiving treatment for 
other conditions[Footnote 3] and are estimated to be 1 of the top 10 
causes of death in the United States. For example, a patient may 
acquire an infection from bacteria on a device used to treat them, such 
as a needle or tube to deliver medicine, fluids, or blood. According to 
CDC, the most common HAIs are urinary tract infections, surgical site 
infections, pneumonia, and bloodstream infections. 

HAIs can be expensive. In 2005 the average payment for a 
hospitalization in Pennsylvania was over six times higher for patients 
who contracted a hospital-acquired infection than for patients who did 
not acquire infections, according to a report by the Pennsylvania 
Health Care Cost Containment Council.[Footnote 4] A 2007 study of 1.69 
million patients who were discharged from 77 hospitals found that the 
additional cost of treating a patient with an HAI averaged 
$8,832.[Footnote 5] The costs of HAIs are borne not only by the 
patients who suffer infections, but also by those who pay for care, 
such as the Centers for Medicare & Medicaid Services (CMS). According 
to the American Hospital Association, Medicare paid for over one-third 
of all hospital costs in 2005.[Footnote 6] 

Although not all HAIs are preventable, public and private organizations 
have established standards and other activities aimed at controlling 
and preventing them. CMS has established health and safety standards-- 
known as conditions of participation (COP)--with which hospitals must 
comply in order to be eligible for payment by Medicare and Medicaid and 
which include the COP for infection control.[Footnote 7] Hospitals may 
choose one of two ways to show that they have met these or equivalent 
standards: they may be certified by a state agency under agreement with 
CMS to survey the hospital's compliance with the COPs or they may be 
accredited by one of two private organizations--the Joint Commission or 
the Healthcare Facilities Accreditation Program of the American 
Osteopathic Association (AOA).[Footnote 8] Most hospitals are 
accredited by the Joint Commission.[Footnote 9] Other activities within 
the Department of Health and Human Services (HHS) aimed at addressing 
the problem of HAIs in hospitals include the development of guidelines 
by CDC, which contain recommended practices that hospitals may adopt, 
and the management of several databases in different parts of HHS that 
contain information about HAIs in hospitals. According to the Institute 
of Medicine, prevention of HAIs through implementation of evidence- 
based guidelines can lead to improvements in quality of care.[Footnote 
10] Furthermore, the collection of national data on these infections 
can provide a benchmark for individual hospitals to gauge their 
performance and design targeted interventions. 

Federal and state lawmakers are also concerned about HAIs and have 
taken action to reduce them. With the passage of the Deficit Reduction 
Act of 2005 (DRA),[Footnote 11] the Congress took steps to revise the 
way Medicare pays hospitals so that beginning on October 1, 2008, they 
would not receive higher payments for patients that acquire certain 
preventable conditions (including any of three HAIs) during their 
hospital stays.[Footnote 12] The HAI-related preventable conditions 
that CMS identified in the final regulation implementing subsection 
5001(c) of the DRA were urinary tract infections caused by catheters, 
infections caused by vascular catheters, and mediastinitis following 
coronary artery bypass graft surgery.[Footnote 13] According to 
Consumers Union--a nonprofit organization that has a campaign to stop 
HAIs--23 state legislatures have enacted laws that require public 
reporting of hospital HAI rates or HAI-related information.[Footnote 
14] 

My statement today is based on the report that you are releasing 
today.[Footnote 15] In that report, we examined (1) CDC's guidelines 
for hospitals to reduce or prevent HAIs, and what HHS does to promote 
their implementation; (2) CMS's and the accrediting organizations' 
required standards for hospitals to reduce or prevent HAIs, and how 
compliance is assessed; and (3) HHS programs that collect data related 
to HAIs in hospitals, and the extent to which the data are integrated 
across HHS. 

In carrying out this work for the report you are releasing today, we 
interviewed officials from CDC, CMS, the Agency for Healthcare Research 
and Quality (AHRQ), the Food and Drug Administration, the Joint 
Commission, and AOA. We also interviewed selected experts in the field 
of infection control. In addition, we reviewed and analyzed CDC's 
infection control and prevention guidelines issued from 1981 through 
2007; minutes of the Healthcare Infection Control Practices Advisory 
Committee; the World Health Organization's guideline on hand 
hygiene;[Footnote 16] CMS's COPs for hospitals and interpretive 
guidelines,[Footnote 17] which describe the COPs and provide survey 
procedures used to determine compliance with them; the Joint 
Commission's standards for hospitals and its hospital standards manual; 
and AOA's standards for hospitals and its hospital standards manual. We 
refer to the guidance that CMS provides about its COPs in the 
interpretive guidelines, and that the Joint Commission and AOA provide 
about their standards in their respective manuals, as "standards 
interpretations."[Footnote 18] We also reviewed manuals and other 
documents that explain the HHS programs that collect HAI-related data, 
and related publications and data analyses conducted by the agencies 
based on the data collected. We conducted the performance audit for the 
report you are releasing today from January 2007 to March 2008, in 
accordance with generally accepted government auditing standards. Those 
standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives. A detailed explanation of 
our methodology is included in our report. 

In brief, we found that federal authorities and private organizations 
have undertaken a number of activities to address the problem of HAIs. 
CDC has 13 guidelines for hospitals on infection control and 
prevention, which contain almost 1,200 recommended practices. However, 
activities across HHS to promote implementation of these practices are 
not guided by a prioritization of the practices. Although most of the 
practices have been sorted into categories primarily on the basis of 
the strength of the scientific evidence for the practice, other factors 
to consider in prioritizing, such as costs or organizational obstacles, 
have not been taken into account. We concluded that a lack of 
department-level prioritization of CDC's large number of recommended 
practices has hindered efforts to promote their implementation. While 
CDC's guidelines describe specific clinical practices recommended to 
reduce HAIs, the infection control standards that CMS and the 
accrediting organizations require of hospitals describe the fundamental 
components of a hospital's infection control program. The standards are 
far fewer in number than CDC's recommended practices and generally do 
not require that hospitals implement all recommended practices in CDC's 
guidelines. We noted that a few of CDC's strongly recommended practices 
were required by CMS or the accrediting organizations but that it was 
not reasonable to expect CMS or the accrediting organizations to 
require additional practices without prioritization. Other federal 
efforts include multiple HHS programs that collect data on HAIs, but 
limitations in the scope of information collected and a lack of 
integration across the programs' databases constrain the utility of the 
data. We concluded that HHS has not effectively used the HAI-related 
data it has collected through multiple databases across the department 
to provide a complete picture about the extent of the problem. 

In order to help reduce HAIs in hospitals, we recommended that the 
Secretary of HHS take the following two actions: (1) Identify 
priorities among CDC's recommended practices and determine how to 
promote implementation of the prioritized practices, including whether 
to incorporate selected practices into CMS's conditions of 
participation (COP) for hospitals. (2) Establish greater consistency 
and compatibility of the data collected across HHS on HAIs to increase 
information available about HAIs, including reliable national estimates 
of the major types of HAIs. In commenting on a draft of our report, HHS 
generally agreed with our recommendations. It indicated that CMS would 
consider whether to incorporate some of CDC's recommended practices 
into CMS's hospital COPs, and it identified some steps CMS would take 
to achieve greater consistency and compatibility of the data collected 
on HAIs. In response to comments from the Joint Commission, we 
clarified our discussion of Joint Commission activities; in addition, 
we incorporated technical comments from the Joint Commission and AOA. 

CDC Has 13 Infection Control and Prevention Guidelines Containing 
Almost 1,200 Recommended Practices, but Activities across HHS to 
Promote Implementation Are Not Guided by Prioritization of Practices: 

CDC has 13 guidelines for hospitals on infection control and 
prevention, and in these guidelines CDC recommends almost 1,200 
practices for implementation to prevent HAIs and related adverse 
events. (See table 1.) The guidelines cover such topics as prevention 
of catheter-associated urinary tract infections, prevention of surgical 
site infections, and hand hygiene. An example of a recommended practice 
in the hand hygiene guideline is the recommendation that health care 
workers decontaminate their hands before having direct contact with 
patients. Most of the practices are sorted into five categories--from 
strongly recommended for implementation to not recommended--primarily 
on the basis of the strength of the scientific evidence for each 
practice. Over 500 practices are strongly recommended. CDC and AHRQ 
have conducted some activities to promote implementation of recommended 
practices, such as disseminating the guidelines and providing research 
funds. However, these steps have not been guided by a prioritization of 
recommended practices. One factor to consider in prioritization is 
strength of evidence, as CDC has done. In addition to strength of 
evidence, an AHRQ study identified other factors to consider in 
prioritizing recommended practices, such as costs or organizational 
obstacles. Furthermore, the efforts of the two agencies have not been 
coordinated. For example, we found that CDC and AHRQ independently 
examined various aspects of the evidence related to improving hand 
hygiene compliance, such as the selection of hand hygiene products and 
health care worker education. Although this could have been an 
opportunity for coordination, an official from the HHS Office of the 
Secretary told us that no one within the office is responsible for 
coordinating infection control activities across HHS. 

Table 1: CDC's Infection Control and Prevention Guidelines, with Number 
of Recommended Practices, Issued between 1981 and 2007: 

1; Guideline (issue date): Guideline for Prevention of Catheter- 
associated Urinary Tract Infections (1981); 
Total number of recommended practices: 24. 

2; Guideline (issue date): Guideline for Infection Control in Health 
Care Personnel (1998); 
Total number of recommended practices: 183. 

3; Guideline (issue date): Guideline for Prevention of Surgical Site 
Infection (1999); 
Total number of recommended practices: 63. 

4; Guideline (issue date): Guidelines for Preventing Opportunistic 
Infections among Hematopoietic Stem Cell Transplant Recipients (2000); 
Total number of recommended practices: [A]. 

5; Guideline (issue date): Guidelines for the Prevention of 
Intravascular Catheter-Related Infections (2002); 
Total number of recommended practices: 111. 

6; Guideline (issue date): Guideline for Hand Hygiene in Health-Care 
Settings (2002); 
Total number of recommended practices: 42. 

7; Guideline (issue date): Recommendations for Using Smallpox Vaccine 
in a Pre-Event Vaccination Program (2003); 
Total number of recommended practices: [B]. 

8; Guideline (issue date): Guidelines for Environmental Infection 
Control in Health-Care Facilities (2003); 
Total number of recommended practices: 329. 

9; Guideline (issue date): Guidelines for Preventing Health-Care- 
Associated Pneumonia (2003); 
Total number of recommended practices: 208. 

10; Guideline (issue date): Guidelines for Preventing the Transmission 
of Mycobacterium Tuberculosis in Health-Care Settings (2005); 
Total number of recommended practices: [B]. 

11; Guideline (issue date): Influenza Vaccination of Health-Care 
Personnel (2006); 
Total number of recommended practices: 6. 

12; Guideline (issue date): Management of Multidrug-Resistant Organisms 
in Healthcare Settings (2006); 
Total number of recommended practices: 80. 

13; Guideline (issue date): Guideline for Isolation Precautions: 
Preventing Transmission of Infectious Agents in Healthcare Settings 
(2007); 
Total number of recommended practices: 152. 

Total: 
Total number of recommended practices: 1,198. 

Source: GAO analysis of CDC guidelines. 

[A] For the purpose of this table, we do not include a count of the 
recommended practices in this guideline because the guideline is 
targeted to a specific patient population that not all hospitals treat. 
However, for the hospitals that do treat such patients, this guideline 
provides at least another 164 recommended practices. 

[B] The practices in these guidelines are not organized in a way that 
supports counting the total number of practices. 

[End of table] 

CMS's and Accrediting Organizations' Required Hospital Standards 
Describe Components of Infection Control Programs, and Compliance with 
These Standards Is Assessed through On-Site Surveys: 

While CDC's infection control guidelines describe specific clinical 
practices recommended to reduce HAIs, the infection control standards 
that CMS and the accrediting organizations require as part of the 
hospital certification and accreditation processes describe the 
fundamental components of a hospital's infection control program. These 
components include the active prevention, control, and investigation of 
infections. Examples of standards and corresponding standards 
interpretations that hospitals must follow include educating hospital 
personnel about infection control and having infection control policies 
in place. The standards are far fewer in number than the recommended 
practices in CDC's guidelines--for example, CMS's infection control COP 
contains two standards. Furthermore, CMS and the accrediting 
organizations generally do not require that hospitals implement all 
recommended practices in CDC's infection control and prevention 
guidelines. Only the Joint Commission and AOA have standards that 
require the implementation of certain practices recommended in CDC's 
infection control guidelines. For example, the Joint Commission and AOA 
require hospitals to annually offer influenza vaccinations to health 
care workers, whereas CMS's interpretive guidelines, or standards 
interpretations, are more general, stating that hospitals should adopt 
policies and procedures based as much as possible on national 
guidelines that address hospital-staff-related issues, such as 
evaluating hospital staff immunization status for designated infectious 
diseases. CMS, the Joint Commission, and AOA assess compliance with 
their infection control standards through direct observation of 
hospital activities and review of hospital policy documents during on- 
site surveys. 

Multiple HHS Programs Collect Data on HAIs, but Lack of Integration of 
Available Data and Other Problems Limit Utility of the Data: 

Multiple HHS programs collect data on HAIs, but limitations in the 
scope of information they collect and the lack of integration across 
the databases maintained by these separate programs constrain the 
utility of the data. Three agencies within HHS--CDC, CMS, and AHRQ-- 
currently collect HAI-related data for a variety of purposes in 
databases maintained by four separate programs: CDC's National 
Healthcare Safety Network (NHSN) program, CMS's Medicare Patient Safety 
Monitoring System (MPSMS), CMS's Annual Payment Update (APU) program, 
and AHRQ's Healthcare Cost and Utilization Project (HCUP). Each of 
these databases presents only a partial view of the extent of the HAI 
problem because each focuses its data collection on selected types of 
HAIs and collects data from a different subset of hospital patients 
across the country. (See table 2.) Although officials from the various 
HHS agencies discuss HAI data collection with each other, we did not 
find that the agencies were taking steps to integrate any of the 
existing data by creating linkages across the databases, such as 
creating common patient identifiers. Creating linkages across the HAI- 
related databases could enhance the availability of information to 
better understand where and how HAIs occur. For example, data on 
surgical infection rates and data on surgical processes of care are 
collected for some of the same patients in two different databases that 
are not linked. As a consequence, the potential benefit of using the 
existing data to monitor the extent to which compliance with the 
recommended surgical care processes leads to actual improvements in 
surgical infection rates has not been realized. Although none of the 
databases collect data on the incidence of HAIs for a nationally 
representative sample of hospital patients, CDC officials have produced 
national estimates of HAIs. However, those estimates derive from 
assumptions and extrapolations that raise questions about the 
reliability of those estimates. 

Table 2: Selected Characteristics of HHS Databases That Contain HAI- 
Related Information: 

Responsible agency and database: CDC's National Healthcare Safety 
Network (NHSN); 
HAI-related data collected: Infection types; 
* central-line-associated BSI; 
* catheter-associated UTI; 
* VAP; 
* postprocedure pneumonia; 
* SSI; 
* MDRO[A]; 
* other[B]; 
Population for which data are collected: Most hospitals report on 
patients in selected critical care units and those undergoing selected 
procedures such as coronary bypass surgery and colon surgery. 

Responsible agency and database: CMS's Medicare Patient Safety 
Monitoring System (MPSMS); 
HAI-related data collected: Infection types[C]; 
* central-line-associated BSI; 
* catheter-associated UTI; 
* postoperative pneumonia; 
* antibiotic-associated C. difficile; 
* MRSA; 
* VRE; 
Population for which data are collected: National sample of 
hospitalized Medicare patients. 

Responsible agency and database: CMS's Annual Payment Update (APU) 
database; 
HAI-related data collected: Practices to prevent or reduce SSIs; 
* providing antibiotics within 1 hour of surgery; 
* selecting appropriate antibiotics to prevent surgical infections; 
* stopping the administration of the antibiotics within 24 hours of end 
of surgery; 
Population for which data are collected: National inpatient population 
for selected surgical procedures.[D] 

Responsible agency and database: AHRQ's Healthcare Cost and Utilization 
Project (HCUP) database, Nationwide Inpatient Sample; 
HAI-related data collected: Infection types; 
* postoperative sepsis[E]; 
* "infection due to medical care" (focused on intravenous and catheter 
infections); 
Population for which data are collected: A sample of inpatients in 
hospitals in 37 states. 

Source: GAO analysis of CDC, CMS, and AHRQ information. 

Notes: BSI is bloodstream infection; C. difficile is Clostridium 
difficile; MDRO is multidrug-resistant organism; MRSA is methicillin- 
resistant Staphylococcus aureus; SSI is surgical site infection; UTI is 
urinary tract infection; VAP is ventilator-associated pneumonia; and 
VRE is vancomycin-resistant enterococci. 

[A] For patients whose infections are laboratory-confirmed, NHSN 
collects data on the pathogens identified, and for specified pathogens 
(including those responsible for MRSA and VRE), the result of any 
testing of their resistance to specific antibiotics. Participating 
hospitals have the option to report separately the number of times in a 
given month that they tested specimens of any of eight specified 
organisms for resistance to selected antibiotics, as well as the 
results of those tests. From these data, NHSN produces rates of 
antimicrobial resistance relative to the number of nonduplicative 
specimens tested (i.e., excluding multiple tests for the same organism 
in the same patient). This part of NHSN does not distinguish between 
MDRO infections acquired in the hospital and community-acquired 
infections present at admission. 

[B] Hospitals can choose to submit to NHSN data on other types of HAIs, 
such as skin and soft tissue infections, cardiovascular system 
infections, and gastrointestinal system infections. CDC does not 
provide data collection protocols for these types of infections, but 
they can be entered into NHSN as "custom events" using definitions 
provided separately by CDC. 

[C] In 2007, CMS added catheter-associated UTIs, VAP, MRSA, and VRE to 
MPSMS and dropped insertion-site infections associated with central 
vascular catheters, BSIs, and postoperative-associated UTIs. 

[D] The three practice measures are assessed for certain categories of 
surgeries: coronary artery bypass graft; other cardiac surgery; colon 
surgery; hip arthroplasty; knee arthroplasty; abdominal hysterectomy; 
vaginal hysterectomy; and vascular surgery. 

[E] The rate of postoperative sepsis is computed only for patients 
undergoing elective surgeries. 

[End of table] 

Concluding Observations: 

HAIs in hospitals can cause needless suffering and death. Federal 
authorities and private organizations have undertaken a number of 
activities to address this serious problem; however, to date, these 
activities have not gained sufficient traction to be effective. 

We identified two possible reasons for the lack of effective actions to 
control HAIs. First, although CDC's guidelines are an important source 
for its recommended practices on how to reduce HAIs, the large number 
of recommended practices and lack of department-level prioritization 
have hindered efforts to promote their implementation. The guidelines 
we reviewed contain almost 1,200 recommended practices for hospitals, 
including over 500 that are strongly recommended--a large number for a 
hospital trying to implement them. A few of these are required by CMS's 
or accrediting organizations' standards or their standards 
interpretations, but it is not reasonable to expect CMS or accrediting 
organizations to require additional practices without prioritization. 
Although CDC has categorized the practices on the basis of the strength 
of the scientific evidence, there are other factors to consider in 
developing priorities. For example, work by AHRQ suggests factors such 
as costs or organizational obstacles that could be considered. The lack 
of coordinated prioritization may have resulted in duplication of 
effort by CDC and AHRQ in their reviews of scientific evidence on HAI- 
related practices. 

Second, HHS has not effectively used the HAI-related data it has 
collected through multiple databases across the department to provide a 
complete picture of the extent of the problem. Limitations in the 
databases, such as nonrepresentative samples, hinder HHS's ability to 
produce reliable national estimates on the frequency of different types 
of HAIs. In addition, currently collected data on HAIs are not being 
combined to maximize their utility. HHS has made efforts to use the 
currently collected data to understand the extent of the problem of 
HAIs, but the lack of linkages across the various databases results in 
a lost opportunity to gain a better grasp of the problem of HAIs. 

HHS has multiple methods to influence hospitals to take more aggressive 
action to control or prevent HAIs, including issuing guidelines with 
recommended practices, requiring hospitals to comply with certain 
standards, releasing data to expand information about the nature of the 
problem, and soon, using hospital payment methods to encourage the 
reduction of HAIs. Prioritization of CDC's many recommended practices 
can help guide their implementation, and better use of currently 
collected data on HAIs could help HHS--and hospitals themselves-- 
monitor efforts to reduce HAIs. We concluded that leadership from the 
Secretary of HHS is currently lacking to do this. Without such 
leadership, the department is unlikely to be able to effectively 
leverage its various methods to have a significant effect on the 
suffering and death caused by HAIs. 

Mr. Chairman, this completes my prepared remarks. I would be happy to 
respond to any questions you or other members of the committee may have 
at this time. 

Contact and Acknowledgments: 

For further information about this statement, please contact Cynthia A. 
Bascetta at (202) 512-7114 or [email protected]. Contact points for our 
Offices of Congressional Relations and Public Affairs may be found on 
the last page of this statement. Key contributors to this statement 
were Linda T. Kohn, Assistant Director; Shaunessye Curry; Shannon 
Slawter Legeer; Eric Peterson; and Roseanne Price. 

[End of section] 

Appendix I: Abbreviations: 

AHRQ: Agency for Healthcare Research and Quality: 

AOA: Healthcare Facilities Accreditation Program of the American 
Osteopathic Association: 

APU: Annual Payment Update: 

BSI: bloodstream infection: 

CDC: Centers for Disease Control and Prevention: 

CMS: Centers for Medicare & Medicaid Services: 

COP: condition of participation: 

DRA: Deficit Reduction Act of 2005: 

DRG: diagnosis-related group: 

FDA: Food and Drug Administration: 

HAI: health-care-associated infection: 

HCUP: Healthcare Cost and Utilization Project: 

HHS: Department of Health and Human Services: 

MDRO: multidrug-resistant organism: 

MPSMS: Medicare Patient Safety Monitoring System: 

MRSA: methicillin-resistant Staphylococcus aureus: 

NHSN: National Healthcare Safety Network: 

SSI: surgical site infection: 

UTI: urinary tract infection: 

VAP: ventilator-associated pneumonia: 

VRE: vancomycin-resistant enterococci: 

[End of section] 

Footnotes: 

[1] See app. I for a list of abbreviations used in this statement. 

[2] GAO, Health-Care-Associated Infections in Hospitals: Leadership 
Needed from HHS to Prioritize Prevention Practices and Improve Data on 
These Infections, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-
283] (Washington, D.C.: March 31, 2008). 

[3] In general, HAIs are distinct from community-acquired infections, 
that is, infections that patients may have acquired before entering the 
hospital. 

[4] See Pennsylvania Health Care Cost Containment Council, Hospital- 
Acquired Infections in Pennsylvania (Harrisburg, Pa.: November 2006). 

[5] See D. Murphy et al., Dispelling the Myths: The True Cost of 
Healthcare-Associated Infections (Washington, D.C.: Association for 
Professionals in Infection Control and Epidemiology, February 2007). 

[6] Medicare is a federal health insurance program that serves over 42 
million elderly and certain disabled beneficiaries and pays for health 
care needs, such as inpatient hospital stays and physician visits. 

[7] See 42 C.F.R. ï¿½ 482.1 (2007). 

[8] Section 1865(b)(1) of the Social Security Act also provides that 
any other national accreditation body that meets certain requirements 
as determined by the Department of Health and Human Services may 
accredit hospitals. 

[9] In calendar year 2007, about 81 percent of hospitals were 
accredited by the Joint Commission, state survey agencies certified 
approximately 16 percent of hospitals, and less than 2 percent were 
accredited by AOA. Less than 1 percent of hospitals were accredited by 
both the Joint Commission and AOA. The Joint Commission was formerly 
known as the Joint Commission on Accreditation of Healthcare 
Organizations or "JCAHO." 

[10] See K. Adams et al., Priority Areas for National Action: 
Transforming Health Care Quality, Institute of Medicine of the National 
Academies (Washington, D.C.: The National Academies Press, 2003). 

[11] Pub. L. No. 109-171, ï¿½ 5001(c), 120 Stat. 4, 30. 

[12] Under Medicare, hospitals generally receive fixed payments for 
inpatient stays based on diagnosis-related groups (DRG), a system that 
classifies stays by patient diagnoses and procedures. Some DRGs take 
account of certain comorbidities or complications associated with a 
diagnosis or procedure and pay at a higher rate than would otherwise be 
paid for the diagnosis or procedure. In a final regulation implementing 
section 5001(c) of the DRA, CMS identified certain preventable 
conditions it would not consider as a comorbidity or complication that 
would lead to the higher payment. See 72 Fed. Reg. 47130, 47200-217 
(Aug. 22, 2007). The DRA also requires hospitals to indicate the 
diagnoses that were present in patients at the time of admission in 
order for CMS to determine if a preventable condition developed during 
a patient's hospital stay. 

[13] Mediastinitis is inflammation of the area between the lungs (the 
heart, the large blood vessels, the trachea, the esophagus, the thymus 
gland, and connective tissues). Additional preventable conditions that 
will no longer result in higher payments to hospitals include hospital- 
acquired injuries, such as fractures, pressure ulcers, objects left in 
the body during surgery, air embolisms, and blood incompatibility. CMS 
plans to propose additional conditions in the fiscal year 2009 Hospital 
Inpatient Prospective Payment Systems proposed rule. See 72 Fed. Reg. 
47130 (Aug. 22, 2007). 

[14] See Consumers Union, "State Hospital Infection Disclosure Laws," 
available at [hyperlink, 
http://www.consumersunion.org/campaigns/stophospitalinfections/learn.htm
l], accessed on March 10, 2008. 

[15] [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-283]. 

[16] See World Health Organization, WHO Guidelines on Hand Hygiene in 
Healthcare (Advanced Draft): Global Patient Safety Challenge 2005-2006: 
Clean Care Is Safer Care (Geneva, Switzerland, 2006). 

[17] In addition to reviewing CMS's interpretive guidelines that can be 
found in CMS's State Operations Manual, we reviewed CMS's revised 
interpretive guidelines for the infection control COP, which were 
published in November 2007. Throughout this report, where we refer to 
the interpretive guidelines for infection control we are referring to 
the November 2007 revision. 

[18] Standards interpretations are given by CMS primarily in its State 
Operations Manual, which is arranged by COP (Appendix A of the State 
Operations Manual contains the COPs for hospitals); by the Joint 
Commission in its Comprehensive Accreditation Manual for Hospitals: The 
Official Handbook, which identifies rationales and performance 
expectations that are used to measure each standard and is organized 
into 11 chapters of safety and quality standards, such as "Medication 
Management" and "Leadership;" and by AOA's standards manual, 
Accreditation Requirements for Healthcare Facilities, which provides 
explanations for surveyors and the scoring procedures along with its 
standards and is organized into 32 chapters. 

[End of section] 

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