On July 12, 2005, Pennsylvania, through the Pennsylvania Health Care Cost Containment Council (PHC4), released a report that helped to change the national conversation about infections contracted by patients during their stay in a hospital. The first of its kind, PHC4's four-page Research Brief reported the results of 11,668 hospital-acquired infection cases confirmed and submitted by Pennsylvania hospitals for the year 2004. Since its first report, PHC4 has released two additional briefs on hospital-acquired infections, one in November 2005 and the other in March 2006.
This first report received significant national attention because for the first time, actual numbers, rather than estimates or extrapolations, were made public. The report also highlighted the quality of care and financial consequences of hospital-acquired infections. But perhaps the most important result of this modest study was its contribution to the discussion among patients, policymakers, purchasers and medical professionals that hospital-acquired infections are not inevitable, unavoidable by-products of health care, and that many can be prevented. This has helped to lend force to the tidal wave of positive action already occurring in many health care institutions. These actions include cultural and behavioral changes that are saving numerous patient lives, improving the quality of life for countless others and saving ample health care dollars today.
A hospital-acquired infection is an infection that a patient contracts while hospitalized. At the time of admission, the infection would not have been either present or developing. Hospital-acquired infections represent a direct threat to patient safety and health care quality. They are life threatening and costly.
Impact on patient safety and finances
During 2005, Pennsylvania hospitals identified 19,154 hospital-acquired infections. The mortality rate for patients with a hospital-acquired infection was 12.9%, while the mortality rate for patients without a hospital-acquired infection was 2.3%. The average length of stay for patients with a hospital-acquired infection was 20.6 days, while the average length of stay for patients without a hospital-acquired infection was 4.5 days. The average hospital charge for patients with a hospital-acquired infection was $185,260, while the average for those patients without such infections was $31,389.
When looking at private sector insurance reimbursements (which do not include Medicare and Medicaid), the average payment for a case in 2005 with a hospital-acquired infection was $53,915, while the average payment for a case without a hospital-acquired infection was $8,311. The fact that infections have such a significant impact upon resources should be a major concern for businesses and labor unions that pay insurance premiums through the commercial markets, as well as to public sector programs like Medicare and Medicaid.
We may not know if there were other factors that contributed to the outcome of a given patient's case, including whether or not an infection contributed to a patient's death. However, it is universally agreed that hospital-acquired infections in the aggregate have a significant impact upon the cost of care, as well as on patient care outcomes. Efforts to reduce and prevent infections should be among our highest priorities.
Preventable, not inevitable, not unavoidable
In some circles, pointing to inevitability, instead of identifying and correcting problems with the processes of care that lead to infections, has been the norm. Although the myth of inevitability surrounding this issue has been powerful, it is changing. It is not uncommon to hear health professionals say “we used to think these infections were inevitable, but no longer.”
Many hospital-acquired infections can be prevented, and experts are coming to believe that goals of zero hospital-acquired infections are appropriate, honorable and necessary targets. There are many simple and effective methods that can dramatically reduce the incidence of hospital-acquired infections: hand washing; using gloves and properly sterilized equipment; and following the same established best practices every time, all the time, for procedures like the insertion of an intravenous tube to deliver fluids and medication.
This hospital-specific report, the first of its kind, is a snapshot of activity over a one-year period and represents the beginning of a process. It establishes a baseline against which a hospital's future performance can be measured. Hospitals differ in terms of the volume and types of care provided, and the completeness of infection reporting across hospitals may vary.
For example, a low number of infections reported by a hospital in this report could mean that they are doing an excellent job in reducing their infection rate and ensuring patient safety. On the other hand, it could indicate that they are underreporting their infection numbers to PHC4. Conversely, a hospital with a high number of infections might appear to be less effective at patient safety. Yet, in reality, they may be doing a very good job of identifying and reporting infections - a positive contribution to patient safety. Hospitals using electronic surveillance approaches may report higher numbers for this very reason, and these hospitals are noted in the report.
As a result, this report should be used to measure individual hospital performance over time, rather than to compare hospitals to each other. It should be used as a tool to ask hospital representatives informed questions, especially about their infection control and prevention program. It is not intended to be the sole source of information in making decisions about hospital care, nor should it be used to generalize about the overall quality of care provided by hospitals.
Here in Pennsylvania, work done through the Pittsburgh Regional Healthcare Initiative (PRHI), as well as through other hospital initiatives across the state, has dramatically reduced the rate of central line-associated bloodstream infections and ventilator-associated pneumonia while demonstrating that the costs of treating a hospital-acquired infection can outstrip the payment system. Based on those experiences, the Jewish Healthcare Foundation and PHC4 collaborated in 2005 in awarding grants to Charles Cole Memorial Hospital, Holy Spirit Hospital, Hamot Medical Center, Lehigh Valley Hospital and Thomas Jefferson University Hospital which were attempting to replicate these results.
In 2006, PHC4 and the Highmark Foundation awarded grants to 11 facilities to implement new technology to track and proactively prevent hospital-acquired infections. Hospitals selected for the Reducing Hospital-Acquired Infections with Electronic Surveillance Demonstration Project received funding to assist them in implementing an approach which allows for more timely and comprehensive identification of hospital-acquired infections, and allows infection control professionals to get out of the data collection business and onto the floors of the hospital where they can do what they have been trained to do - identify and prevent hospital-acquired infections.
Consumers and patients have a role to play as well. Become informed. Wash your hands. Make sure your providers and hospital visitors have washed theirs as well. Become an advocate for stellar care. Ask questions of your doctors and hospital about their infection control processes.
There are additional examples of groundbreaking patient safety work being done by hospitals, physicians, nurses and other medical staff all over the country that are gaining more notoriety. The Institute for Health Improvement's 100,000 Lives Campaign provides many success stories. For example, Baptist Memorial Hospital for Women, a 140-bed facility in Memphis, Tennessee, was able to lower its surgical site infections through appropriate pre- and postoperative use of antibiotics. Transferring responsibility for administering antibiotics to pre-op nurses from anesthesiology staff was one specific change this hospital made. In Florida, Tallahassee Memorial Hospital tackled surgical site infections by banning shaving in operating rooms. Surgeons that insist on shaving a patient must bring their own razor, shave the patient themselves and record it in the patient's record. This has greatly increased compliance with the “no shave” protocol. Porter Hospital, a 45-bed acute care facility in rural Middlebury, Vermont, saw its surgical site infection rate drop from almost three percent in October 2004 to zero - 302 infection-free cases - through July 2005. One successful strategy involved utilizing a more accurate method to measure and maintain normal body temperature during and after surgery.
It is clear from these examples and countless others that the issue of prevention has taken center stage. Pennsylvania hospitals have acknowledged that this is a problem that cries out for solutions, leadership and resources, and that measurement of the problem is needed before solutions can be identified and implemented. By making infection prevention a top priority, safer environments are being created for patients. And while the primary responsibilities for patient safety rest with health care professionals, the establishment of these safe environments must be the result of the collective efforts of all health care stakeholders. Together, these actions will save lives, improve the quality of care and help to ease the financial impact of these events on our health care delivery system.
Finding solutions is what this process is about. What is not measured cannot be improved. According to the New England Journal of Medicine, between 1975 and 1995, the number of patient days spent in the hospital decreased by 36.5%, the average length of stay decreased by 32.9%, the number of inpatient surgical procedures decreased by 27.3%, and the number of infections generally decreased by 9.5%, but the incidence of hospital-acquired infections per 1,000 bed days increased by 36.1%.
This report includes information on approximately 1,570,000 patients treated in the 168 Pennsylvania general acute care hospitals during calendar year 2005. The hospital-acquired infections listed in this hospital-specific PHC4 report were identified, confirmed and submitted by Pennsylvania hospitals for the following categories: central line-associated bloodstream infections, ventilator-associated pneumonia, indwelling catheter-associated urinary tract infections and surgical site infections for circulatory, neurological and orthopedic procedures. For the third and fourth quarters of 2005, the surgical site infection category was expanded to include all surgical procedures. For the fourth quarter of 2005, the pneumonia, bloodstream and urinary tract infection categories were expanded to include hospital-acquired infections that were not device-related. As of January 2006, Pennsylvania hospitals are now required to submit data on all hospital-acquired infections to PHC4. PHC4 did not use billing data to identify hospital-acquired infections. Pennsylvania uses a hospital-acquired infection reporting system that every state has the capability to replicate.
To define a hospital-acquired infection, PHC4 adopted the Centers for Disease Control and Prevention (CDC) definition: an infection is a localized or systemic condition that 1) results from adverse reaction to the presence of an infectious agent(s) or its toxin(s) and 2) was not present or incubating at the time of admission to the hospital. In simple terms, you did not have it when you entered the hospital, and you contracted it while you were there.
PHC4 also adopted, with minor clarifications, the CDC's 13 major site categories that define the hospital-acquired infection location, and expanded the list of 13 to include a category for multiple infections and to differentiate device related and non-device related infections. We then redefined a two-character data field (Field 21d) on the Pennsylvania Uniform Claims and Billing Form, which is submitted along with administrative and billing data for each inpatient hospital admission. Hospital personnel enter one of a defined set of codes into this field when the relevant hospital-acquired infection is present.
The 2005 hospital-acquired infection data provided by hospitals underscores that the problem was larger and more costly than originally estimated for 2004. The increase, however, can partly be attributed to the fact that Pennsylvania hospitals continued to get better at the reporting process and the expansion in surgical site infection data collection requirements and the inclusion of non-device related urinary tract infections, bloodstream infections and pneumonia.
Most Pennsylvania hospitals are making a good faith effort to fully comply with the hospital-acquired infection reporting requirements, and consistent improvement in data submission can be seen from first quarter 2004 through fourth quarter 2005.
However, some data submission disparities among hospitals still exist, and there may be potential underreporting occurring. To resolve any potential underreporting, PHC4 has taken a number of steps. In addition to giving hospital chief executive officers the opportunity to explain and/or re-verify their quarterly submissions, PHC4 has notified the Secretary of the Pennsylvania Department of Health about possibly underreporting hospitals and, on a separate track, began an auditing process of hospitals that PHC4 felt might be possibly underreporting.
The national discussion regarding the public reporting of hospital-acquired infection data has included an ongoing debate about how, or whether, to risk-adjust this information. That is, should the illness level of a patient be considered when analyzing the data? One argument against risk-adjusting hospital-acquired infection data is that we should all strive toward the goal of zero hospital-acquired infections. The reporting of actual numbers, rather than risk-adjusted numbers, highlights actual results and encourages root cause analysis of every patient who contracted an infection while in the hospital. For this report, PHC4 addressed the concerns illuminated in the risk-adjustment debate in two ways.
First, patients being treated for burns, undergoing organ transplants, or being treated for complications of an organ transplant were excluded from the report because they may be at a greater risk of acquiring an infection while in a hospital. Second, hospital peer groups were created to ensure that hospitals that offer similar types and complexity of services and treat a similar number of patients are displayed together.
The debate about the relationship of patient risk factors and characteristics to hospital-acquired infections will certainly continue, and PHC4 intends to follow and contribute to this dialogue.
This report includes information on approximately 1,570,000 patients treated in the 168 Pennsylvania general acute care hospitals during calendar year 2005. Information is provided on cases for which the hospital was required to report hospital-acquired infections, which includes patients that were at least two years old and were hospitalized for reasons other than mental disorders or alcohol and drug related disorders. Patients that were hospitalized for an organ transplant, complications of an organ transplant, and/or burn treatment were not included in the report.
The following information is presented for cases in the report:
Number of Cases - The number of cases with infections represents the hospital-acquired infections identified and reported by the hospital.
Infection Rate - This is the rate of infection per 1,000 cases. The rate is based on the number of patients for which hospitals were required to report hospital-acquired infections, with one exception. For surgical site infections, only patients undergoing surgical procedures were included.
Mortality - The number and percent of mortality represents the number/percent of patients who died during the hospitalization. It is important to note that the cause of death may not have been related to the hospital-acquired infection.
Average Length of Stay - This measure represents the average number of days a patient stayed in the hospital.
Average Charges - This measure represents the average amount the hospital charged for a patient's care. The charges do not include professional fees (e.g., physician fees) and do not reflect the amount that a hospital is actually reimbursed. Generally, hospitals do not receive full reimbursement of charges because insurance companies and other large purchasers of health care usually negotiate large discounts.
The four peer groups identified in this report were developed to assist the reader in recognizing “like” hospitals. Hospitals were grouped according to the complexity of services offered, the number of patients treated, and the percent of surgical procedures performed. Unlike the first report, hospitals using electronic hospital-acquired infection surveillance were not separated out from their respective peer group; they were, however, noted as using electronic surveillance.
Peer Group 1 includes hospitals that provide more complex services and treat a larger number of patients than Peer Groups 2, 3, and 4. Hospitals that are designated as trauma centers are included in this group. All of the hospitals in Peer Group 1 perform open-heart surgery. They treat an average of 25,800 patients a year. On average, 36 percent of these patients undergo surgical procedures.
Peer Group 2 includes hospitals that provide more complex services and treat a larger number of patients than Peer Groups 3 and 4. All of the hospitals in Peer Group 2 perform open-heart surgery. They treat an average of 11,000 patients a year. On average, 31 percent of these patients undergo surgical procedures.
Peer Group 3 includes hospitals that treat a larger number of patients than Peer Group 4. They treat an average of 7,600 patients a year. On average, 22 percent of these patients undergo surgical procedures.
Peer Group 4 hospitals treat an average of 2,000 patients a year. On average, 16 percent of these patients undergo surgical procedures.
Traditional infection surveillance is a time-consuming process; infection control staff must manually review numerous reports daily in order to identify hospital-acquired infections, infection trends, and other issues — with limited time left for other important job functions.
Furthermore, without electronic tools, hospital-wide surveillance is difficult. As a result, “targeted” surveillance has often been used in the past. However, this approach may not find infections occurring outside of the selected patient population. In addition, the lack of uniformity in manual data capture leads to debate about what is or is not an infection, rather than focusing on more rapid identification and prevention of infections.
Electronic surveillance systems eliminate both the human involvement in reviewing and finding infections hidden in patient data, and the potential for human error in distinguishing between what is and what is not an infection when reporting this information. Because the data is available in real time, facilities can reduce preventable infections, improve safety, decrease costs, and report infections more accurately.
During the period covered by this report, three facilities were using a form of total electronic surveillance. Total electronic surveillance used to submit hospital-acquired infection data to PHC4 utilizes automated software that identifies hospital-acquired infections based on laboratory and/or clinical data criteria.
Some facilities may use electronic surveillance software as a screening tool only. Cases flagged by the electronic surveillance software as having a potential hospital-acquired infection are reviewed by an infection control professional, who makes the final determination of whether or not a hospital-acquired infection is present.
The three facilities using total electronic surveillance are noted to alert the reader that their higher number of reported infections may be due to more comprehensive reporting, and not that they have, in reality, a higher infection rate than facilities not using such strategies. As other hospitals adjust to the process and become more comprehensive in their reporting, infection rates should start to “normalize,” and it will become clearer as to whether higher reported numbers are due to higher infection rates or simply superior identification and reporting of infections.
PHC4 wishes to acknowledge and thank the many infection control professionals, medical records staff, and infectious disease physicians for their commitment to this process and their dedication to providing the highest quality care possible to all Pennsylvanians. PHC4 also wishes to thank its Technical Advisory Group and its Hospital-acquired Infection Advisory Panel for their invaluable assistance.
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