Law Calls for Mandatory Education and Penalties

A new health insurance law calls for mandatory education for healthcare workers and penalties for employees and facilities that don't comply with infection prevention measures, which health officials are developing.

State Senator Richard T. Moore, an Uxbridge Democrat who is chairman of the Health Care Financing Committee, filed legislation yesterday that eventually would require health officials to make public the infection rates for individual hospitals, and state health officials said public disclosure probably would be part of any new reporting requirements placed on hospitals.

Because hospitals are not required currently to report hospital-acquired infections to public health agencies, researchers don't know how often they occur. But patient safety and public health specialists estimate that nationally hundreds of thousands of hospital patients a year contract infections. Bacteria spread down tubes, also called central lines or catheters, placed in their veins to deliver medicine or in their lungs to help them breathe, and through incisions made during surgery.

The Federal Centers for Disease Control and Prevention estimates that each year patients contract 250,000 infections from catheters alone, infections that kill between 12 percent and 25 percent of patients who get them and cost about $25,000 each to treat. A small Massachusetts study published in 2002 suggested that 13 percent of 1,953 cardiac bypass patients suffered infections at the site of their surgery, including ones detected after patients were discharged.

Aside from the risk to patients and the cost to the healthcare system, another reason for the industry's growing focus on the problem is the increasing proportion of hospital infections that are resistant to common antibiotics, which makes them more dangerous and difficult to treat. At the same time, specialists believe that many infections are preventable with proper sterilization techniques and timely administration of antibiotics and more judicious use of catheters and ventilators.
"Hospital-acquired infections lead to significant harm to patients and significant unnecessary cost in the healthcare system," said John McDonough, executive director of the consumer advocacy group Health Care For All, which is also pushing legislation to require hospitals to reduce infection rates. "A variety of folks across Massachusetts are attempting to draw more focus on this problem so Massachusetts can assume a strong leadership position and perhaps be one of the first states to drive rates down to zero."

Hospitals are required by several federal agencies and organizations to have infection-prevention programs and have been monitoring their rates internally and trying to lower them for years. But the 2006 law that requires all Massachusetts residents to have health coverage by this July included $1 million for the Massachusetts Department of Public Health to implement a mandatory statewide infection prevention program in healthcare facilities. The program will begin in hospitals.
Health officials recently hired an outside consulting company to oversee development of the program and appointed advisory boards to make recommendations on how to collect incidence data from hospitals and what specific infection-control practices should be put in place and monitored, said Paul Dreyer, director of the Division of Health Care Quality. He said health officials probably will be ready to implement the program in a year.

The department has authority to discipline hospitals for poor infection-control practices, but health officials generally know about problems only if they get a complaint, which Dreyer said they rarely do.

"For a long time, there's been a sense that hospital-acquired infections are inevitable and the cost of doing business," Dreyer said. "Partly because of the patient safety movement, people don't think that's the right way of looking at them anymore. They're no more the cost of doing business than wrong-side surgery."

This shift in thinking has been reinforced as some hospitals have shown it's possible to reduce infection rates to near zero by focusing more on prevention. Michigan hospitals that rigorously implemented infection-control procedures, such as doctors and nurses washing their hands and cleaning patients' skin with an antibacterial agent before inserting intravenous lines, reduced catheter-related blood stream infections in intensive-care patients from an average of 7.7 per 1,000 days of catheter usage to 1.4 per 1,000 days a year and a half later, researchers reported in the New England Journal of Medicine last month. And 32 hospitals in Pennsylvania reported in October 2005 that they reduced catheter-related infections 68 percent through similar measures.

"One of the keys to making health reform work and getting people to buy and maintain health insurance is to keep costs down without necessarily cutting out" benefits , Moore said. "One of the biggest ways to do this is to prevent infections that occur in hospitals and drive up the costs. Most of it is preventable. We'll be able to save some money and save some lives."
He said public reporting will give hospitals added incentive to improve their infection rates. Several states, including Pennsylvania and Missouri, now require hospitals to publicly report their rates.

Paul Wingle, a Massachusetts Hospital Association spokesman, said the group will work with Moore on his bill to make sure that appropriate infection data is publicly reported. "There's no philosophical barrier to it," he said. "It's all a question of how it's done."

Doctors warn that coming up with ways to fairly compare hospitals through public reporting will be a challenge, partly because hospitals that look harder for problems may have higher rates but not necessarily have more infections. Rates also must be adjusted for patient risk factors, such as obesity.

Last month, Beth Israel Deaconess Medical Center president Paul Levy posted his hospital's rates for central line-related infections on, in part to spur other hospitals to be more transparent about their quality of care. Bacteria on the tubing can flow quickly through the bloodstream and to major organs, making these infections of particular concern.

The hospital's rate was about 3 central line infections per 1,000 patient days about a year and a half ago. Since then, the rate has dropped to an average of 1.5 central line infections, hospital executives said.

Dr. Kenneth Sands, vice president and medical director for healthcare quality, said the hospital started requiring healthcare workers to follow specific procedures for inserting catheters and to document each step, for example, covering the patient's entire body with sterile cloth, rather than just the area immediately around the catheter site.

Beth Israel Deaconess also began investigating each infection as a major event, rather than just collecting data, a key shift in thinking. "We think we saved some lives from our intervention," he said.

By Liz Kowalczyk, Globe Staff
January 11, 2007