General Acute Care Facilities

How do the new regulations and accreditation requirements affect patients who require hospitalization in the state of California?

After the release of the second Institute of Medicine report in 2001 — “Crossing the Quality Chasm” — consumers and payers began asking hospitals to disclose their rates of healthcare-associated infections and other adverse outcomes associated with hospitalization. California legislators, quality organizations (e.g., National Quality Forum, Institute of Healthcare Improvement), and accreditation agencies were quick to respond to consumer demands of increasing transparency of medical errors and implementation of safe patient care practices.

The Healthcare Associated Infections Advisory Committee (HAI-AC) was appointed by the California Department of Public Health (CDPH) in June 2007 as required by the passage of SB 739. HAI-AC would go on to lay groundwork for California hospitals to report process measures related to healthcare-associated infections and to utilize the National Healthcare Safety Network as a reporting tool for healthcare-associated infections as mandated by this legislation. HAI-AC continued into 2008 after passage of two additional bills related to infection prevention, SB 1058 and SB 158.

HAI-AC made several recommendations related to implementation of the legislative requirements to CDPH, which in turn notified general acute care facilities of their responsibility and timeline in which to implement evidence-based guidelines for the prevention of healthcare-associated infections and reporting requirements.

In July 2008, general acute care facilities began collecting and reporting on four process measures to CDPH:

• central line insertion practices
• compliance with surgical antibiotic prophylaxis guidelines
• compliance with receipt of influenza vaccination to include declination of both healthcare personnel and physicians
• compliance with influenza vaccination of high-risk patients

Also in July, general acute care facilities were required to have a process in place for documenting the necessity of a central line, where the attending physician must determine the necessity of the central line on a daily basis.

As of January 1, 2009, SB 1058 requires general acute care facilities to report the following infections and healthcare-associated outcome measures to CDPH:

• healthcare-associated MRSA bloodstream infection
• healthcare-associated VRE bloodstream infection
• Clostridium difficile infection
• central-line-associated bloodstream infection — facility wide
• all deep tissue and organ space surgical site infections — HAI-AC submitted corrective language to the state senator to clarify reporting of this last requirement.

Also included in this legislation is a requirement for hospitals to screen high-risk patients for MRSA within 24 hours of admission. The screening requirement was effective January 1, 2009. High-risk patients are defined in the legislation as:

• being transferred from a skilled nursing facility
• receiving dialysis
• admitted to an intensive care unit
• previously admitted to an acute care facility within the last 30 days prior to admission
• surgical patients at risk for MRSA infection as determined by the CDC

The legislation also requires patients to be informed and educated about MRSA.

SB 1058 states that if a patient tests positive for MRSA, the attending physician shall inform the patient or the patient’s representative immediately or as soon as practically possible. If a patient tests positive for MRSA infection, the patient shall receive oral and written instruction, prior to discharge from the hospital, regarding aftercare and precautions to prevent the spread of infection to others. The legislation does not state the method to be used to test the patient for MRSA. Tests available range from traditional culture where the result is available within two to three days to molecular testing where the result can be available within two hours once the specimen reaches the laboratory.

HAI-AC still has work remaining to advise CDPH on implementation of the legislation, in hopes of standardizing hospital reporting. Because the program remains unfunded, HAI-AC was placed on hiatus until funds become available. The last meeting of CDPH was held in January 2009.

In addition to legislation, The Joint Commission revised its standards of performance of hospitals for survey in 2009. Healthcare organizations that receive accreditation by The Joint Commission must also implement safe patient care practices to meet compliance of the new national patient safety goals. The requirement has a one-year phase-in period with full implementation by January 1, 2010. In addition to complying with the CDC or WHO guidelines for hand hygiene, hospitals must implement specific measures to prevent three healthcare-associated infections. The Joint Commission has determined that there is evidence to support the fact that hospitals can reduce or prevent the occurrence of three healthcare-associated infections: infection associated with multi-drug-resistant organisms such as MRSA, VRE, and Clostridium difficile, central-line-associated bloodstream infection, and surgical site infection.

Based on the hospital’s risk assessment for multi-drug-resistant organism acquisition and transmission, the hospital must educate staff and licensed independent practitioners (physicians, physician assistants, nurse practitioners) about healthcare-associated infections, multi-drug-resistant organisms, and prevention strategies at hire and annually. The hospital must also educate patients and their families, as needed, who are infected or colonized with a multi-drug-resistant organism about healthcare-associated infection strategies.

Prior to insertion of a central venous catheter, the hospital must educate patients and, as needed, their families about central-line-associated bloodstream infection prevention. The hospital must use a catheter checklist and a standardized protocol for central venous catheter insertion. The checklist must include the following:

• Do not insert catheters into the femoral vein unless other sites are unavailable.
• Use maximum sterile barrier precautions during central venous catheter insertion.
• Use a chlorhexidine-based antiseptic for skin preparation during central venous catheter insertion in patients over 2 months of age, unless contraindicated.
• Disinfect catheter hubs and injection ports before accessing the ports.
• Remove nonessential catheters.

Surgical site infection rate data and prevention outcome measures must be provided to key stakeholders, including leaders, physicians, nursing staff, and other clinicians. The hospital must educate patients, and their families, as needed, who are undergoing a surgical procedure about surgical site infection prevention. Antibiotic prophylaxis must be administered within one hour prior to the incision (two hours for vancomycin and fluoroquinolones) and be discontinued within 24 hours after surgery (within 48 hours for cardiothoracic surgery).

To view the national patient safety goals in their entirety, visit The Joint Commission website at www.jointcommission.org.

FAQ sheets have been developed in partnership with the CDC and the Society for Healthcare Epidemiology of America (SHEA) to educate patients on the prevention of several healthcare-associated infections. The FAQ sheets can be found at www.shea-online.org/about/patientguides.cfm.

As hospitals continue to implement practices proven to prevent healthcare-associated infections and other adverse outcomes from occurring, the quality of patient care provided in hospitals has improved. This has been demonstrated recently in a report issued by the CDC published in JAMA in February of this year (1). The report concluded that the incidence of MRSA central line-associated bloodstream infection has been decreasing in recent years in most ICU types reporting to the CDC. The decrease is believed to be related to efforts in the United States over the past decade to prevent central-line-associated bloodstream infections.

Reference:

(1) D. Burton, J. Edwards, T. Horan; et al. Methicillin-Resistant Staphylococcus aureus Central Line Associated Bloodstream infections in US Intensive Care Units, 1997-2007. JAMA. 2009;301(7):727-736