Hospital-acquired infection reporting laws and legislation

1394 • AORN JOURNAL

JUNE 2006, VOL 83, NO 6 Health Policy Issues

Editor’s note: This article concerns lawsand legislation related to reporting of infec-tions acquired in hospital settings only.Infections acquired in other health care set-tings are not the subject of current report-ing legislation and laws.

ommenting on the high costof hospital-acquired infec-tions in Pennsylvania hospi-tals, Marc P. Volaka, execu-tive director of the Pennsyl-

vania Health Care Cost ContainmentCouncil (PHC4), stated “it is not afact that people must get hospital-acquired infections. The goal ought tobe the prevention of every single hos-pital-acquired infection.”1

Pennsylvania was the first state torequire that hospitals report hospital-acquired infections, (ie, nosocomialinfections contracted in a hospital set-ting). It also was the first state torelease hospital infection rate data tothe public.2 The infection rate reportsof the PHC4, an independent stateagency created to collect, analyze, anddisseminate information to improvethe quality and the cost of health care,have drawn significant attention inboth the public and private sectors.

Health care consumers want toknow whether a hospital in whichthey might receive care is diligent inthe prevention of hospital-acquiredinfections, and thus they want infec-tion rates to be reported and pub-lished for public access.1 Health careprofessionals and hospital adminis-trators, however, are concerned thatdata collected from hospitals will notbe “gathered or presented in a stan-dardized, accurate, and understand-able way,”3 resulting in an inaccurateportrayal of hospital infection rates.

Although people in both the publicand private sectors agree that hospital-

Hospital-acquired infectionreporting laws and legislation

H E A L T H P O L I C Y I S S U E S

Catherine Becker

acquired infections are a serious threatto patient safety as well as a significantfactor in the rising cost of health care,striking a balance between the public’s“right to know” and the hospitals’“right to a standardized reporting sys-tem” can be quite challenging.

HOSPITAL-ACQUIREDINFECTIONS

With approximately5% to 10% of all hospi-talized patients acquir-ing an infection duringtheir hospital stay, hospi-tal-acquired infectionscurrently are the mostcommon complicationaffecting patients.4

Viruses, protozoa, fungi,and bacteria, some ofwhich are resistant toantibiotics, are the pri-mary causes of infectionsin hospitals. One of themain purposes of a hos-pital stay is to have ill-nesses treated; thereforeinfectious pathogenscommonly are presentand can be transferred inthe hospital setting.5

“Hospitals are giant repositories for allkinds of infectious organisms thatpatients bring with them. These bugscan [easily] spread to other patients. . ..”3 Infection rates from these organ-isms are increased because manypatients in the hospital have compro-mised immune systems and, therefore,are more susceptible to acquiring aninfection.3

Although some infections are theresult of poorly sterilized or unsterilizedmedical instruments, epidemiologicalstudies have determined that the majori-ty of infections result from contact with

C Health careconsumers wantto know whether

a hospital inwhich they might

receive care isdiligent in theprevention of

hospital-acquiredinfections.

SOLUTIONSOne solution to this prob-

lem is to require that hospi-tals report their infectionrates. Reporting could serveas an incentive to improveinfection control methods andto share infection control bestpractices with other reportinghealth care facilities. Report-ing also could increase the

health and safety of patientsand alleviate the burden ofrising health care costs.

Beginning on Jan 1, 2004,Pennsylvania hospitals wererequired to submit data onspecific surgical site anddevice-related infections.8

Eighteen months later, inJuly 2005, these hospitalswere required to report infec-tion rates in an additional

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Health Policy Issues JUNE 2006, VOL 83, NO 6

health care providers.6 Someresearchers have determinedthat at least 20% to 30% of suchinfections are preventable.4

Specifically, the Association forProfessionals in Infection Con-trol and Epidemiology (APIC)stated that “hand hygiene,either by hand washing orhand disinfection, remains thesingle most important measureto prevent healthcare-associat-ed infections.”7

Patient safety implicationsaside, the costs of managingthese infections is astronomi-cal, with $4.5 to $5.7 billion inhealth care costs being attrib-uted to hospital-acquiredinfections.4 A recent studypublished by PHC4, forexample, indicated that theaverage hospital payment fora patient who did not acquirean infection was $8,078 whilethe cost for a patient whoacquired an infection duringhis or her hospital stay aver-aged $60,678.2 The PHC4 fur-ther stated that

patients with hospital-acquired infections spentmany more days in thehospital, underwent moreextensive procedures, andwere seven times morelikely to die.2

Although these results onlyrepresent the findings fromPennsylvania, it is not unrea-sonable to extrapolate this datato the national level and assertthat hospital-acquired infec-tions clearly compromisepatient safety and have con-tributed to the unprecedentedincrease in health care costs.

It is not unreasonable to

assert thathospital-acquiredinfections clearly

compromise patientsafety and have

contributed to anunprecedented

increase in healthcare costs.

seven categories of surgicalsite infections related to thefollowing body systems:endocrine, gastrointestinal,genitourinary, reproductive,respiratory, skin and soft tis-sue, and miscellaneous.8 Asof Jan 1, 2006, Pennsylvaniahospitals were required toreport all hospital-acquiredinfections.8 The Hospital-Acquired Infections in Penn-sylvania Research Brief issuedin March 2006 indicated thatin the first nine months of2005, 13,711 infections werereported by hospitals com-pared to 11,668 that werereported during all of 2004.8

The PHC4 contends that thisincrease in reported infec-tions is due, in part, toimproved reporting practicesby hospitals. Their reportconcludes that a significantrelationship exists betweenthe length of stay for patientswho had a hospital-acquiredinfection and the costs asso-ciated with their treatment.There also was a 10% higherdeath rate among patientswho had hospital-acquiredinfections versus those whodid not.8

Allegheny General Hospi-tal, Pittsburgh, showed amarked decrease in the num-ber of infections occurring inthe intensive care unit (ICU)after it implemented infec-tion-reduction policies. Thesepolicies included standardiz-ing procedures and investi-gating every infection within24 hours.9 In AlleghenyGeneral Hospital’s ICU,infections decreased from 49to three, and deaths related



to hospital-acquired infec-tions decreased from 19 toone within one year. RichardShannon, MD, chief medicalofficer of Allegheny GeneralHospital, set a goal of zeroinfections after discoveringthat more than half of thepatients who developed abloodstream infection froman IV line died as a result ofthe infection. Dr Shannonalso found that the averagecost for handling the 54 IVline-related infections wasalmost $20,000 more than theactual payment received forservices.2

Although patient safety im-provements like those at Alle-gheny General Hospital areencouraging, hospital officialsargue that the report does nottake into account the healthstatus of different patientswhen they are admitted to thehospital. For example, somepatients may arrive older,sicker, or with a preexistingbut undiagnosed infection.Health care provider groupsand hospital officials arguethat without standardizing themethods of infection report-ing, the reports “would bemeaningless to the public—and possibly damaging tohospitals.”3 Results from thesereporting systems also may beskewed depending on the dili-gence of the facility and thecompleteness of each hospi-tal’s reporting methods.

LAWS IN OTHER STATESCurrently, only six otherstates (ie, Florida, Illinois,Missouri, Nevada, NewYork, Virginia) have imple-

mented some level of man-datory public reporting ofhospital-acquired infectionrates.6 Similar arguments,both for and against infectionreporting, have been heardin response to the reportinglaws in these states.

In Florida, a mandatoryhospital-acquired infectionreporting law was passed in2004, and in 2005, Florida be-came the first state to releasehospital-specific informationabout hospital-acquired patientinfections (ie, infections thatwere not part of a patient’s ini-tial diagnosis at admission).10

The hospital-specific informa-tion is available through a website called “Florida CompareCare,” which provides infor-mation regarding hospital-acquired infection rates foreach hospital.11 This web sitenot only provides informationto help patients determine

where to go for their healthcare needs, but it also mayserve to improve infection con-trol practices at hospitals byallowing them to comparetheir infection rates with otherfacilities. Hospital officials inFlorida have argued that thereporting system is flawed andthat reporting will be mean-ingful to the public only if uni-form reporting standards aredeveloped which would putall hospitals on the sameplaying field.3

The five other states thatmandate reporting of hospital-acquired infection rates havetaken different approaches tohow the data will be used, butto date, none of these stateshas released public informa-tion on their hospital-acquiredinfection rates. In fact, Nevadarequires that the reports frommedical facilities be madeavailable only to the state’shealth department.12 A lawpassed in Illinois requires thatthe Department of PublicHealth publish a consumer’sguide to health care in January2007, including rates for surgi-cal infections and complica-tions in hospitals and ambula-tory surgical centers.12 AMissouri law that was passedin 2004 permits a hospital toreview the aggregate databefore the data are made pub-lic on a quarterly basis.12 NewYork requires reports “no morefrequently than every sixmonths,” but hospitals do nothave to make a public disclo-sure of their first year data (ie,2006) so that an analysis can beperformed and necessaryadjustments can be made to

Hospital officialsargue that without a

standard forhospital-acquired

infection reporting,the reports could be

inaccurate andpossibly damaging

to hospitals.

• Oklahoma,• Washington, and• West Virginia.13

As a result, these bills eitherwere not voted on before theend of the states’ sessions, orthey failed to meet the cross-over deadline.

Approximately 20 otherstates, however, still are con-sidering and debating billsthat would require reportingof hospital-acquired infec-tions. It remains to be seenwhich states will find the

scale tipping to the side of thepublic’s right to know or tothe side of the hospital offi-cials’ request that standardsbe in place before a mandato-ry reporting law is passed.The legislative sessions formany of these states willadjourn by June 2006, atwhich point if the bills havenot been voted on andpassed, they will have to berefiled and taken up by sub-sequent legislatures.

Some states’ legislative ses-sions, however, are longer,



the manner and type of report-ing.12 Like New York, Virginiapassed a mandatory reportinglaw in 2005, but it will onlymake the infection rate infor-mation available to the publicon request.12

PENDING LEGISLATIONIN OTHER STATES

A number of states are fol-lowing the example set bythese seven states and haveintroduced legislation torequire hospitals to reporthospital-acquired infections.To date, only one state (ie,Maryland) has successfullypassed a law during the2006 legislative sessionrequiring that hospital-acquired infection rates bereported. Maryland’s SB 135and companion HB 78passed the legislature andbecame law, despite notbeing signed by Gov RobertL. Ehrlich, Jr.13 A related billin Maryland (ie, SB 535/HB966) would have requiredhospitals to implement evi-dence-based methods toprevent the spread of antibi-otic-resistant “superbugs,”but because of rigorousopposition from hospitalofficials, it did not pass outof the legislature.13 Likewise,hospital-acquired infectionreporting bills did not passout of committee in the fol-lowing 10 states:• Georgia,• Hawaii,• Idaho,• Iowa,• Kansas,• Kentucky,• Mississippi,

Several states havepending legislationwhich would require

health carefacilities to reporthospital-acquiredinfection rates.

and, therefore these stateshave more time to debate theissue and potentially pass ahospital-acquired infectionreporting bill. For example, theCalifornia 2006 legislative ses-sion does not adjourn untilAugust 2006, and there aretwo relevant bills being con-sidered by California legisla-tors. California SB 739requires hospitals to reportcertain hospital-acquiredinfections to the Departmentof Health and would makesuch information available tothe public.13 Conversely, SB1780 requires hospitals toreport all hospital-acquiredinfections to the Office ofStatewide Health Planningand Development, but suchinformation would only bemade available to local healthdepartments.13

In Massachusetts, the leg-islature will not adjournuntil January 2007, and thusit will continue to debatepassage of HB 2729, whichrequires disclosure by hospi-tals of hospital-acquired in-fections and quarterly re-ports for public access.13 In2005, Michigan legislatorsproposed HB 4504 and com-panion SB 368, both ofwhich were assigned to theappropriate Committee onHealth Policy.13 These billsrequire the reporting of hos-pital-acquired infectionrates, but they were silent onwhether such informationwould be made available tothe public. Although thesebills carried over to the 2006legislative session, no actionhad been taken at the time



this article was written. The New Jersey legisla-

ture will not adjourn untilJanuary 2007, which allowsfor continued debate onassembly bill A667 and com-panion SB 147, which requirenot only the disclosure byhospitals of hospital-acquired infections but alsomakes such informationavailable for public dissemi-nation and use.13 Finally, inOhio, HB 197 is up for con-sideration by the Ohio legis-lature until they adjourn inJanuary 2007. This bill re-quires hospitals to reporthospital-acquired infectionrates as well as requiringthat these reports be madeavailable to the public.13

OTHER INTERESTED AGENCIESStates are not the only en-

tities engaged in the hospi-tal-acquired infection report-ing discourse. In February2006, the CDC released itsGuidance on Public Reportingof Healthcare-AssociatedInfections: Recommendations ofthe Healthcare Infection ControlPractices Advisory Committee,which provides a frameworkfor public reporting systemsfor health care-associatedinfections.14 The CDC guid-ance document recommends,among other things, thatstates in the process of devel-oping reporting systemsshould• use established public

health surveillancemethods;

• involve people with infec-tion control expertise inthe process;

demiology of America,issued a resource titledModel Legislation on PublicReporting of Healthcare-Associated Infections.16 Themodel legislation includessuch components as • assigning the collection of

infection reports by a stateagency,

• requiring an advisorypanel to devise the meth-ods for tracking andreporting, and

• phasing in a public informa-tion system that compareshospital rates on a statewidebasis as well as againstnational benchmarks.

Although not included inthis model legislation, APIChas publicly stated in itsMarch 2005 Position State-ment on Mandatory Reportingof Healthcare-Associated Infec-tions, that in order for re-porting systems to be effec-tive, standardized methodsand measures should beimplemented at the statelevel for meaningful hospi-tal comparison.6

The guidance documentsissued by the CDC and APICencapsulate a genuine bal-ance between the consu-mer’s right to know andmany hospitals’ request for astandardized system ofreporting. These documentsdemonstrate that both needscan be met in the develop-ment of hospital-acquiredinfection reporting systems.These tools can be of greatbenefit to lawmakers, policyplanners, consumer advo-cates, and hospital officialsinvolved in developing and

• track practices that preventinfections, in addition tomeasuring infection rates;and

• provide regular and confi-dential feedback to healthcare providers.15

Efforts should be focused onestablishing solidly devel-oped methods and measuresfor reporting. A CDC officialstated that “the goal of man-datory reporting is to provideconsumers with informationthey can use to make in-formed health care choices.”15

Similarly, on Jan 17, 2006,APIC, in conjunction withthe Infectious DiseasesSociety of America and theSociety for Healthcare Epi-

The Association forProfessionals inInfection Controland Epidemiologyrecommends that

standardizedmethods andmeasures be

implemented at thestate level for

meaningful hospitalcomparison.



healthcare-associated infectiondata,” The National Quality For-um, http://www.qualityforum.org/txNQFprojectsummaryHAI11-18-05rynl.pdf (accessed 19 April 2006).5. P Nolan, “Unclean hands:Holding hospitals responsiblefor hospital-acquired infections,”Columbia Journal of Law and SocialProblems (Winter 2000) 135-140.6. “APIC position on mandatorypublic reporting of healthcare-associated infections,” Associa-tion for Professionals in InfectionControl and Epidemiology,http://www.apic.org/Content/NavigationMenu/GovernmentAdvocacy/MandatoryReporting/state_legislation/state_legislation.htm (accessed19 April 2006).7. “APIC Guideline for hand-washing and hand antisepsis inhealth care settings,” NationalGuideline Clearinghouse, http://www.guideline.gov/summary/summary.mary.aspx?ss=15&doc_id=2226&nbr=1452 (accessed 19 April 2006).8. “Numbers rise as data submis-sion improves, additional insur-ance payments could total $613.7million,” PHC4 Research Briefs 9(March 2006) 3. Also available athttp://www.allhealth.org/recent/audio_04-07-06/Hospital%20acquired%20infections%20on%20Pennsylvania.pdf (accessed 19 April 2006).9. “Capitol Hill watch: NewPennsylvania analysis on cost ofhospital-acquired infections re-leased; House Energy and Com-merce Committee to review is-sue,” Kaiser Daily Health PolicyReport, http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=36287 (accessed 19 April 2006).10. “Florida issues the firsthospital-specific report on in-fections,” ConsumersUnion.org,http://www.consumerunion.org

implementing comprehen-sive and effective reportingsystems.

Clearly, hospital-acquiredinfection rate reporting isbecoming more common,and the effect can only im-prove patient safety. Thequestion for states that donot yet have a reporting sys-tem in place is not “if,” but“when” it will happen. ❖

CATHERINE BECKERMSPH, JD

LEGISLATIVE AND REGULATORY

RESEARCH ANALYST

GOVERNMENT AFFAIRS DEPARTMENT

NOTES1. J Goldstein, “Hospital Infec-tions’ Costs Get Attention,” Phila-delphia Inquirer, 29 March 2006,B01. Also available at http://www.philly.com/mld/philly/14209380.htm?template=contentModules/printstory.jsp (accessed 19 April 2006).2. C Connolly, “Infections TakeHeavy Toll on Patients, Profit,”Washington Post, 29 March 2006,sec A, 03. Also available athttp://www.washingtonpost.com/wp-dyn/content/article/2006/03/28/AR2006032801631.html(accessed 20 April 2006).3. V Honeycutt-Spears, JWarren, “Hospital-acquiredInfection Rates Largely Undis-closed,” Lexington Herald-Leader,26 March 2006. Also available athttp://www.kentucky.com/mld/kentucky/news/14189379.htm(accessed 19 April 2006).4. “National voluntary consensusstandards for the reporting of

/public/core_health_care/002841.html (accessed 19 April 2006).11. Florida Compare Care,http://www.floridacomparecare.gov(accessed 20 April 2006).12. “Government advocacy:Mandatory public reporting ofhealthcare-associated infections,”Association for Professionals inInfection Control and Epidemio-logy, http://www.apic.org/Content/NavigationMenu/GovernmentAdvocacy/MandatoryReporting/state_legislation/state_legislation.htm(accessed 19 April 2006).13. “2006 Legislative session:Hospital-acquired infection publicreporting bills,” ConsumersUnion.org, http://www.consumerunion.org/pub/2006_CHART_SHI.pdf(accessed 19 April, 2006).14. L McKibben et al, “Guidanceon public reporting of healthcare-associated infections: Recommen-dations of the Healthcare Infec-tion Control Practices AdvisoryCommittee,” National Center forInfectious Diseases, http://www.cdc.gov/ncidod/hip/PublicReportingGuide.pdf (accessed 19 April 2006). 15. “CDC Advisory Committeeoffers guidance to states on de-veloping systems for public re-porting of healthcare-associatedinfections,” Centers for DiseaseControl and Prevention, http://www.cdc.gov/od/oc/media/pressrel/r050228.htm (accessed 21April 2006).16. “Model legislation on publicreporting of healthcare-associatedinfections,” Association for Profes-sionals in Infection Control andEpidemiology, http://www.apic.org/Content/NavigationMenu/GovernmentAdvocacy/MandatoryReporting/mr_resources/Model_Legislation_-_APIC__IDSA__SHEA.pdf(accessed 20 April 2006).

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Hospital-acquired infection reporting laws and legislation