You asked for information on states that have passed legislation addressing hospital-based infections (also known as “nosocomial infections”). You are also interested in Connecticut’s actions to date on this issue.

SUMMARY

Six states, Florida, Illinois, Missouri, New York, Pennsylvania, and Virginia, have passed legislation addressing the collection and reporting of information on hospital-based infections. Of these states, only Pennsylvania is currently providing this information to the public. In January 2004, Pennsylvania hospitals began submitting data on hospital-acquired infections to the Pennsylvania Health Care Cost Containment Council (“PHC4”). The council recently issued a research brief on the topic which states that hospitals reported 11,668 such infections in 2004 or 7. 5 per 1,000 patients admitted. PHC4 also reported that hospital-based infections resulted in a significant amount of additional hospital charges.

Connecticut, while not enacting a law specifically on hospital-based infections, is requiring hospitals to report nosocomial infections that result in death or serious injury as part of quality of care/adverse event reporting legislation enacted in 2002 and amended in 2004.

BACKGROUND

Hospital-acquired infections (also known as nosocomial infections) are developed by between five and 10% of patients admitted to hospitals in the United States (over 2 million cases per year). Such infections are usually related to a procedure or treatment used to diagnose or treat the patient’s illness or injury. It is estimated that about 25% to 33% of these infections can be prevented by healthcare workers taking proper precautions when caring for patients.

Bacteria, viruses, fungi, or parasites can cause hospital-acquired infections. These microorganisms may already be present in the patient’s body or may come from the environment, contaminated hospital equipment, healthcare workers, or other patients. Most infections that become clinically evident after 48 hours of hospitalization are considered hospital-acquired. Infections that occur after the patient’s discharge from the hospital can be considered to have a nosocomial origin if the organisms were acquired during the hospital stay.

Viruses are the leading cause of nosocomial infections. During a hospital stay, patients may acquire viral respiratory infections in winter (e. g. influenza, parainfluenza, respiratory viruses) or enteroviral infections in the summer. Bacterial and fungal infections are less common. Most patients who are infected with nosocomial bacteria and fungal pathogens have a predisposition caused by invasive supportive measures such as intubation and the placement of intravascular lines and urinary catheters.

While all hospitalized patients are susceptible to contracting a nosocomial infection, some patients are at greater risk than others: young children, the elderly, and persons with compromised immune systems.

CONNECTICUT

While Connecticut has not passed legislation specifically on hospital-based infections, legislation governing quality of health care and adverse event reporting addresses the issue.

Public Act 04-164, An Act Concerning the Quality of Health Care, made significant changes to a two-year-old law on health care quality that is generally referred to as the “medical error” or “adverse event” reporting law. The original legislation (PA 02-125) required hospitals and outpatient surgical facilities to report adverse events to the Department of Public Health (DPH). Generally, adverse events were injuries caused by or associated with medical management that resulted in death or measurable disability. The act classified adverse events as A through D, with Class A being the most serious. Adverse event reports generally became public information under the 2002 law six months after their filing with DPH.

PA 04-164 (CGS Sec. 19a-127n) amends the 2002 law by replacing the adverse event classification reporting system with a list of reportable events identified by the National Quality Forum (NQF) or DPH. It also restricts disclosure of the adverse events reports. The NQF “Serious Reportable Events” list includes 27 serious events in six major categories that may occur in hospitals and outpatient facilities. But based on experience with PA 02-125, DPH determined that it needed certain additional information critical to its efforts to improve the safety of patients in Connecticut. DPH has added six Connecticut-specific events to the NQF list, one of which is “nosocomial infections defined as reportable sentinel events by the Joint Commission on Accreditation of Healthcare Organizations. ” These are basically hospital-acquired infections that result in death or serious injury to the patient.

DPH reports that it collects data pertaining to this issue in three areas- (1) as part of the adverse event reporting discussed above, (2) when there is an infection outbreak in a facility involving a number of patients (this would involve infection control activities and an epidemiological investigation), and (3) when other infections arise.

The department is not currently making available to the public information on any specific hospital infection cases; any public reporting would be in aggregate form. DPH can publicly release information on specific cases only when the case is the subject of a complaint and the department has fully investigated it. The law (PA 04-164) requires DPH to report to the legislature annually on October 1 on the adverse event-reporting program.

More information on this issue can be found in OLR Reports 2004-R-0532 and 2000-R-0801.

FLORIDA

Florida passed legislation in 2004 (Chapter 2004-297, HB 1629) requiring hospitals to report their infection rates. This requirement, passed as part of a larger health bill, simply requires hospitals to submit “data on hospital-acquired infections as specified by rule” (Sec. 9(1)(a)). The state’s Agency for Health Care Administration is responsible for implementation. State health officials are in the process of developing standards but are not expected to make infection rates public until 2006. (See attached article on the Florida situation. )

ILLINOIS

Illinois passed legislation in 2003 known as the “Hospital Report Card Act” (PA 03-0563, SB 59). Section 25 of this act requires hospitals to submit quarterly reports to the Illinois Department of Public Health (IDPH) and make them available to the public through the department. These reports must include nosocomial infection rates for the hospital for specific clinical procedures as determined by the department through regulation and in the following categories: (1) Class I surgical site infection, (2) ventilator-associated pneumonia, and (3) central line- related bloodstream infections.

The law also imposes a detailed validity and accuracy protocol that IDPH must follow before the public release of hospital information. This mandated process includes establishment of an advisory committee involving representatives from the department, public and private hospitals, physicians, nursing staff, academic researchers, health insurers, organized labor, and organizations representing hospitals and physicians.

The law is currently in the implementation phase, and no hospital-based infection reports have been issued as yet.

MISSOURI

Missouri enacted the “Missouri Nosocomial Infection Control Act of 2004” to encourage health care facilities to take appropriate actions to decrease the risk of infection (SB 1279). The Missouri Department of Health and Senior Services is currently implementing the law. Beginning July 1, 2005, Missouri hospitals began reporting the rate of central-line infections and those associated with the placement of an intravenous catheter. Beginning in January 2006, they will be required to report all surgical infections and as of July 2006, they will have to start reporting rates of ventilator-assisted pneumonias.

Information on infection rates will be available on the department’s website (www. dhss. mo. gov) beginning December 2006.

NEW YORK

New York passed legislation in 2005 (S 5086, A 8698) requiring hospitals to report the incidence of infections acquired by patients to the state health department, which will be responsible for making the information available to the public. (The bill was recently sent to Governor Pataki for his approval. ) The legislation requires hospitals to track and report infections that occur in critical care units and fall into three categories: (1) surgical site infections, (2) infections associated with catheters, and (3) pneumonia in patients on ventilators. The act makes the New York Public Health Department responsible for issuing an annual report on each hospital’s performance, which must be available to the public online within two years from the date the legislation is signed.

PENNSYLVANIA

Data Collection

To date, Pennsylvania is the most advanced among the states that have adopted hospital infection legislation in regard to gathering data and making information available to the public. Under a general law on hospital quality, the Pennsylvania Health Care Cost Containment Council (“PHC4”) was authorized to collect and report hospital-acquired infection rates. Beginning January 2004, Pennsylvania hospitals were required to start submitting data to PHC4 on the following types of hospital-acquired infections: (1) surgical site infections for orthopedic surgery, neurosurgery, and surgery related to the circulatory system and (2) all device-related infections for (a) Foley catheter-associated urinary tract infection, (b) ventilator-associated pneumonia, and (c) central-line associated bloodstream infection. As of January 1, 2006, hospitals must submit data on all hospital-acquired infections to PHC4.

Pennsylvania’ data collection effort is designed to assist in reducing the number of these infections by providing current, accurate data to providers, purchasers, and consumers of health care.

Report Findings

Earlier this month, PHC4 released a report on hospital-based infections. (The report and other information can be obtained at http: //www. phc4. org). In 2004, there were 1. 9 million admissions to Pennsylvania’s hospitals. PHC4’s analysis focused on the 1. 56 million admissions to 173 general acute care hospitals.

Hospitals reported 11,668 hospital-acquired infections, a rate of 7. 5 infections per 1,000 patients admitted. Of those patients with a hospital-acquired infection, 15. 4% (1,793) died, compared to a mortality rate of 2. 4% for patients who did not have such infections. The difference in mortality rates equated to an additional 1,510 deaths for those patients with hospital-acquired infections — 446 with bloodstream infections, 423 with urinary tract infections, 393 with pneumonia, and 8 with surgical site infections, according to the PHC4 report.

Mortality rates were highest (31. 9%) for patients reported with ventilator-associated pneumonia, while such rates for reported central-line associated bloodstream infections and Foley catheter-associated urinary tract infections were 25. 6% and 9. 4% respectively. Patients with hospital-acquired surgical site infections had a mortality rate of 3. 1%.

The average additional length of stay for patients who contracted either a bloodstream infection or pneumonia was about 26 days. Patients with urinary tract infections spent an average of 12. 4 additional days in the hospital, while those with surgical site infections spent an average of 7. 8 additional days.

In total, the patients who contracted hospital-acquired infections, as reported to PHC4 for 2004, accounted for more than 205,000 additional hospital days and $ 2 billion in additional hospital charges, when compared to hospitalizations for patients who did not have a hospital-acquired infection.

The PHC4 report cautions “results from the first year of data collection indicate that while some hospitals worked hard to meet the hospital-acquired infection data collection requirements, other hospitals provided minimal information. There was a steady increase each quarter of 2004 in the number of hospital-acquired infections reported. Yet, submission disparities among hospitals raised concerns regarding the accuracy and completeness of the reported data. ” The report concludes that the numbers of infections that patients contracted while in the hospital were likely underreported.

VIRGINIA

Virginia Governor Warner recently signed legislation ( Chapter 444, HB 1570) requiring hospitals to disclose information about infections that patients develop during treatment. Under the new law, acute care hospitals in Virginia must report information about infections to the federal Centers for Disease Control and the Virginia Board of Health. The board must develop regulations outlining the data hospitals will have to report, including the types of infections covered and the patient populations included. After that time, hospital infection data can be released to the public. The new law takes effect July 1, 2008.

JK: ro