You asked for information on states that have passed legislation specifically addressing methicillin-resistant Staphylococcus aureus (MRSA) infection screening and reporting.

SUMMARY

Also referred to as a “staph infection,” MRSA is a bloodstream infection with strong defenses against common antibiotics like penicillin.

A report from the federal Centers for Disease Control and Prevention (CDC) found that nearly 19,000 people died from MRSA in 2005. The study, reported in the Journal of the American Medical Association, found that more than 94,000 Americans contracted life-threatening MRSA infections in 2005. Most of the infections were traceable to hospitals, nursing homes, or medical clinics.

We have identified at least six states and a city (New York City) that have recently passed legislation, amended regulations, or taken some other formal action concerning MRSA testing and reporting. Illinois recently passed legislation requiring every hospital to establish a MRSA control program and report all MRSA infections to the state health department.

Missouri requires hospitals to report on a quarterly basis combined data on MRSA infections in hospitals. New Jersey requires all general hospitals to implement infection control programs, beginning with their ICUs and later, in other high-risk units. The facility's infection control program must include certain strategies concerning MRSA infections. Hospitals must also report the number of hospital-acquired MRSA cases to the state health department.

New York City is amending its health code to require laboratories to report electronically on positive MRSA test results to the city health department. North Carolina, by legislation, created an advisory commission on hospital infection control and disclosure with the goal of passing further legislation to require public disclosure of hospital-acquired infections, including MRSA, in 2009.

In July 2007, Pennsylvania enacted legislation that requires testing and prevention standards for health care-associated infections in most healthcare facilities in the state. In a program to be phased in over several years, hospitals and nursing homes will be required to test for resistant bacteria in all high-risk patients, patients admitted to hospitals from nursing homes, and staff who come in contact with infected patients. Direct financial incentives for hospitals to reduce infections also will be incorporated by awarding bonus payments to facilities that cut the number of infections by at least 10%.

Finally, Virginia enacted an emergency regulation to require laboratory reporting of MRSA infections in normally sterile sites to the state health department.

ILLINOIS

Public Act 095-312 of Illinois' 2007 Legislative session creates the “MRSA Screening and Reporting Act” that requires every hospital to establish a MRSA control program and report all MRSA infections to the Illinois Department of Health. Hospitals' MRSA control programs must:

1. identify all MRSA-colonized (carrier) patients in all intensive care units (ICUs) and other at-risk patients identified through active surveillance testing,

2. isolate identified MRSA-colonized or MRSA-infected patients in an appropriate manner,

3. monitor and strictly enforce hand hygiene requirements, and

4. maintain case records and reporting as required by law.

The law requires the Health Department, beginning October 1, 2007, to compile separately aggregate data for all hospitals on the total number of reported MRSA infections that (1) are present on admission to a hospital and (2) occurred during the hospital stay.

The Health Department must make this data available on its web site, in an annual report, and on its hospital report card.

MISSOURI

Individual cases of MRSA infections are not reportable to the Missouri Department of Health and Senior Services (DHSS). But Missouri law mandates that “any unusual expression of illness in a group of individuals which may be of public health concern is reportable...” This means that outbreaks of all infections, whether or not they are included in the list of reportable conditions, are reportable. Thus, outbreaks caused by MRSA are reportable.

Missouri does require hospitals to report quarterly combined data on MRSA infections that occur in the hospital from specific sites monitored by that hospital. This data is not identified by hospital and is only used along with test data on antibiotics from laboratories throughout the state to provide DHSS with information to monitor resistance trends in facilities. This information is used internally and, by law, is not made public (19 CSR 20-20.020).

NEW JERSEY

A recently enacted law in New Jersey (P.L. 2007, Chapter 120; S. 2580) requires all general hospitals licensed by the Department of Health and Senior Services (DHSS) to implement an infection prevention program in their ICUs. If the hospital does not have an ICU, then it must be established in another high-risk unit such as a surgical, or other unit where there is a significant risk of facility-acquired infections.

Ultimately, under the act, the hospital must expand the infection prevention program to all areas of the hospital, with the exception of inpatient psychiatric units. The program expansion must be completed as quickly as feasible, taking into account the hospital's patient population, physical plant, and other facility-specific circumstances.

In addition to best practices and effective strategies, the hospital must incorporate the following:

1. identification and isolation of both colonized and infected patients by screening patients upon admission in order to break the transmission chain;

2. contact precautions for patients who are MRSA positive, as “contact precaution” is defined by CDC;

3. patient cultures for MRSA upon discharge or transfer from the unit where the infection program has been implemented, and flagging patients who are readmitted to the hospital;

4. strict adherence to hygiene guidelines;

5. a written infections prevention and control policy with input from frontline caregivers; and

6. a worker education requirement concerning modes of MRSA transmission, use of protective equipment, disinfection policies and procedures, and other preventive measures.

The New Jersey act also requires a general hospital to report to DHSS the number of cases of hospital-acquired MRSA that occur in its facility. This must be reported in a manner and schedule DHSS determines.

Depending on funding, DHSS must report within 18 months to the Governor and the Senate and General Assembly health committees on the act's effect in reducing MRSA infections in hospitals.

NEW YORK CITY

Earlier this month, the New York City Department of Health and Mental Hygiene adopted a resolution amending the city's Health Code to require electronic laboratory reporting to the department of positive MRSA, rotavirus, norovirus, respiratory syncytial virus, and varicella test results. Separate reporting by health care providers is not required (Sec. 11.03 of the New York City Health Code). These diseases and conditions are being added because they can cause widespread illness in the community, have recently emerged, or have become of greater public health concern. The department states, “to better understand the epidemiology of community-associated MRSA in New York City and to develop targeted prevention strategies, population based surveillance is necessary.”

NORTH CAROLINA

In 2007, North Carolina passed legislation (Session Law 2007-480, HB 1738) that creates an “Advisory Commission on Hospital Infection Control and Disclosure” with the goal of passing further legislation to require public disclosure of hospital-acquired infections in 2009. Specifically, the commission's purpose “is to prepare state agencies, hospitals, and the public for the reporting and public disclosure of hospital-acquired infection incidence rates as may be required by law for specific clinical procedures under the following categories; (1) Class I surgical sites, (2) Ventilator-associated pneumonia, and (3) central line-related bloodstream infections.”

The commission must develop a process to ensure that information on hospital-acquired infection incidence rates available to the general public be reviewed, adjusted, and validated according to the following criteria.

1. The entire methodology for collecting and analyzing the data is disclosed to all relevant organizations and all hospitals and ambulatory surgical facilities before any public disclosure.

2. Data collection and analytical methodologies must meet accepted standards of validity and reliability before any information is made public.

3. Comparisons among hospitals and freestanding ambulatory surgical facilities must adjust for patient case mix and other relevant risk factors and control for provider peer groups, when appropriate.

4. The limitations of the data sources and methodologies used to develop comparisons must be clearly identified and acknowledged, including appropriate and inappropriate data uses.

5. To the greatest extent possible, comparative hospital and freestanding ambulatory surgical facility information initiatives must use standard-based norms derived from widely accepted provider-developed practice guidelines.

6. Comparative and other information that the statewide data processor or health department has compiled must be shared with the hospital or surgical facility under review before the information is made public; the hospital or surgical facility must have 30 days to make corrections and add helpful explanatory comments about the information.

7. Safeguards must protect against the (a) unauthorized use or disclosure of information and (b) dissemination of inconsistent, incomplete, invalid, inaccurate, or subjective data.

8. A process to ensure that the quality and accuracy of reported information by a hospital or surgical facility and its data collection, analysis and dissemination methodologies are evaluated regularly.

9. A process to ensure that only the most basic identifying information from submitted reports is used; information identifying a patient, employee, or licensed professional cannot be released, except as otherwise authorized by law.

The advisory commission must submit an interim report to the General Assembly by May 1, 2008; a final report is due at the start of the 2009 session.

PENNSYLVANIA

Pennsylvania's “Health Care-Associated Prevention and Control Act” (SB 968; Act 52 of 2007), amends the state's medical error reduction law to address the reduction and prevention of health care-associated infections. Under the law, health care facilities (hospitals, nursing homes, and ambulatory surgical facilities) must develop and implement an infection control plan. The plan must then be submitted to the Pennsylvania Department of Health for review. The facility must also notify all its health care workers, physical plant personnel, and medical staff about the plan. Facilities had to do this by December 31, 2007.

A facility's infection control plan must identify effective measures for the detection, control, and prevention of health care-associated infections. The legislation specifically addresses MRSA by requiring the plan to have a system for identifying and designating patients known to be colonized or infected with MRSA or other multi-drug resistant organism (MDRO) that includes:

1. procedures necessary for requiring cultures and screenings for all nursing home residents admitted to a hospital;

2. procedures for identifying other high-risk patients admitted to the hospital who need routine cultures and screenings;

3. procedures and protocols for staff who may have had potential exposure to a patient or resident known to be colonized or infected with MRSA or MDRO, including cultures and screenings, prophylaxis, and follow-up care; and

4. procedures and processes for notifying a receiving health care or ambulatory surgical facility of any patient known to be colonized before transfer within or between facilities.

By February 15, 2008, hospitals must report health care-associated infection data to the CDC through its National Healthcare Safety Network (NHSN) internet-based surveillance system. Nursing homes must report infection data to the state Health Department and the state Patient Safety Authority using nationally recognized standards based on CDC definitions. Such reporting must be for all patients throughout the facility at all times. It must be conducted monthly, and each hospital must authorize the Health Department, Patient Safety Authority, and the Pennsylvania Health Care Cost Containment Council to access data from NHSN.

By December 31, 2007, the law required each hospital that was not currently using an electronic surveillance system to conduct a strategic assessment of the utility and efficacy of such a system. The assessment had to include an examination of the financial and technological barriers to implementation of such a system.

The law charges the state Department of Public Welfare, in consultation with the Health Department, to make a quality improvement payment to a health care facility that achieves at least a 10% reduction in the total number of reported health care-associated infections in that facility, beginning January 1, 2009 (for the preceding year).

VIRGINIA

On October 24, 2007, Virginia enacted an emergency regulation to require laboratory reporting of MRSA infections in normally sterile sites to the Virginia Department of Health. The regulation is intended to help the department in tracking the occurrence and trends over time of the most serious forms of MRSA infection.

Specifically, the regulation amends the state “Regulations for Disease Reporting and Control,” concerning the list of conditions that must be reported by laboratory directors. The amended language adds MRSA as follows: “Staphylococcus aureus infection, resistant, as defined below… Methicillin-resistant-by antimicrobial susceptibility testing of a Staphylococcus aureus isolate, with a susceptibility result indicating methicillin resistance, cultured from a normally sterile site” (12 VAC5-90-80, par. B).

A “normally sterile site” is defined as blood, cerebrospinal fluid, amniotic fluid, pleural fluid, peritoneal fluid, pericardial fluid, bone and bone marrow, joint fluid, and certain internal body sites (i.e., specimens obtained from surgery or aspirates). Urine, wounds, and sputum are not considered sterile sites for purposes of this surveillance.

The reporting requirement applies to laboratories processing human clinical specimens for diagnostic purposes. They already report dozens of different diseases to the Health Department.

The emergency regulation is in effect for one year, during which time the state administrative process will be followed to make it permanent.

JK:dw