HHS Report to Congress: Healthcare-Associated Infections: FY 2010 State Action Plans

I. Executive Summary

This report is requested in the joint explanatory statement to accompany H.R. 1105, the Omnibus Appropriations Act, 2009 (Public Law 111-8) and includes the following;

“That each [healthcare-associated infection prevention] State plan shall be consistent with the Department of Health and Human Services’ national action plan for reducing healthcare-associated infections and include measurable 5-year goals and interim milestones for reducing such infections: Provided further, That the Secretary shall conduct a review of the State plans submitted pursuant to the preceding proviso and report to the Committees on Appropriations of the House of Representatives and the Senate not later than June 1, 2010, regarding the adequacy of such plans for achieving State and national goals for reducing healthcare-associated infections.”

In response to the provisions, the report addresses the adequacy of State Healthcare-Associated Infection (HAI) Action Plans for achieving state and national goals for reducing HAIs. The Omnibus Appropriations Act required States receiving Preventive Health and Health Services block grant funds to certify that they would submit a plan to reduce HAIs to the Secretary of the Department of Health and Human Services (HHS) no later than January 1, 2010.

For the purposes of the provisions outlined in the Act, the term “State” referred to “each of the 50 States, the District of Columbia, and the Commonwealth of Puerto Rico.” Based on a review of the 52 State Action Plans received, the Secretary reports that each State Action Plan submitted is consistent with the Department’s national Action Plan to Prevent Healthcare-Associated Infections, and where appropriate, includes measurable five-year goals and interim milestones for reducing such infections.

Each State’s timely completion of an Action Plan despite innumerable competing public health priorities is a testament to the weight of importance of this public health issue and the commitment of States to improve health outcomes for their citizens.

II. Background

Healthcare-associated infections (HAIs), infections that patients acquire while receiving treatment for another condition in a healthcare facility, are a significant public health and medical concern in the United States. Studies have clearly demonstrated that implementation of science-based recommendations can reduce certain HAIs by as much as 70 percent.^1,2 HAIs are among the leading causes of preventable death in the United States and accounted for an estimated 1.7 million infections and an associated 99,000 deaths in 2002.³ 

The Centers for Disease Control and Prevention (CDC) estimates that beyond the human toll, HAIs are responsible for $28 to $33 billion in excess healthcare costs each year.

In order to improve coordination of prevention efforts and raise the profile of this important issue across its agencies, HHS established the senior-level Steering Committee for the Prevention of Healthcare-Associated Infections in 2008. Members of the Steering Committee include federal clinicians, scientists, and public health leaders who marshaled the extensive and diverse resources of the Department, formed public and private partnerships, and initiated discussions that identified new approaches to HAI prevention and collaborations.

The Steering Committee developed the HHS Action Plan to Prevent Healthcare-Associated Infections, which offers a road map to prioritizing science-based interventions and outlines a multi-faceted public health approach to prevent HAIs in acute care hospitals. The plan uses a tiered approach focusing on the most common infections in acute care, inpatient settings and outlines recommended clinical practices; a prioritized research agenda; an integrated information systems strategy; policy options for linking payment incentives or disincentives to quality of care and enhancing regulatory oversight of hospitals; and a national messaging plan to raise awareness of HAIs among the general public. The HHS Action Plan includes specific measures and five-year goals to track national progress in reducing the five most prevalent infections (see Table 1). The plan was initially released in January 2009 for public comment and a final version that incorporated additional content and responses to comments was released in June 2009.

The initial emphasis for HAI prevention focused on acute care settings. Yet the Steering Committee recognizes the need for prevention activities in other settings, including outpatient facilities. The healthcare and public health communities are increasingly challenged to identify, respond to, and prevent HAIs across the continuum of settings where healthcare is delivered. The public health model’s population-based perspective can be deployed to enhance the prevention of HAIs, particularly given the shifts in healthcare delivery from acute care settings to ambulatory and long-term care settings. Thus, the HHS Action Plan is currently undergoing expansion to include strategies for preventing HAIs in Ambulatory Surgical Centers (ASCs) and hemodialysis centers. The Steering Committee intends to maintain the HHS Action Plan as a “living document” and develop successor plans in conjunction with stakeholders to incorporate advances in science and technology, shifts in the ways healthcare is delivered, changes in healthcare cultural norms, and other factors.

In addition to the Steering Committee’s activities, increased funds to support HAI work have greatly enhanced elimination efforts throughout the country. The Agency for Healthcare Research and Quality (AHRQ) has distributed funds to increase prevention efforts to a variety of investigators and CDC has distributed funds made available through the American Recovery and Reinvestment Act (ARRA) of 2009 to State Health Departments to help enhance state-based HAI efforts. The Centers for Medicare & Medicaid Services (CMS) has also distributed ARRA funds to State Survey Agencies to enhance the inspection of ASCs to further support HAI prevention (see Section VI).

III. State Action Plans

The HHS Action Plan outlined key strategies needed to achieve and sustain progress toward reducing HAIs on a national level. However, measurable progress depends on the involvement of States in coordinating prevention efforts at the state, local, and community level. The purpose of the State Action Plans was primarily to outline strategies to leverage and enhance state capacity to reduce and prevent HAIs, focusing on achievement of the HHS Action Plan goals for hospitals.

In an effort to assist States in the development of their Action Plans and create a standardized process of gathering information across States, a plan template was developed. The template provided a framework for preventing HAIs that complements a coordinated effort of federal, regional, state, and partner organizations. The framework is based on a collaborative public health approach that includes surveillance, outbreak response, research, training and education, and systematic implementation of prevention practices. The template also provided States with choices for developing or enhancing HAI prevention activities and was designed to be flexible to accommodate States at different levels of engagement and planning. Additional support was provided to States in the form of webinars, conference calls, and a meeting with CDC ARRA-funded grantees in Atlanta, Georgia in October 2009.

In addition, States were encouraged to establish statewide HAI prevention leadership through the formation of multidisciplinary groups or State HAI advisory councils led by State Health Departments.

States were asked to address four areas in their Action Plan:

1. Program Infrastructure;
2. Surveillance, Detection, Reporting, and Response;
3. Prevention; and
4. Evaluation, Oversight, and Communication.

States indicated their levels of planning in each of the above categories and indicated current versus planned activities. Current activities were those in which States were already engaged and included those activities that were scheduled to begin using currently available resources. Planned activities represented future directions in which the State would like to proceed to address critical areas, contingent on available resources and competing priorities.

Through the State Action Plans, States had the opportunity to articulate areas of strength and areas requiring support in their HAI programs; identify which stakeholders to engage in HAI prevention activities; and set benchmarks for future activities. States outlined a uniform way of addressing HAI prevention focusing not only on acute care facilities but, when possible, on other healthcare settings, complementing the expanding scope of the HHS Action Plan. By having each State identify its own goals based on the level of infrastructure and resources presently in place, HHS has been able to gather valuable information that is further guiding prevention efforts.

IV. Review Process

All 52 State Action Plans were received by HHS in January 2010, yielding a 100 percent completion rate. Following an initial review of the plans by CDC Public Health Advisors (PHAs), the State Action Plans were distributed to CDC subject matter experts (SMEs) for qualitative review. SMEs included physicians, healthcare epidemiologists, and public health analysts. This extensive review entailed outlining the strengths and weaknesses of individual plans and recommendations for improving future activities. A final group review involving SMEs, PHAs, and other interested parties was conducted in February 2010 and plans with the greatest deficiencies were further discussed. Each State received feedback on the strengths of their plan as well as recommendations for how to continue to improve their State Action Plan in the presence of challenges.

V. Analysis

There is a great degree of variability across States regarding current prevention activities and resources available to support HAI prevention. However, the Steering Committee reports that each State has successfully demonstrated that an HAI program infrastructure is in place, including the creation of partnerships, hiring a State HAI Coordinator, forming a multi-disciplinary HAI advisory committee, and implementing education and communication strategies.

Some States had more mature HAI prevention programs and demonstrated excellent understanding of the necessary scope for an effective and ambitious prevention program. These States had not only identified target initiatives, but had begun implementation several years ago and were already involved in multiple prevention collaboratives. States with the strongest HAI programs indicated that they have completed extensive efforts to validate HAI data from CDC’s web-based surveillance system, the National Healthcare Safety Network (NHSN). These States are also progressing towards interoperability of electronic systems and lab capacity enhancements to improve HAI reporting.

Although some States had longstanding programs in place, others are just beginning to launch HAI prevention programs and still need considerable support to strengthen basic program infrastructure, communications, lab capacity, and data collection systems.

Review of the plans demonstrates that all States share some common needs that fall into the categories outlined below. ARRA funds have had a considerable impact in supporting advancements in each category, but significant challenges remain. Enhanced and sustained federal investment in staffing at various levels (i.e., national, regional, state, local/community), research, investigation of human and organizational factors that contribute to the occurrence of HAIs, communication technology, and health information technology will be necessary to overcome these challenges.

A. Building Program Infrastructure

Recognizing that staffing is one of the most basic components necessary to support HAI prevention efforts, ARRA funding has enhanced the ability of States to build or strengthen their HAI programs through the hiring of an HAI coordinator. HAI coordinators oversee all state-based HAI surveillance and prevention activities, manage logistics, coordinate meetings and communications, monitor progress, and oversee day-to-day HAI program operations.

In addition, through the development of State Action Plans, those States without a previously established multidisciplinary advisory committee each formed an advisory group consisting of stakeholders at various levels. These advisory groups have been integral in providing leadership and guidance and selecting initial HAI targets for each State. Also, similar to the HHS Steering Committee, members of these state councils assisted in developing their plan’s aims and content, as well as determining measurement strategies based on the State’s current level of activity. Texas was one such State in which the Department of State Health Services convened a statewide HAI planning meeting with participants including representatives from the healthcare delivery system. Many other States, including Wisconsin, Arkansas and Iowa, convened their stakeholders to gather ideas that would guide the development of their State Action Plan.      

There is a strong need to continue outreach efforts and engagement of various stakeholders at the national, regional, state, and local/community level including health departments, healthcare facilities (i.e., mentor hospitals), payers, purchasers, hospital associations, and professional organizations, as well as to define the roles and responsibilities of various entities. The specific needs of small rural hospitals and tribal communities should be identified through broader engagement of relevant stakeholders and involvement on State HAI Advisory Councils. New Mexico is one State that has already outlined how it plans to use focus groups that include tribal populations, pueblo populations, and Spanish-speaking populations to ensure that information on State HAI prevention priorities is disseminated effectively. HHS agencies and other entities are attempting to streamline and enhance national HAI efforts through the structure of the HHS Steering Committee and development and implementation of the HHS Action Plan. Through an analogous structure, States will need to continually monitor the effectiveness of their prevention initiative activities and the time it takes for full implementation of strategies.

Building an effective communication network to allow peer-to-peer sharing of progress and lessons learned will be instrumental to the success of State HAI programs. In an attempt to share information and gain support for State efforts, certain States such as North Dakota have already developed manuals to describe State HAI prevention plans for stakeholders within the State. However, State Action Plans illustrate that there is a continued need to improve coordination among governmental agencies, including State Survey Agencies, State Licensing Boards, and State Health Departments. Additionally, HHS is exploring options to facilitate communication for HAI prevention purposes and effective coordination of interventions across various entities and levels (i.e., national, regional, state, and local/community).       

B. Surveillance, Detection, Reporting, and Response

States with less extensive HAI activities will need to establish baseline data and further define plans for validation of surveillance data. These States will need to take a tiered approach and focus initial efforts on building basic surveillance and prevention programs before embarking on larger efforts in areas such as electronic reporting.

Continuing the recruitment of facilities to join and participate in NHSN monthly calls will be important for information sharing, learning about best practices, and developing strategies for data validation. Parallel to the efforts to enroll users in NHSN, States will also need to develop plans to measure the accuracy and reliability of HAI data. Although many States have plans for developing a data validation strategy, they will need continued resources to pilot-test validation methods in facilities, analyze and report validation findings, and implement validation plans in all healthcare facilities participating in HAI surveillance.

Beyond data collection, States will need to improve their overall use of surveillance data to inform and support HAI prevention efforts. New Mexico is an example of one State that has taken a multi-pronged approach and has been active in developing its surveillance, detection, and reporting program. The New Mexico Department of Health (NMDOH) has been successful in promoting NHSN participation among facilities by holding statewide trainings, monthly teleconferences, and an in-person conference in February 2010.     

Each State will also need to continue developing their infrastructure and partnerships across the healthcare continuum to improve detection, reporting, and investigation of HAI outbreaks in both inpatient and outpatient facilities.      

C. Health Information Technology

Hospitals in all 50 States are using NHSN to collect data on HAIs and an increasing number of States are requiring hospitals to participate in NHSN as part of legislated state mandates for HAI reporting. The increasing burden of data collection for facilities compounded by a shortage of resources and staffing highlights an urgent need to adopt integration and interoperability standards for HAI information systems and data sources. Enhancing electronic reporting and information technology for healthcare facilities will reduce the reporting burden and increase timeliness, efficiency, comprehensiveness, and reliability of data. Some States are working with CDC and hospitals to take advantage of electronic healthcare data and implement technical solutions that decrease the burden of manual case finding and data entry.    

D. Prevention and Implementation

Many States have already established or are progressing towards establishing “prevention collaboratives” to reduce HAIs. The majority of States are targeting reductions in central line-associated bloodstream, surgical site, methicillin-resistant Staphylococcus aureus, and Clostridium difficile infections through these prevention initiatives.

The prevention collaborative model has been used successfully in many HAI prevention projects and brings a group of healthcare facilities together to work in a coordinated fashion on a specific HAI. Participants in the collaboratives work towards implementing science-based practices, such as those issued by the HHS Healthcare Infection Control Practices Advisory Committee (HICPAC). States with experience participating in these collaboratives will need to formulate plans to expand these efforts to other settings and infection types and ensure engagement of the State HAI advisory committee. States that are just initiating these efforts will need to develop the necessary skills to ensure the success of prevention collaboratives, ensure engagement of the State HAI Advisory Committee, and carefully monitor progress towards achieving prevention targets.(Figure 1 summarizes the HAIs that are being targeted by the various state-based HAI prevention collaboratives.)

New York has demonstrated considerable success in building HAI prevention collaboratives and continues to share its experiences with other States. The University of Rochester School of Medicine and Dentistry is one such example, in which six hospitals are implementing evidence-based protocols for central line insertion and daily care outside intensive care units to reduce or eliminate central line-associated bloodstream infections. Other ongoing collaboratives in New York include efforts to reduce hospital-associated Clostridium difficile infection, ventilator-associated pneumonia, and methicillin resistant Staphylococcus-aureus.       

E. Training and Communication

There continues to be a strong need to develop or strengthen communication methods to share best practices for HAI prevention among healthcare facilities and local health departments in each State. Washington and Iowa are examples of two States that have already created an HAI prevention website where the public and healthcare professionals can learn more about HAIs. It is evident that the majority of States have hospitals that will need to continue to provide training to their healthcare personnel about HAI initiatives and will need to work closely with a variety of partners to provide training resources to assure the successful uptake of their initiatives. Development of State surveillance training competencies through conducting local trainings for appropriate use of surveillance systems is also essential.

VI. Investments to Support Regional and State Activities

The Recovery Act provided a total of $50 million in funding for state level HAI prevention activities in Fiscal Years (FYs) 2009 and 2010. In addition, other HHS funds from annual appropriations to AHRQ, CDC, CMS, and the Office of the Secretary (OS) are being used to directly support regional, state, and local/community prevention efforts.

States applied for and received ARRA funds from CDC totaling $40 million to enhance state capacity to reduce and prevent HAIs, focusing on the HHS Action Plan goals for hospitals. These funds have allowed State Health Departments to work collaboratively with dedicated healthcare professionals across the continuum of care and establish multidisciplinary HAI advisory councils with a broad representation of stakeholders in each State. Thirty-eight million dollars was disbursed to States in September 2009 to support the development of State Action Plans, expand participation in NHSN, build HAI collaboratives, and support data use and plan implementation. State Health Departments submitted applications for a competitive review process and could request funds in one or more of three areas: enhancing State Health Department HAI capacity, expanding and improving the use of NHSN, and implementing HAI prevention activities. All States that requested funds to enhance HAI capacity received some funding. (Figure 2 summarizes the funding by region, state, and activity level supported.) Funding for improving use of NHSN and HAI prevention activities was allocated based on the strength of the application. State-based HAI prevention efforts have been expedited by the availability of ARRA funds. However, state officials have expressed concern that sustaining these efforts may prove challenging without the availability of a long-term, sustainable funding mechanism.

CMS received $10 million in ARRA funds to support State Survey Agencies in their efforts to enhance the inspection process of Medicare-participating ASCs, including a case tracer methodology and an infection control assessment tool that was co-developed by CDC and CMS. Funding for the project was divided between FY 2009 (10 percent) and FY 2010 (90 percent). (State Survey Agencies are frequently, but not always, housed in State Health Departments, but are typically organizationally separate from the portions of the health departments that developed the State Action Plans to prevent HAIs.) Twelve States volunteered to begin using the enhanced inspection process in the fourth quarter of FY 2009 and were provided ARRA grants to support this work. Through CMS’ policy setting mechanism, all States were required to use the enhanced inspection process and survey one third of ASCs in FY 2010. The States were invited to apply for ARRA grants to cover their resulting increased costs. CMS received and funded applications from 42 States for their FY 2010 ASC surveys and was able to fund all requests. (Figure 3 summarizes the funding by fiscal year, state, and funding level.) Prior to the ARRA-funded program, ASCs were inspected at an average frequency of every 10 years. The goal with the program is to inspect facilities every three years. The FY 2011 President’s Budget includes increased funding to continue the enhanced inspections and to allow for ASC inspections on a four year cycle.

In efforts to support state level HAI collaboration, AHRQ involves State Hospital Associations in their overall efforts. Funds from AHRQ have been awarded for projects that address critical implementation science gaps that are in alignment with the HHS Action Plan and demonstrate generalizability and feasibility for widespread implementation. The Comprehensive Unit Based Safety Program (CUSP) is one such program that has been supported by these funds and has demonstrated how a structured strategic framework for safety can result in dramatic improvements in patient care. The CUSP approach was designed to improve the culture of safety and help clinical teams learn from mistakes by integrating safety practices into the daily work of a unit or clinical area. CUSP comprises five steps: 1) Educate staff on the science of safety; 2) Identify safety defects; 3) Engage executives; 4) Learn from identified defects; and 5) Implement tools, including clinician checklists, to improve teamwork, communications, and other systems of care. CUSP has been implemented at a large number of organizations and has achieved significant reductions in central line-associated bloodstream infections. AHRQ is currently expanding this effort to the prevention of other forms of HAIs.

In addition to providing technical assistance and epidemiologic and laboratory support for outbreak investigations through appropriated funds, CDC has provided staffing to States (Council of State and Territorial Epidemiologists fellows) for work on HAI surveillance and prevention. CDC has also funded state injection safety activities, including an educational campaign to promote safe injection practices and best practices to prevent and manage potential exposures.

To support regional efforts to prevent HAIs, OS will be funding various projects in FY 2010 sponsored by the HHS Regional Offices. Goals of this program include supporting needs identified in the State Action Plans, fostering partnerships and communication across States within identified regions of the country, and directly and indirectly supporting the work of the overall HAI prevention initiative by coordinating activities at the regional level. In addition, OS plans to launch a national media campaign in October 2010 to raise awareness of HAIs and HAI prevention among the public and providers.

VII. Longitudinal Program Evaluation of HAI Prevention Strategies

An ongoing longitudinal program evaluation is being conducted by an independent evaluation group that will not only monitor the progress and impact of the individual State HAI Action Plans and initiatives linked to the plans, but also examine other activities that are taking place within States performed by state hospital associations, health departments, CMS Quality Improvement Organizations (QIOs), and other entities. The Steering Committee believes that it is important to not only examine the activities explicitly mentioned in the State Action Plans, but other activities within a given State to determine how well the various efforts are being coordinated and their overall impact on care and health outcomes.

VIII. Conclusions

Review of the State Action Plans reflects both the progress States are making towards preventing HAIs and the variability in these activities. Plans from States with less experience in working on HAIs indicate they are working to develop an infrastructure and establish relationships that will support surveillance and prevention activities. Plans from States with more experience demonstrate how they plan to build on current efforts to expand HAI prevention efforts.

Establishing a strong network of collaborations and communications involving State Hospital Associations, State Health Departments, QIOs, State Survey Agencies, and other entities will also be an important role for HAI coordinators in the coming years. Funding provided to State Health Departments and State Survey Agencies for HAI prevention work through ARRA has greatly expanded work in this area. However, these efforts will require on-going financial support to secure and advance gains that are being made.

Amidst multiple challenges, States should be commended for their ongoing efforts to prevent, reduce, and ultimately eliminate HAIs, as well as for broader efforts to improve patient safety and protect the health of their citizens.

A. Appendix

Table 1. HAI Five-Year Reduction Targets for Measuring Progress (HHS Action Plan to Prevent Healthcare-Associated Infections).

^‡ LabID, events reported through laboratory detection methods that produce proxy measures for infection surveillance

^§ Inclusion of SSI events detected on admission and readmission reduces potential bias introduced by variability in post-discharge surveillance efforts 

Figure 1. Summary of HAI Measures as Indicated by States in HAI State Action Plans.

CLABSI: Central line-associated blood stream infection
SSI: Surgical site infection
MRSA: Methicillin resistant Staphylococcus aureus
C. Diff: Clostridium Difficile
CAUTI: Catheter-associated urinary tract infection
VAP: Ventilator-associated pneumonia

Figure 2. HAI Recovery Act Funding by Region, State, and Activity Level Supported (CDC).

*Activity A: Building State HAI Program; Activity B: Expansion of HAI Surveillance; Activity C: Establishment of Prevention Collaboratives; CSTE: Council of State and Territorial Epidemiologists; EIP: Emerging Infections Program

Figure 3. HAI Recovery Act Funding by Fiscal Year, State, and Funding Level (CMS).

The Secretary acknowledges the contributions of the U.S. Department of Health and Human Services Steering Committee for the Prevention of Healthcare-Associated Infections in preparing this Report to Congress:

Don Wright (Chair)
Office of the Secretary, Office of Public Health and Science, Office of Healthcare Quality

Denise Cardo
Centers for Disease Control and Prevention

Thomas Hamilton
Centers for Medicare & Medicaid Services

David Henderson
National Institutes of Health

David Hunt
Office of the Secretary, Office of the National Coordinator for Health Information Technology

Susan Karol
Indian Health Service

Rima Khabbaz
Centers for Disease Control and Prevention

William Munier
Agency for Healthcare Research and Quality

Kyu Rhee
Health Resources and Services Administration

Jim Scanlon
Office of the Secretary, Office of the Assistant Secretary for Planning and Evaluation

Joshua Sharfstein
Food and Drug Administration

Barry Straube
Centers for Medicare & Medicaid Services

Patrick J. Brennan (Ex-Officio)
Healthcare Infection Control Practices Advisory Committee, Chair

Gary Roselle (Ex-Officio)
Department of Veterans Affairs