Methicillin-Resistant Staphylococcus aureus (MRSA)
and Other Healthcare-Associated Infections
Frequently Asked Questions
State Legislation Database
This searchable database includes state laws pertaining to healthcare-associated infections. Currently, laws enacted from 2006 through 2010 are included.
Approximately 27 states have enacted laws that require hospitals, and sometimes other healthcare facilities, to report data related to hospital-acquired infections. Since 2005, the number of states with these laws has increased from five to 27.
The content of the laws differs widely. Some state legislatures have chosen to monitor process measures—for example, how often a prophylactic antibiotic is given to a patient prior to surgery. A greater number of states have mandated the reporting of outcome measures, or occurrences of certain types of infections.
State legislatures are also split on whether data reported by hospitals should be disclosed to the public. Most states have set up publicly-accessible databases comparing hospitals' infection data, while some have mandated that hospitals only report to a state agency or oversight committee.
Additionally, state laws vary in their selection of which infections to measure and report. This and other variations in reporting make comparisons across the states difficult. The CDC National Healthcare Safety Network (NHSN) is the only national system designed for the collection of hospital-acquired infection incidence and prevention data. Because the voluntary network allows for a more uniform collection and analysis of data, several states, including California, Colorado, Illinois, Missouri, New York, Oklahoma, Pennsylvania, South Carolina, Tennessee, Vermont, Virginia and West Virginia, require their facilities to report directly to the network.
The Healthcare-Associated Infection Working Group, which is comprised of experts from societies for infectious disease professionals and CDC representatives, has put together a tool kit for states and healthcare facilities on public reporting.
The CDC's federal advisory committee, the Healthcare Infection Control Practices Advisory Committee (HICPAC), also has guidance on public reporting.
Vermont has required its hospitals to publish annual hospital community reports
containing various quality, financial, and cost data since 2003. In 2006, certain hospital-acquired infections were added to the list of measures included in these reports. The state is gradually phasing in more and more measures for hospitals to collect and disclose publicly—reporting on central line-associated bloodstream infections began in 2007, reporting on surgical site infections for hysterectomies is scheduled for 2008, and reporting on two new infection measures is scheduled for 2009. All data is published on a state website and the CDC's NHSN. In addition to these outcomes measures, Vermont hospitals are required to report on certain infection prevention measures, including measures aimed at preventing and controlling multidrug-resistant infections.
Expert Positions on Public Reporting:
The Association for Professionals in Infection Control and Epidemiology (APIC) is supportive of public reporting, according to a 2005 position paper, but is concerned over the lack of standardization in the collecting, analyzing, comparing and reporting of hospital infection data across hospitals and states. Both APIC and the Society for Healthcare Epidemiology of America (SHEA) believe that infection reporting would also be more meaningful if rates were risk-adjusted according to the severity of an individual's illness, their age, and other factors. In its position paper, SHEA calls for the development of a validated method of risk adjustment for HAIs to help states with this task.
In September 2008, the Government Accountability Office (GAO) released a report, Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections, examining 23 states' public reporting systems.
Infection Control Laws:
A handful of states have enacted laws mandating that certain healthcare facilities implement infection control plans, specifically targeting MRSA infections.
Infection control laws may include recommendations for preventing and controlling the spread of MRSA infections (i.e. hand hygiene protocols, patient-physician contact precautions) or suggestions for antibiotic stewardship to control the overuse of antibiotics.
Active Surveillance: A central provision of most states' infection control laws is the screening of high-risk patients upon admission for specific infection-causing bacteria. Screening patients upon admission—so-called active surveillance—is implemented with the expectation of identifying carriers of antibiotic resistant bacteria so they may be isolated and treated before spreading the bacteria.
Pennsylvania was one of the first states to mandate hospital-acquired infection
reporting and the first to release public reports on infection data. In 2007, the state
went a step further by requiring health care facilities, including hospitals, nursing
homes, and ambulatory surgical facilities, to develop internal infection control plans
based on evidence-based practices. The law specifically targets MRSA by mandating that hospitals screen high-risk individuals, such as patients admitted from nursing homes, for the antibiotic-resistant bacteria. Testing positive would call for a different admission protocol for the patient, including isolation. Bonus payments will be available to facilities that reduce infections by 10 percent by January 1, 2009.
Illinois was the first state to enforce reporting of hospital-acquired infections. In 2007, the state enacted two opposing pieces of legislation regarding hospital infection control. The first law (SB 233) requires each hospital to establish a MRSA control program and mandates that, as a part of the infection control program, a system of active surveillance testing be put in place to identify all MRSA-colonized (individuals carrying the bacteria but without symptoms) intensive care patients and other at-risk patients. Any patient with the MRSA bacteria (either colonized or infected) would then be isolated. The law also requires hospitals to report annually on MRSA incidences among intensive care patients and other at-risk patients and to specify whether the infection was present on admission or acquired during the hospital stay.
The second law (HB 192) takes a more gradual approach to infection control and is
backed by APIC. The law mandates that hospitals perform annual risk assessments and develop infection control plans that follow CDC guidelines for all multidrug-resistant organisms—not only MRSA.
Expert Positions on Infection Control Laws:
The Society for Healthcare Epidemiology of America (SHEA) and the Association for Professionals in Infection Control and Epidemiology (APIC) oppose the use of active surveillance as a blanket method for infection control, but support its use to screen high-risk patients only. See their joint position statement for details.
The Deficit Reduction Act (DRA) of 2005 instructed the Centers for Medicare & Medicaid Services (CMS) to identify at least two hospital-acquired conditions that are high cost or high volume, result in higher payments when acquired during a hospital stay, and can reasonably be prevented by following evidence-based guidelines. The DRA specified that these conditions would be subject to a payment revision.
In 2007, CMS selected eight conditions for non-payment by Medicare, including two hospital-acquired infections: catheter associated urinary tract infection and surgical site infection-Mediastinitis. Two more infections were added to the Medicare nonpayment list in 2008: surgical site infections following certain elective procedures and infections following bariatric surgery for obesity. Under the rule, on October 1, 2008, hospitals will no longer receive payment for medical services used to treat any of the listed conditions if the condition was not present upon admission.
Recently, state policymakers and Medicaid officials asked CMS to issue guidance on how states should coordinate Medicaid payments with the new Medicare nonpayment rules. Some state officials are concerned that Medicaid may be billed for Medicare's portion of dual eligibles' claims denied under the nonpayment rule. In response, CMS issued a letter to State Medicaid Directors encouraging states to submit State Plan Amendments to bring Medicaid reimbursement practices in line with the current Medicare nonpayment rules.
On the Horizon
On October 8, 2008, five national healthcare organizations, including the accrediting body for hospitals, the Joint Commission, partnered to announce the release of updated strategies to prevent HAIs. The Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals was authored by SHEA and the Infectious Diseases Society of America (IDSA), in partnership with the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology, Inc. (APIC), and The Joint Commission.
The strategies for hospitals come in a synthesized, easy-to-use format and distill the thousands of existing recommendations on infection prevention and control down to tens of recommendations. The supporting organizations hope that the compendium will serve as a guide to states in crafting their infection prevention and control laws.
Because bacteria are quickly developing resistance to current antibiotics, the slow pace of new antibiotic development is of great concern to physicians and public health experts. According to a policy brief by Extending the Cure, the number of antibiotics approved by the Food and Drug Administration (FDA) has fallen consistently since 1980. There are some new antibiotics in the pipeline; six new drugs are pending with the FDA and at least 30 are either in the early or final stages of clinical testing.