HAI reporting: Should it be legislated?

So assume for the purposes of argument that hospitals do not eliminate hospital-acquired infections, and that the states in which they operate require them to begin public reporting of their infection rates — as a means of (choose your motivator) shaming them into doing better, or warning the public if they do not.

This argument is not hypothetical: Nineteen states have enacted HAI-reporting legislation, and another half-dozen have HA-MRSA reporting requirements, with more states considering MRSA bills this spring.

On the one hand, we know that infection control is difficult: Bugs linger not just in obvious places — walls, floors — but on essential objects with complex, hard-to-clean surfaces such as computer keyboards and stethoscopes. But on the other hand, we know that good infection control saves not only lives, but money and time as well.

So, infection control — specifically, "search and destroy" — by legislation: Fair or not fair?

A set of articles published last year argues the two sides. From Dr. Barry Farr, professor emeritus at the University of Virginia Health System, long-time leader in infection control: Legislation is not the best solution, but it should be enacted because the healthcare industry has been dragging its feet for too long. From the boards of directors of the Association of Professionals in Infection Control and the Society for Healthcare Epidemiology of America: Legislating specific actions that hospitals must take creates an unfunded mandate and may have unintended consequences.

More about hospital-acquired infections

As I said earlier, a panel of heavy hitters (and me, just the moderator) will meet later this month to debate the trend of states forcing hospitals to fess up to hospital-acquired infections. Nineteen states now require it and an additional handful have additional laws that specifically require MRSA reporting.

The unstated assumption behind those laws is that hospitals both should and can control hospital-acquired (AKA nosocomial) infections. But in the real world, the strategies for doing that are still being argued about. This is surprising, to say the least, since hospital-acquired MRSA has been brewing in the United States for 40 years. (First cite, for medical-history geeks: Barrett FF, McGehee RF Jr, Finland M.Methicillin-resistant Staphylococcus aureus at Boston City Hospital. Bacteriologic and epidemiologic observations. N Engl J Med. 1968 Aug 29;279(9):441-8.)

The tactic that has worked the best — in hospital units, whole hospitals, geographic areas and in Europe entire countries — goes by the jargon name "Active detection and isolation (ADI)" and the shorthand description "Search and destroy." Briefly, it calls for identifying new hospital patients whose recent history puts them at risk of being infected or colonized, testing them for the bug, and putting them under isolation until they are cleared of the bug.

It sounds straightforward, and currently there are about 150 studies to prove that it works. (Here is one of the most recent, about Evanston Northwestern Healthcare in Illinois.) But in the United States, hospitals take their infection-control cue from several official authorities, including the Healthcare Infection Control Practices Advisory Committee (HICPAC) chartered by the Centers for Disease Control; and a joint task force of the members of two professional organizations, the Society for Healthcare Epidemiology of America (SHEA) and the Association for Professionals in Infection Control (APIC). And those two groups do not agree: The task force says ADI should be used routinely — but HICPAC delinks detection from isolation and makes isolation just one of many options a hospital can try as a means of curbing a bug's spread.

The difference provokes furious debate among infection-control professionals, leaves hospitals confused, and has sparked a grassroots movement among families of victims of nosocomial infections. For a great overall exploration, check out Arthur Allen's recent article at the newly launched Washington Independent.