Infection control targeted in proposed Medicare rule
Infection control targeted in proposed Medicare rule
APIC supports rule for federal reimbursement
Infection control must be "an integral part" of hospital quality improvement efforts to maintain participation in Medicare and Medicaid programs, according to a proposed rule by the Health Care Financing Administration (HCFA) in Washington, DC.1
However, to allow local flexibility and emphasize patient outcomes over departmental processes, HCFA is dropping a previous requirement that a log be kept recording incidents related to infections and communicable diseases.
"In keeping with the outcome-oriented approach of this rule, we propose that the hospital must have a method of identifying problems in its infection control program and take appropriate actions that result in improvement," the proposed HCFA rule states. "Although use of a log may be one method to identify problems, we do not intend to prescribe how a hospital should identify problems."
HCFA is proposing to maintain infection control as a separate condition of participation (COP) because it is vital for protecting patient health and safety, the rule states.
"We propose to retain most of the standards under the current COP, but we would strengthen its focus by requiring hospitals to take appropriate actions that result in improvement when problems are identified in their infection control programs," HCFA states in the rule. "This is in concert with the proposed quality assessment and performance improvement COP, of which infection control must be an integral part."
Specific standards not required
Infection control professionals have until Feb. 17, 1998, to submit comments on the HCFA rule, which was published in the Dec. 19, 1997, Federal Register. (See editor’s note below.) The Association for Professionals in Infection Control and Epidemiology had not issued an official reaction at press time, but supports the infection control aspects of the proposed rule and the emphasis on patient outcomes, according to the APIC governmental affairs office in Washington, DC.
The HCFA emphasis on outcomes and interventions is much in keeping with the infection control approach recommended by the Joint Commission on Accreditation of Healthcare Organizations. (See Hospital Infection Control, September, 1997 129-134.) HCFA cites the Joint Commission as a resource, along with APIC, the Centers for Disease Control and Prevention, the Occupational Safety and Health Administration, and the American Hospital Association.
"We considered requiring hospitals to meet CDC and OSHA standards for providing an environment to avoid sources of infections and communicable disease," HCFA states. "However, such a requirement would raise questions as to which CDC or OSHA standards must be met. Moreover, where alternative sets of professionally recognized standards exist, we do not wish to restrict hospital flexibility by mandating compliance with a particular body of standards. Therefore, we are not mandating that hospitals follow any specific set of infection control guidelines; however, such guidelines are published by CDC, APIC, AHA, and JCAHO and are available as resources on infection control practices."
In general, HCFA strongly endorses the importance of infection control in the proposed standard, additional highlights of which are summarized as follows:
• Nosocomial infections subject patients to significant additional pain and risk, prolong hospital stays, and lead to significant additional costs in health care spending.
• The proposed infection control COP places accountability on hospitals to prevent, control, and investigate infections and communicable diseases, and take actions that result in improvements.
• The proposed COP allows flexibility for hospitals to determine how to meet these objectives. This includes the flexibility to determine how much training in infection control is necessary for the hospital’s personnel.
• HCFA also considered including specific requirements concerning employee health status issues. However, the agency decided the hospital’s obligation to protect patients from employees with communicable diseases is covered in the proposed language that states that the hospital maintains an effective infection control program that protects patients and hospital staff by preventing and controlling infections and communicable diseases.
[Editor’s note: To comment on the proposed rule, mail one original and three copies of written comments to HCFA, department of health and human services, Attn: HCFA-3745-P, P.O. Box 7517, Baltimore, MD 21207-0517.]
Reference
1. Department of Health and Human Services. Health Care Financing Administration. Medicare and Medicaid programs; hospital condition of participation; provider agreements and supplier approval: Proposed rule. 62 Fed Reg 66,726-66,760 (Dec. 19, 1997).
Roghmann M, McCarter Jr. RJ, Brewrink J, et al. Clostridium difficile infection is a risk factor for bacteremia due to vancomycin-resistant enterococci (VRE) in VRE-colonized patients with acute leukemia. Clin Infect Dis 1997; 25:1056-1059.
C. difficile infection was a statistically significant risk factor for VRE bacteremia in VRE-colonized patients with acute leukemia, the authors found.
Patients with VRE bacteremia and acute leukemia were also more likely to have had C. difficile infection after VRE colonization. In addition, they had a higher rate of antibiotic use, especially of vancomycin, during follow-up. However, when adjustments were made for different follow-up times, only C. difficile infection was significantly associated with VRE bacteremia.
A cohort study was conducted in a cancer center to identify risk factors for bacteremia with vancomycin-resistant enterococci (VRE) in neutropenic cancer patients colonized with VRE. There were 10 patients with VRE bacteremia among 56 colonized with VRE, of whose charts 51 were available for review. All of the patients with VRE bacteremia (10 of 10) vs. 56% of patients without VRE bacteremia (23 of 41) had acute leukemia. Four of the 10 patients with VRE bacteremia had a positive C. difficile toxin assay within six days of their first positive VRE blood culture. Both C. difficile infection and antimicrobial (vancomycin and ciprofloxacin) use during VRE colonization were significant risk factors for VRE bacteremia in univariate analysis.
The association between C. difficile infection and VRE bacteremia may be causal, but also could serve as a marker of increased morbidity in patients with acute leukemia, the authors note. Other factors associated with increased morbidity, such as chemotherapy-induced mucositis, may be responsible for the increased VRE bacteremia.
"Nevertheless, the association between C. difficile infection and VRE bacteremia is biologically plausible," they concluded. "[Other] investigators of case series of patients with C. difficile infection and acute leukemia have reported concurrent bacteremia involving organisms typically found in gastrointestinal flora."
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