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CDC Expanding Quality of Care Efforts

 |  By cclark@healthleadersmedia.com  
   July 10, 2014

Denise Cardo, MD, director of the CDC's Division of Healthcare Quality Promotion, cites the agency's growing ability to collect data and its improved relationship with CMS as tools in the fight to prevent hospital-acquired infections and other avoidable harms.


Denise Cardo, MD

The Centers for Disease Control and Prevention is commonly perceived as the federal germ detective agency that investigates disease outbreaks, and keeps statistics on national trends in illnesses and injuries such as STD rates and bicycle accidents.

But to healthcare providers it might seem that the agency's role has quietly morphed into one with much more influence on how care should be delivered in hospitals, surgical centers, and even physician's practices.

Every few weeks it seems, the agency announces another campaign, research project, or program designed to define and improve quality of care.

Now, in addition to chasing emerging infections throughout the country, the CDC is trying to prevent healthcare settings from causing avoidable harm.

Just this year, the agency has announced campaigns and published papers on the need for more careful use of antibiotics, for faster recognition and treatment of sepsis, for more careful insulin prescribing and it expanded its One & Only campaign, to promote injection safety practices such as single-use of syringes, needles, vials in healthcare settings.

In a paper last month, CDC officials recommended strategies to guard against drug diversion, the increasingly recognized problem of addicted healthcare workers stealing opioid drugs.

These new or enhanced programs come as the CDC's National Healthcare Safety Network or NHSN, has grown to become the nation's largest nosocomial tracking system. Reporting to NHSN is required by the Centers for Medicare & Medicaid Services to track five types of hospital-acquired infections: central line bloodstream, catheter-associated urinary tract, C. difficile, methicillin-resistant Staphylococcus aureus (MRSA), and surgical site.


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The NHSN, which evolved in 2000 from what was the much more narrowly focused National Nosocomial Infections Surveillance System created decades earlier, started with only 300 participating hospitals.

 

Today, it collects reports from more than 12,000 medical facilities, including hospitals, ambulatory surgical centers, dialysis treatment centers skilled nursing facilities, and long-term acute care settings.

That number is expected to grow as state and federal mandates evolve. So far, data collection has expanded from hospital ICUs to acute care settings. In total, 31 states and the District of Columbia now require hospitals to report to NHSN.

In a recent interview with HealthLeaders, Denise Cardo, MD, director of the CDC's Division of Healthcare Quality Promotion, answered questions about what hospital systems and doctors can expect going forward. The interview was edited for clarity.

HLM: It seems that recently the CDC has been moving beyond areas of public health with efforts to define how care is delivered, how quality is measured, and what improvements we should expect from healthcare reform, among other initiatives. Is that off-base, or has the CDC's role changed?

Cardo:I wouldn't use the word "changed," but rather evolved and expanded. And it's not just the past few years. We are responsible for the health of the nation, and that's not just in a community, but also in healthcare. And as you know, one depends on the other. Our director, Tom Frieden, is very clear about the connection between healthcare delivery and public health.

HLM:But the CDC's role seems to be different today, with the expansion of the NHSN, antibiotic stewardship, and other types of harm prevention. That's not a space you used to be in, right?

Cardo:We were, but more with outbreaks. And we worked with healthcare settings, but the impact of our work was not as great as it is now, and the scope of activities not as big.

A decade or so ago, people in healthcare thought of healthcare infections as an acceptable complication. Science at the time said we might be able to prevent only 30%.

Things started to change in early 2000 when consumers began to fight back. They would say "my family member got an infection and I don't accept that. I want to know what is going on in that hospital." Legislation in various states required hospitals to begin reporting their infection rates to the CDC.

A critical series of [GAO] reports in 2008 indicated the CDC could do even more to prioritize areas needing stronger guidance. In response to these reports, HHS in 2009 developed the National Action Plan to Prevent Health Care-Associated Infections, with national five-year goals for HAI prevention.

HLM:So what changed?

Cardo:We started working more closely with CMS and the Agency for Healthcare Research and Quality. In addition, we learned that when you start having data (through NHSN), and you make it available, that's when people start paying attention.

Having the data can put people at the table. A lot of the CDC's effort was to make sure that hospitals that were reporting data were reporting it the same way, using the same definitions, and changing those definitions as science advances. In the past, one group used administrative data, another created its own definitions. To participate in NHSN, you have to follow the set definitions; it's a condition of participation.

The CDC also has been working with hospitals to make sure they have the appropriate data collection technology. It has introduced the TAP system, Targeted Assessment for Prevention, to help hospitals with more than the expected rates of infection.

Also of importance is that the CDC and states have several ways of validating the data that hospitals submit. One thing that's great about having data is that you can see what prevention strategies are working, and what more needs to be done.

HLM:One issue is that often providers aren't using the same definitions. How do you get everyone on the same page, to clarify definitions?

Cardo:We get input from users, hospital associations, and health departments to identify ways to improve definitions.

HLM:How are you working with the CMS? Data collection by NHSN is now used in two pay-for-performance programs, the hospital-acquired condition penalty that begins Oct. 1, and the value-based purchasing program that now includes weights for CLABSI and CAUTI.

Cardo:If you ask me what is now different, it's that CMS is part of the solution. It's putting teeth into the process and making prevention a priority. It's not optional anymore. People have to report and people have to prevent.

If we didn't have this, I would be talking with you not in terms of 5,500 hospitals and 6,000 dialysis units, but I would be talking only about 200 hospitals that were motivated to do something.

The more I see infections and other adverse events happening, the more I remind my division that elimination is our goal. We are going to make a difference here, and that's what's happened in the last few years.

We want to know which hospitals have more infections than predicted, and then let's see why and provide assistance. It's not acceptable to keep having infections we know how to prevent.

HLM:What's next for the CDC and the NHSN?

Cardo:We’re releasing something new on antimicrobial resistance in hospitals. We have already have the capability to electronically track antibiotic use from pharmacy electronic records systems. And at the end of July, we're releasing a new module allowing hospitals to electronically capture data on antibiotic resistant strains from clinical laboratories.

As soon as we start receiving data electronically, we want to know how we can extend our ability to collect additional things, like adverse drug events and medication errors. We recently published an article in the New England Journal of Medicine, highlighting some medication errors that are more frequent, like insulin prescribing and hypoglycemia. And we're looking at not just hospitals but across healthcare systems and how that information can be shared.


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We also have programs for nursing homes, and the capability for them to be reporting in the future; though it's harder for them to start reporting. And we're developing systems for ambulatory surgical centers that capture data on patient outcomes.

There's much more work to be done. As healthcare expands outside of hospitals, infections and antibiotic resistance can be transmitted between facilities.

We realize that you can have a great program in your hospital, but if you are in a community with other providers who aren't doing well, like a nursing home or a long-term acute care hospital, you're going to get these people with C. diff coming to your facility.

So we need better regional approaches in which the health departments, in collaboration with quality improvement organizations (QIOs) and other partners have access to the data, and can look not just at how one hospital is doing, but how various healthcare settings work together to prevent these events.

HLM:That's interesting, because if there's a complication requiring a hospital admission, it wouldn't be counted as a hospital readmission.

Cardo:We're trying to capture that information to provide feedback to the ambulatory center where the procedure was done. We're working on that.

HLM:Are you considering a new kind of database that would collect information from the patient's perspective?

Cardo:This is an interesting idea, but I don't think we're there yet. I'm not saying in the future it's not possible. Because we're always open to whatever is needed to really move the needle.

HLM:The CDC is the investigating agency that takes over when there's a serious outbreak or healthcare problem. And hospitals and physicians don't welcome that. Do you think they're more receptive to your intervention, for example, since the 2012 case of the compounding pharmacy contamination?

Cardo: We don't go if we're not invited. And I don't think we have that problem, especially when local health departments are involved. But they are calling us more and earlier. They know it's better not to have something in the press say, "They didn't call the CDC."

We're working more with CMS to prepare inspectors who investigate complaints about healthcare quality, so they know what to look for and can have an impact. And I think that's happening.

That inspection process is changing, and we have calls with CMS leadership every other week. I have to say that's a process that's much better than it was many years ago, when we weren't even talking.

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