HHS Seeks Comments on Infection Prevention

Members | July 30, 2012

On July 26, the U.S. Department of Health and Human Services announced the availability of public comment for the long-term care facilities (chapter 10) of the  (HAI Action Plan). The draft module specifically addresses HAI prevention in nursing homes and proposes to expand the activities of federal and nonfederal partners to combat prevalent HAIs, including urinary tract infections (UTI), lower respiratory tract infections, influenza and influenza-like illness,  infection (CDI), and skin, soft tissue, and wound infections. HHS is seeking comments from a broad range of stakeholders.

On July 26, the U.S. Department of Health and Human Services announced the availability of public comment for the long-term care facilities (chapter 10) of the National Action Plan to Prevent Healthcare-Associated Infections (HAIs): Roadmap to Elimination (HAI Action Plan). 

The new Long-Term Care (LTC) chapter, which focuses on combating HAIs in nursing facilities and skilled nursing facilities, extends earlier efforts that focused on: 

  • Acute care hospitals (Phase 1).
  • Ambulatory surgical centers and end-stage renal disease facilities (Phase 2).
  • Influenza vaccination of healthcare personnel (Phase 2).

HHS is seeking comments from a broad range of stakeholders and requests that all responders self-identify by name and stakeholder 'category,' e.g., caregivers or health system providers; Healthcare, professional, educational organizations. 

HHS also stipulates that the submission of written materials should not exceed 10 pages, not including appendices and supplemental documents.

Recommendations for change or amendment should be submitted to LeadingAge (emunley@LeadingAge.org) ASAP, but no later than, Tuesday, August 14.

Comments may be also submitted directly to OHQ@hhs.gov by the OHQ Notice Deadline: August 22, 2012: Attention: Draft Phase 3 Long-Term Care Facilities Module.

HAI Background 

The HHS Steering Committee for the Prevention of Healthcare-Associated Infections was established in July 2008 and charged with developing a comprehensive strategy to progress toward the elimination of HAIs.

In 2009, the Steering Committee issued the initial version of the National Action Plan to Prevent HAIs: Roadmap to Elimination. The initial strategy (Phase 1) focused on the prevention of infections in the acute care setting.

Phase 2, released in 2010, expanded the effort to outpatient facilities (ambulatory surgical centers and endstage renal disease facilities). Phase 2 also addressed strategies to increase influenza vaccination coverage for healthcare personnel.

The phase 3 draft module specifically addresses HAI prevention in SNFs/NFs. Similar to Phases 1 & 2, the HAI reduction strategies contained in this module are expected "…to be executed through research and guideline development, implementation of national quality improvement initiatives at the provider level, and creation of payment policies that promote infection control and reduction in healthcare facilities."

Please see the HHS web site for additional information about the HAI Initiative and the HHS Partnership for Patients.       

HAI Highlights and Summary 

  • The focus on NFs/SNFs includes (5) five priority areas and goals: National Healthcare Safety Network (NHSN) enrollment, Urinary tract infections/Catheter Associated Urinary tract infections (UTIs/CAUTIs), Clostridium difficile infection( CDI), resident influenza and pneumococcal vaccination and healthcare personnel influenza vaccination. "These are intended not as a final goal but as a first step."

  • "The long-term goal is to develop a data collection system that can support multiple components for assessing the quality of healthcare delivery including disease surveillance, effectiveness of prevention and control activities, quality improvement, public reporting, and financial incentive determinations."

  • The chapter details strategies for addressing these issues. "Proposed activities include expanded research, extended application of existing practice guidelines, development of new practice guidelines, provider implementation of national quality improvement initiatives, and payment policies that promote infection control and reduction."

  • Data Collection Resources and Challenges: 

    • MDS:  "Assessments provide snapshots of patients at a particular point in time, and the time between assessments may not capture important changes. Therefore, infection events could be missed between measurement periods. Second, the definitions of certain events, such as UTI, are not standardized and their validity using the MDS 3.0 is unknown."

    • Administrative claims data: Administrative claims data cover many different sites. "While there may be technical challenges for the ICD-9 to ICD-10 transition and for cross-walking codes across different settings and payment systems, these are likely to be surmountable. More concerning is that coded diagnosis of UTI, CAUTI, and CDI is neither a sensitive nor specific indicator of clinical diagnosis." Several authors have shown that ICD-9-CM coding of CAUTI is poor because the procedure code for catheter insertion is rarely used…"

    • National Healthcare Safety Network (NHSN): "The CDC's National Nosocomial Infections Surveillance (NNIS) system began in 1970 as a voluntary, hospital-based reporting system to monitor HAIs and inform local and national prevention efforts. In 2012, NHSN will be releasing a LTCF Component."

    • National Center for Health Statistics (NCHS): "The NCHS Long-Term Care Statistics Branch (LTCSB) conducts a nationally representative sample survey on LTC providers and care recipients. NCHS collected the following infection-related topics in recent surveys: strategies to encourage influenza vaccinations among employees; percentage of employees and patients/residents receiving the influenza vaccine in the last influenza season; influenza and pneumonia vaccination programs for patients/residents; percentage of patients/residents ever receiving pneumonia vaccinations; presence of infection control staff; and, use of a written plan for managing patients/residents during an influenza pandemic."

    • Patient Safety Organizations (PSOs) and Common Formats: The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) authorized the creation of Patient Safety Organizations (PSOs) to improve the quality and safety of U.S. healthcare delivery. The AHRQ is coordinating the development of the Common Formats, which standardize the definitions and reporting formats for patient safety events.

    • The Department of Veterans Affairs (VA): The VA is a large provider of LTC in the US; 133 Community Living Centers (CLCs) previously known as Nursing Home Care Units.

    • Metrics and Evaluation

    • "This section provides a framework to assess short and long-term measurement of progress toward HAI prevention in LTCFs that reflects the National Quality Strategy and HHS priorities."

    • The focus is on HAIs "…that are nationally burdensome, due to high prevalence and/or high cost, and known to be preventable through implementation of evidence-based care practices. Based on the literature reviewed, the following HAIs were selected: 1) UTIs, including CAUTI and catheter care processes, and 2) CDI."

    • 2 additional priority modules focus on vaccination (influenza, pneumococcal) of residents (Priority Area 3) and Healthcare Personnel (Priority Area 4) Influenza vaccination

  • Promising Practices in Infection Control in LTCFs

    • Infection Surveillance
    • Healthcare Personnel Influenza Vaccination
    • Education and Training Initiatives [e.g. AMDA Clinical Practice Guidelines]
    • State Financial Incentives 

  • Federal Regulatory Oversight and Performance Incentive Programs in NFs/SNFs. 

    • The Centers for Medicaid and Medicare's Nursing Home Value-Based Purchasing (NHVBP). Demonstration. "This system could prove instructive when contemplating strategies for financially incentivizing HAI reductions in nursing facilities."

    • Broader Application of the HAC-POA Policy. "In 2007-2008, CMS launched the Hospital Acquired Condition Present on Admission Policy (HAC-POA), which was applied to Inpatient Prospective Payment System Hospitals. This system could prove instructive when contemplating strategies for financially incentivizing HAI reductions in nursing facilities."

    • Pay for Performance

    • The CMS NH Quality Assurance and Performance Improvement (QAPI) program
  • Next Steps and Future Directions

    • Antibiotic Stewardship. Several recommendations are proposed: "1) an assessment of current resources dedicated to antibiotic stewardship programs within LTCFs, 2) pilot or demonstration projects that evaluate the implementation of the antibiotic stewardship programs and their impact on antibiotic use practices in LTCFs; and 3) identification of the best methods to implement and sustain antibiotic stewardship programs within LTCFs."

    • Promoting Influenza Vaccination among LTC Healthcare Personnel. "Additional research is needed to determine barriers to implementation of staff influenza vaccine programs and causes for low vaccine uptake among LTC staff."

    • Tracking Hospitalizations and Re-hospitalizations.