Non-governmental organizations: role in infection control

Table I.

Non-governmental organization	Key elements of mission statement	Comment
Society of Healthcare Epidemiology of America(SHEA)	Prevent and control healthcare-associated infections and advance the field of healthcare epidemiology through:Conducting research and education. Translating knowledge into effective policy and practice.Promotion of professional development in healthcare epidemiology.Collaborating and sharing expertise with other organizations.	SHEA is a leading North American professional organization in infection prevention.SHEA is instrumental in shaping infection prevention policies for control of pathogens in both endemic and outbreak situations.SHEA publishes Infection Control and Hospital Epidemiology.
Association of Professionals in Infection Control(APIC)	APIC focuses on the following goals:Emphasize prevention and promote zero tolerance for healthcare-associated infections and other adverse events.Ensure that appropriate standards and measures are set by which infection prevention and control programs are evaluated by regulatory agencies, healthcare executives, payers, and consumers.Serve as a catalyst for leading edge research for the prevention of infection and associated adverse outcomes.Play a leadership role in emergency preparedness related to infection prevention and control.	APIC is the largest infection prevention society in the United States.APIC membership largely consists of nurses specializing in infection prevention.APIC is instrumental in shaping infection prevention policies for the control of pathogens in both endemic and outbreak situations.APIC publishes the American Journal of Infection Control.
Institute for Healthcare Improvement(IHI)	IHI focuses on the improvement of the lives of patients, the health of communities, and the joy of the healthcare workforce.IHI’s improvement aims for the healthcare system are:Safety, effectiveness, patient-centeredness, timeliness, efficiency, equity.	The 100,000 lives campaign enlisted 3,100 hospitals to consistently implement risk reduction practices to limit harm in hospitals. Infection prevention areas of focus included:Prevent central line infections by implementing a series of interdependent, scientifically grounded steps.Prevent surgical site infections by reliably delivering the correct peri-operative antibiotics at the proper time.Prevent ventilator-associated pneumonia by implementing a series of interdependent, scientifically grounded steps.
Hospital Infections Society (HIS)	The HIS focuses on:The provision of information to those interested in hospital acquired infections.Publishing available reports and guidelines from the working parties funded and supported by the Society.Providing scientific grants relevant to infection prevention.	Based in the United Kingdom, the HIS is a European and worldwide leader in infection prevention.HIS is instrumental in shaping infection prevention policies for the control of pathogens in both endemic and outbreak situations.HIS publishes the Journal of Hospital Infection.
Consumer’s Union(CU)	CU is an expert, independent, non-profit organization whose mission is to work for a fair, just, and safe marketplace for all consumers and to empower consumers to protect themselves.CU employs a dedicated staff of lobbyists, grassroots organizers, and outreach specialists to change legislation and the marketplace in favor of the consumer interest.	CU is based in the United States.CU publishes Consumer Reports.CU advocates mandatory public reporting of hospital-acquired infections and calls for alignment of payment with performance.
The Joint Commission	An independent, not-for-profit organization, The Joint Commission accredits and certifies more than 18,000 healthcare organizations and programs in the United States.The Joint Commission aims to continuously improve healthcare for the public, in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.	Joint Commission accreditation is essential for all healthcare systems as this is both a sign of quality and impacts reimbursement from third party payers. Joint Commission accreditation standards include demonstration of infection prevention best practices in healthcare facilities.

What are the conclusions of clinical trials or meta-analyses regarding non-governmental organizations that guide infection control practice and opinion?

Although there are no clinical trials or meta-analyses specifically assessing the role and effectiveness of NGOs in infection prevention efforts, the current body of literature suggests that NGOS can have an impact on infection prevention through promotion and implementation of infection prevention best practices.

Since 2002, several consumer organizations have successfully established campaigns that heighten awareness of hospital-acquired infections. Most noteworthy is the Consumer’s Union’s Stop Hospital Infections Campaign and the RID campaign sponsored by the committee to Reduce Infection Deaths.

A major focus of this campaign is to increase demand on the mandatory public reporting of hospital-acquired infections in the United States. As of 2010, most states have legislation enacted or in progress for the reporting of hospital-acquired infections. At present there is no national standard for the reporting of hospital-acquired infections such that the data reported vary from state-to-state. The most commonly reported infections are central-line associated bloodstream infections.

The national and regional impact of mandatory public reporting, however, is not well known. A major challenge is that not all hospital-acquired infections are preventable, Thus the maximal extent to which reporting can impact infection reduction is unknown.

Successful hospital infection prevention initiatives sponsored by NGOs are reported in the literature. These initiatives typically involve both local and regional partnerships and aim to implement risk reduction practices supported by the medical literature.

The Pittsburgh Regional Healthcare Initiative is an independent organization with the aim of improving healthcare safety and quality in southwestern Pennsylvania. Under this program, a consortium of healthcare facilities, insurers, employers, healthcare providers, and local health authorities were able to implement risk reduction practices and thus decrease the rate of central-line associated bloodstream infections by 68% over a four year period.

The Michigan-based Keystone Project was similarly able to decrease central-line associated bloodstream infections by implementing evidence based risk reduction interventions. The Institute for Healthcare Improvement initiated its 100,000 lives campaign in 2005; and by 2006, the IHI announced that more than 20 participating hospitals had not reported a case of ventilator-associated pneumonia in more than one year.

With 2000 hospitals involved in implementation of infection prevention best practices, the IHI reported that greater than 100,000 deaths had been prevented since initiation of the project. These studies suggest that NGOs and partnerships can successfully engage healthcare systems to implement risk reduction strategies with resultant decreases in hospital-acquired infections.

What are the consequences of ignoring key principles and concepts?

Although non-governmental authorities do not have legal mandates and are not enforcement agencies, their impact on hospital infection prevention efforts are nevertheless significant.

The Joint Commission is an independent, not for profit organization that accredits and certifies more than 18,000 healthcare facilities in the United States. The primary role of the Joint Commission is to evaluate and certify healthcare facilities in the areas of patient safety and quality healthcare.

Infection prevention criteria safety measures assessed by the Joint Commission for hospital accreditation include implementation of central line bundles, hand hygiene promotion, and monitoring and control of multi-drug resistant pathogens, such as MRSA. Failure to obtain and maintain accreditation by the Joint Commission impacts the prestige of an institution and may have repercussions on reimbursement by third party payers.

Summary of current controversies.

Controversies regarding the role of NGOs in hospital infection prevention center on the underlying assumptions in support of public reporting along with the paucity of clinical evidence that public reporting translate into safer patient care. In addition, the degree to which hospital-acquired infections can be maximally averted is still unknown, further questioning the potential efficacy of public disclosure of infections data.

The principle controversies regarding the role of NGOs in infection control are the assumptions and potential impact of mandatory public reporting of hospital-acquired infections. In brief, the transformation of healthcare in the United States and the view of healthcare as a commodity have resulted in a strong role for consumer advocacy. The push to disclose data publicly has important underlying assumptions. The key assumptions are as follows:

• Transparency and open exchange of information will be readily available and will satisfy the public’s right for information.

• Hospital-acquired infections are preventable; however, the current state of infection prevention science cannot eliminate all infections.

• Accurate hospital-acquired infection data will be risk adjusted to account for severity of illness and the complexity of care offered in each hospital. At present, there is no national standard for the reporting of hospital-acquired infections.

• Consumers will make rational decisions about choices in healthcare. There is little research to support this statement. It seems that in times of urgent or emergency care, the choice of a healthcare facility will not be based on a comparative analysis. A recently published systematic review of how consumers use quality of care information concluded that producing and publishing comparative data has had little impact on public attention and selective consumer behavior.

• Consumers are fully free to choose their medical plans, their physicians, and their site of care. At present, the United States healthcare system is a poorly co-ordinated and fragmented system with a mix of private, federal, and state administered health plans. Many Americans are enrolled in health maintenance organizations. Approximately 40 million Americans are uninsured. The complexity of the system, the payer mix, the health maintenance organizations, and the uninsured status of many citizens limit consumer choice globally.

• Market forces will provide incentives for hospitals to improve quality.

Despite the drive towards elimination of hospital-acquired infections, the current state of science cannot prevent all infections. Thus, the maximal extent to which reporting can impact infection reduction is unknown.

To date, there are no robust clinical data to conclude that public reporting has resulted in a significant improvement in hospital infection outcomes.

References

Harbarth, S, Sax, H, Gastmeier, P. “The preventable proportion of nosocomial infections: an overview of published reports”. Hosp Infect.. vol. 54. 2003. pp. 258-266.

“Centers for Disease Control and Prevention. Reduction in central line-associated bloodstream infections among patients in intensive care units—Pennsylvania, April 2001-March 2005”. MMWR Morb Mortal Wkly Rep. vol. 54. 2005. pp. 1013-1016.

Pronovost, P, Needham, D, Berenholtz, S. “An intervention to decrease catheter-related bloodstream infections in the ICU”. N Engl J Med.. vol. 355. 2006. pp. 2725-2732.

Hackbarth, AD, McCannon, CJ, Martin, L, Lloyd, R, Calkins, DR. “The hard count: calculating lives saved in the 100,000 Lives Campaign. ACP Guide for Hospitalists”.

Edmond, MB, Bearman, GM. “Mandatory public reporting in the USA: an example to follow”. J Hosp Infect. vol. 65. 2007 Jun. pp. 182-8.

Faber, M, Bosch, M, Wollersheim, H, Leatherman, S, Grol, R. “Public reporting in health care: how do consumers use quality-of-care information”. A systematic review. Med Care. vol. 47. 2009 Jan. pp. 1-8.

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