Background
Healthcare-associated infections (HAI) are infections that patients acquire during the course of receiving medical treatment for other conditions. HAIs are the most common complication affecting hospitalized patients, with between 5 and 10 percent of patients acquiring one or more infections during their hospitalization.
In 2006, the General Assembly amended the MHCC’s statute to give it authority to collect and report information on healthcare-associated infections in hospitals. HG 19-134(e)(6). Certain information on HAI process measures are publicly reported for each Maryland hospital in the Commission’s Maryland Hospital Performance Evaluation Guide (http://mhcc.maryland.gov/consumerinfo/hospitalguide/index.htm). As discussed below, information on additional quality measures is being collected and will be reported.
The Commission convened an HAI Technical Advisory Committee (TAC) composed of hospital infection preventionists, hospital epidemiology, public health professionals, and patients/health care consumers. In December 2007 the TAC released its Report and Recommendation for Developing a System for Collecting and Publicly Reporting Data on Healthcare-Associated Infections in Maryland. The MHCC has been implementing the recommendations of its TAC in stages. You can access the Committee’s Report by clicking on the link below.
In 2006-07, the Commission began collecting and reporting HAI information on three process measures designed to prevent infections for patients undergoing hip, knee, and colon surgery: (1) proportion of patients receiving antimicrobial prophylaxis within one hour prior to incision (SCIP-INF-1); (2) proportion of patients receiving the appropriate antimicrobial agent based on current guidelines (SCIP-INF-2); and, (3) proportion of patients whose antimicrobial prophylaxis is discontinued within 24-hours following surgery (SCIP-INF-3). These measures, referred to as Surgical Care Improvement Project (SCIP) measures, have been endorsed by the National Quality Forum (NQF) and adopted by the Centers for Medicare and Medicaid Services (CMS), the Joint Commission, and Hospital Quality Alliance (HQA). As of January 1, 2009, the MHCC expanded its collection of SCIP INF 1-3 measures to include all surgical strata (CABG, other cardiac, hysterectomy, and vascular surgery). The MHCC added additional SCIP measures, effective for discharges after January 1, 2009: cardiac surgery patients with controlled 6 a.m. postoperative serum glucose (SCIP-INF-4); surgery patients with appropriate hair removal (SCIP-INF-6).
In 2008, the MHCC required all Maryland acute general hospitals to enroll in the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) system, effective July 1, 2008, and to use the NHSN system to report data to the Maryland Health Care Commission on Central Line-Associated Blood Stream Infections (CLABSI) in all intensive care units, beginning on that date. The Commission held a training session in April 2008 that was attended by about 100 infection preventionists (IPs) and related professionals from all Maryland acute hospitals. The MHCC intends to report information on CLABSI, once audited, in the Hospital Guide. In addition, the Commission will collect data by surveys on two additional measures. The first, active surveillance testing for MRSA for patients upon admission to the ICU. The second measure, health care worker influenza vaccination rates. Additional information is provided below.
Health Care Associated Infections (HAI) Advisory Committee
Committee Members
2009 Meeting ScheduleSeptember 23 meeting rescheduled to October 8, 2009
Agendas/Minutes (2009)
Hospital Hand Hygiene Campaign
Report and Recommendations
Health Care Worker (HCW) Seasonal Influenza Vaccination
2009-2010 Maryland Hospital Health Care Worker (HCW) Seasonal Influenza Vaccination Survey
HCW Seasonal Influenza Vaccination Rate Survey - FAQs
Active Surveillance Testing (AST) for MRSA
2009 Maryland Hospital Quarterly Survey of Active Surveillance Testing (AST) for MRSA
Active Surveillance Testing (AST) for MRSA - FAQs
Surgical Care Improvement Project Measures
Maryland Register Notice (12/16/08)
Central Line-Associated Blood Stream Infections (CLABSI)
Maryland Register Notice (4/11/08)