MEMORANDUM
TO: Senator Joseph Brannigan, Chair
Representative Anne Perry, Chair
Members of the Health & Human Services Committee
FROM: Mary Mayhew, Vice President
DATE: April 7, 2009
RE: LD 1038 An Act Regarding the Prevention and Reporting of
Methicillin-resistant Staphylococcus Aureus
Senator Brannigan, Representative Perry and members of the Health &
Human Services Committee, I am Mary Mayhew and I represent the Maine
Hospital Association. I am here today to speak in opposition to LD 1038.
However, we sincerely appreciate the intentions of the sponsors, acknowledge
the significance of this issue, and emphasize that we share the goals
of preventing health care associated infections and publicly reporting
valid comparable quality data.
Recognizing the national struggle to prevent MRSA transmission, Maine's
hospitals proactively and voluntarily formed the Maine Infection Prevention
Collaborative, in partnership with the Maine Quality Forum, the Maine
Centers for Disease Control and Prevention and the Northeast Health
Care Quality Foundation, under contract with the Centers for Medicare
and Medicaid Services to be the Quality Improvement Organization for
northern New England.
- Maine is a national leader in forming such a Collaborative, which
is an established effective method of quality improvement. In fact,
it was just announced April 1st that formation of such a private/public
sector collaborative will be required in order to receive federal
stimulus funds dedicated to preventing health care associated infections.
- Every hospital in Maine sends front line infection prevention professional
to one of the two regional work groups. And every hospital CEO has
signed a Pledge of Support for the work of the Collaborative.
- The Collaborative's scope of work includes data development and
quality improvement-both ensuring compliance with established recommendations
as well as piloting new innovative strategies.
We support the Collaborative and know that the combined expertise and
authority of this public/private partnership will result in the best
possible approach to reducing health care-associated MRSA infections.
In contrast, we are troubled by the contradiction between federally
established evidence-based infection prevention practices and the directives
in LD 1038.
As just one example, LD 1038 proposes testing every hospital patient
upon admission for MRSA colonization. The federal Centers for Disease
Control and Prevention Guidelines recommend culturing for targeted multiple
drug resistant organisms (such as MRSA) only from high risk patients.
Similarly, the 2008 Supplement Article: SHEA/IDSA Practice Recommendation
Strategies to Prevent Transmission of Methicillin Resistant Staphylococcus
aureus in Acute Care Hospitals states: "The effectiveness of active
surveillance testing in the prevention of MRSA transmission is currently
an area of controversy, and optimal implementation strategies (including
timing and target populations) are unresolved."
- In fact, there is evidence that universal screening does not reduce
health care associated MRSA infections. In 2008, the Journal of the
American Medical Association published the study,
- Universal Screening for MRSA at Hospital Admission and Nosocomial
Infection in Surgical Patients" that concluded that a universal,
rapid MRSA admission screening strategy did not reduce nosocomial
MRSA infections.
- All of the federal recommendations for infection prevention are
based on the best research available and are constantly being updated
to reflect new proven strategies to reduce infections. While innovative
strategies are constantly being researched and tested, any state mandated
practices should be consistent with established evidence-based federal
standards.
Mandating the practices outlined in LD 1038 that are in conflict with
federal standards would also have negative unintended consequences.
- In light of the questionable benefits, it would be fiscally irresponsible
to ignore the costs of implementing LD 1038. The cost of each test
for every hospital admission as well as the laboratory staff and resources
necessary to perform each test would be extraordinary.
- Maine's infection prevention resources should be dedicated to the
established practices proven to prevent the transmission of all pathogens,
not just one or even just the ones we know about today. We learned
that applying universal precautions to protect against all blood-borne
diseases was a better infection prevention strategy than testing every
patient for HIV. Similarly, the national standard for infection prevention
is to use standard precautions for all patients, with contact precautions
for patients known to be colonized or infected.
- Focusing the extraordinary resources necessary to implement these
proposed practices would mean fewer resources available for infection
prevention, control and surveillance for other potentially life-threatening
drug-resistant pathogens.
- Emerging infectious diseases and antimicrobial resistance are moving
targets that are best managed through the ongoing public/private partnership
of the Maine Infection Prevention Collaborative that was created to
assure that Maine is doing all we can, today and tomorrow, to prevent
health care associated infections.
- Maine simply does not have the hospital bed capacity at this time
to isolate every admission while awaiting MRSA screening results or
determining the cause of fevers of unknown origin. The lack of space
would necessitate referring acutely ill citizens out of state for
their hospital care.
- Isolation is a stigmatizing practice that should only be employed
when necessary rather than as a routine practice. The Centers for
Disease Control and Prevention guidelines dictate contact precautions
rather than isolation for patients colonized or infected with MRSA.
The public reporting requirements of LD 1038 are also contrary to national
recommendations.
- First, we must emphasize that sharing patient-specific information
such as whether someone is colonized or infected with MRSA would violate
state and federal privacy laws.
- Regarding hospital-specific reports, the National Quality Forum
(NQF) is the "gold standard" for recommended health care
quality metrics and they do not endorse reporting MRSA rates of colonization
or infection. Specifically, following extensive review, the NQF concluded:
"Given the high variability associated with acquiring an antimicrobial-resistant
infection, a comparison of raw rates would not be meaningful data
for the comparison and selection of health care facilities."
- Similarly, the 2008 Supplement Article: SHEA/IDSA Practice Recommendation
Strategies to Prevent Transmission of Methicillin Resistant Staphylococcus
aureus in Acute Care Hospitals states: "…specific recommendations
for external reporting of process and outcome measures cannot be made."
- However, the NQF does recommend that "each facility should
monitor rates of every antimicrobial-resistant infection for internal
quality improvement. A new national data program was just released
in March 2009 for drug-resistant pathogens such as MRSA. The Collaborative
has already launched a pilot of the program with four hospitals in
partnership with the Northeast Health Care Quality Foundation.
- Although we oppose the public reporting metrics in LD 1038, we support
providing hospital-specific reports of performance data that are evidence-based,
meaningful, valid and comparable such as the clinical data collected
by the Centers for Medicare and Medicaid Services and the Maine Quality
Forum. We would be pleased to work with the sponsor and other interested
parties to develop alternative public reporting metrics around infection
prevention and control before the work session.
Thank you very much, and I'd be happy to answer any questions.
