PE R S PE C TI V E
Infection-Control Report Cards — Securing Patient Safety
Robert A. Weinstein, M.D., Jane D. Siegel, M.D., and P.J. Brennan, M.D.
F or many of us, the specter of
report cards conjures up anx-
iety dreams. Nevertheless, public
report cards have infiltrated many
industries — airlines and bank-
ing, for instance — and various
levels of government, and health
care appears to be next. The be-
lief that hospitals reporting low-
er infection rates are safer and
that informed consumers will ob-
tain safer care has driven many
U.S. states to consider legislation
requiring report cards on noso-
comial infections.
Advocates of public reporting
have been spurred on by the oc-
currence of nosocomial infections
in 5 to 10 percent of hospitalized
patients; increasing rates of anti-
biotic resistance; press coverage
of cases of devastating nosoco-
mial infection; and the view that
many infections should be pre-
ventable. In little more than a
year, 39 states introduced legis-
lation and 6 states passed laws
requiring disclosure of such in-
fections to the state and, in most
cases, to the public (see map). Al-
though the movement is consum-
er-driven, health care providers
share the goals of reducing infec-
tion rates and improving patient
safety.1
The public reporting of hos-
pitals’ performance is not new,
although older systems paid little
attention to nosocomial infec-
tions. For decades, several states
have required that hospitals re-
port death rates associated with
cardiac surgery and other condi-
tions. Although the effectiveness
of these experiments has been
mixed, reductions in the rate of
death associated with coronary-
n engl j med 353;3
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infection-control report cards — securing patient safety
artery bypass grafting in New
York and Pennsylvania have been
attributed, in part, to public re-
porting.
A key lesson from past report-
ing is the importance of “risk
adjusting” the outcome data to
account for essential differences
in populations of patients. For
example, surgical risk among
80-year-old patients with diabe-
tes is greater than that among
previously healthy 45-year-olds.
We have also learned that we
must select denominators care-
fully in order to avoid artificial
inflation or deflation of rates;
that sophisticated information
technology is required; and that
it can be difficult to define useful
benchmarks, especially for small
hospitals, so that reporting a
trend for a particular hospital
may provide more useful infor-
mation than does comparing hos-
pitals.
The Joint Commission on Ac-
creditation of Healthcare Orga-
nizations and the Center for
Medicare and Medicaid Services
(CMS) have established Web-
based public reports for partici-
pating hospitals. Both groups
initially focused on process mea-
sures rather than outcome mea-
sures, a strategy that avoided the
quagmire of risk adjustment.
Neither group has yet addressed
nosocomial infections, although
the CMS is developing a Surgical
Care Improvement Project that
will probably report process and
outcome measures. The Centers
for Disease Control and Preven-
tion (CDC), through its National
Healthcare Safety Network, pro-
vides a mechanism for the confi-
www.nejm.org july 21, 2005
dential disclosure of nosocomial
infections, allowing hospitals to
compare their performance with
that of others. Several states are
considering statewide participa-
tion in the network as a report-
ing solution.
Current report cards focus on
three types of common infections
that are associated with high
morbidity and mortality and that
are likely to be controllable: in-
fections associated with central
venous catheters, surgical-site in-
fections, and ventilator-associat-
ed pneumonia. We know that
informing surgeons of their
wound-infection rates can lead
to reductions in those rates,
presumably by reinforcing the
use of sensible interventions
(e.g., limiting the amount of
movement in and out of operat-
ing rooms in order to lower bac-
terial loads). The most rigorous
study of the impact of surveil-
lance — the CDC’s Study on the
Efficacy of Nosocomial Infection
Control, conducted in the 1970s
— demonstrated a 32 percent
decrease in infection rates in
hospitals that implemented stan-
dardized surveillance methods and
ongoing control measures and
that had adequate infection-con-
trol staffing and expert physi-
cian epidemiologists.
Studies of infections related to
devices, particularly vascular and
urinary catheters and ventilators,
have demonstrated the usefulness
of key performance measures —
such as site preparation and care
and operator expertise for the
control of venous catheter–related
infections — and of “bundling”
evidence-based prevention mea-
225
PE R S PE C T IV E infection-control report cards — securing patient safety

Disclosure of
nosocomial-infection
Legislation for disclosure
of nosocomial-infection
Legislation for disclosure
of nosocomial-infection ∗ Original bill vetoed;
new bill submitted
rates required rates submitted rates not submitted
Status of Legislation Requiring Public Disclosure of Rates of Nosocomial Infection, by State.

sures into comprehensive control
programs.2 Studies have also
highlighted certain difficulties in-
volved in measuring some out-
comes — for instance, the lack
of an easily applied clinical defi-
nition of ventilator-associated
pneumonia, the difficulty of track-
ing surgical-site infections in the
community (now that the average
postoperative stay is shorter than
the incubation period for most
wound infections), and the large
confidence intervals around re-
ported infection rates in smaller
hospitals and for uncommon pro-
cedures.
In the light of these difficul-
ties, will this type of public re-
porting result in the sort of im-
provements achieved by reporting
wound-infection rates to surgeons?
The answer is uncertain. Many ex-
perts recommend further study
before states initiate costly, labor-
intensive reporting programs, and
a few states have passed laws that
require such studies (see map).
But more states have already em-
barked on the path of public re-
porting, and their legislators need
advice urgently.
Recent recommendations from
the CDC suggest that states focus
on a combination of linked pro-
cess and outcome measures.1 We
support the study of reporting
when possible. For states that
have passed laws requiring pub-
lic reporting, we suggest measur-
ing rates that can be compared
meaningfully, that should be
tracked anyway, and whose re-
porting is most likely to lead to
improved care. Such process mea-
sures include assessments of the
timely administration of periop-
erative antibiotic prophylaxis, vas-
cular-catheter insertion practices,
and hand hygiene. Outcome mea-
sures include the rate of infec-
tions in the intensive care unit
associated with central vascular
catheters and the rate of reop-
eration or rehospitalization for
surgical-site infections. Other mea-
sures for special settings could
include the rates of nosocomial
influenza, respiratory syncytial vi-
rus, rotavirus infection, and cases
of diarrhea associated with Clos-
tridium difficile. Infections caused
by multidrug-resistant pathogens,
such as methicillin-resistant Staph-
ylococcus aureus and vancomycin-
resistant enterococci, are also im-
portant, but because of laboratory
logistics and the difficulty of ver-
ifying an infection’s nosocomial
origin, meaningful reporting is
not yet possible.
States that have involved ex-

226 n engl j med 353;3 www.nejm.org july 21, 2005

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PE R S PE C TI V E
perts in health care epidemiology
early in the development of laws
have produced the most useful
legislation. In addition, we favor
phasing in reporting requirements
incorporating the process mea-
sures that are the most readily
obtained and compared, in order
to allow hospitals and health de-
partments to develop, refine, and
validate data-collection systems.
States must also consider the cost
of these programs and work with
hospital associations to develop
realistic plans for support and
funding.
To understand other relevant
concerns, states should review the
reasons given by Governor Arnold
Schwarzenegger for his recent veto
of California’s legislation, which
included problems with auditing
and validating data, the need to
n engl j med 353;3
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Copyright © 2005 Massachusetts Medical Society. All rights reserved.
infection-control report cards — securing patient safety
redirect resources from success-
ful programs, and extant man-
dates from national organizations
that already scrutinize infection
control. Most important, states
must work with experts in health
care communications and con-
sumer reporting to define the
sorts of rates that will tell patients
what they need to know.
Report cards assessing noso-
comial infections are a reality.
Their success will require inter-
disciplinary collaboration, a great-
er commitment of resources to
infection-prevention practices, and
conspicuous inclusion of these
efforts in patient-safety programs.
Research is needed to identify the
most meaningful metrics, deter-
mine the best way to report them,
and assess whether such report-
ing improves patient safety. These
www.nejm.org july 21, 2005
challenges present unprecedented
opportunities to improve patient
care, if we can only put our anx-
ieties to rest and move forward.
Dr. Weinstein is the chair of infectious dis-
eases at John H. Stroger (Cook County)
Hospital and a professor of medicine at
Rush University Medical Center, Chicago;
Dr. Siegel is a professor of pediatrics at the
University of Texas Southwestern Medical
Center and chair of the Infection Control
Committee at Children’s Medical Center
Dallas; and Dr. Brennan is a professor of
medicine and chief medical officer at the
University of Pennsylvania School of
Medicine and Health System, Philadelphia.
1. McKibben L, Horan TC, Tokars JI, et al.
Guidance on public reporting of healthcare-
associated infections: recommendations of
the Healthcare Infection Control Practices
Advisory Committee. Am J Infect Control
2005;33:217-26.
2. Institute for Healthcare Improvement:
100k Lives Campaign. (Accessed June 30,
2005, at http://www.ihi.org/IHI/Programs/
Campaign.)
227
 New England Journal of Medicine

CORRECTION

Infection-Control Report Cards — Securing Patient

Safety

Infection-Control Report Cards — Securing Patient Safety . On page

226, in the map showing the status of legislation requiring public dis-
closure of rates of nosocomial infection, Indiana, Louisiana, Texas,
and Utah should have been highlighted as states in which legislation
for the study of the reporting of nosocomial infection has been passed.
(Updated information about the status of such legislation is available
at www.apic.org.) Also, on page 227, the volume and page numbers
in reference 1 should have read ``26:580-7,´´ rather than ``33:217-26,´´
as printed. We regret the error.

N Engl J Med 2005;353:1869-a

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Copyright © 2005 Massachusetts Medical Society. All rights reserved.