Yvonne Hanato-Well’s son crashed into a tree three years ago while driving home one night on the Big Island. Suffering severe trauma to his head, neck and spine, the 19-year old was flown to a Honolulu hospital for treatment.

Two weeks into his hospital stay, he was diagnosed with MRSA – a drug-resistant staph infection that can be fatal. He was given 10 days to live if he didn’t respond to antibiotics.

He is one of an unknown number of Hawaii residents who have acquired the infection in a local health-care facility.

Health-care associated infections are the sixth leading cause of death in the country, killing more people than automobile accidents and homicides combined, and the associated cost to the health-care system is estimated to be as high as $45 billion, according to data from the U.S. Centers for Disease Control and Prevention. Up to 70 percent of the infections are believed to be preventable.

States have increasingly adopted laws mandating that health-care facilities report data on infection rates, but Hawaii has resisted. Thirty-one states now have laws that require health-care facilities to report data to either the federal or state governments.

Hawaii passed similar legislation this year. But the Safe Patient Project, an organization that tracks state laws mandating reporting and public disclosure of infection rates, is now considering taking Hawaii off its list.

The actual law that passed was a stripped-down version of the originally proposed bill. Rather than mandating health-care facilities to report data to either the state or federal government, it says that they shall follow federal rules — which are optional.

“We don’t want to force people to do things that they don’t want to do,” said Sarah Park, the state epidemiologist at the Hawaii Department of Health. “These are our partners, the hospitals, the people in the health-care community.”

But advocates of public disclosure of facility-specific data argue it’s important to consumers, and pressures health-care facilities to follow protocols that can significantly reduce infection rates.

A perceived reluctance on the part of the state health department has led some to argue that the state isn’t looking out for the public interest.

“The health department sees itself as more responsible to the hospitals than the public,” said Lisa McGiffert, who directs the Safe Patient Project for Consumers Union, a nonprofit consumer protection organization. “They don’t sense any public responsibility to account for thousands of people dying throughout the state from preventable infections.”

One in every 20 patients contracts an infection through a health-care procedure and about 90,000 people die each year from such infections, according to the CDC. The CDC doesn’t have specific data for Hawaii.

Hawaii Fights National Trend of Reporting Mandates

In 2010, legislation failed that would have required health-care facilities to report data.

Testifying against the legislation, was Chiyome Fukino, former state Department of Health director, appointed under Gov. Linda Lingle.

“While all infections are always a serious concern, we should first determine whether Hawaii’s HAI rates rise to the level reported by the news media, the CDC and other organizations before adding reporting and public disclosure requirements,” wrote Fukino in testimony to the Legislature.

The bill that was proposed this year initially had stringent reporting requirements, but they ended up being deleted from the final legislation

The original bill included mandated reporting of infections, public disclosure of data for individual facilities and stiff penalties for hospitals that don’t comply – including loss of licensure and a fine of $1,000 a day for non-compliance.

The final law, signed by Gov. Neil Abercrombie in July, not only eliminated the mandate, it also struck the requirement that the state health department is required to disclose data to the public on infection rates in individual facilities. And because there is no mandate, there is no penalty.

“The bill that was finalized was a compromise that had less opposition and could therefore pass,” wrote Betty Wood, an epidemiologist at the state health department, by email. “Bills similar to the original version failed to pass out of committee at the Legislature in previous years.”

Bills proposed in the past five years all failed, prior to this year.

“Relative to the past eight years, these are good times,” said Wood, who authored the legislation. “In the past we were told not to apply for things like this.”

She said with Abercrombie there has been more support.

What the law does do is afford the state health department access to future data that is reported to the CDC by health-care facilities that choose to report. And it requires the health department to issue an annual public report beginning in June 2013. Though, the health department has discretion over what is – and isn’t – included in the report.

After reviewing the final legislation for Civil Beat, McGiffert said that whether there would be reporting and public disclosure in Hawaii was unclear.

“Most laws have been mandated,” said McGiffert. “[In Hawaii], it could happen, it could not happen, maybe, I don’t know.”

She noted that the law used the word ‘may’ a lot.

Hospitals Struggle with Epidemics

While there has been stiff resistance to public reporting mandates, local hospitals have been internally combatting the problem, according to Wood, who has been training hospitals in implementing precautionary measures.

At Hawaii Pacific Health, rates have declined dramatically, according to Dr. Melinda Ashton, medical director for patient safety and quality services. While she wouldn’t disclose the rates, she said that for the past two to three years, combatting the infections has been a high priority.

Wood said that other hospitals have also experienced declines.

Ashton said that part of the concern with public disclosure is that while reporting requirements can be standardized, surveillance methods are not, which could lead to skewed results.

“It’s commonly been known that the reporting is dependent on your knowledge of what is going on, and if you don’t look hard you can fail to report things that are really going on because you don’t really look for them,” she said.

The CDC provided the following response:

“The reason to track infections is so you know what is happening in your facility so you can use that data for prevention action,” said Dan Pollock, chief of the surveillance branch for CDC’s division of health-care quality promotion. “CDC provides training materials and user support that serve the purpose of standardizing infection case finding between health-care facilities and within the same facility over time.”

The state health department has said that monitoring local hospitals to make sure that they aren’t underreporting statistics is difficult because it lacks the personnel and funding. Federal stimulus money for developing surveillance programs was available to states, but Hawaii didn’t take advantage of it.

Park also said that it could be unfair to compare large trauma centers to small community hospitals because of disparate risk factors.

But McGiffert said that this wasn’t an issue because data could be risk adjusted for the different facilities, which the CDC will do as part of its data analysis.

“It’s interesting because that is the kind of response that we have heard in many states over the years,” said McGiffert. “But we don’t really hear it very often anymore.”

Another reason some health-care facilities are concerned about facility-specific disclosure is the risk of litigation.

Lawsuits related to hospital-associated infections are on the rise, according to the Wisconsin Law Journal.

After a Massachusetts woman died of a flesh-eating bacteria acquired in the hospital, her family sued and was awarded $13.5 million. Another man was awarded $2.58 million after a MRSA infection resulted in the loss of his kidney and leg. A Utah woman also won a malpractice lawsuit, for an undisclosed sum, after a flesh-eating infection acquired at a hospital resulted in the loss of three limbs and multiple organs.

Not all infections are the result of negligence on the part of health-care workers. But approximately 70 percent of all infections are preventable, according to the CDC. This rate can be lower in hospitals in urban settings and trauma hospitals.

Federal Rules Could Make a Big Difference

Starting this year, the federal Centers for Medicare and Medicaid Services will begin penalizing health-care facilities that don’t report certain infections to the CDC.

Infections resulting from what are called “central lines,” such as IV’s, must be reported beginning this year. Next year, the CDC will begin collecting data on infections from surgery, and in 2013, on MRSA.

While hospitals are not required to report the data, if they don’t, they will receive a 2 percent reduction in Medicare payments.

It’s technically a voluntary reporting program, Ellen Griffith, a spokeswoman for the Centers for Medicare and Medicaid Services, told Civil Beat by email.

“However, Congress has sweetened the pot, or probably more accurately added vinegar to it, by mandating in statute that hospitals that do not participate in the reporting program receive a 2 percentage point reduction in the annual update for the following year,” she wrote.

The penalty is significant, according to McGiffert, but it remains to be seen what effect it will ultimately have in Hawaii.

“We really don’t know if the incentive is big enough for hospitals to do these reports because in some states, like Hawaii, they’ve been pretty resistant,” she said.

Hawaii isn’t alone. Earlier this year, the California Hospital Association filed a lawsuit against its state health department to block a state mandate requiring hospitals to report surgical site infections to the CDC.

So far, Wood said that all of Hawaii’s hospitals that are subject to the rules were reporting data, or preparing to report data, to the federal government.

How much of this information will be made publicly available via the state will be up to the discretion of the Department of Health when it begins publishing annual reports two years from now.

Park said that infection rates for individual health-care facilities are unlikely to be disclosed. Other states, such as South Carolina, New York, New Hampshire, Missouri and Florida, are required to disclose such data.

At the federal level, the CDC will not be publishing hospital level data on any of the infection rates, said Wood, but will probably aggregate the data for statewide comparisons.

However, the Centers for Medicare and Medicaid is expected to begin publishing hospital-specific data on its Hospital Compare website.

For Hanato-Wells, whose son was infected with MRSA after his accident, such disclosure is an important step to increasing public awareness.

“I’m thankful to them because they did save his life,” she said. “But then to save his life and then give him something that could come back, that’s the frustrating thing.”

“People need to be educated about this,” she said. “They need to know.”

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