(See the article by Weiner et al, on pages 1105–1108.)

For decades, the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) and its precursor, the National Nosocomial Infections Surveillance System, have provided a standardized mechanism by which facilities report healthcare-associated infections (HAIs) in the United States. The NHSN has grown exponentially from 211 healthcare facilities representing 40 states and the District of Columbia in 2006 to a repository of all HAI data from more than 17,000 diverse medical facilities nationwide in 2015.Reference Edwards, Peterson and Andrus ^{1 , 2} Participation in the NHSN has been largely driven by state regulatory requirements and mandates from insurers, including the Centers for Medicare and Medicaid Services.

In this issue of Infection Control and Hospital Epidemiology, Weiner et alReference Weiner, Webb and Walters ³ present NHSN data from the required Annual Hospital Survey, including policies for the control of multidrug-resistant organisms (MDROs). Their main finding was that approximately 80% of acute care hospitals (ACHs), 85% of long-term acute care hospitals (LTACHs), and 65% of inpatient rehabilitation facilities (IRFs) employ contact precautions for patients infected or colonized with an MDRO. Across all facility types, contact precautions were less commonly employed for extended-spectrum β-lactamase-producing organisms (ESBLs) than for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), or carbapenem-resistant Enterobacteriaceae (CRE). Many facilities reported not using contact precautions for MRSA or VRE. This finding is consistent with recent trends toward discontinuing contact precautions for MRSA and/or VRE.Reference Morgan, Murthy and Munoz-Price ⁴ The median frequency at which ACHs report being notified of a patient’s MDRO status on transfer into the facility was 75% of admissions (higher for LTACHs and IRFs).

Weiner et al also report that in some regions as many as 32% of facilities do not use contact precautions for CRE and that more than 2% of facilities report having no policy on the use of contact precautions for CRE. Routine CRE screening was uncommon and was reported by only 7.0% of ACHs, 11.9% of LTACHs, and 5.7% of IRFs, with limited details describing how screening was performed. Taken together, these CRE-related findings are concerning, and they are divergent with CDC recommendations, including the recommendation that all ACHs and high-acuity post-acute-care settings use contact precautions for the care of patients with CRE. ⁵

The authors do not report the survey response rate, although presumably it is nearly 100% given that participation is required. The authors acknowledge that there may be a discrepancy between reported policies and actual practice, and there remains some ambiguity regarding the nuances of actual practices due to questions about wording or response details, which are not reported here. ⁶ These issues, however, do not significantly diminish the findings. To our understanding, this survey captures an accelerating trend of forgoing contact precautions for MRSA and VRE, and it describes a concerning lack of precautions or preparations for CRE as well as inadequate communication among transferring facilities regarding MDRO carriage by transferred patients.

While this survey of reported practices is informative, we believe that NHSN has much greater potential to directly impact health policy regarding the control of MDROs and HAIs in the United States. These potential activities include (1) promoting a strategic shift from focusing on the control of MDROs within individual hospitals to a coordinated response across healthcare, (2) developing more robust research investigating the effect of differing policies on HAIs and MDROs, and (3) identifying facilities practicing outside the recommended standards of care for possible review of practices and outcomes.

Coordinated MDRO tracking has been successful in small countries, including the Netherlands for MRSA and Israel for CRE.Reference Schwaber, Lev and Israeli ^{7 ,} Reference Palmore and Henderson ⁸ It is surprising, therefore, that despite improved efficiency and transparency of reporting of CRE threats by the CDC as well as guidance on CRE prevention, a significant proportion of facilities in this survey do not employ screening or contact precautions for CRE. Successful control of MDRO will require coordination of care among healthcare networks and regions. Persuasive data support the role of MRDO transmission not only at the level of individual facilities but also on a network scale.Reference Datta, Brown and Nguyen ⁹ In this study, the rate of MDRO reporting among patients transferred among facilities was as low as 10% in the lowest decile of ACHs. The US healthcare system has responded to the opioid crisis in part by developing state-level prescription drug monitoring programs (http://www.cdc.gov/drugoverdose/pdmp/). Is it time to consider an analogous intervention such as a statewide or nationwide MDRO registry? Could the resources spent on misguided mandatory MRSA surveillance laws be transitioned into such a registry? An initial registry of rare organisms like CRE could be initiated by NHSN to remedy the inadequacy of identifying MDRO status on interfacility transfers.

NHSN reporting is standardized and nearly universal, and it is being used for public accountability and reimbursement. Given these characteristics, the data provided to the NHSN have been underutilized as a resource for infection control research. For example, the NHSN could be a foundation for conducting observational or effectiveness trials. This function could be directly performed by the CDC or through coupling with research groups like the Society for Healthcare Epidemiology of America Research Network.Reference Safdar, Anderson and Braun ¹⁰

Finally, having access to prevention practices and MDRO and HAI rates puts the NHSN in an excellent position to identify facilities with non-normative practices or particularly high rates. Facilities not using proven or accepted prevention practices (eg, contact precautions for CRE) may benefit from nonpunitive notification and review. Likewise, facilities with successful outcomes not practicing standard-of-care prevention interventions may be innovative, with practices worth sharing. The CDC’s forthcoming Targeted Assessment for Prevention (TAP) strategy, which partners with national and regional organizations to identify facilities with “a disproportionate burden of HAIs” for HAI prevention resources will hopefully fill this role. ¹¹

This NHSN survey provides the infection control community with useful information about contact precautions for the control of MDROs in US healthcare facilities. The NHSN, however, has potential to be used more broadly to prevent MDROs and HAIs by improving communication and coordination of HAI prevention across facilities, promoting high-quality research, and scrutinizing rates and prevention practices.