Clinical, fiscal costs face off

Making the business case for infection prevention improves outcomes and bottom line

The flip side of patient care is caring for the coffers.

An infection prevention program can consume considerable resources. Unfortunately, infection prevention programs do not generate income. Add to that, when Centers for Medicare & Medicaid Services (CMS) stopped reimbursing for never events, such as healthcare-acquired infections (HAIs), the coffers took a major hit.

For infection preventionists to get an adequate piece of the budget pie, they must provide to the C-suite the information it needs to view the infection prevention program as more attractive fiscally. It is vital that administration understands the importance of allocating adequate funds for it. Infection preventionists are in a position to educate the C-suite that a properly funded infection prevention program can be a money saver. In fact, it can save more money than it costs to fund the program, through profit, reduction in losses, or cost avoidance. It is important to use the numbers to back up your argument. The numbers reveal the fiscal implications of not doing enough to prevent infection: increased length of stay, nonreimbursable expenses, readmissions, and more. This is the sort of information needed to build an effective business case for infection prevention. Improved patient care and outcomes can be the happy result of a well-assembled business case.

Carol McLay, DrPH, RN, CIC, Infection Prevention Consultant, Lexington, KY, and Chair of APIC's Communications Committee, talked to Healthcare Purchasing Nervs about the relationship between business cases for preventing infection and quality patient care. "Healthcareassociated infections are the fifth leading cause of death in acute-care hospitals, yet are often preventable. According to the Centers for Disease Control and Prevention, on any given day, about 1 in 25 hospital patients has at least 1 HAI. There were an estimated 722,000 HAIs in US acute-care hospitals in 2011, and approximately 75,000 hospital patients with HAIs died during their hospitalizations."1

McLay cited more staggering numbers. "It is estimated that US healthcare system costs attributable to the 5 most common HAIs (central line-associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated pneumonia, surgical-site infection, and Clostridium difficile infection) amount to $9.8 billion."2

One would think that, since HAIs come with such heavy financial burden, that HAI prevention would be at the top of the list for resources, but not so, noted McLay. "Healthcare-associated infection prevention has been declared a national priority; yet, resources targeted to prevent these infections are limited. A recent national survey of infection preventionists indicated that only 13% reported receiving more hospital support following implementation of CMS reporting requirements, and about onethird reported that the emphasis on reportable HAIs led to less time available for prevention of other nontargeted HAIs."3

McLay reiterated the important link between preventing infection, quality patient care, and business cases for infection prevention. "Making a business case for infection prevention is vital to provide the impetus necessary to achieve progress towards a higher quality of care."

As vital as it is to the health of the infection prevention program, making a business case to support it is not something all have experience with, perhaps not even understanding the impact it can have. It would be a mistake not to use this valuable tool, which can lead to improved patient care while also making the hospital accountants happy. It is a winwin situation. Step up your game. Do it with research and planning.

McLay outlined the main points that should be addressed when preparing a business case for preventing infections and offered tips useful when presenting your case to administration.

Step 1: Clearly identify the problem, the possible solutions, and the desired outcome. Link this to the mission and vision of the organization.

Step 2: Before beginning the analysis of your business case, meet with key administrators to obtain agreement that the issue you are addressing is important and has the support of leadership; identify the key personnel and departments affected; and identify critical costs and factors that should be included in the analysis.

Step 3: Determine the annual cost.

Step 4: Determine what costs can be avoided. Include information on the effect of length of stay, reduced réadmissions, morbidity and mortality, and cost of the infection.

Step 5: Highlight the benefits. Reduction in the incidence of HAIs can lead to cost efficiency, cost reduction, revenue enhancement, and balance sheet improvements. Focus on optimizing the investment in fixed costs instead of focusing on cost savings. For example, patients who do not develop infections are discharged sooner, allowing additional revenue to be generated by filling these beds.

Step 6: Calculate the financial impact. Costs of the up-front outlay should be subtracted from the cost savings/profits to present the total economic impact.

Step 7: Include intangible benefits: reduced malpractice suits; higher satisfaction scores for patients, families, and staff; better market position; improved reputation.

Step 8: Make your business case. Tips on presenting the gathered information to administration successfully include knowing the members of your C-suite, communicating clearly and effectively, speaking up and being heard, being credible, sharing your expertise, displaying your knowledge, understanding the C-suite perspective, speaking the language of business, and emphasizing that improving quality will also improve cost.

Step 9: Continue to collect outcome data and costs to show stable outcome rates and quality improvement to maintain support.

Follow their lead

There are many who have seen the wisdom of using business cases for prevention of infection, thus furthering better health care. Some examples follow.

Giving hygiene a hand

Lisa Moore, Director of Infection Prevention, Risk Management and Patient Relations, Baptist Memorial Hospital, Memphis, TN, described their facility. "Baptist Memorial Hospital-Memphis is a greater than 700-bed, private, not-for-profit hospital serving the greater Memphis area. Baptist Memorial is one of Tennessee's highest-volume hospitals, and, according to HealthGrades (http:// www.healthgrades.com/hospital-directory/ tennessee-tn/baptist-memorial-hospitalhgstb7fae6a6440048), the hospital has ranked in the top 10% percent nationally for cardiac surgery 7 years in a row. It is also ranked in the top 5% in the nation for neurosciences."

Baptist Memorial's campaign to reduce costs associated with infection focused on a tried-and-true method of infection prevention: hand hygiene. Moore related their experience. "Our initial focus at Baptist Memorial was a review of hand-hygiene monitoring throughout the hospital. In the past, we performed visual monitoring of hand-hygiene practices, utilizing dedicated infection control nurses and unit-based safety officers to observe staff handwashing upon entering and exiting rooms. However, the compliance rates were not consistent on a day-to-day basis using this method. We decided to explore electronic monitoring of hand-hygiene compliance. We chose the heart-transplant unit as the first area to implement this new technology."

"The transplant unit at Baptist Memorial is a small 12-bed unit that focuses on heart transplants. Since the unit cares for seriously ill patients, it was especially critical to eliminate infection. Additionally, since the transplant unit has a smaller group of nurses than other departments in the hospital, it was an ideal location to implement the new system on an initial small-scale."

"Our initial goal was to reduce deviceassociated infections, such as ventilator-associated pneumonia, central line-associated bloodstream infections, and catheter-associated urinary tract infections," explained Moore. "Hand hygiene is the most basic tool for preventing infections and their spread. Because infections can be spread through contact, it is essential for staff to be diligent about washing their hands."

"To improve hand-hygienecompliance rates, we selected an automated hand-hygiene-monitoring technology, the nGage system (Proventix Systems Inc., Birmingham, AL; endorsed by Kimberly-Clark Healthcare, Roswell, GA). With nGage, the staff receives personalized messaging in the form of professional, educational, and user-identified content, through an active communication display located above the soap and sanitizer dispensers. RFID [radio frequency identification] tags are used to monitor compliance and create data that can be reviewed by hospital managers and executives."

"We aimed to increase individual accountability and transparency by monitoring 26 soap and 22 sanitizer dispensers used by 49 employees, including nurses, patient-care assistants, and unit clerks. Hospital leaders met with the nurses and patient care technicians in the transplant department to educate them on the importance of hand hygiene for infection prevention and show them how the nGage system worked."

All the research and good intentions in the world are for naught if the C-suite does not buy in. Here is how Baptist Memorial gained support, said Moore. "Our CEO at Baptist Memorial, at the time of the initial project, was very interested in using technology to improve productivity within each unit. A compliance monitoring system was a way to take the monitoring task out of the hands of individuals, making the process completely automated and, therefore, more efficient."

"The proof was in the data. The leadership team, impressed by the results, was fully on board with the project and became actively involved by setting unit-level goals, initiating targeted employee education, and implementing a feedback and accountability campaign. Baptist Memorial also supported plans to expand the compliance system to additional units in the hospital."

"This top-down approach was critical to getting staff actively involved in improving infection prevention. We saw the biggest push in compliance improvement when the unit began to post the results publicly within the department. Each nurse can see their team's compliance rates, which created friendly competition among staff. Top compliers are rewarded with fun prizes, and the hospital CEO provides pizza to the units with the highest compliance rates."

"Today in healthcare, there is a huge focus on saving costs," noted Moore. "With the decrease in reimbursement and a potential for penalties, Baptist Memorial maintains its focus on infection prevention, length of stay, and patient safety."

The numbers are impressive. "After several months of using nGage, an analysis was conducted that included 81,313 hours of care delivery, 199,054 caregiver-patient interactions, and 523,442 hand cleansings," said Moore. "Success was measured by tracking hand-hygiene-solution dispensing, hand-hygiene compliance, and HAI rates. By applying the nGage technology alone, soap and sanitizer use increased 36% and 61.5%, respectively. Following leadership engagement, hand-hygiene-solution dispensing increased an additional 42.9%, and hand-hygiene compliance improved another 65.9%. Individual hand-hygiene-compliance rate increases were also statistically significant. Over the full 20-month study, hand-hygienesolution dispenses per patient-day increased 104.3%, and hand-hygiene-compliance rates increased 178.1%."

"Ventilator-associated pneumonia, centralline-associated bloodstream infection, catheter-associated urinary tract infection, and Clostridium difficile rates declined 73.9%, 69.5%, 66.3%, and 81.1% respectively. These reductions saved more than $463,000 in direct cost and 236 days length of patient stay."

Prevention of hospital-onset Clostridium difficile Infection

Dr. Brian Koll, Chief, Infection Prevention, of Beth Israel Medical Center in New York, implemented and assessed the impact of a CDI Intervention Model with his CDI collaborative, a broad-based partnership with the Greater New York Hospital Association (GNYHA). The Collaborative's CDI Intervention Model was implemented and tested among 47 hospitals and consisted of infectionprevention bundles and compliance checklists to reduce the incidence of hospital-onset CDI. As part of the infection-prevention bundle, environmental cleaning was performed for daily and terminal cleaning using a 1:10 sodium hypochlorite-based disinfectant.

80% of the hospitals that participated and reported results in the Collaborative's CDI Intervention Model experienced a reduction in hospital-onset CDI. The mean incidence of hospital-onset CDI decreased by 20% (10.7 to 8.6 per 10,000 patient days). It is estimated that the hospitals that participated in this study will collectively experience 1,084 fewer cases of hospital-onset CDI, which implies cost savings amounting to $2.7M-$6.8M.

Previous research has shown that C. difficile spore cultures are found facility wide:

* C. diffidle spore cultures have been recovered from up to 58% of individual samples from high-touch areas in patient rooms.

* Hand and glove cultures yielded C. difficile in 59% of healthcare workers caring for CDI patients.

* 33% of non-CDI rooms have > 1 positive culture

Study findings included:

* CDI Intervention Models help interrupt patient-to-patient transmission of CDI and reduce the incidence of hospital-onset CDI.

* Maintain consistent use and monitoring of infection-prevention bundles and compliance checklists.

* Support implementation of CDI Intervention Models by gaining frontline staff "buy-in."

The study was conducted in partnership with the Greater New York Hospital Association (GNYHA), which is made up of 140 hospitals in the New York metropolitan region. 47 hospitals participated in the study, 35 of which contributed data, between the months of March 2008 and December 2009.

Treating CDI and its complications costs the U.S. healthcare system more than $3.2 billion annually, and mortality is now esti- mated at 23.7 deaths per million. Therefore, interventions that interrupt CDI transmission are a critical component of CDI prevention programs. The study reported the outcome of a collaborative program in which 35 acute care hospitals in the New York metropolitan area participated in a comprehensive CDI reduction intervention and formed multidisciplinary teams to implement the program. New York has the highest CDI infection rate in the United States. Participating institutions were almost exclusively teaching hospitals with more than 100 beds. Standardized clinical infection prevention and environmental cleaning protocols were adopted and monitored using checklists.

Outcomes for the program showed that it achieved a significant reduction in the incidence of hospital-onset CDI. Participating hospitals had 1,084 fewer cases of hospitalonset CDI than expected, with a total estimated cost savings of $2.7 million to $6.8 million. This reduction occurred without any interventions intended to alter antimicrobial prescribing practices and without adding extensive new resources.

"Interventions to interrupt and prevent C. diff transmission maybe more successful when implemented on a regional basis, which suggests that community and regional factors, including transferring patients between healthcare facilities, contributes to the epidemiology of C. diff and other healthcare-associated pathogens," said lead author Dr. Koll, M.D.

Safe environments with robots

Palos Community Hospital added TRU-D SmartUVC to its patient safety and infection control arsenal and will be using the UV disinfection robot in patient rooms as well as surgical suites to eliminate harmful pathogens after traditional cleaning routines are carried out.

"The acquisition of this technology is simply another way we are working to protect the integrity of our health care environment, and ultimately, safeguard the well-being of every patient who walks through our doors at Palos," said Larry Trump, Palos housekeeping supervisor.

TRU-D has been shown to have a 99.9 percent disinfection rate of all viruses and bacteria, killing pathogens including Clostridium difficile (C. diff.) and Methicillinresistant Staphylococcus aureus (MRSA) and making the hospital safer for patients and employees. The remotely operated robot works by generating UV light energy that modifies the DNA structure of an infectious cell so that it cannot reproduce - and a cell that cannot reproduce cannot colonize and harm patients.

"The efforts of housekeeping in implementing several new processes and technologies, such as TRU-D has really helped to reduce the incidence of health care-acquired infections," said Anne Myron, infection control practitioner at Palos Community Hospital.

Palos recently achieved an "A" Hospital Safety Score rating from hospital watchdog The Leapfrog Group. The score, which includes 28 different data points, measures how well a hospital protects patients from accidents, errors, injuries and infections.

Recently, TRU-D was the sole device utilized in an extensive, Centers for Disease Control-funded$2 million study, "The Benefits of Enhanced Terminal Room (BETR) Disinfection," by Duke University's (DICON) Epicenters Program, the University of North Carolina and eight other hospitals in the region. In 2013, research released from the study showed that TRU-D is effective in significantly reducing VRE, MRSA, C. diff. and Acinetobacter spp.r and it concluded that UV-C disinfection devices without built-in technology to measure and calculate proper disinfection times either under or overestimate the necessary dose of UV-C light.

Tom Peck, Director, Environmental Services Department, University of Wisconsin Hospital & Clinics (UWHC), Madison, WI, described their facility. "UWHC is a 566bed facility that ranks among the finest academic medical centers in the United States. Frequently cited in publications listing the nation's best healthcare providers, UWHC is recognized as a national leader in fields such as cancer treatment, pediatrics, ophthalmology, surgical specialties, and organ transplantation. With more than 1,200 UW Health physicians and 85 outpatient clinics, UWHC also offers 6 intensive care units (trauma and life support, pediatric, cardiac, cardiothoracic, burn, neurosurgery), with 83 total beds. UWHC is 1 of only 2 organizations in Wisconsin with designated level-1 adult and pediatric trauma centers."

Top players on the Who's Who list of pathogenic organisms was the focus of UWHC's campaign. Peck talked about the approach taken by UWHC. "There is accumulating evidence that the healthcare environment plays a major role in the transmission of multidrug-resistant organisms. This is particularly the case with Clostridium difficile, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant euterococci, as well as multidrug-resistant gram-negative organisms. Recent studies have shown that environmental disinfection interventions can lead to decreased transmission of hospitalacquired pathogens. In coordination with UWHC's infection control and nursing departments, 2 and later 4 additional patient units were identified as having higher rates of C. diff. infection than the other patient units in the 566-bed facility. We also addressed the issue of HAIs, and the 6 chosen patient units also met these criteria. Healthcare-acquired infections can cost a hospital upwards of $15,000 to $20,000 per infection and will no longer be reimbursed by Medicare. This was both a patient safety and a fiscal decision for UWHC."

Room disinfection did the trick for UWHC. "After much research," said Peck, "a Xenex room-disinfection device was leased for 1 year and used on 2 patient units identified as having higher C. diff. infection rates. After 1 year, lower C. diff. rates on the 2 test units provided us the validation and impetus to purchase the leased machine and purchase a second Xenex machine. Two more patient units were chosen to be disinfected by the Xenex equipment. After a second year, the decrease in C. diff. infections on these 4 units was so promising that a third Xenex machine was purchased for our high patient acuity units, trauma life center and bum.

How did staff convince administration that introducing this new product was a cost-effective move? "Any HAI is an unreimbursed expense costing between $15,000 and $20,000 per infection," explained Peck. "Results from the initial lease demonstrated that using the new Xenex ultraviolet technology was very cost beneficial. With strong backing from the infection control department and nursing, and the initial documented results, the budget request was approved."

The results paid off for the patients and the pocketbook. "The C diff. infection rate has declined on 4 of the 6 patient units. On 1 patient unit, the C. diff. infection rate dropped to zero during the first quarter of 2014. We consider this a huge success, both in patient safety and financially. Treating a C. diff. infection costs approximately $20,000, and preventing just 3 infections per year pays for the Xenex device. Our infection-reduction results from the initial lease demonstrated that using the new Xenex ultraviolet technology was very cost-beneficial, because the number of infections we prevented more than covered the cost of the lease or a future purchase. We saw similar results in infectionreduction rates as we added devices and disinfected other patient units."

Greg Takahashi, Co-Founder, SteriDesign, Laguna Niguel, CA, talked about how their products could save costs through reduction of HAIs. "SteriDesign's SteriBox and SteriHood use the power of low-power ultraviolet light, which is safe, cost-efficient, environmental friendly, and easy to use to eliminate bacteria, germs, and viruses commonly found on multiple-user devices, including keyboards, mice, remote controls, mobile and corded phones, two-way radios, and other small handheld devices."

No small advantage of the SteriBox and SteriHood is its environmental friendliness, explained Takahashi. "Designed to be environmentally friendly, using an energy-saving, low-power, efficient design, this 'green' cleaning method uses no chemicals that can damage the equipment or leave a chemical residue, nor do they produce waste, as do wipes. SteriDesign's sustainable and environmentally friendly solution attacks the DNA of the pathogens on the target device to effectively reduce their occurrence by 99.999%, based on independent laboratory tests."

Takahashi talked about cost saving when using their products as opposed to wipes, as well as ease of use. "The reduction in costs from disinfectant wipes is significant, based on the cost of the SteriDesign products versus disinfectant wipes that fill our landfills with chemically laden material. With wipes, an operator must manually wipe the target device and keep it wet for 3 to 4 minutes to clean them effectively. SteriDesign's products automatically start their cleaning cycle once the hood or cover is closed. Very little additional work is required by the hospital staff to increase their compliance and reduce the pathogens on their devices."

SteriHood cost is $49 the first year. Every year following, just replace the bulb, currently at a cost of $20, to ensure the unit is sterilizing effectively. In contrast, said Takahashi, "Hospital wipes cost over $175 per year, every year, per keyboard, based on being used 6 times per day. At less than $0.14 per day, SteriHood reduces a hospital's cost by 71% per keyboard. That is a significant savings for hospitals trying to increase their compliance but reduce overall costs." Similarly, SteriBox costs $39 the first year, then $20 per year after. HPN

References

1. Magill SS. Edwards JR. Bamberg W, et al. Multistate pointprevalence survey of health care-associated infections. N Engl J Med 2014;370(13):1198-1208.

2. Zimlichman E, Henderson D, Tamir O, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med 2013;173(22):2039-2046.

3. Lee GM, Hartmann CW, Graham 0, et al. Perceived impact of the Medicare policy to adjust payment for health care-associated Infections. Am J Infect Control 2012;40(4):314-319.

by Susan Cantrell, ELS