Business Case for Infection Control

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Business Case for Infection Control

• James P. Steinberg, MD
• Professor of Medicine
• Emory University School of Medicine

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Objectives

• Present the case for a Business Case
• Provide overview of recently implemented
  infection control measures at Emory
• Discuss measures not implemented

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• Infection Control a cost center
• Demonstrating value to administrators important
• Business case looks at , ignores morbidity and
  mortality
• Compares cost effectiveness, cost-utility,
  cost-benefit with business cases analyses
• Critiques infection control intervention studies
• 69 quasi-experimental, 4 had cost analysis
• 30 studies claimed economic analyses 5 properly
  done
• Step-wise approach to creating a business case

ICHE 2007281121
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Current Landscape

• Enhanced scrutiny of HAI
• Public/consumer groups
• Legislators
• Payors and regulatory agencies
• Legal liability
• Patient safety initiatives
• Expectation of best practices
• Prospects of decreased payment
• ? pressure on administrators to ? infection rates

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Infection Control InterventionsEmory Healthcare

• Introduce new technologies
• Chlorhexidine patches for central line insertion
  sites
• Chlorhexidine cloths
• New valves for IV lines
• Under consideration rapid MRSA screening
• Improve global infection control efforts
• Hand hygiene campaign
• Process improvement efforts to standardize and
  reliably perform processes known to reduce
  infections
• VAP and central line bundles
• SCIP efforts/cardiac surgery initiative
• Decision support software
• Antibiotic stewardship

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Cost-benefit of CHG Cloths
Average cost to treat one Surgical Site Infection
(SSI) 25,500.00 per infection Average number
of surgical procedures performed per year
1,000 Sage 2 CHG cloth 9707 _at_ 5.85/pkg (3
applications per procedure) 17,374.50/annually
Break even point 1.00 avoided SSI(s)

• Analysis assisted by vendor
• Are costs per infection accurate?
• Need to consider attributable costs and variable
  costs
• Consideration of excess LOS reasonable
• Patients who develop an SSI spend 710 additional
  days in the hospital

Conducted by an independent laboratory data on
file.
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• Figures don't lie, but liars figure
• - Mark Twain
• - But figures can lie too

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Active Surveillance Cultures (ACS)

• To prevent person to person transmission through
  detection of colonization
• Allows institution of barrier precautions
• Has been shown to improve detection
• Controversial
• Recent high-profile studies using ACS for MRSA
  control with conflicting results

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ASC

• Strategies include
• Contact isolation when MRSA identified
• Empiric isolation pending results of screening
  cultures
• Delay in getting results complicates process
• Newer DNA technologies more expensive but allow
  for rapid detection

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Cost of ASC in Emory ICUs

• Instrument 156,450
• Service 20,250
• Reagents
• MRSA 42.00 / test
• Swabs 0.70 / swab
• Reagent Rental Option
• Based on 833 MRSA / MO. 47.70 / test
• Total approx 600,000

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Called a cost savings estimate

• Analysis from vendor
• Estimates number of infections
• Uses avg. costs from literature to estimate cost
  per infection
• Proposes 30 reduction in infections
• Factors in cost of screening
• Estimates Total reductions

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Preemptive strategy estimates costs of isolating
all patients empirically and savings using rapid
test
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Does ACS Work for MRSA?
Crossover design study showing no reduction in
MRSA infections with ASC Harbarth, JAMA
20082991149
Observational study showing reduction in MRSA
with hospital-wide ACS Robicsek, Ann Int Med
2008148409
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Nosocomial and Non-hospital Acquired MRSA
isolates at ECLH 1997-2007
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Nosocomial and Non-hospital Acquired MRSA
isolates at ECLH 1997-2007
Non-hospital acquired
Nosocomial 2005-7
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MRSA HAI in Emory ICUs

• 2006 2007
• Inf/yr Inf/yr
• VAP 25 11
• CLABSI 4 4

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Burden of MRSA at ECLH, 2005-7

• Infection ECLH MRSA
• VAP 13
• BSI 7.0
• SSI 9.2
• Total 8.6

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ASC Unintended Consequences

• May redirect limited resources away from other
  important IC issues including MDROs not targeted
  by surveillance efforts
• Increase in laboratory resources
• Logistical issues, especially in hospitals with
  semiprivate rooms
• Increase LOS
• More ambulance diversions in some settings

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ASC Unintended Consequences

• Patients more likely to experience adverse events
• Decubiti
• Falls
• More likely to file formal complaints
• Decrease patient satisfaction
• Less likely to have VS recorded
• More days without progress notes

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Hand Hygiene Program

• Monitoring 60,000
• Advertising/media 5,690
• Posters 5,000
• Kiosks 5,000
• Training portal 4,000
• Ribbons/pins/buttons 4,300
• Gift cards 1,000
• Scrub logo 6,500
• 90,000

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Hand Hygiene Compliance--1994-1997 University of
Geneva Hospitals
Lancet 2000 3561307
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Attributable Costs and LOS of HAI

• Infection type Mean costs Excess LOS
  days)
• VAP 22,875 (9,986-54,503) 9.6 (7.4-11.5)
• CA-BSI 18,432 (3,592-34,410) 12
  (4.5-19.6)
• CABG-SSI 17,944 (7,874-26,668) 25.7
  (20-35)
• UTI 1,257 (824-1,710)
• Attributable costs in 2005 dollars ICHE
  2007281121

• Applying these costs to HAI seen at Emory
  Hospitals
• Return on investment in hand hygiene campaign
  over one year
• 10 reduction in HAI RIO 900
• 20 reduction in HAI RIO 1900

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Conclusion

• Economic realities important
• Current climate may lead to increased infection
  control resources
• Easy to find ways to make both sides of a
  business case