ICPs getting innovative to prove cost-effectiveness
Looking at the forest rather than the trees
In a cost-saving measure that was at once innovative and seemingly heretical, an infection control professional farmed out surveillance duties and eliminated a vacant full-time position in her own department.
"Before you order a psych consult on me, let me tell you why," Arlene Potts, MPH, CIC, said recently in Baltimore at the annual conference of the Association for Professionals in Infection Control and Epidemiology. Potts is manager of infection control at Robert Wood Johnson Univers ity Hospital in New Brunswick, NJ, where the infection control department was staffed by two full-time ICPs until a co-worker resigned in 1996.
While advertising and interviewing for a replacement, Potts assumed the task of conducting chart review to identify nosocomial infections. In doing so, she noticed that outcomes managers — case managers assigned to every patient admitted to the hospital — were also reviewing and identifying infections and similar adverse events. Observing the duplication of effort, Potts proposed that the infection control position be eliminated and the outcomes managers be formally trained to identify nosocomial infections.
"Needless to say, the proposal was well-received," she said.
The program included establishment of common definitions, a computer software program to compile data, and training of the case managers, she noted. Now the case managers are accurately reporting infections and the elimination of the ICP position saves the hospital $60,000 in salary and benefits annually. The change required $40,000 in start-up costs for the initial development and coding of the computer programs, and the new surveillance system cost the hospital about $10,000 annually thereafter. Thus, the new system results in a net annual savings of approximately $50,000 due to the elimination of the ICP position.
The hospital returns a portion of profits to employees, but job security still would be the obvious benefit of such efforts, even for ICPs that do not have bonus plans, she noted. Even if she finds another ICP position is needed later, the case manager surveillance would likely continue and new infection control staff would assume other duties, Potts tells Hospital Infection Control.
"I work for a very supportive institution, and as we are growing they see that I am already spreading myself a little thin with meetings, reports [etc.]," she says. "So there probably will come a day when we are going to need another [ICP] position. But if that comes next year, I’ve already saved the hospital $150,000."
In another APIC study, Sanjay Saint, MD, MPH, a physician in the department of general medicine at the University of Michigan Health System in Ann Arbor, found that silver-alloy catheters can reduce the incidence of urinary tract infections (UTIs) and associated morbidity, mortality, and costs in certain patients.
The catch: The catheters cost $5.30 more apiece than standard designs. Saint looked at the clinical and economic impact of using silver alloy urinary catheters compared to standard devices in a simulated cohort of 1,000 hospitalized patients requiring urethral catheterization for three to seven days. Use of silver-coated catheters led to a 45% decrease in the incidence of symptomatic UTIs, from 21.5 to 12 cases per 1,000 patients. The silver catheters also resulted in a 51% decrease in the incidence of bacteremia from 3.8 to two cases per 1,000 patients compared to standard catheters. In addition to the clinical advantages, use of the catheters resulted in an estimated cost savings of $6.27 per patient, even after accounting for their higher purchase price.
"Hospitals in which the mean duration of catheterization is between three and seven days are likely to see cost savings," he tells HIC. "In general, every 1,000 [silver alloy] catheters used prevent 10 symptomatic UTIs and two cases of bacteremia, and save over $6,000. You can extrapolate that." The problem, he concedes, is getting hospital administrators and finance officers to spend more up front to save more later.
"You need to get to someone who is responsible for seeing the big picture — someone at the forest level rather than at the trees level," he says. "Because material services and purchasers are more concerned about making sure when they purchase things that they are less than what they spent last year. They don’t see the benefits of preventing catheter-related bacteremia two or three years down the road."
Penny-wise and pound-foolish
However, ICPs must stress the cost benefits of infection prevention if they are to survive in the health care delivery system, said Denise Murphy, RN, MPH, CIC, director of infection control at BJC Health System in St. Louis. BJC is a corporation of 13 acute care and six long-term care facilities in Missouri and Illinois. ICPs at the BJC facilities have formed a consortium that emphasizes cost savings and infection prevention.
"Know the impact of nosocomial infections," Murphy emphasized. "Know that bloodstream infections cost greater than $4,000 and add about seven days to the length of stay; that a VRE [vancomycin-resistant enterococci] bloodstream infection can cost between $28,000 and $40,000; that CABG [coronary artery bypass graft] surgical site infections are also very costly — at BJC we have seen them cost between $15,000 and $30,000 routinely. And a vent-associated pneumonia case can cost between $8,000 and $14,000."
While her consortium strives to track and prevent infections on an ongoing basis, Murphy noted that even an outbreak situation provides an opportunity to underscore the importance of preventing such infections in the future. For example, rates for arthroscopy procedures, which typically run .1%, shot up to 2.7% during an outbreak at a BJC hospital in 1997, she noted.
"So we looked at what the average length of stay was for the [infected] cases, and that was 5.2 days, vs. the controls, which was .6 days," she says. "The average cost for the controls was $5,600. The cost of a case that did get infected was $21,000. So the excess cost associated with those arthroscopy SSIs [surgical site infections] was $15,400." Extrapolating that number further, Murphy and consortium members pointed out that preventing a continuation of the epidemic rate over some 600 procedures annually projected out to $231,000 saved.
In developing this kind of cost-effectiveness information, it is critical to focus surveillance efforts on "value-added" data — high-risk, high-cost infections where intervention and prevention efforts can translate to lives and dollars saved. A comprehensive indicator evaluation process led to the selection of surveillance targets for the various facilities in the BJC consortium. For example, surveillance indicators for hospitals of more than 200 beds in the system include CABG SSIs, BSIs in intensive care unit patients, and VRE. Small community hospitals in the system track surveillance indicators that include house-wide BSI rates, SSIs that are historically problematic for them, and both methicillin-resistant Staphylococcus aureus (MRSA) and VRE. Long-term care indicators include UTIs, influenza and pneumococcal vaccine compliance, VRE, and MRSA.
"[Selected indicators] had to involve a high-risk population where there was morbidity or mortality involved, or some kind of documented serious clinical indication or epidemiological significance," Murphy said. "And what was really important was that there had to be interventions, either in the literature or that we could come up with, that we believed would impact that indicator so that we could drive the rates down."
For example, interventions used to reduce CABG SSI rates included discontinuation of razor-shaving of surgical sites, better traffic control in operating rooms, and feedback of SSI rates to surgical staff.
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