APIC: Recession hits IPs, shortsighted cuts endanger patients and drive future costs
APIC: Recession hits IPs, shortsighted cuts endanger patients and drive future costs
Joint Commission: APIC survey findings 'disturbing'
In findings that dramatically undercut the growing perception that infection prevention has become a top priority for the health care system, many IPs are having budgets slashed and critical functions such as surveillance compromised, the Association for Professionals in Infection Control and Epidemiology (APIC) reported recently in Fort Lauderdale, FL, at the group's annual conference.
Critics may argue that infection prevention cannot expect to be recession-proof, as all medical programs are vulnerable in the current economic downturn. That said, patients will pay the price for shortsighted cuts that do not even bear up to the economic rationale that presumably motivated them, APIC leaders warned.
"Clearly, health care executives need to understand that investing in infection prevention not only saves lives, but saves hospitals money," said APIC president Christine J. Nutty, RN, MSN, CIC. "While cuts in staff, training and technology may save money in the short term, the effect of increased infections will erode the bottom line over time, not to mention the costs in pain, suffering, and death."
The online survey was conducted March 20-27, 2009, netting 1,943 responses out of some 12,000 APIC members. Overall, 41% of respondents reported cuts in budgets for infection prevention in the last 18 months. According to the APIC survey, three-quarters of those whose budgets were cut experienced decreases for necessary education to train health care workers to prevent the transmission of health care-associated infections (HAIs) such as methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. Half saw reductions in overall budgets for infection prevention, including money for technology, staff, products, equipment, and updated resources. Nearly 40% had layoffs or reduced hours, and a third experienced hiring freezes. (See chart.)
APIC decided to survey its members after anecdotal reports began surfacing of widespread cutbacks.
"Recently, a colleague of mine said, 'My hospital, which has 500 beds, cut the infection prevention staff from 2.5 FTEs down to one.'" Nutty said at an APIC press conference. "Reports like this alarmed us. Budgets [are being] slashed for education, staff, and technology. This is a problem because we can't protect patients from HAIs without an adequate number of properly trained professionals."
Also speaking at the press conference was Denise Murphy, RN, MPH, CIC, former APIC president and now vice president for quality at the Main Line Health System in Bryn Mawr, PA. Though she is known as a leading expert on making the business case for infection prevention, Murphy emphasized the human costs before crunching the numbers.
"I would like to say, as an infection preventionist whose parent died in 2001 of an HAI, the most important bottom line that we can underscore when we discuss HAIs is the deaths in this country," she said. "Thirty-thousand deaths occur every year from bloodstream infections alone and another 36,000 from ventilator-associated pneumonias. When we look at the overall impact and we see in publication after publication [reports of] 100,000 deaths a year — this number is thrown around like it's not associated with the devastation of people's lives. More and more consumers are coming forward with their stories and talking about what it has been done to them and their families. I can't stress enough that though we are talking about the business case here, the most important bottom line is how many people die of these infections."
The Joint Commission is APIC's critical professional partner in securing adequate resources for IPs, with accreditation standards and patient safety goals continuing to emphasize the importance of preventing patient infections. Hospital Infection Control & Prevention immediately sought a reaction to the survey findings from a leading Joint Commission official who was speaking at the APIC conference.
"Pretty disturbing numbers — numbers that we will try to understand in our survey process," replied Robert Wise, MD, vice president for standards at The Joint Commission. "Although most administrators fortunately understand the impact of resources, one of the things we are doing in our discussions with APIC, is [finding out] if a surveyor goes on a site — what are some of the obvious warning signals of this."
Coincidentally, The Joint Commission's resources arm just released a report urging hospital executives to attack the problem of multidrug-resistant organisms (MDROs) such as MRSA. "The job of controlling and eradicating MDROs is the job of many, but the responsibility must ultimately be borne by organization executives," the report states. "Patients, payers, and legislators are demanding accountability and transparency. With all this in mind, can the health care leader afford not to take action?"
Still, it must be duly noted that 59% of respondents to the APIC survey did not report program budget cuts. Nevertheless, IPs may have a hard time seeing the glass more than half-full because the cuts come at a time of unprecedented public attention and political action on preventing HAIs. Indeed, IP budgets are being reduced at a time when federal reimbursements are being cut for preventable infections, senior federal health officials and national political leaders have HAIs blinking brightly on their radar, and the first influenza pandemic in 41 years has just been officially declared. Concerning the latter, if H1N1 becomes more severe and widespread in the fall flu season, American IPs might have to relearn the lessons of their colleagues in Toronto. One of the primary reasons given for the devastation caused by the SARS outbreak there in 2003 was that hospital infection control programs were underfunded and understaffed.
Moreover, just last year the Centers for Medicare & Medicaid Services (CMS) cut reimbursements for three infections (catheter- associated urinary tract infections, catheter- associated blood stream infections, and mediastinitis). Other infections are being targeted for future CMS reimbursement cuts. In addition, in January, the U.S. Department of Health and Human Services unveiled a national HAI Action Plan with metrics and targets to reduce six categories of infections.
The economic stimulus package passed in February allocates $50 million toward using HAI reduction strategies, so some relief may be forthcoming in the form of competitive grants. However, demands for accountability in outpatient settings are on the rise. In the considerable aftermath of the Las Vegas hepatitis C outbreak last year, the Government Accountability Office called for beefed-up oversight of ambulatory care. Already stymied in hospitals, many IPs responding to the survey reported responsibility for a wide variety of outpatient settings. (See chart.) Meanwhile, some 30 states have passed infection rate reporting laws and six others have created committees to study the issue. There also are 12 separate state statutes on MRSA. The infection prevention community decided the fight against infection rate transparency was unwinnable in the public square, but there were clear warnings that such laws could lead to the unintended consequences of IPs mired in front of computers collecting and reporting endless data streams. Unfortunately, that appears to be what has happened in some cases.
"The ICP is now an IP — an infection preventionist," Nutty told some 3,000 attendees at the opening session of the conference. "Or they want to be. The reality is a lot of you are stuck behind computers and you have to do a lot of work in your office because of all the data collection you now have to do."
Such mandated data collection and reporting underscores the need for surveillance technology, but APIC found that only one in five respondents have data mining programs — electronic surveillance systems that allow infection preventionists to discover and investigate potential infections in real-time.
"We asked what activity they had to curtail to compensate for being underresourced," Nutty said at the press conference. "The answer that disturbed us the most: a quarter of respondents had decreased surveillance activity to detect, track, and manage infections. This concerned us because surveillance is at the heart of what we do. Identifying and isolating sources of infection to prevent their spread is the essence of infection prevention."
Nearly two-thirds of respondents have one or less than one full-time staff person dedicated to infection prevention, while almost 90% less than one full-time clerical or analytical staff person or none at all. APIC leaders have long dismissed the old ratio of one IP per 250 beds, noting that research has confirmed that the demands of the job warrant more on the order of one IP per 100 beds.1
In addition, there remains the lingering perception that infection prevention does not generate revenue, but researchers such as Murphy have blasted that myth in a series of presentations on making the business case for the field. For example, HAIs exact huge costs by prolonging patient length of stay, leaving beds filled even as patient reimbursement dwindles, she says.
"HAIs are probably the largest subset of what CMS is now refusing to reimburse for," Murphy reported.
A surgical-site infection (SSI) following coronary artery bypass surgery, for example, results in an average of 26 more days of hospitalization.
"That's just on average, we've seen people spend months in the intensive care unit having plastic surgery, having their chest reconstructed," Murphy says. "Just preventing 10 of these SSIs would open up 260 bed-days. If you are able to, on average, come in and have a [bypass] surgery and only spend four days, then 65 new patients could have been admitted."
Yet even though the power of prevention can be clearly outlined, Murphy conceded that the reality in hospitals is there are competing priorities for limited dollars. Other departments can effectively argue that they need new equipment and resources to save patients' lives, she notes. "Operating rooms are now looking at in-suite MRIs in order to conduct even safer surgery," Murphy said. "[Infection prevention] is a very important issue, but so is safe neurosurgery — the ability to remove a brain tumor without neurological deficits. I could go on and on, but the point is when we sit at the executive table, patient safety and quality — with infection prevention being the biggest chunk of that — is one of many competing priorities."
That is why IPs must argue that if there programs are adequately funded, the result will be seen in saved lives and dollars. A 300-bed hospital could adequately fund a comprehensive infection prevention program — including two IPs, clerical support and equipment, and educational resources — for somewhere in the range of $300,000, she estimated.
"That is peanuts when you look at the operating cost in a hospital," Murphy said. "If they were only to avoid 10 bloodstream infections, that would pay for an effective program."
(Editor's note: The complete APIC survey report is available at www.apic.org/EconomicSurvey.)
- O'Boyle C, Jackson M, Henly SJ. Staffing requirements for infection control programs in U.S. health care facilities: Delphi project. Am J Infect Control 2002; 30(6):321-333.
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