ICPs show the power of prevention in efficacy efforts, cost-saving projects

But many still worried about economic trends, job security

Amid dramatic ongoing changes in the delivery and financing of health care, an increasing number of infection control professionals are striving to demonstrate the efficacy and cost savings of their programs, readers tell Hospital Infection Control.

ICPs responding to our exclusive 1996 reader survey reported numerous ongoing efficacy demonstration and cost-saving projects undertaken to convince health care administrators and managed care organizations of the value of the profession.

’I don’t think hospitals realize the enormity of the problems with infection control and how much [nosocomial infections] actually cost them,” says Jerold Crawford, RN, CIC, infection control manager at University Community Hospital in Tampa, FL. ’If they invest a couple of dollars in infection control it will pay for itself many times over. But our facilities don’t understand this unless it’s in black and white and in terms of dollars.”

Indicative of the growing trend among ICPs, Crawford issues annual reports on his cost-saving and efficacy efforts to both hospital administration and the board of trustees.

’It has made my job easier as an infection control professional,” he says. ’Because the hospital realizes that what I do is important, and if I need a new piece of equipment or an upgrade on the computer, it is not just money being poured down the drain. ’

Such efforts may be more important than ever under managed care with its shorter lengths of stay, more outpatient care, and facility consolidations and closings. Given such trends, there has been much concern expressed that infection control programs may fall prey to budget cuts and cost-saving measures if the field declines in perceived importance. (See Hospital Infection Control April 1996, pp. 41-46.) Indeed, generally positive responses to our survey revealed undercurrents of concern — both about the economic stability of their facilities and their own job security. Overall, 36% of the 658 respondents to our survey reported they have been advised that they may have to make department budget cuts this year. Another 19% rated the economic health of their health care facility as questionable, and 15% reported their job security was also in doubt.

Ultimately, the impact of health care economic changes on individual ICPs and their department budgets may depend largely on their ability to demonstrate the importance of their programs. Though the power of prevention can be hard to measure, epidemiologic skills of ICPs are being applied to projects that attack unnecessary expense, eliminate ritual, and demonstrate cost savings without sacrificing quality. Though our survey found little evidence of complacency, 52% of ICPs rated their job security as good, and 32% said it was excellent. In addition, some three-fourths of respondents said infection control is perceived as an important program in their facility. Still, 23% of respondents said their program was declining in importance in the eyes of administration.

The message many ICPs are trying to underscore is that infection control speaks to both issues of quality and the bottom line. For example, the Centers for Disease Control and Prevention in Atlanta estimates that some two million patients acquire nosocomial infections annually in the United States at a cost of more than $4.5 billion.1

Adverse consequences of nosocomial infections and their associated costs vary by type of infection, but extended hospital stays, additional costs, and attributable deaths are clearly documented. While prevention aspects vary for individual infections, hospitals can generally expect to reduce their nosocomial infection rates by approximately one-third if they fund infection control programs that emphasize surveillance activities and vigorous control efforts, at least one full-time infection control practitioner per 250 beds, a hospital epidemiologist, and feedback of surgical site infection (SSI) rates to surgeons.2

One ICP reports that implementing a SSI reporting program — which includes reporting surgeon-specific rates and conducting post-discharge surveillance — effectively lowered rates and reduced costs by nearly $13,000 in one year. Under the program, the number of SSIs was reduced from 16 to 12 from 1994 to 1995, reports Lorri Goergen, RN, CIC, infection control coordinator at Genesee Memorial Hospital in Batavia NY. Using CDC cost estimates, Goergen calculated that the effort reduced annual total extra days due to infections from 116.8 days to 87.6 days and lowered extra charges from $50,432 to $37,824.

’We have had an awful lot of quality improvement from it and by decreasing the number of surgical site infections there is a decrease in cost,” Goergen says.

Likewise, another ICP reported substantial savings by implementing a respiratory care program that included extending ventilator circuit changes out to seven days. Once routinely changed every 24 hours, there is mounting evidence in the literature that ventilator circuits and tubing can be changed at less frequent — and costly — intervals without increasing the risk of nosocomial pneumonia.3

’What we wanted to do was decrease the number of ventilator-associated pneumonias, to decrease the use of respiratory care service manpower hours, and to decrease the cost of equipment,” says Lillian Steinert, RN, BS, CIC, infection control and employee health service coordinator at Brookhaven Memorial Hospital and Medical Center in Patchogue, NY.

Conducted by the infection control department, respiratory care services, and the pulmonology department, the project included risk stratification and increased surveillance of all ventilator patients. Measures to prevent nosocomial pneumonia were emphasized, including frequent mouth care, elevation of the head of the bed (if possible), using proper suctioning techniques in handling of tube condensate, and suctioning the patient before deflating the cuff on endotracheal tubes. With such reinforced efforts holding the rate of nosocomial pneumonias steady, ventilator circuit changes were extended from three to five days and then last year all the way out to one week. The number of nosocomial pneumonias was reduced by 50%, going from 28 in 1994 to 14 in 1995.

Using standard estimates of nosocomial pneumonia costing a hospital in the range of $5,000 and $20,000, Steinert was able to report to administration that the program saved the hospital between $70,000 and $280,000 due to the lowered infection rate. Not figured into that total were the additional dollars saved by using less ventilator equipment and by reducing the labor and maintenance required by the respiratory therapy department, she adds.

’So we saved money in that aspect also,” Steinert says. ’This also freed up the respiratory therapists — by not having to change the vent tubes but every seven days — to actually treat more patients and spend more time with patients. It really worked out well for us.”

While it can be difficult to capture all cost savings due to infection control efforts, ICPs are using cost estimates in the medical literature to show savings if specifically targeted rates are lowered in such special projects. Beyond that, ICPs can include estimates of the number of infections that may have occurred in the absence of an effective program to show how the efficacy of their program is translating to cost savings for the hospital.4,5 For example, Crawford includes in his reports the number of infections which could be projected to occur in the absence of an infection control program, which he estimates from the literature would be in the 50% range for many of the major nosocomial infections. Reminding administration how many infections are being prevented by having the program underscores the concept of ’cost avoidance,” he says.

Not rocket science

’This is not rocket science,” Crawford reminds. ’It’s nice if you have a computer and do a spreadsheet, but if not, you can still do it by hand. It’s a little time-consuming, but important in the long run.”

Regardless, the key is presenting the information to the powers that be, underscoring the efficacy of the program, and showing the cost-saving power of infection prevention. To do so, Crawford recommends writing an annual report that includes an overall summary of activities and outlines ’SMART” goals for the upcoming year. (See goals, above.) Make sure that the report gets to quality management, the medical staff, and to administration, he recommends. Rather than the traditional image of a nonrevenue-generating department, it should portray infection control as an important part of the team that keeps the hospital fiscally sound and functioning.

’I can’t stress this enough,” Crawford says. ’No one is going to toot your horn for you. This is the place for you to toot it yourself.”

To do so, include any analysis of what nosocomial infections are costing the facility, how prevention efforts lowered specific rates, and what an infection control program is saving the facility, he says.

’The bottom line is that the more that they trim infection control activities and cut infection control professionals, the more infections there are going to be, and the more it is going to cost in the long run,” he says.

References

1. Centers for Disease Control and Prevention. Public health focus: Surveillance, prevention, and control of nosocomial infections. MMWR 1992; 41:783-785.

2. Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and control in preventing nosocomial infections in U.S. hospitals. Am J Epidemiol 1985; 121:182-205.

3. Centers for Disease Control and Prevention: Hospital Infection Control Practices Advisory Committee. Guideline for prevention of nosocomial pneumonia. Infect Control Hosp Epidemiol 1994; 15:587-627.

4. Dixon RE. ’Costs of Nosocomial Infections and Benefits of Infection Control Programs.” In: Wenzel RP, ed. Prevention and Control of Nosocomial Infections. Baltimore, MD: Williams & Wilkins; 1987, pp. 19-25.

5. Haley RW. Managing Hospital Infection Control for Cost-Effectiveness: A Strategy for Reducing Infectious Complications. Chicago: American Hospital Publishing; 1986.