Hospital infections cost U.S. $5 billion annually

ICPs showing prevention cost savings

Nosocomial infections cost the United States health care system about $5 billion annually, meaning prevention efforts by infection control professionals translate not only to lives saved but also to substantial cost savings, epidemiologists emphasized at the Centers for Disease Control and Prevention’s 4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections, held in March in Atlanta.

The CDC estimates that nearly 2 million patients annually get an infection while being treated for another illness or injury, and nearly 88,000 die as a direct or indirect cause of their infection. "Our greatest concern is the illness and death that result from these infections," said William Jarvis, MD, chief of the investigations and prevention branch in the CDC hospital infections program. "But the economic costs are also quite high, and provide another compelling reason to reduce the number and severity of healthcare-associated infections."

The economic costs of infection largely result from days added to the patient’s length of stay. For example, the CDC estimates that an additional one to four days of hospitalization will result from a urinary tract infection; seven to eight days for an infection at the site of a surgery procedure; seven to 21 days for a bloodstream infection; and seven to 30 days for pneumonia.

"The costs vary, too," Jarvis said, "anywhere from $600 or so for a urinary tract infection to $5,000 or more for pneumonia. Prolonged bloodstream infections can top $50,000." Because insurance companies and other payers such as Medicaid may reimburse the hospital on the basis of the patient’s original condition and not for the infection the patient acquired during treatment, hospitals can lose hundreds or thousands of dollars on each infection. To offset such losses and underscore the value of their programs, ICPs are increasingly showing the cost savings of their efforts by generating their own data or using estimates from the medical literature.

While ICPs must deal with outbreaks and clusters as they arise, waiting for the next "fire" was not the program direction desired by Victoria Fraser, MD, associate professor of medicine at the Washington University School of Medicine in St. Louis.

"We really try to adopt a reorganized approach to infection control that is proactive and not reactive," she said. "We spent the first seven years in our [department] doing outbreak investigations and putting out fires [and] we thought we should move a little past that."

Emphasizing that ICPs must link cost savings and improved outcomes back to their infection control programs, Fraser said her department uses marketing approaches and strives to pique the interest of professionals who are directly involved in patient care. "We’ve gotten pretty big into marketing so that people understand what infection control is and they can actually see it through posters, signs, buttons, pens, whatever helps them bond with us," she says.

Providing feedback regarding infection rates or compliance rates to try to motivate better practices can be an effective strategy, she notes. For example, partnering an infection control performance improvement team with surgeons and staff in the operating room lowered the endemic rate of surgical site infections related to cardiac bypass surgery. "We are seeing a substantial decline in cardiac surgery deep chest infections at one of the system hospitals," she said. From 1998 to 1999, the rate fell to .77% and resulted in a cost savings of between $150,000 and $300,000, she said. "In our data concerning our own costs, controlling for severity of illness and matching for diabetes, obesity, [and other patient risk factors], deep chest infections cost us about an extra $20,000 a case," Fraser said.

In general, the field of infection control has too often accepted endemic levels of infection, rather than "striving for perfection," she added. "You have heard the excuses: We are a teaching hospital, our patients are sicker, we’re overwhelmed, we don’t have any resources, no one believes us, I get no respect, blah, blah, blah,’" she told attendees. "But maybe we should really be striving for perfection — not benchmarked infection rates, but incredibly low infection rates. Surgical site rates of not 1% but .1% or .01%. Apply the same goals and principles to infection control as industry has for making widgets."

Doing more with what we have

Asked about the question of resources to accomplish such goals, Fraser tells Hospital Infection Control, "I think we can probably do more with the resources we have if we really focus on high priority [items] and have a specific goal of trying to decrease infections as opposed to trying to collect data," she says. "We just collect a lot of data. So sometimes it involves letting go of some things to really focus on other things. Some of it is making a business case to your administration to show them the return on the investment, that you can improve outcomes and therefore they should invest further in you. They have expanded our budget this year. Our administrators are about as bought into this as you can be. They believe in the interventions, the improvements, and they see the financial differences. So we asked for more money this year to do more interventions more quickly, and they agreed that that would be a good investment."

The funding of a new infection control position can be a tough sell in today’s health care market, but the money spent may yield money saved, said Fran Slater, RN, MBA, CIC, infection control manager at Methodist Hospital in Houston. The problem Slater faced was an increase in nosocomial bloodstream infections (BSIs) in a 32-bed surgical intensive care unit. Such BSIs are typically associated with the use of an intravascular device like central venous catheters, and cause increased morbidity, mortality, and significant costs. The attributable mortality for BSIs in surgical ICUs has been estimated to be 35% but will vary according to the specific pathogen, Slater said. BSIs can cost an estimated $40,000 per survivor in an ICU.

Beyond putting out fires

In 1997, the CDC National Nosocomial Infec tions Surveillance system reported a range of 0.4 to 9.1 BSIs per 1,000 central line days among patients in surgical ICUs. "We were having a rather nightmarish situation because our incidence of central catheter bloodstream infection certainly exceeded the data that was available to us from CDC," Slater said. ". . . In the first quarter of 1997, we were at a 12.7 incidence of BSIs per 1,000 patient days."

A committee was formed to address the problem and choose interventions. In addition to education and feedback to staff, the use of antibiotic-coated catheters was recommended if the patient was projected to have catheter indwell time beyond seven to 10 days. The other major intervention was justifying to administration the hiring of a vascular catheter care nurse to focus specifically on that aspect of care in the ICU. "There was a great deal of discussion about the need for an IV team," Slater said. "[We were aware of] a couple of institutions that had IV teams in place. However, they were experiencing downsizing, even to the point of elimination of IV teams. So we came up with the concept of a vascular catheter care nurse, who would be a member of the infection control team."

The catheter care nurse monitors the incidence of BSIs among patients with central lines, and reviews nursing practices from the point of catheter insertion to the point of removal. She offers education and feedback, using a flex sched ule to ensure all shifts are included, Slater added. Funded in the $50,000 range, the position and other interventions resulted in 18 fewer BSIs in 1999. A formal cost analysis is in progress that will include patent lives saved in the calculations. In the interim, Slater used a $5,000 estimate from the literature to project that the prevented infections saved $90,000. Most of the infections involved coagulase-negative Staphylococcus, and the cost estimates were for dealing with that particular pathogen. While the hiring of a catheter care nurse and other interventions resulted in a net savings in the $40,000 range, Slater says individual ICPs must assess their own situations in making such decisions.

"It was what we needed to have done," she tells HIC. "We were dealing with an intensive care unit that was relying on an agency for staffing, so we didn’t have a consistent group of nurses in there. And we were also finding that they were short-staffed, so our nurse-to-patient ratio was not optimal. So [the catheter care nurse] worked for us."

It helped that the catheter care nurse was already working at the hospital in another capacity and was familiar with the staff. "We felt that the traditional approach of education and pounding [in] what needs to be done wasn’t going to work," Slater says. "We needed somebody right there at the bedside who was going to be watching what they were doing and then very quietly tell them what needs to be done. It was someone that they respected and knew. If we can tie [the position] to lives saved, then I think we will be able to keep it."