But as healthcare acquired infections (HAIs) become more common, more resistant and take on a much more public face, the powers that be are taking notice. As a result, the influence of the ICP is starting to carry more weight in value analysis and product evaluation committees across the country.

"There’s an empowerment taking place within the infection control profession and it is effecting change," said Bill Brandmeyer, director, commercial development for Leawood, KS-based Enturia Inc., makers of ChloraPrep. "Everyone is starting to understand the real economic impact of healthcare-acquired infection - harder to treat patients requiring additional treatments," What’s more, "infection is now exposed as a common preventable problem as mainstream news coverage has increased," he said.

As Debra Johnson RN, OCN, infection control coordinator at The Westerly Hospital in Westerly, RI, has witnessed, as infections become more commonplace, there’s a much greater chance that people have a friend or family member who has experienced an infection. "People attach themselves to the process now. They’re personally involved in the process," she said.

With empowerment comes responsibility. There are so many new technology and practice innovations that can help to reduce the risk of infection and make real improvements in quality of care, and more often than not, so few budget dollars. That’s why any new clinical product that’s implemented should be thoroughly evaluated by a multi-disciplinary team and proved to be safe, contribute to good patient outcomes, and be cost effective.

"Most hospitals are strapped for money, that’s not anything new across the country," said Johnson. "There have been so many cutbacks in funding, etc., so any new product is highly scrutinized. You have to be able to develop a return on investment (ROI) for the product."

Dan Peterson, MD, Mph, vice president and medical director for the Premier healthcare alliance, Charlotte, NC, speculated that, "Administration always has probably a few hundred things they could spend money on to improve the quality of care, from hiring more nurses, to a lot of other things. They’re naturally going to gravitate towards the things with the highest ROI, that allows them to actually do more."

Developing an ROI can be a challenge for ICPs, many of whom have an excellent grasp on the science behind a clinical product evaluation, but may be less familiar with financial dynamics.

"As an infection control nurse, you have to be able to present yourself to the financial heads and to administration, to give the rationale," said Johnson. "And you have to talk money, obviously, and how much money is this going to save the hospital?"

ROI for an infection prevention product starts with determining the cost associated with treating patients with infections.

Bonnie Harris, CIC, infection control practitioner with Prince William Hospital in Manassas, VA, noted that "measuring product acquisition cost against potential cost savings in avoiding HAIs" may help ICPs to command interest from hospital administration who are certainly concerned about HAIs, but often need convincing when it comes to product costs.

She added, "many times HAI rates are compared to the national average. And if the facility is under average or better than other facilities, HAIs are not viewed as a problem."

What works best, sources agreed is when you can pin a dollar amount on infection costs using hospital-specific data.

Virginia Kennedy, principal, Infection Prevention & Management Associates Inc., Houston, TX, explained, "I think facilities always prefer to have their own cost data utilized. One can say in the literature that a central line infection can cost between X and Z, but my experience has been that the administrator will want to know what the cost of infection is at their specific facility."

One way to look at ROI is to compare costs and reimbursements for patients who have infections and those who don’t, explained Peterson. "When you do that you’ll find out just how much infections are costing you and that you’re not being reimbursed."

"Most HAIs are being poorly reimbursed now, but I think many CEOs and CFOs don’t realize that," commented Suzanne Pear, RN, PhD, CIC, associated director of infection prevention practices, Kimberly-Clark Health Care, Roswell, GA.

A clear understanding of reimbursement issues is vital, indicated Pear. "It is important to understand how the facility is reimbursed for patient care. Federal facilities generally are not reimbursed in the same manner (e.g., DRG-based), as non-governmental, private facilities are." She added, "the ICP needs to understand how reducing patient length of stay and improving bed turn-over rate raise the fiscal bottom line; as well as, what are the financial metrics that the organization looks at and how does it measure ROI. With this knowledge, a business case for the infection prevention interventions can be couched using the common language of a cost-benefit analysis."

On the wish list for many ICPs, automated surveillance programs, such as Premier’s Safety Surveillor or Cardinal Health’s MedMined, provide an excellent way of capturing infection risk data for product evaluation and analysis.

Explained G.T. LaBorde, vice president of operations for MedMined services, Cardinal Health Inc., Dublin, OH: "MedMined can help ICPs to be able to measure the clinical and financial impact of those infections so that you reinforce why the prevention of infections is important — not just to patients, but the hospital, and to the payers, insurance companies and others."

"A part of our service is to periodically take all of this clinical data and what we’re learning from it in terms of who has infections or not, and actually link it to each of our hospital customers’ own cost accounting system data so that we can make the business case," LaBorde continued. "With their own financial data, we say, how do patients that acquire infections in your hospital differ from patients in the same DRG that don’t acquire infections in the hospital, in regards to direct costs, profitability and length of stay?"

"First, we have an objective way of keeping track of infection rates over time, and to view it by type of infection, by unit, and different subgroups, and secondly we’re tying that information to financial data. And so we tell our hospitals, ‘for a urinary tract infection in your facility with your own financial data, this is how much that cost you to your bottom line, in cost, in profitability, in length of stay. This is how much a respiratory infection costs; this is how much as surgical site infection costs, etc.,’" LaBorde related.

Elements to include in calculating the cost of infection, said Brandmeyer, include "length of stay, nursing time, additional antibiotics, blood cultures and other diagnostic testing, the patient’s quality of life and impact on the patient’s support network."

Harris related that in making the business case for a recent implementation of Sage Products’ 2% Chlorhexidine Gluconate Cloths for preoperative skin prep at Prince William Hospital, readmissions were closely examined. Within six months of using the wipes, the 170-bed facility experienced a 75% reduction in readmissions due to surgical site infections, and saved approximately $160,000. Avoiding readmissions for SSIs was a key element of the ROI model. "Many hospitals are boarding patients due to lack of bed availability," she said.

LaBorde suggested tying pharmacy costs for antibiotic usage to central line bloodstream infections, for example, as another persuasive method of showing the CFO the hard bottom-line costs of infection.

"If you are proposing a change in product that may be more expensive, you must show a true reduction in infections if the product is used properly," described Kennedy. "You should also be able to show how the expenditure for the product can be absorbed by the cost avoidance benefits. This may require education on both the clinical and administrative/financial sides, and requires a true partnership that doesn’t always exist in healthcare facilities. Fixed and variable costs must be known, and discussion must be conducted in a way that is meaningful to both groups of stakeholders."

She provided the example of the full barrier bundle practice for central line insertions to make sure good practices are followed and all necessary items are readily available for performing the procedure, including hand hygiene products and practices, patient prep items, draping, staff attire, insertion products, and dressings.

"This practice results in an expensive custom kit, but saves much time in gathering products and ensuring that everything is immediately available and that there is full practice compliance," said Kennedy. "The cost differential is minute once you add up the costs associated with gathering the items independently and the costs to a patient and a hospital (health-related, emotional, financial and legal) of a procedural site infection."

Brandmeyer reminded ICPs not to overlook soft costs, which can be uncovered using simple "time and motion" calculations. For example, "Calculate the time it currently takes to prep a patient’s skin prior to a surgical procedure using traditional prepping protocols, if a new prep delivers superior efficacy and can save up to 7 minutes on every patient you prep, additional surgical procedures might be possible. A lot depends on the mindset of the surgical team, but we know that in the OR time equals money," he said.

Make use of industry studies and literature that show real-life examples of how infections are being prevented, suggested Peterson. "Document that you really can drop central line blood stream infections, maybe to zero – so much lower than we ever thought. And likewise with VAP."

Once you’ve demonstrated the cost of infections, and shown that infection rates can be reduced, then you can present a particular product or application and demonstrate how it plays a role in reducing infections. "Using our own hospital data, with our own payer mix and our infection rate, here’s what our costs are and here’s what the impact [of this product] can be. That’s the piece that finally has the most impact on someone like the CFO," said Peterson.

An excellent example of outcome driven care impacting a reduction in HAIs is the Rhode Island ICU (Intensive Care Unit) Collaborative, which aims to improve care for adult ICU patients throughout the state by reducing length of stay, complications and associated costs. With guidance from Dr. Peter Pronovost of Johns Hopkins University, Rhode Island hospitals are implementing and evaluating proven strategies that address these issues.

Johnson said "What we’ve done is standardize the way patients are cared for in ICUs in the state of Rhode Island. And it’s huge. We’ve standardized on everything – we’ve developed and implemented bundles for ventilator associated pneumonia, central line bloodstream infections, tight glucose control."

Results from the collaborative will be published this fall, but the benefits are already clear. "We’re a small state but we have a million people and 20 hospitals," said Johnson. "So being able to do that is huge. It’s really an excellent process and we’ve decreased infection rates at ICUs in the state significantly."

As part of the initiative, Johnson recently brought an oral care product before her facility’s multi-disciplinary Products Evaluation Committee, based on published data that the product could help prevent ventilator associated pneumonia (VAP). She also helped implement a central line securement device to reduce bloodstream infections (BSIs); next on her list are Sage Products’ rinse-free disposable bathing washcloths to reduce the risk of waterborne infections in immune-compromised patients.

Trial runs with the end user are critical to clinical product evaluation. Among the criteria you’ll need to consider: indication, ease of use, is the product single use or reusable?; what are the sterilization/reprocessing requirements; what type of vendor support and service is available?

Also, suggested Pear, "Is there a less expensive product that produces the same results? Is the difference in cost worth the outcome benefit?"

Johnson emphasized, "You can’t just go out and purchase something because it looks like a good idea. You have to really evaluate the product. It’s physically putting it out there on the units and letting the nurses or the techs who do the work everyday, who are out on the floors, letting them interact with the product to be sure it’s going to fit within the unit."

"We certainly listen to what the nurses have to say," agreed Harris. "If it’s easy to use, or if they have problems with it." Evaluation forms available through vendors are helpful, but she also asks nurses at the point of care for their input on new products.

"I believe it is critical that as many of the primary users of the product have an opportunity to evaluate the product and be able to evaluate the suitability of the product as possible," said Pear. "Often times a single type of device, such as a safety needle/syringe, will be used for a number of different procedures, so it’s important to make sure the device performs well in each scenario. Therefore, including the users early in the evaluation process will help minimize the likelihood of product incompatibility and user dissatisfaction. It’s not an easy or simple process, but it may save having to repeat the process later."

Kennedy added, "Bedside workers have multiple patients to care for, so ICPs have the best chance to effect change by offering processes and products that are easily adopted. For example, hand sanitizers are much easier to use frequently than soap and water."

"We have had much success is implementing the Partners in Your Care Patient Empowerment Program from STERIS Corporation and the University of Pennsylvania, which is a multi-faceted hand-hygiene compliance program that includes product selection and placement, staff and patient education, and feedback using data that measures hand hygiene compliance with product usage," said Kennedy. "We provide patient and family information and education when the patient is admitted, and we also added information on the hospital educational channel regarding hand hygiene to complement the program. The vendor partnership was the key to the success of the implementation, but we also gained the support of facility leadership and the commitment of the facility’s ICP in order to ensure a successful program. Hospital leaders also provided staff incentives to assist in driving healthcare worker compliance. The data collected has shown improved and sustained compliance and a reduction in specific infections, including multi-drug resistant transmissions, throughout the facility."

Setting up protocols that facilitate compliance is an industry-wide initiative, said Peterson. "One of the things that’s happening at APIC, is they are trying to re-brand who they are from doing infection control programs to doing infection prevention systems. The idea is that we need systematic thinking about these things that prevent infections. They shouldn’t really be choices – they should be built into what happens every time for every patient in the hospital. What you want to put in place is not products, but solutions."

Product trials require more data gathering, another great way to use automated surveillance.

"What you would like to do in your hospital, when you do anything related to infection prevention, be it purchasing a different kind of soap, a new urinary catheter, some other kind of wound dressing, whatever the products are, what you would like to do ideally is test the product in your own hospital, use it in a couple of wards for a couple of months and see what impact it makes in your setting. But that becomes very labor intensive unless you have an electronic system in place," said Peterson. "For instance, if it was a skin prep before a blood draw, with an electronic system you could easily look at your blood draws before and after, also comparing the wards where you’re testing the new product versus the existing product. Running these kind of analyses becomes significantly easier with an automated system."

Commented LaBorde, "We’ve seen a lot of our customers, once they have a way of electronically, comprehensively measuring the scope of the problem, they wind up getting more support, not just for other products, but for additional resources for the IC department."

Having collected six months of baseline data from the pre-op cleansing wipe implementation, Harris is ready to propose other antimicrobial products. "Focus on a specific product for a designated time period, establish a limited trial or pilot program for evaluation, and if successful, implement in other areas," she said. "Pre- and post-implementation data collection is essential."

Sue Wasserman, infection prevention marketing manager, 3M Health Care, St. Paul, MN, noted "sometimes we watch our customers make many interventions at one time in their quest to minimize infections. Different treatment changes might be made and the final outcome is a lower rate of infection, but you’re not really sure how much of that reduction was due to the individual changes that you made in your process. Those are very difficult to sort out. I think that’s another reason why in the busy world we live in, it’s not always easy to say, I have the data, I know the intervention I want to make."

Wasserman continued, "there are so many demands on healthcare workers, to make a policy change in a healthcare facility requires a cross-functional team, a multi-disciplinary team to come together with the data and look at, ‘the data is telling us we should make a change, how are we going to implement that in our hospital?’ So it’s quite an undertaking to say that we’re going to do it differently."

Pear advised that materials management and central supply/sterile processing departments be kept in the loop throughout all stages of product implementation, and that communication lines stay open.

"One situation I personally experienced during my career at the VA, involved a safety lancet that went on backorder by the manufacturer," recalled Pear. "The SPD department supply clerk did not recognize this device’s self-retracting safety features as being critical to the selection of an interim-replacement product. He ordered a standard, non-retracting lancet and I became aware of the inappropriate substitution when I received a report from Occupational Health about a healthcare worker incurring a needlestick associated with the unsafe lancet. It then became standard operating procedure (SOP) for infection control approval to be required when any interim device or product substitution was made."

"A new product conversion process must be multi-functional and multi-faceted. It touches so many people," said Brandmeyer. You’ll need to consider, "What does the normal workflow look like? How many people need to know about this? How will we confirm understanding?"

Noted Kennedy, "Education and communication among all parties (clinical, materials management, supply chain and others) is the key, and there must also be a strong commitment facility-wide to the success of the implementation. Training must be carried out so that all involved staff members are included. After implementation, you must measure compliance and give the staff timely feedback. If there is poor compliance, staff opinion must be sought as to why this is happening. A major key to successful implementation is ensuring staff buy-in from the beginning."

Sometimes the best thing you can do is walk a mile in each other’s shoes.

"I would encourage ICPs to look at attending some of these ‘Quality’ conferences that are taking place throughout the country," said Brandmeyer. "Acquiring a clear understanding of what leaders of large healthcare systems and facilities are thinking about in terms of delivering quality of care, the dynamics of spreading best practice across an organization, and how to make their businesses successful and profitable will go a long way to raising your level of influence. Understanding the point of view of the administrator and what they’re up against, will help you connect and build trust. This trust is important in establishing a peer-to-peer relationship and creating a platform for you to be heard."

ICPs often find themselves up against head surgeons debating over physician preference items, for example.

"Being able to go toe-to-toe with a surgeon, takes some confidence, takes the ability to measure yourself and know that you can deliver a message and not get knocked down," said Brandmeyer. "That’s why I believe this empowerment idea is so important. ICPs must continue to elevate their issues and equip themselves with the language of business case economics and the language of the clinical facts. They can then gauge exactly what the message should be to deliver to the person that they’re responding to as a peer and not as a subordinate."

"If they ignore the fact that these executives are under tremendous pressure and don’t connect, they will miss an opportunity to elevate the relationship to something based more on trust and mutual understanding," he continued. "ICPs might be afraid to have this kind of relationship with hospital administrators, but it’s important to remember we’re all on the same team. Everyone’s learning that it’s all about teamwork and execution of best practice at all levels."

Offered Pear, "If the ICP can find out the metrics on which the "Boss’s Bosses" use to evaluate the CEO’s performance, then the ICP can drive his/her point home by demonstrating how the improved outcomes, attributable to the infection prevention product, would positively impact these performance metrics. This creates a win-win situation for all parties involved."

She added, "the ICP needs to understand what goes into the bottom line and what makes the hospital tick. Or, maybe more to the point: what keeps the CEO up at night? The ICP needs to ask about and keep a pulse on financial and outcome-related issues of the hospital administration, materials management and CFO."

Peterson named several drivers for increasing awareness of the infection prevention message including the cost of infections and the loss sustained for each infection a facility has; clearly documented evidence that we can make a difference with infection prevention; public reporting of HAIs, and moving towards publishing those results on a per hospital basis; and litigation fears.

"The litigation risks are clearly increasing," said Peterson. "The days when infections were seen as a bad thing that sometimes happens, hospitals could hide under that shield. As we see how low those numbers can go, if your numbers are high, it’s clear that you’ve got a problem."

Likewise, according to Philip Onigman, director, AdvanDx, makers of a rapid diagnostic test, "if a hospital loses reimbursement for an HAI then that is a red flag that hospitals need to manage better, that they need to take more proactive measures to reduce infections and they also need to take proactive measures to reduce antibiotic and antifungal resistance to them."

"Anything that involves reimbursement gets the attention of the folks in the C-Suite," remarked LaBorde.

As the stakes continue to increase, infection prevention will no longer be viewed as simply a money pit, predicted Kennedy. "I believe that in the past, the infection control department has been viewed as a cost center that is required by regulatory agencies. Now, I really think that we are seeing a dramatic shift in respect for the infection prevention profession in healthcare environments. Administrators are gaining the understanding that well-run infection control programs are improving patients’ outcomes and are proving to be a cost avoidance factor. They are truly having a ‘bottom-line’ impact."

Look for vendors to play a more critical role in influencing product evaluation as well. "I think facilities will be demanding critical information and studies from vendors to compare products and their effectiveness in infection prevention, including side-by-side product comparisons, to understand the true effectiveness of products," said Kennedy.

"The vendor should take responsibility for helping to prepare the economic evaluation, equipping the ICP with solid data," said Brandmeyer. He noted that Enturia’s Train the Trainer program is targeted towards teaching the OR nurse and the IC nurse ways to influence surgeon behavior on a peer-to-peer basis.