While reducing the incidence of HAIs is important from a public health and patient care perspective, it also has significant financial implications. At the national level, it is estimated that HAIs affect approximately 1.7 million patients each year,2 resulting in increased healthcare utilization and an estimated annual cost of at least $4.5 billion.3

At the facility level, there is greater economic incentive than ever to focus on prevention of HAIs since the Centers for Medicare & Medicaid Services (CMS) eliminated incremental payment for treating certain healthcare-associated conditions last October, three of which are categorized as HAIs. These include: select surgical site infections (related to coronary artery bypass graft (CABG), orthopedic and bariatric surgeries), vascular catheter-associated bloodstream infections and catheter-associated urinary tract infections (UTIs).

The conditions targeted by CMS were selected on the basis that they can reasonably be prevented through the application of evidence-based guidelines. The new CMS policy is intended not only to improve patient safety, but also strip away the perceived incentive by which institutions with higher rates of preventable conditions could be rewarded with higher Medicare payments.

The new HHS action plan and CMS payment policies put more of an impetus on healthcare facilities to reduce risk of infections, thereby reducing financial burden on the facility itself and the healthcare system as a whole. While HAIs may not be 100 percent preventable, the key takeaway is that adherence to best practices is crucial to minimizing their occurrence. Following are some top-line tips based on my experience and current clinical approach. While many of these prevention measures may be intuitive, diligent attention to the basics is key.

•Skin preparation – Skin antisepsis according to evidence-based guidelines should be a top focus for any facility looking to minimize risk of infections, because it is one of the cheapest and easiest preventive measures available. A variety of devices and products are available to help clinicians adhere to skin preparation protocols, and it is important to consider data when making a purchasing decision.

While alcohol is a fast-acting solution, it doesn’t have a persistent antimicrobial effect. Iodine compounds are effective in reducing microorganisms but may be inactivated by protein-laden material. Several studies and guidelines support the efficacy of chlorhexidine gluconate (CHG) alone as well as in combination with alcohol for skin antisepsis.4,5,6,7 One trial compared 2% CHG in 70% isopropyl alcohol (IPA) against 70% IPA alone for skin disinfection to prevent peripheral venous catheter colonization and contamination. Results demonstrated that the addition of 2% CHG statistically significantly reduced the number of peripheral venous catheter tips with microorganisms present on the surface.8

In another study, adoption of a skin preparation technique utilizing 2% CHG and 70% IPA (the ChloraPrep antiseptic system) instead of tincture of iodine at the Suma Health System in Akron, OH, resulted in a statistically significant reduction in the percentage of contaminated blood cultures drawn in the emergency department. This protocol change is expected to result in a savings of $875,000 per year for the facility.9

The method of applying a selected antiseptic solution also contributes to infection prevention. Some bacteria, including MRSA, are transmitted almost exclusively by the hands. Therefore, it is important to minimize direct hand-to-patient contact to help reduce the risk of cross-contamination of microorganisms. When selecting skin preparation solutions, keep in mind that certain applicators, including those in the ChloraPrep line, are designed to eliminate direct hand contact.

• Nurse-led models for catheter monitoring – Catheter-associated UTIs are high volume, with 12,185 cases occurring in 2007.10 And, given that existing evidence-based guidelines exist for prevention of catheter-associated UTIs, they make sense as a target for prevention under the new HHS action plan and CMS payment guidelines. Simple steps taken during routine patient care can make an impact on ensuring catheters are removed as quickly and efficiently as clinically reasonable to reduce the incidence of UTIs.

Consider empowering your nursing staff with a set of pre-approved criteria to make decisions related to catheter use that can decrease the number of unnecessary urinary catheters and UTIs. A checklist for daily rounds can prompt staff to assess several variables such as how long the catheter has been in place and whether it is still needed. Using this nurse-led model, a 2006-2007 study of 10 hospital units saw a 45 percent decrease in unnecessary urinary catheters during the intervention period with only small numbers of catheters requiring re-insertion.11

• Clipping hair – Data supports pre-operative clipping of hair versus shaving, making it the standard in many facilities. Clipping avoids the abrasions and trauma to the skin associated with shaving, which can contribute to infection due to skin-dwelling microorganisms. While the purchase of clippers constitutes an initial increase in cost, facilities using the clipping method can reasonably expect a longer-term cost savings.

• Patient warming – Temperature control is important to the immune system and therefore helps prevent wound infections following procedures. Your facility may choose to utilize patient warming devices peri-operatively to prevent hypothermia which could compromise the immune system. Studies have demonstrated a reduction in surgical site infections when normothermia is achieved during surgical procedures.12

• Barrier precautions, including gloves – Use of maximal sterile barrier precautions during the insertion of invasive vascular catheters decreases the risk of catheter-related bloodstream infections. These precautions include sterile gowns, sterile gloves, masks and caps for the healthcare practitioner and a sterile drape for the patient. Since microorganisms are primarily passed on by the hands between patients and healthcare employees, gloves are central to preventing transmission. From a purchasing standpoint, take into account different glove materials and associated barrier protection when making a decision, along with cost per use. Even when gloves are used, proper hand hygiene protocols must be followed. Alcohol-based waterless agents are excellent for routine patient care unless the patient harbors Clostridium difficile in which case soap and water are required.

• Prophylactic antibiotics – When risk of postoperative infection is present, preoperative administration of antibiotics can help to reduce risk. The Surgical Care Improvement Project (SCIP) offers guidance on improving the timing, selection and duration of prophylactic antibiotic use to reduce the incidence of surgical site infections.13 In particular, SCIP suggests that the first antibiotic dose be administered within an hour before the incision is made and that the antibiotic be discontinued within 24 hours of elective surgery and 48 hours for cardiac surgery. In regards to antibiotic selection, SCIP acknowledges the wealth of guidelines available with recommendations for specific antibiotics. It is important to reference existing evidence-based recommendations during the selection process.

Preventive measures to minimize and prevent HAIs not only help reduce the financial burden on the healthcare system, but they also help improve patient outcomes. While HAIs will still occur in even the most diligent of facilities, the new HHS action plan and CMS payment guidelines draw attention to the serious need for proper prevention protocols. To reduce the incidence of costly HAIs in your facility, take into account data supporting various infection control processes and products and remember that simple actions can have a significant cumulative impact on your patients’ wellbeing and your hospital’s bottom line.

References

1 U.S. Department of Health & Human Services. Healthcare-Associated Infections. Available at: http://www.hhs.gov/ophs/initiatives/hai.

2 Centers for Disease Control and Prevention. Estimates on Healthcare Associated Infections. Available at: http://www.cdc.gov/ncidod/dhqp/hai.html.

3 Weinstein RA. Nosocomial infection update. Emerg Infect Dis. 4 1998:416-420.

4 Nicholas Fletcher, D’Mitri Sofianos, Marschall Brantling Berkes and William T. Obremskey. J Bone Joint Surg Am. 2007: 89:1605-1618.

5 Roger V. Ostrander, Michael J. Botte and Michael E. Brage. J Bone Joint Surg Am. 87:980-985, 2005.

6 Centers for Disease Control and Prevention. Guidelines for the Prevention of Intravascular Catheter-Related Infections. MMWR 2002:51 (No. RR-10).

7 The Association of Perioperative Registered Nurses (AORN). Recommended Practices for Preoperative Patient Skin Antisepsis. Perioperative Standards and Recommended Practices. 2008.

8 Small H, et al. Efficacy of Adding 2% CHG to 70% IPA for Skin Disinfection Prior to Peripheral Venous Cannulation. Infection Control and Hospital Epidemiology. 2008; 29:963-965.

9 Tepus D. Effectiveness of ChloraPrep in Reduction of Blood Culture Contamination Rates in Emergency Department. J Nurs Care Qual. 23:3:272-276.

10 Federal Register 2008;73:23551

11 Infect Control Hosp Epidemiol 2008;29:815 and 820.

12 Pettis A. Temperature check for surgical site infection prevention. Presented at: the 34th Annual Education Conference & International Meeting of the Association for Professionals in Infection Control; June 24-27, 2007; San Jose, Calif.

13 Surgical Care Improvement Project (SCIP). Measures: Infections. Available at: http://qualitynet.org/dcs/ContentServer?level3=Measures&c=MQParents&pagename=
Medqic/Measure/MeasuresHome&cid=1089815967030&parentName=Topic.