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Understanding statistical data on central-line bloodstream infections (CLABs) and applying appropriate strategies to reduce CLABs can be more difficult than it might first appear. To work toward a zero-infection goal, some experts argue, hospitals need a whole new way of looking at infections. That’s just what happened at Allegheny General Hospital in Pittsburgh, where CLABs were slashed by 90 percent in under two years, saving an average of $14,500 per infection. How were such impressive results accomplished? Read on.

Until recently, the health care professionals at Allegheny General Hospital in Pittsburgh thought they had a handle on their infection problem. They knew they weren’t the leaders in preventing hospital-associated infections (HAIs). But they weren’t a disaster either. Their infection rates were average and in keeping with most national standards; and the statistics backed them up. Allegheny General saw 5.1 central-line-associated bloodstream infections (CLABs) per 1,000 line days, a respectable if unspectacular rate.

But the figure bothered Jerome E. Granato, M.D., the medical director for the hospital’s coronary care unit. He looked at it again and again: 5.1 infections per 1,000 line days. Each time, he had the same nagging thought: What exactly does that mean?

Granato can read statistics as well as anybody. He knows the figure represents the number of infections developed if the hospital’s central lines were left in patients for 1,000 days (i.e., almost three years).

“But that number is fairly meaningless to a nonclinician—even to some clinicians,” Granato says. “It doesn’t tell you how many people are actually getting sick. It doesn’t tell you how many people are actually dying.”

In fact, 49 central-line related HAIs occurred in both Allegheny’s medical and surgical ICUs in 2003. When the numbers were put into that context, Granato realized he had been thinking about HAIs all wrong. “The stats don’t tell you the costs in people’s lives,” he says. “Just think of someone coming in for a minor problem—a hernia repair or a gall bladder removal. They end up getting a line infection and dying. That’s not 5.1 per 1,000 days. That’s devastating.”

To the Allegheny General staff, changing the way they viewed HAIs led to a major shift in hospital philosophy and an all-out assault on infections.

Using evidence-based best practices and working toward a zero-infections goal, Allegheny General reduced its CLABs by 90 percent in under two years. The hospital went from 49 CLABs to three, while saving an average of $14,500 per infection. For one 15-month period, Allegheny General had no CLABs.

“We need a whole new way of looking at infections,” Granato says.

That’s the exact message the Association for Professionals in Infection Control and Epidemiology (APIC), Washington, D.C., is trying to promote. With the publication of its 2007 report, “Dispelling the Myths: The True Cost of Healthcare-Associated Infections,” APIC hopes to change the HAI landscape by taking a fresh look at data and challenging old assumptions. No longer, the report maintains, should HAIs be viewed as an inevitable cost of doing business—or even as a cost-neutral complication. On the contrary, the report urges infection control professionals, and all hospital personnel, to wage war on HAIs.

“We need to be—and I think we are becoming—more aggressive in our approach to reducing HAIs,” says Kathy Warye, APIC’s executive officer and an editor of the report. “But there is still a community within health care that believes we are doing as well as we can. They think it’s good enough to just meet the CDC benchmarks. But it’s not. We have to strive toward zero HAIs.”

Myths and truths

Every year about 2 million people develop an HAI. That’s about one in every 136 hospitalized patients. The financial cost of the nation’s HAI epidemic is $5 billion to $6 billion a year, APIC maintains. And the human toll is worse. About 100,000 people die from an HAI each year. One CDC report says that HAIs cause more deaths in the United States than the top 10 other killers. According to some estimates, preventing a case of HAI saves an average of $10,000 per patient. And it cuts the risk of death during a hospital stay from 7 percent to about 1.5 percent.

But many health care officials still labor under common HAI misconceptions. And HAI myths die hard. According to APIC officials, three prevalent myths cloud the health care world and make the battle against HAIs even more difficult:

Myth No. 1: HAIs are simply the cost of doing health care business. HAIs are considered by some to be an inevitable byproduct of treating older and sicker patients with invasive procedures.

Warye says that myth doesn’t hold up to scrutiny. Health care facilities that have instituted a zero-HAI tolerance have seen their infection rate drop significantly. Allegheny General has not only seen steep declines in its CLAB figures, but it’s also reduced ventilator-associated pneumonia (VAP) cases and urinary-tract infections.

“Not all HAIs are preventable,” Warye says. “But for every institution, there is an irreducible minimum. Health care institutions need to be working toward that irreducible minimum. You need to get as close to zero as you can go.”

Myth No. 2: HAIs don’t really cost any money. The argument here is that additional costs are offset by insurance reimbursement.

In the past, HAIs have largely been viewed as revenue neutral. They may not make money for a hospital, but they didn’t cause hospitals to lose money either, common wisdom held. Insurance reimbursements were widely believed to cover HAI costs.

But experts say that thinking is outdated. “In this day and age, it’s hard to defend the notion that these infections are not costing institutions money above and beyond what they are reimbursed for,” Warye says.

HAIs are expensive. Patients with HAIs eat up valuable bed days. They can’t be discharged and that leaves less room and resources for newer patients. One study showed that HAIs add a total of 7.5 million excess patient days nationwide each year. In Pennsylvania alone, 24,000 hospital-admitted patients developed HAIs in 2005, notes the Pennsylvania Healthcare Cost Containment Council. Their average length of stay was 23 days. The 1.9 million patients who didn’t develop HAIs were hospitalized less than five days.

And, increasingly, insurers are refusing to pay for hospital-related conditions. As of October 2008, the Centers for Medicare & Medicaid Services (CMS) will no longer reimburse health care facilities for costs related to many HAIs.

Myth No. 3: There just aren’t enough HAIs to make eliminating them a financial priority. As surveillance methods improve, experts say hospitals are finding that HAIs are rampant in health care. And their costs are staggering. One study of 1.69 million admissions from 77 hospitals found that patients with an HAI reduced overall net inpatient margins by $286 million—essentially $5,000 per infected patient.

Warye says infection control professionals bear some responsibility for perpetuating this myth. Poor information collection and faulty communication has bogged down infection stats. The health care world thinks of them in terms of line days, she says, instead of lives. “Our community hasn’t done a good job of creating data that is easily understood by non-clinicians,” she says.

Or, as Granato puts it, “When you put it in human life terms—the amount of lives saved—it has much more impact. In those terms, you wonder why more health care settings don’t target HAIs as hard as they can.”

Translating the effect of HAIs into human terms may turn heads. But making a business case for combating them will open wallets.

“We live in a world of restricted resources,” Warye says. “Our institutions have to be as efficient as they possibly can. Reducing HAIs and freeing up those resources for other types of patient care seems like a strong argument to me.”

The financial impact of HAIs can be hard to quantify. In the past, administrators have seen cutting HAIs as cost avoidance rather than cost savings. Stopping an HAI doesn’t lead to, for example, hiring one less ICU nurse or purchasing one less MRI machine.

Ideally, the anti-HAI case involves comparing the costs of treating patients with infections to treating those who don’t develop HAIs. But a counter argument holds that the most susceptible people—older patients, smokers, those with diabetes and weight issues—would develop infections anyway.

And often, Warye says, infection control pleas fall on deaf ears inside hospital walls. “It’s hard to get the attention of some physicians and administrative leaders,” she laments. “Surgeons, particularly, won’t relate to infections that occur weeks after a procedure. There’s a real disconnect.”

One way to open doors is by recruiting financial managers to the infection control team. The business case can spark the attention of leadership and persuade upper management to throw more resources at HAIs.

But changing minds isn’t easy. And making the case involves doing homework and following detailed steps:

• To quantify the economic impact of HAIs, APIC recommends surveying groups of patients with similar health histories, ages and genders. Analyze individual insurance payments and identify the total costs associated with the cases. Then separate the costs for the services related solely to HAIs. Subtracting the expenses from the reimbursement will leave you with the gross margin—the most revealing statistic. Then compare the gross margin for HAI cases against similar cases without an HAI.
• Once your economic analysis is complete, target problem areas. Find a high-risk procedure that leads to high-volume infections, such as CLABs or VAPs, and focus your efforts on eliminating them. While you may not reach the theoretical zero level, you can make “pursuing perfection,” as Warye puts it, a hospital goal.
• Educate health care workers about infection prevention. Choose a staff champion to lead the culture change.
• Once you’ve identified processes and practices that aren’t working, measure your performance. Nothing makes your anti-HAI case as well as results.

Putting it in play

BJC HealthCare, a 13-hospital system in St. Louis, used the business case to secure a $350,000-investment toward snuffing out HAIs. In 2000, hospital officials presented senior management and the board with a business plan. They estimated the costs of four infections: CLAB and VAPs along with CABG surgical-site infections (SSI) and  spinal SSIs. They documented that the infections alone cost the system more than $8 million a year. One year after targeting those four HAIs, BJC’s infection-related costs dropped by more than $2 million.

And in Pittsburgh, Allegheny General continues to battle HAIs. It’s a hospital-wide fight, Granato says. Each week, Granato convenes a “bug meeting”—a staff conference to rate and review infection control procedures. Granato invites residents and trainees along with housekeeping. Corporate staff also plays a large role in the bug meetings. A vice president for safety regularly attends. “To make this work, I need support from the CEO level on down,” Granato says.

But the most vital member of the team are nurses, who Granato calls “the vanguard of this fight.” Allegheny General gives nurses ultimate authority over meeting infection standards. Nurses are empowered to shut down any procedure that doesn’t conform to the hospital policy. Granato has told nurses, for example, to stop residents who aren’t gloved properly or halt clinician teams if surgical drapings aren’t correct. “Nurses are the enforcers of policy and procedure,” Granato says.

Meanwhile, Allegheny General diligently monitors infection procedures in real time to review the staff’s response. “If an infection occurs, we immediately find out where it happened, why it happened, who participated in it,” Granato says.

Indeed, even as infection rates fall, Allegheny General continues to educate its staff on HAIs. Each year, clinicians and other staffers participate in an online training program. They must pass a written test and undergo 30 minutes of practical simulations. And the hospital recertifies its staff every year.

“It comes down to this: process standardization, mandatory training, continuing surveillance and improvement,” Granato says. “Everyone who walks in this door knows we are serious about keeping HAIs out of this building.”

John DiConsiglio is a freelance writer based in Arlington, Va.

Death from HAIs in the United States, 2002

N=98,987

Source: Public Health Reports, Vol. 122, No. 2, 2007

This article first appeared in the May 2008 issue of Materials Management in Health Care.

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