This was a presentation that I was invited to give at a "Summit" - Special Board meeting with invited guests - of the Association for Professionals in Infection Control. I remeember Rick Shannon also speaking and being impressed by his work, and CDC being there too. I was invited to talk about incentives for improving patient safety in VA, and I also added in slides about my frustration with the data on HAIs at that time.

1. Incentives for Improving
Safety and Preventing
Infections in the Veterans
Health Administration
APIC Futures Summit
Savannah, Georgia, 4/3/06
Noel Eldridge, MS
Department of Veterans Affairs
Veterans Health Administration
National Center for Patient Safety

2. Outline
 VA Background
 Incentives in VA
 Implementing CDC’s Hand Hygiene
Guideline
 Two Problems

3. VA Background

4. Mission of the Department of
Veterans Affairs
“With malice toward none, with
charity for all, with firmness in
the right as God gives us to
see the right, let us strive on to
finish the work we are in,
to bind up the nation’s wounds,
to care for him who shall
have borne the battle
and for his widow, and his
orphan, to do all which may
achieve and cherish a just and
lasting peace among ourselves
and with all nations.”
- Abraham Lincoln
2nd Inaugural Address

5. VHA Statistics (FY 2005)
 7.7M enrollees, 5.3M uniques
 VA Medical Centers (Hospitals): 156
 Admissions: 587,000
 Community Based Outpatient Clinics: 708
 Outpatient Visits: 57.5M
 Rx Dispensed (30-day equiv): 231M
 Lab Tests: 215.9M
 Total FTE: 197,800

6. VHA Budget for 2006
 VA gets a budget and has to make it work
(provide to veterans who present for
care)
 Medical Services = $22,547,141,000




Medical Administration = $2,858,442
Medical Facilities = $3,297,669
Information Technology = $1,213,820,000
2006 Current Estimate, Unique Patients = 5,441,952
 Simple arithmetic says $4,143 per patient
for 2006

7. Veterans Health Administration
21 Veterans Integrated Service Networks
IN J A N U A R Y 2 0 0 2
V IS N S 1 3 A N D 1 4
W E R E IN T E G R A T E D
R E N A M E D V IS N
AND
23

8. How is $22+ Billion allocated to
21 Networks?
10 Categories of VHA Patients (& 2003 values)






Non-reliant care: $263
Minor medical: $2,413
Mental health: $3,562
Heart & Lung: $3,772
Oncology, etc.: $8,337
Multiple problems: $7,935





Specialized care: $18,751
Supportive Care: $29,780
Chronically mentally ill:
$39,448
Critically ill: $61,117
These are adjusted to
compensate for different
costs in different regions

9. VA Incentives

10. Some Incentives in VA
Fixed payment to entire agency ($22.5B)
1.
•
Encourages support of innovation at HQ.
Fixed payments to networks…
1.
•
“Zero sum game” encourages innovation locally.
Performance Measures that are Reviewed by
Management at local, network, and HQ…
1.
•
•
Vaccines (flu, pneumococcus)
Pre-op Antibiotics (“SIP” Project)
•
•
But only For 5-10% of all operations, and about 80% of
specific type in the denominator
Wide variety unrelated to infection (~80)

11. Payment is “lump-sum”
 Pocket-sized alcohol-
based hand rub cost
59 cents on VA
contract.
 If an infection costs
$5,900 that’s 10,000
of these…
 Persuasive argument.

12. VA Financial Incentives Incentivize
Leaders to Lead
 Example: major effort to codify and
implement requirements of CDC Hand
Hygiene Guideline…
 See Our Paper in JGIM (e-mailed before
meeting)
 Used 3M Six Sigma Process to implement
Guideline
 Measurements: Mass of ABHR, Observed
Practices, and Attitudes (Questionnaire)

13. Another Major Incentive: JCAHO
National Patient Safety Goals

[7A] Does Joint Commission require implementation of
all the recommendations in the CDC hand hygiene
guidelines?
Each of the CDC hand hygiene recommendations is
categorized on the basis of the strength of evidence
supporting the recommendation. All “category I”
recommendations (including categories IA, IB, and IC)
must be implemented. Category II recommendations
should be considered for implementation but are not
required for accreditation purposes. [Revised 12/05]
http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/

14. Implementing CDC’s
Hand Hygiene Guideline

15. The Evidence

423 references in CDC Guidelines







From Laboratory Tests
From Hospitals
From Long-term Care Facilities
From Schools
On Bacteria, Viruses, Fungi
On Wild-type and Antibiotic-resistant Strains
But more is needed:

Find articles on infections going down when hand
hygiene practices get better… (I have a collection.)

16. Study of Alcohol Hand Rub use at a
Long-Term Care Facility

Compared the 2 units of the facility where
alcohol hand-rubs were used with the rest of
the facility. Key findings:

30% fewer infections over a 34 month period
• 2.27 (alcohol) vs. 3.19 (soap) per 1000 pt-days
• Primary infections were urinary tract with Foley catheter,
respiratory, and wound
• 253,933 pt-days total; 81,036 in alcohol group

Reference: Fendler et al, AJIC, June 2002

17. Study of Alcohol Hand Rub use at
an Acute Care Facility

Compared one unit (orthopedic surgery) of a
hospital before and after introduction of
alcohol handrubs in that unit. Key Findings:

36% fewer infections (6 months before, 10 after).
•
•
•
•
8.2 vs. 5.3 infections per 1,000 patient days
“Teachable” patients given 4 oz. alcohol gel too
Primary infections: urinary tract and surgical site
Cost savings studied:



Mean cost per infection: $4,828 +/- 4,868
Cost of 10 months of supplies for unit: $1,688
Reference: Hilburn et al, AJIC, April 2003

18. VA Summary of JCAHO-required
CDC Recommendations
(19 in 4 categories)
1.
2.
3.
4.
All Health Care Workers with Direct Patient
Contact (8)
Surgical Hand Hygiene (3)
Facility Management: Supplies (5)
Facility Management: Administrative Action
(3)
Total Length: 732 words (minus 45%)

19. Summary of VHA Summary (1)
All Health Care Workers (HCWs) with
Direct Patient Contact
I.
•
•
•
Decontaminate hands before and after
touching a patient (regular soap doesn’t do
it)
Specific gloving recommendations
Soap and water for soiled hands

20. Summary of VHA Summary (2)
Surgical Hand Hygiene
II.
•
•
Guidance on surgical scrub with soap and
water (e.g., shorter scrub times are OK)
Guidance on surgical scrub with no-rinse
alcohol-based products with additional
compounds for persistent action

21. Summary of VHA Summary (3)
III. Facility Management: Supplies






Alcohol at room entrance and/or bedside
Alcohol available in pocket-sized dispensers
Alcohol in other convenient locations (e.g., in
corridors is OK within limits)
Antimicrobial soap as an alternative to alcohol
Provide hand lotion to HCWs
Store alcohol safely – it is flammable

22. Summary of VHA Summary (4)
Facility Management: Administrative
Action
IV.
•
•
•
Make HH a priority and provide financial
and administrative support
Solicit input from employees on products
Monitor adherence and provide feedback
on hand hygiene performance

23. Hand Hygiene Compliance at
4 VA ICUs
100
90
80
70
60
50
40
30
20
10
0
Initial
Final
MICU
SICU
ARK
IOWA
OVERALL

24. Two Problems

25. Problems…
1. Quantifying how many people die from
hospital acquired infections?



CDC: 90,000
Chicago Tribune: 104,000
Context: ~810,000 people die in hospitals
2. How much to these infections cost?



Depends what cost means…
Depends on which types you count (GI?)
Depends on which ones are reported?

26. 90,000 deaths from infections?
We need numbers describing the quantity who:

Died in hospitals only because of HAI (i.e., they
would have gone home otherwise)


“90,000” would be >10% of in-hospital deaths – we should all
agree to stop using this number unless it can be explained or be
made credible. It’s now quoted in thousands of web pages and
articles.
Suffered other various bad outcomes due to
infections, some ideas to consider:



ICU admissions that would not have been necessary otherwise?
Additional LOS >7 days due to infection?
Additional pain medication prescribed due to infection?

27. Source of 90,000: Weinstein,1998?

Over the past 25 years, CDC's National Nosocomial
Infections Surveillance (NNIS) system has received
monthly reports of nosocomial infections from a
nonrandom sample of United States hospitals; more
than 270 institutions report. The nosocomial infection
rate has remained remarkably stable (approximately
five to six hospital-acquired infections per 100
admissions); however, because of progressively
shorter inpatient stays over the last 20 years, the rate
of nosocomial infections per 1,000 patient days has
actually increased 36%, from 7.2 in 1975 to 9.8 in
1995. It is estimated that in 1995, nosocomial
infections cost $4.5 billion and contributed to more
than 88,000 deaths — one death every 6 minutes.
http://www.cdc.gov/ncidod/eid/vol4no3/weinstein.htm

28. Sample use of 90,000 from 2004
NIH web page
http://www.niaid.nih.gov/factsheets/antimicro.htm
“The Problem of Antibiotic Resistance”
 “Nearly two million patients in the United States
get an infection in the hospital each year”
 “Of those patients, about 90,000 die each year
as a result of their infection - up from 13,300
patient deaths in 1992.”
 Does anyone here believe the point above is
accurate?

29. Average cost is more confusing
than it may seem

We need data on costs of infection that goes
beyond average (mean) cost - variation is huge.




e.g., Mean cost of a UTI doesn’t mean much
Mean, Std. Deviation, and Median?
Cost Categories, something like: # <$1,000, # from
$1,000 to $10,000, # >$10,000?
Need some consensus on what we’re talking
about when we say “cost”, e.g., what is the cost
of something simple as a post-discharge office
visit and prescription for Cipro?

30. What is the average cost of nosocomial
(hospital acquired) infections?


Two VA estimates I’ve seen: $5,900 & ~$21,000
Hypotheses:



The average depends which infections you don’t
count.
Because the first infections to be counted are the
worst (the most conspicuous and most expensive),
the more you count, the less they cost.
See recent PHC4 data for Urinary Tract Infection
- average payment is $42,316 - average LOS is
18.1 days & 5.7% died.

Are UTIs a cause or an effect of morbidity? Both?
Depends?

31. Closing Thoughts
 “Insanity: doing the same thing over
and over again and expecting different
results”
Albert Einstein
 “They say that time changes things,
but you actually have to change them
yourself”
Andy Warhol

32. On-line VA Patient Safety Resources
 See VA’s www.patientsafety.gov

Hand Hygiene Tools and Information
• Infection: Don’t Pass it on Campaign

33. Recently we have received a number of questions about whether
is it legal to buy facial tissues. At issue is whether or not the facial tissues are considered personal
items. We have discussed this issue with Department logistic and financial staff as well as VHA clinical staff.
The following provides a basis for the decision that was reached:
For patient-care areas and areas frequented by those who come in direct contact with patients, facial tissues should be considered
similarly to other expendable supplies that VA workers may use as they perform their duties during work hours. For example, VA
supplies disposable respirators, gloves, and surgical scrubs and gowns, all of which are employed by staff to protect patients from
the spread of infectious agents. This type of expenditure is clearly appropriate. On the second point, recent guidance from the CDC,
JCAHO, the National Health Information Center of the Department of Health and Human Services, and the American Lung
Association have all included recommendations for using tissues to cover coughs and sneezes to prevent the spread of infectious
agents. First among these infectious agents are viruses that cause upper respiratory infections such as cold and flu, but another
agent of concern is Staph. aureus (SA), including methicillin-resistant SA (MRSA), either of which can cause skin and wound
infections. Various estimates put the percentage of healthcare workers whose nasal passages are colonized with SA at about 3040%. (The percent colonized by MRSA is not well described and seems likely to vary widely.) SA and MRSA can be expelled from
the nose during a sneeze and live for days or weeks on substrates such as clothes, linens, curtains, countertops, and other
environmental surfaces where they can be picked up on hands or transferred to other surfaces and eventually patients. Using a
tissue to reduce the dispersion of droplets and the gross contamination of hands or clothes is imperfect but is widely recommended
as a basic measure to control the spread of infectious agents.
Conclusion: Facial tissues to be used in patient care areas and
areas frequented by those who come in direct contact with
patients can be purchased with appropriated funds. This memo should not be
taken as a mandate to generate any new requirement to provide tissues in specific locations or at any pre-set density. Decisions on
this topic should be made locally and incorporate local circumstances and considerations.
(Agreed upon by: Fiscal, Accounting, Legal, Network Clinical
Managers, Public Health, Environment of Care, Infectious
Diseases, Patient Safety, in about 3 weeks.)