APIC "Futures Summit" Presentation April 2006

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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.

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APIC "Futures Summit" Presentation April 2006

  1. 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. 2. Outline  VA Background  Incentives in VA  Implementing CDC’s Hand Hygiene Guideline  Two Problems
  3. 3. VA Background
  4. 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. 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. 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. 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. 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. 9. VA Incentives
  10. 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. 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. 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. 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. 14. Implementing CDC’s Hand Hygiene Guideline
  15. 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. 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. 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. 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. 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. 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. 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. 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. 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. 24. Two Problems
  25. 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. 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. 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. 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. 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. 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. 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. 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. 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.)

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