The worlds healthcare system is burdened with an estimated $20 billion of added cost each year to battle hospital-acquired infections (HAIs) often caused by multidrug-resistant organisms (MDROs). An effective infection prevention program can greatly reduce this burden without much of an investment or change in the healthcare economic structure.
A 1 percent reduction in HAIs for a facility treating 13,000 annually can save or at least provide cost avoidance of about $4.2 million. The common denominator of HAIs today is the healthcare environment. All patients, staff, physicians and members of the public come in contact with these environmental surfaces. Why then are these sources not the most targeted? Prevention programs must first be constructed with the backbone of mechanical daily cleaning of all surfaces, then proper staff education and best practice protocols (i.e., the central line bundle).
For the first time in our history there are revolutionary products such as polymer technologies and ion technologies to help us tame our environment. These Environmental Protection Agency (EPA)-approved disinfectants hold onto surfaces for longer periods and will continue to work once they have dried. The polymer products provide protection for surfaces and prevent cross-contamination of surfaces from microorganisms.
Prevention must be viewed as a necessary investment in the scheme of healthcare economics a minimal investment can avoid costly hospital-acquired conditions. A true prevention program targets zero and will invest the needed resources to achieve this mark; not just from a financial perspective but because it is the right thing for our patients.
If you take into account the plethora of studies, statistics, scientific reports, professional association recommendations and governmental hearings, we still walk away with the same never-ending question: Where is healthcare going? The actual question we should be asking ourselves is, Is the industry still healthcare or has it become health business? Graves reports that incremental and marginal analyses are concerned with changes to cost and benefit.1 Graves goes on to say that infection control programs will only produce incremental changes due to increased variable cost in staffing and equipment related to the increase in services provided to additional patients as a result of making patient beds more available.1 This is concerning because hospitals should look to free up the scarce resource of patient beds and provide more services to more patients, not hold sicker patients longer. Hospitals profit when patient beds are turned more frequently and more services are provided across the spectrum. So what does all of this have to do with developing an infection prevention program? Everything! The viewpoint that is passed down far too often is cut costs, control costs, stop spending, and save. The mindset that everything within the organization adds up only to a cost places that organization in a control or reactive state.
Control programs put out fires, they react to negative situations, they respond to epidemics or disease outbreaks only when it financially impacts the organization. A prevention program is the entirely opposite way of thinking and behaving. Prevention is to plan ahead, to deter events from occurring and to avoid negative outcomes. Prevention is a purely proactive method of behaving and organizational design. Yes, some prevention items have a cost added to them. These costs should not be viewed as purely monetary expenditures but as an investment that will avoid future cost or negative outcomes that may result in lawsuits as we now see happening in New Jersey.
The Centers for Disease Control and Prevention (CDC) estimates that an HAI costs $32,500 extra per day. As the Centers for Medicare and Medicaid Services (CMS) moves to a pay-for-performance reimbursement system over the next few years, can hospitals afford to risk $32,500 a day in treatment costs that may not be reimbursed? Not only is preventing infections the right thing to do, it is the best thing to do for the bottom line. Prevention reclaims the industry title of healthcare while maximizing scarce resources of bed availability, nurse staffing and consumable supplies. Zero can be achieved.
A 32-bed acute-care facility with 13 emergency bays and five surgical suites has been using a polymer technology disinfectant (PTD) made by Byotrol called Polysphere since March 2007. This facility is not exceptional but it can say that there has not been a single documented case of HAI related to methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE) or Clostridium difficile since opening in October 2006. (It is noted that there have been surgical site infections, urinary tract infections and hospital-acquired pneumonia).
Since 83 percent of all HAIs come from healthcare workers and their environment, it was important for this organization to stress proper hand hygiene, environmental surface cleaning and safe work practices eliminating the mode of transmission. Initially, PTDs were looked at to sanitize the custom drapes throughout the facility. Testing began where both MRSA and VRE were grown under controlled conditions, killed with the disinfectant and shown no return growth for three consecutive days. This PTD continued to provide disinfecting properties once it dried compared to traditional disinfectants that disappeared once they have dried. These PTDs hold biocides onto environmental surfaces for a longer period of time, thus reducing the ability of organisms to remain and survive on surfaces.
Initially, the 98,000-square-foot building was cleaned and disinfected with the PTD. All areas and items such as telephones, computers, biometrics readers and light switches were cleaned. As the weeks passed by, it was noticed that areas such as bathrooms, including the showers and toilets, became easier to clean; nothing was adhering to the surfaces (no lime, no rust stains and no calcium build-up). The staff began to use the product more frequently on a daily basis and it became the cornerstone of the infection prevention program.
New studies have been conducted in the facility to document the PTD products performance. A comparison study of high-touch surfaces was created to measure the emergency department (ED) and the medical/surgical nursing units. One-hundred forty-four cultures were taken from five surfaces over a two-month period. The ED was cleaned for one week with a 1:10 hypochloride solution and then daily with a neutral quaternary ammonium disinfectant, as well as once a week with the PTD. The nursing unit was disinfected daily with the PTD. Over the duration of the study, the nursing unit did not return any positive cultures, while the ED returned two positive cultures of Gram-negative rods.
The most recent study was designed to test for organisms present on environmental surfaces on the medical/surgical nursing unit with bioluminescent chemistry technology. The system was designed to identify the presence of Adenosine Triphosphate (ATP), which is the energy-carrying molecule common in all organisms. The device measures the amount of ATP on surfaces by using ultraviolet light waves and producing a report in relative light units (RLU). The test began prior to a room cleaning where the ATP levels reported were from 122 to 197 respectively. Twice a week, five rooms were tested that had been previously cleaned with the PTD. As the test progressed, the RLUs dropped from triple digits down to a range of 2 to 17 respectively. This test indicates that micro-organisms cannot remain on environmental surfaces for days after cleaning with the PTD.
All of the test studies conducted at the facility have proved to be valuable in validating the PTDs effectiveness against MRSA, VRE, C. difficile and other pathogenic microorganisms. The prevention program has elevated environmental surface cleaning to the top of the priority list.
Developing a Prevention Program
There are three main ingredients in developing a program that is prevention focused: education, administrations commitment to make the investment and staff ownership. A full prevention program must include all measures available on the market to prevent any infection in order to target zero acquired infections. Prevention measures currently available with little to no cost include:
Polymer technology disinfectants on all surfaces
Ventilator-acquired pneumonia (VAP) protocols
Central line bundle protocols
Hand hygiene for healthcare workers and visitors
Sterile dressing changes on open wounds
Pneumonia protocols: head of bed at 45 degree
Employee health and vaccinations
Personal protective equipment (PPE for staff
Proper sterilization protocols
Cleaning protocols for each department
MDRO assessments and protocols
Education of staff (including physicians) should be the first item and maintained on a quarterly basis. Topics such as properly disinfecting environmental surfaces are the most important ones to cover. Other educational efforts should relate to the cycle of disease, properly using protective equipment, why using protective equipment is important, the risk of a healthcare worker acquiring a disease due to lack of adherence with protective equipment, that isolation precautions are intended to protect the healthcare worker and standard precautions are intended for all staff on all patients. The next step is to educate administrative staff that preventing infections is beneficial to the organization and to the bottom line. Initial investments could be about $300 per patient, which will help to avoid additional care costing as much as $32,500 a day.
Begin an educational campaign to teach those involved in disinfecting environmental surfaces on the how and why of disinfecting. We have learned to clean, as a society, based on marketing schemes. We must fully understand the importance in the methodology of cleaning from top to bottom and from the inside to the outside, using one rag per room to contain pathogenic microorganisms. We are not to use cloth rags to clean one room; dip these rags into a bucket of disinfectant that will be used in the next room. Educate staff on the proper uses of microfiber technology. The job of microfiber is to eliminate biofilm and debris from the surfaces. If you are cutting debris away, how can you apply disinfectant to the same surface at the same time? William Rutala indicates in a 2006 study that products containing quaternary ammonium demonstrated excellent sustained activity against VRE for up to 48 hours after application.2 Now imagine using quaternary products with a PTD backbone; how effective will one be in disinfecting hospital surfaces? All disinfectants work, providing you get the correct amount of the product on the organism for the correct amount of time. The correct amount of time per organism depends on the organism. Imagine a product that will not only kill microorganisms, but prevent them from adhering to surfaces at all. If an organism can not attach to a surface, it will rapidly become unviable. Do not fall into the marketing trap that suggests a kill claim of one minute; these claims are normally based on one organism (HIV) which naturally begins to die within 45 seconds anyway.
The staff will begin to take ownership once it understands how to and why one must properly disinfect surfaces. Staff members must buy into the fact that they are transmitters of disease between environmental surfaces and the patient/public. Staff must begin to take ownership of work areas and know that the common denominator in transmitting disease is the environment in which they work. Cleaning staff should be rotated through different areas of the hospital throughout the year to reduce the natural inclination of taking shortcuts because they are familiar with the area; change keeps our senses at the highest level.
The importance of infection prevention will come to light once healthcare workers understand how the environment plays a part in all processes. A prevention program must take into account all factors of patient and healthcare worker interaction. The environment must be placed on the top of the pyramid, then hand hygiene practices, then isolation precautions, then other professionally recommended precautions. Hospitals are dirty places, no matter how clean they appear.
The last concern in developing a program is to move infection prevention staff into a direct reporting position to either the chief operating officer or to the chief executive officer. When an organization is looking to make things happen, the drag in the chain of command often delays implementation of new protocols and methods. A hospital with an organizational design where the infection prevention department has increased power and is staffed with one professional per 100 beds will begin to show its benefits. Aligning infection prevention with risk management and/or patient safety departments will greatly enhance the organizations ability to be proactive. It only makes sense to align staff who perform similar duties for efficiency and effectiveness; these professionals all perform work which is related to enhancing patient outcomes and decreasing organizational liability.
James Ballard, MBA, is infection preventionist at Monroe Hospital in Bloomington, Ind.
Graves N. Economics and preventing hospital-acquired infection. Emerg Infecti Dis. Vol. 10, No. 4. April 2004.
Rutala WA, White SW, et al. Bacterial contamination of keyboards: Efficacy and functional impact of disinfectants. Infect Control Hosp Epidem. Vol. 27, No. 4. April 2006.