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Cost-effective applications of the centers for disease control guidelines for prevention of nosocomial Infections
ARTlCLES
qeffective
applications of th ers for Disease Control uidelines for Prevention of osocomial Infections risti
Buffy, R.N., CIC
urha
th Carolina
Infection control, once viewed as an admirable ‘“self-improvement” function, is changing that image to one in which infection control is considered a necessary and critical function.’ This change is necessary to insure survival in a more cost-conscious era. For too many infection control practitioners (ICPs), their “reason for being” was the Joint Commission on Accreditation of Hospitals mandate for infection control programs. The ICP no longer needs this mandate. With the publication of the Centers for Disease Control (CDC) Study on the Efficacy of Nosocomial Infection Control (SENIC) data, it has become clear that infection control measures can not only significantly reduce morbidity and mortality, but save dollars as well.2 The ICP must not only be familiar with the methods used to assess the cost of nosocomial infections but also understand the methods and results of studies assessing the benefit of various infection control measures.’ Finally, ICPs must be able to apply the various recommendations and results in their own institutions. Outside pressures to reduce the number of health care dollars will not decrease. As information from the SENIC project becomes available to hospital directors and financial planners, there will be an ever greater pressure on the ICP to objectively evaluate recommendations and guidelines for their cost benefit. Not Presented at the Twelfth Annual Educational Association for Practitioners in Infection Ohio, May 13-l 7, 1985
Conference of the Control, Cincinnati,
Reprint requests: Kristi Riggs Duffy, R.N., CIC, Infection Consultant, 9 Georgetown Court, Durham, NC 27705.
Control
only will the ICP have to understand and be able to use the language and methods of science and objectivity, but he or she will need to be able to speak with those controlling the financial resources about issues of cost and benefit. Reasoning such as “we’ve always done it this way“, or “‘I’ll just feel better if . . .‘I, or “well - says we have to” can no longer be the basis of action. In 1981 the CDC began issuing a series of guidelines to assist hospitals in focusing their infection reduction activities. These guidelines, consolidated into a manual and sent to every hospital in the United States have become “a bible of musts” for many institutions. The CDC, however, never meant for these guidelines to become rote, but rather to be what their name implied-guidelines. In order to help achieve this end, a series of categories were developed and each recommendation was assigned a category. Category I recommendations are those measures that are strongly supported by welldesigned and controlled clinical studies that show effectiveness in reducing the risk of nosocomial infections or are viewed as useful by a majority of experts in the field. Category II measures are moderately recommended for adoption. They are supported by highly suggestive clinical studies or by definitive studies in institutions that may not be representative of other hospitals. Category III measures are weakly recommended for adoption. They have been proposed by some investigator authorities or organizations but lack either supporting data or a strong theoretical rationale. The Association for Practitioners in Infection
Volume October,
13 Number
5
1985
Control (APIC) Standards Committee, in recognition of the role expansion of the ICP in financial management and in support of the guidelines activity, undertook the task of reviewing the guidelines for their cost-effectiveness. The result of the committee review was presented at the APIC Educational Conference in Cincinnati, Ohio, in an open forum. The committee members subsequently expanded their presentation for publication. In this issue, four of the guidelines are reviewed. Dr. William A. Rutala addresses the cost-effective application of the CDC Guideline for Handwashing und Hospital Environmental Control. It is important here to note that whenever a guideline revised from the original series has been issued, the revision, not the original, has been reviewed. Dr. Rutala presents compelling evidence that the guidelines, when carefully reviewed with an individual hospital in mind, can be significant in helping a hospital reduce costs. Dr. Edward J. Septimus reviews the cost-effective application of the CDC Guideline for Infection Control in Hospital Personnel. After reviewing the guideline, he “costs out” the savings to an institution if only four of the recommendations are implemented. More than $18,000 could be saved by the institution in just one year if certain unnecessary practices were eliminated and one case of hepatitis B prevented. Dr. John NI. Boyce and others at his institution looked at the cost-effectiveness of the Guideline for Prevention of Nosocomial Pneumonia. The SENIC data show that nosocomial pneumonias are responsible for 25% of the extra days spent in hospitals by patients. Nosocomial pneumonias are also one of the most common causes of death resulting from nosocomial infection. Review of the cost-benefit of this guideline in light of those statistics is meticulous and well considered. Again, considerable money can be saved without posing risk to patients. The Guideline for Prevention of Surgical Wound Infections is reviewed by Barbara Terry. Her comments and review should be well read by the ICP. By implementing just the Category I recommendations, a hospital could save con-
Cost-eip&tive applicatio~z of Guidelines siderable money. Again, costs are reduced wiihout risk to the patient. But how does one calculate the cost benefit on this subject of any procedure ? “How-to‘s” are sparse in most infection control literature. The APIC Survival Kit (ASK)3 has a small section dealing with cost analysis and in the APIC Notes section of the December 1984 kmericavr Journal oflnfection Control4 there is an excsknt article on micro costing. The control and preW vention aspects of cost in the realm of infection control are similar but with very different results and applications. Control is always a reaction to a problem, a means to keep something within limits or to regulate. Expense is implicit. Prevention, on the other hand, is to keep from happening, to render impossible. Prevention implies elimination of the problem or even elimination of the expense!” Clearly the ICP needs to focus on advance planning to eliminate problems and expenses and then keep a careful eye on the control when problems do arise. An upcoming issue of the American Journal of Infection Control will feature more articles on the cost effective application of the CDC Guidelines for Prevention of Nosocomial Infections. As Dr. Richard Dixon stated so eloquently, it is essential that “as resources for infection control programs become more precious, it is crucial that possibly useful measures be subjected to rigorous scientific study to determine both their efficacy and their costs.“6
References 1. McGowen JE: Cost and benefit: A critical issue for hospital infection control. AM J INFECTCONTROLl&100-1008, 1982. 2. Haley RW, Morgan WM, Culver DH, et al: Update from the SENIC Project. Hospital Infection Control: Recent progress and opportunities under prospective payment. AM J INFECT CONTROL 13:97-107, 1985. 3. APIC survival kit. Mundelein, Ill., Association for Practitioners in Infection Control, 1984. 4. Kahl K, Roth M, Land G: Micro costing isolation care: Renewed importance due to DRGs. AM J INFECTCONTROL 12(6):23A-25A, 1984. 5. Brachman PS: Visions for the future. AM J INFECT CON-
TROL 12:204-209,
1984.
6. Dixon RE: Forging the missing Am J Med 70:976-978, 1981.
link
in infection
control.
qeffective
applications of th ers for Disease Control uidelines for Prevention of osocomial Infections risti
Buffy, R.N., CIC
urha
th Carolina
Infection control, once viewed as an admirable ‘“self-improvement” function, is changing that image to one in which infection control is considered a necessary and critical function.’ This change is necessary to insure survival in a more cost-conscious era. For too many infection control practitioners (ICPs), their “reason for being” was the Joint Commission on Accreditation of Hospitals mandate for infection control programs. The ICP no longer needs this mandate. With the publication of the Centers for Disease Control (CDC) Study on the Efficacy of Nosocomial Infection Control (SENIC) data, it has become clear that infection control measures can not only significantly reduce morbidity and mortality, but save dollars as well.2 The ICP must not only be familiar with the methods used to assess the cost of nosocomial infections but also understand the methods and results of studies assessing the benefit of various infection control measures.’ Finally, ICPs must be able to apply the various recommendations and results in their own institutions. Outside pressures to reduce the number of health care dollars will not decrease. As information from the SENIC project becomes available to hospital directors and financial planners, there will be an ever greater pressure on the ICP to objectively evaluate recommendations and guidelines for their cost benefit. Not Presented at the Twelfth Annual Educational Association for Practitioners in Infection Ohio, May 13-l 7, 1985
Conference of the Control, Cincinnati,
Reprint requests: Kristi Riggs Duffy, R.N., CIC, Infection Consultant, 9 Georgetown Court, Durham, NC 27705.
Control
only will the ICP have to understand and be able to use the language and methods of science and objectivity, but he or she will need to be able to speak with those controlling the financial resources about issues of cost and benefit. Reasoning such as “we’ve always done it this way“, or “‘I’ll just feel better if . . .‘I, or “well - says we have to” can no longer be the basis of action. In 1981 the CDC began issuing a series of guidelines to assist hospitals in focusing their infection reduction activities. These guidelines, consolidated into a manual and sent to every hospital in the United States have become “a bible of musts” for many institutions. The CDC, however, never meant for these guidelines to become rote, but rather to be what their name implied-guidelines. In order to help achieve this end, a series of categories were developed and each recommendation was assigned a category. Category I recommendations are those measures that are strongly supported by welldesigned and controlled clinical studies that show effectiveness in reducing the risk of nosocomial infections or are viewed as useful by a majority of experts in the field. Category II measures are moderately recommended for adoption. They are supported by highly suggestive clinical studies or by definitive studies in institutions that may not be representative of other hospitals. Category III measures are weakly recommended for adoption. They have been proposed by some investigator authorities or organizations but lack either supporting data or a strong theoretical rationale. The Association for Practitioners in Infection
Volume October,
13 Number
5
1985
Control (APIC) Standards Committee, in recognition of the role expansion of the ICP in financial management and in support of the guidelines activity, undertook the task of reviewing the guidelines for their cost-effectiveness. The result of the committee review was presented at the APIC Educational Conference in Cincinnati, Ohio, in an open forum. The committee members subsequently expanded their presentation for publication. In this issue, four of the guidelines are reviewed. Dr. William A. Rutala addresses the cost-effective application of the CDC Guideline for Handwashing und Hospital Environmental Control. It is important here to note that whenever a guideline revised from the original series has been issued, the revision, not the original, has been reviewed. Dr. Rutala presents compelling evidence that the guidelines, when carefully reviewed with an individual hospital in mind, can be significant in helping a hospital reduce costs. Dr. Edward J. Septimus reviews the cost-effective application of the CDC Guideline for Infection Control in Hospital Personnel. After reviewing the guideline, he “costs out” the savings to an institution if only four of the recommendations are implemented. More than $18,000 could be saved by the institution in just one year if certain unnecessary practices were eliminated and one case of hepatitis B prevented. Dr. John NI. Boyce and others at his institution looked at the cost-effectiveness of the Guideline for Prevention of Nosocomial Pneumonia. The SENIC data show that nosocomial pneumonias are responsible for 25% of the extra days spent in hospitals by patients. Nosocomial pneumonias are also one of the most common causes of death resulting from nosocomial infection. Review of the cost-benefit of this guideline in light of those statistics is meticulous and well considered. Again, considerable money can be saved without posing risk to patients. The Guideline for Prevention of Surgical Wound Infections is reviewed by Barbara Terry. Her comments and review should be well read by the ICP. By implementing just the Category I recommendations, a hospital could save con-
Cost-eip&tive applicatio~z of Guidelines siderable money. Again, costs are reduced wiihout risk to the patient. But how does one calculate the cost benefit on this subject of any procedure ? “How-to‘s” are sparse in most infection control literature. The APIC Survival Kit (ASK)3 has a small section dealing with cost analysis and in the APIC Notes section of the December 1984 kmericavr Journal oflnfection Control4 there is an excsknt article on micro costing. The control and preW vention aspects of cost in the realm of infection control are similar but with very different results and applications. Control is always a reaction to a problem, a means to keep something within limits or to regulate. Expense is implicit. Prevention, on the other hand, is to keep from happening, to render impossible. Prevention implies elimination of the problem or even elimination of the expense!” Clearly the ICP needs to focus on advance planning to eliminate problems and expenses and then keep a careful eye on the control when problems do arise. An upcoming issue of the American Journal of Infection Control will feature more articles on the cost effective application of the CDC Guidelines for Prevention of Nosocomial Infections. As Dr. Richard Dixon stated so eloquently, it is essential that “as resources for infection control programs become more precious, it is crucial that possibly useful measures be subjected to rigorous scientific study to determine both their efficacy and their costs.“6
References 1. McGowen JE: Cost and benefit: A critical issue for hospital infection control. AM J INFECTCONTROLl&100-1008, 1982. 2. Haley RW, Morgan WM, Culver DH, et al: Update from the SENIC Project. Hospital Infection Control: Recent progress and opportunities under prospective payment. AM J INFECT CONTROL 13:97-107, 1985. 3. APIC survival kit. Mundelein, Ill., Association for Practitioners in Infection Control, 1984. 4. Kahl K, Roth M, Land G: Micro costing isolation care: Renewed importance due to DRGs. AM J INFECTCONTROL 12(6):23A-25A, 1984. 5. Brachman PS: Visions for the future. AM J INFECT CON-
TROL 12:204-209,
1984.
6. Dixon RE: Forging the missing Am J Med 70:976-978, 1981.
link
in infection
control.