Incentives for Improving Incentives for Improving Safety and Preventing Safety and Preventing

Infections in the Veterans Infections in the Veterans Health AdministrationHealth Administration

APIC Futures SummitAPIC Futures SummitSavannah, Georgia, 4/3/06Savannah, Georgia, 4/3/06

Noel Eldridge, MSNoel Eldridge, MSDepartment of Veterans AffairsDepartment of Veterans AffairsVeterans Health AdministrationVeterans Health Administration

National Center for Patient SafetyNational Center for Patient Safety

OutlineOutline

VA BackgroundVA Background Incentives in VAIncentives in VA Implementing CDCImplementing CDC’’s Hand Hygiene s Hand Hygiene

GuidelineGuideline Two ProblemsTwo Problems

VA BackgroundVA Background

Mission of the Department of Mission of the Department of Veterans AffairsVeterans Affairs

““With malice toward none, with With malice toward none, with charity for all, with firmness in charity for all, with firmness in the right as God gives us to the right as God gives us to see the right, let us strive on to see the right, let us strive on to finish the work we are in,finish the work we are in,to bind up the nationto bind up the nation’’s wounds,s wounds,to care for him who shall to care for him who shall have borne the battlehave borne the battleand for his widow, and his and for his widow, and his orphanorphan, , to do all which may to do all which may achieve and cherish a just and achieve and cherish a just and lasting peace among lasting peace among ourselves and with all nations.ourselves and with all nations.””

- Abraham Lincoln- Abraham Lincoln22ndnd Inaugural Address Inaugural Address

VHA Statistics (FY 2005)VHA Statistics (FY 2005)

7.7M enrollees, 5.3M uniques7.7M enrollees, 5.3M uniques VA Medical Centers (Hospitals): 156VA Medical Centers (Hospitals): 156 Admissions: 587,000Admissions: 587,000 Community Based Outpatient Clinics: 708Community Based Outpatient Clinics: 708 Outpatient Visits: 57.5MOutpatient Visits: 57.5M Rx Dispensed (30-day equiv): 231MRx Dispensed (30-day equiv): 231M Lab Tests: 215.9MLab Tests: 215.9M Total FTE: 197,800Total FTE: 197,800

VHA Budget for 2006VHA Budget for 2006

VA gets a budget and has to make it work VA gets a budget and has to make it work (provide to veterans who present for (provide to veterans who present for care)care)

Medical Services = $22,547,141,000Medical Services = $22,547,141,000 Medical Administration = $2,858,442Medical Administration = $2,858,442 Medical Facilities = $3,297,669Medical Facilities = $3,297,669 Information Technology = $1,213,820,000Information Technology = $1,213,820,000 2006 Current Estimate, Unique Patients = 5,441,9522006 Current Estimate, Unique Patients = 5,441,952

Simple arithmetic says $4,143 per patient Simple arithmetic says $4,143 per patient for 2006for 2006

Veterans Health AdministrationVeterans Health Administration2211 Veterans Integrated Service Networks Veterans Integrated Service Networks

I J 2002

N ANUARY

W ERE INTEGRATED AND

RENAMED

VISN 13 14

VISN 23

S AND

How is $22+ Billion allocated to How is $22+ Billion allocated to 21 Networks?21 Networks?

10 Categories of VHA Patients (& 2003 values)10 Categories of VHA Patients (& 2003 values)

Non-reliant care: $263Non-reliant care: $263 Minor medical: $2,413Minor medical: $2,413 Mental health: $3,562Mental health: $3,562 Heart & Lung: $3,772Heart & Lung: $3,772 Oncology, etc.: $8,337Oncology, etc.: $8,337 Multiple problems: $7,935Multiple problems: $7,935

Specialized care: $18,751Specialized care: $18,751 Supportive Care: $29,780Supportive Care: $29,780 Chronically mentally ill: Chronically mentally ill:

$39,448$39,448 Critically ill: $61,117Critically ill: $61,117

These are adjusted to These are adjusted to compensate for different compensate for different costs in different regionscosts in different regions

VA IncentivesVA Incentives

Some Incentives in VASome Incentives in VA

1.1. Fixed payment to entire agency ($22.5B)Fixed payment to entire agency ($22.5B)• Encourages support of innovation at HQ.Encourages support of innovation at HQ.

2.2. Fixed payments to networks…Fixed payments to networks…• ““Zero sum gameZero sum game”” encourages innovation locally. encourages innovation locally.

3.3. Performance Measures that are Reviewed by Performance Measures that are Reviewed by Management at local, network, and HQ…Management at local, network, and HQ…

• Vaccines (flu, pneumococcus)Vaccines (flu, pneumococcus)• Pre-op Antibiotics (Pre-op Antibiotics (““SIPSIP”” Project) Project)

• But only For 5-10% of all operations, and about 80% of But only For 5-10% of all operations, and about 80% of specific type in the denominator specific type in the denominator

• Wide variety unrelated to infection (~80)Wide variety unrelated to infection (~80)

Payment is Payment is ““lump-sumlump-sum””

Pocket-sized alcohol-Pocket-sized alcohol-based hand rub cost based hand rub cost 59 cents on VA 59 cents on VA contract.contract.

If an infection costs If an infection costs $5,900 that$5,900 that’’s 10,000 s 10,000 of these…of these…

Persuasive argument.Persuasive argument.

VA Financial Incentives Incentivize VA Financial Incentives Incentivize Leaders to Lead Leaders to Lead

Example: major effort to codify and Example: major effort to codify and implement requirements of CDC Hand implement requirements of CDC Hand Hygiene Guideline…Hygiene Guideline…

See Our Paper in JGIM (e-mailed before See Our Paper in JGIM (e-mailed before meeting)meeting)

Used 3M Six Sigma Process to implement Used 3M Six Sigma Process to implement GuidelineGuideline

Measurements: Mass of ABHR, Observed Measurements: Mass of ABHR, Observed Practices, and Attitudes (Questionnaire) Practices, and Attitudes (Questionnaire)

Another Major Incentive: JCAHO Another Major Incentive: JCAHO National Patient Safety GoalsNational 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/http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/

Implementing CDCImplementing CDC’’s s Hand Hygiene GuidelineHand Hygiene Guideline

The EvidenceThe Evidence

423 references in CDC Guidelines423 references in CDC Guidelines From Laboratory TestsFrom Laboratory Tests From HospitalsFrom Hospitals From Long-term Care FacilitiesFrom Long-term Care Facilities From SchoolsFrom Schools On Bacteria, Viruses, FungiOn Bacteria, Viruses, Fungi On Wild-type and Antibiotic-resistant StrainsOn Wild-type and Antibiotic-resistant Strains

But more is needed: But more is needed: Find articles on infections going down when hand Find articles on infections going down when hand

hygiene practices get better… (I have a collection.)hygiene practices get better… (I have a collection.)

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

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

VA Summary of JCAHO-required VA Summary of JCAHO-required CDC Recommendations CDC Recommendations

(19 in 4 categories)(19 in 4 categories)

1.1. All Health Care Workers with Direct Patient All Health Care Workers with Direct Patient Contact (8)Contact (8)

2.2. Surgical Hand Hygiene (3)Surgical Hand Hygiene (3)

3.3. Facility Management: Supplies (5)Facility Management: Supplies (5)

4.4. Facility Management: Administrative Action Facility Management: Administrative Action (3)(3)

Total Length: 732 words (minus 45%)Total Length: 732 words (minus 45%)

Summary of VHA Summary (1)Summary of VHA Summary (1)

I.I. All Health Care Workers (HCWs) with All Health Care Workers (HCWs) with Direct Patient ContactDirect Patient Contact

• Decontaminate hands before and after Decontaminate hands before and after touching a patient (regular soap doesntouching a patient (regular soap doesn’’t do t do it)it)

• Specific gloving recommendationsSpecific gloving recommendations• Soap and water for soiled handsSoap and water for soiled hands

Summary of VHA Summary (2)Summary of VHA Summary (2)

II.II. Surgical Hand HygieneSurgical Hand Hygiene• Guidance on surgical scrub with soap and Guidance on surgical scrub with soap and

water (e.g., shorter scrub times are OK)water (e.g., shorter scrub times are OK)• Guidance on surgical scrub with no-rinse Guidance on surgical scrub with no-rinse

alcohol-based products with additional alcohol-based products with additional compounds for persistent actioncompounds for persistent action

Summary of VHA Summary (3)Summary of VHA Summary (3)III. Facility Management: SuppliesIII. Facility Management: Supplies Alcohol at room entrance and/or bedsideAlcohol at room entrance and/or bedside Alcohol available in pocket-sized dispensersAlcohol available in pocket-sized dispensers Alcohol in other convenient locations (e.g., in Alcohol in other convenient locations (e.g., in

corridors is OK within limits)corridors is OK within limits) Antimicrobial soap as an alternative to alcoholAntimicrobial soap as an alternative to alcohol Provide hand lotion to HCWsProvide hand lotion to HCWs Store alcohol safely – it is flammableStore alcohol safely – it is flammable

Summary of VHA Summary (4)Summary of VHA Summary (4)

IV.IV. Facility Management: Administrative Facility Management: Administrative ActionAction

• Make HH a priority and provide financial Make HH a priority and provide financial and administrative supportand administrative support

• Solicit input from employees on productsSolicit input from employees on products• Monitor adherence and provide feedback Monitor adherence and provide feedback

on hand hygiene performance on hand hygiene performance

Hand Hygiene Compliance at Hand Hygiene Compliance at 4 VA ICUs4 VA ICUs

0

10

20

30

40

50

60

70

80

90

100

MICU SICU ARK IOWA OVERALL

Initial

Final

Two ProblemsTwo Problems

Problems…Problems…

1. Quantifying how many people die from 1. Quantifying how many people die from hospital acquired infections?hospital acquired infections? CDC: 90,000CDC: 90,000 Chicago Tribune: 104,000Chicago Tribune: 104,000 Context: ~810,000 people die in hospitalsContext: ~810,000 people die in hospitals

2. How much to these infections cost?2. How much to these infections cost? Depends what cost means…Depends what cost means… Depends on which types you count (GI?)Depends on which types you count (GI?) Depends on which ones are reported?Depends on which ones are reported?

90,000 deaths from infections?90,000 deaths from infections?We need numbers describing the quantity who:We need numbers describing the quantity who:

Died in hospitals only because of HAI (i.e., they Died in hospitals only because of HAI (i.e., they would have gone home otherwise)would have gone home otherwise)

““90,00090,000”” would be >10% of in-hospital deaths – we should all would be >10% of in-hospital deaths – we should all agree to stop using this number unless it can be explained or be agree to stop using this number unless it can be explained or be made credible. Itmade credible. It’’s now quoted ins now quoted in thousands of web pages and thousands of web pages and articles. articles.

Suffered other various bad outcomes due to Suffered other various bad outcomes due to infections, some ideas to consider: infections, some ideas to consider:

ICU admissions that would not have been necessary otherwise?ICU admissions that would not have been necessary otherwise? Additional LOS >7 days due to infection?Additional LOS >7 days due to infection? Additional pain medication prescribed due to infection?Additional pain medication prescribed due to infection?

Source of 90,000: Weinstein,1998?Source of 90,000: Weinstein,1998?

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

Sample use of 90,000 from 2004 Sample use of 90,000 from 2004 NIH web page NIH web page

http://www.niaid.nih.gov/factsheets/antimicro.htmhttp://www.niaid.nih.gov/factsheets/antimicro.htm

““The Problem of Antibiotic ResistanceThe Problem of Antibiotic Resistance”” ““Nearly two million patients in the United States Nearly two million patients in the United States

get an infection in the hospital each yearget an infection in the hospital each year”” ““Of those patients, about 90,000 die each year Of those patients, about 90,000 die each year

as a result of their infection - up from 13,300 as a result of their infection - up from 13,300 patient deaths in 1992.patient deaths in 1992.””

Does anyone here believe the point above is Does anyone here believe the point above is accurate?accurate?

Average cost is more confusing Average cost is more confusing

than it may seemthan it may seem

We need data on costs of infection that goes We need data on costs of infection that goes beyond average (mean) cost - variation is huge. beyond average (mean) cost - variation is huge. e.g., Mean cost of a UTI doesne.g., Mean cost of a UTI doesn’’t mean mucht mean much Mean, Std. Deviation, and Median?Mean, Std. Deviation, and Median? Cost Categories, something like: # <$1,000, # from Cost Categories, something like: # <$1,000, # from

$1,000 to $10,000, # >$10,000?$1,000 to $10,000, # >$10,000?

Need some consensus on what weNeed some consensus on what we’’re talking re talking about when we say about when we say ““costcost””, e.g., what is the cost , e.g., what is the cost of something simple as a post-discharge office of something simple as a post-discharge office visit and prescription for Cipro?visit and prescription for Cipro?

What is the average cost of nosocomial What is the average cost of nosocomial (hospital acquired) infections?(hospital acquired) infections?

Two VA estimates ITwo VA estimates I’’ve seen: $5,900 & ~$21,000ve seen: $5,900 & ~$21,000 Hypotheses: Hypotheses:

The average depends which infections you donThe average depends which infections you don’’t t count.count.

Because the first infections to be counted are the Because the first infections to be counted are the worst (the most conspicuous and most expensive), worst (the most conspicuous and most expensive), the more you count, the less they cost. the more you count, the less they cost.

See recent PHC4 data for Urinary Tract Infection See recent PHC4 data for Urinary Tract Infection - average payment is $42,316 - average LOS is - average payment is $42,316 - average LOS is 18.1 days & 5.7% died. 18.1 days & 5.7% died. Are UTIs a cause or an effect of morbidity? Both? Are UTIs a cause or an effect of morbidity? Both?

Depends?Depends?

Closing ThoughtsClosing Thoughts ““Insanity: doing the same thing over Insanity: doing the same thing over

and over again and expecting different and over again and expecting different resultsresults””

Albert EinsteinAlbert Einstein

““They say that time changes things, but They say that time changes things, but you actually have to change them you actually have to change them yourselfyourself””

Andy WarholAndy Warhol

On-line VA Patient Safety ResourcesOn-line VA Patient Safety Resources

See VASee VA’’s s www.patientsafety.gov Hand Hygiene Tools and InformationHand Hygiene Tools and Information

• Infection: DonInfection: Don’’t Pass it on Campaignt Pass it on Campaign

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 30-40%. (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.)