Reducing healthcare-associated infections: Medically and financially

Two key programs established by the Affordable Care Act are designed to incentivize hospitals to reduce their HAI rates.

ACA Programs to Reduce HAIs

The Value-Based Purchasing program is an incentive program based on quality of care, rather than quantity of care. To fund the program, a specified percentage of Medicare payments to hospitals are reduced and held each year. These funds are then redistributed to hospitals based on their total performance scores, which include measures for HAIs. Hospitals can earn back incentive payments based on their performance scores that may be less than, equal to, or greater than the reduction that was held in that year. Poorly performing hospitals receive reduced payments while higher performing hospitals are rewarded with incentive payments. In fiscal year 2016, 1806 hospitals will receive a positive adjustment to their payments, while 1235 will receive a negative adjustment averaging around 0.3 percent of their total $455,000 payment.³

In the Hospital-Acquired Condition Reduction program, hospitals in the  lowest-performing quartile are subject to a 1 percent reduction in Medicare payments. The HAC scores include similar measures for HAIs as the VBP. For fiscal year 2016, 758 of 3,308 hospitals will have their payments cut by 1 percent, an increase from 724 hospitals in 2015.⁴ Table 1 provides details of the programs and changes for fiscal years 2017-2020, which have performance periods from 2015 onwards.⁵

Table 1. Key Affordable Care Act programs with incentives to reduce HAIs

With the shift towards payments based on quality of care provided, these ACA programs result in additional financial penalties for poorly performing hospitals, beyond the costs for additional treatments resulting from HAIs that they might already bear. What’s more, there are significant financial incentives available for hospitals reporting HAI levels below national averages. The combined features of penalties and payments, and the emphasis placed on HAIs in the HAC program, make it clear that hospitals can benefit exponentially from tackling HAI rates. 

However, there are a number of tools and strategies available to healthcare organizations to help mitigate the risk of patient infections.

Approaches to Preventing HAIs

To prevent the spread of HAIs, healthcare facilities should focus on a horizontal infection prevention approach, which is most appropriate to address the growing concern of multi-drug resistant organisms such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, carbapenem-resistant Enterobacteriaceae, and others that cause serious infections which are extremely difficult and costly to treat. Within that horizontal approach, strategies to specifically target the pathogens that cause the most HAIs can be very effective. One useful strategy is skin and nasal decolonization. 

Vertical and Horizontal Approaches to Preventing HAIs
Pathogen-specific vertical approaches

• Active surveillance testing

• Contact precautions

• Decolonization of patients

Non-pathogen specific horizontal approaches

•  Daily environmental cleaning and disinfection

•  Standard precautions (e.g. hand hygiene)

•  Universal use of gloves and gowns

•  Universal decolonization

•  Antimicrobial stewardship

Decolonization Methods

Patient bathing with chlorhexidine gluconate is an effective approach to reducing HAIs, particularly CLABSIs. A recent meta-analysis of studies in critically ill patients showed that daily CHG bathing resulted in a 55 percent reduction in the risk ratio for CLABSI compared to the normal standard of care, as well as significant reductions in MRSA and VRE infections.⁸ Daily bathing and nasal decolonization of ICU patients can also reduce the rate of all bloodstream infections.⁹ The 2014 Society for Healthcare Epidemiology of America and the Infectious Disease Society of America recommendations include the daily bathing of all ICU patients with CHG to reduce the risk of CLABSI.¹⁰ CHG bathing is also included as an optional recommendation for a central line maintenance bundle in an implementation guide released by the Association for Professionals in Infection Control and Epidemiology.¹¹

The skin and nasal decolonization component of the preoperative bundle has also been key to preventing SSIs. In general, there are two decolonization strategies that are effective when employed prior to surgery: targeted decolonization in which patients are screened for S. aureus or MRSA and undergo skin and nasal decolonization, or universal decolonization, in which all patients are decolonized prior to surgery, thus avoiding timely and costly screenings.

According to APIC guidelines and SHEA/IDSA Practice Recommendations, the strategy of skin and nasal decolonization prior to surgery and implementation of this pre-operative decolonization protocol is a good practice that can be implemented prior to any major invasive surgical procedures, including colon surgeries, hysterectomy, and arthroplasty.¹²

Up to now, mupirocin ointment, applied twice daily for five days prior to surgery, has been the most common agent used for nasal decolonization. However, the search for a one-time, easy-to-apply antiseptic for decolonization has been prompted by concerns about resistance of S. aureus and MRSA to mupirocin¹³ and the risk of decolonization failure due to patient non-compliance with the five day mupirocin application regimen. ¹⁴

Povidone Iodine: An Antiseptic Alternative for Nasal Decolonization

Povidone iodine has emerged as an effective antiseptic alternative to mupirocin that can address concerns about resistance. Its usage also aligns with national antimicrobial stewardship initiatives that aim to address the growing problem of multi-drug resistant organisms. As products are designed to be applied to patients by healthcare workers, compliance may also be increased.

Studies evaluating the efficacy of povidone iodine for nasal decolonization, when used as part of a decolonization bundle that includes CHG bathing and CHG oral rinse, have shown positive results. A 2015 study showed that implementing this decolonization regimen resulted in a 70 percent decrease in SSI following joint arthroplasty, compared to patients who did not undergo a decolonization regimen.¹⁵ In patients undergoing orthopedic surgeries, povidone iodine was shown to be as effective as mupirocin when used for nasal decolonization.¹⁶ Additionally, a study has also shown that patients decolonized with povidone iodine experienced fewer adverse events compared to those using mupirocin.¹⁷ Allaying concerns about resistance, studies to date have not yet shown that bacteria develop resistance to povidone iodine.¹⁸

There are also financial savings resulting from the use of povidone iodine as part of a universal decolonization protocol prior to surgery. When used in a universal decolonization protocol including CHG bathing and compared to a targeted decolonization protocol using mupirocin and CHG, rates of infection were similar in either group, but per patient costs were approximately $90 lower in the povidone iodine group; the bulk of the higher costs for the targeted approach are the result of the screening of all patients.¹⁹

Conclusion

ACA programs that incentivize hospitals to reduce HAIs have been in place for several years. Important new measures for MRSA and C. difficile infections were added for fiscal year 2017 payment adjustments and new measures relating to hip and knee arthroplasty slated to be implemented for fiscal year 2019 continue to demonstrate the medical and financial benefits to addressing HAIs. While horizontal approaches to infection control that cover many aspects of medical care are critical, a decolonization strategy can be particularly helpful in addressing SSIs. The growing emphasis on antibiotic stewardship has resulted in povidone iodine emerging as an effective antiseptic alternative to antibiotics traditionally used for nasal decolonization. Based on evidence to date, implementation of universal decolonization protocols for patients undergoing surgery and for those in the ICU can help to lower HAI rates, resulting in significant medical and financial benefits to patients and hospitals. 

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[1] Anderson DJ et al. Clinical and financial outcomes due to methicillin resistant Staphylococcus aureus surgical site infection: a multi-center matched outcomes study. PLoS One. 2009 Dec 15;4(12).

[2] Zimlichman E. et. al. Health Care-Associated Infections A Meta-analysis of Costs and Financial Impact of the US Health Care System. JAMA Internal Medicine. 2013; 173(22):2039-46.

[3] Fiscal Year (FY) 2016 Results for the CMS Hospital Value-Based Purchasing Program. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-10-26.html Accessed March 18, 2016.

[4] Fiscal Year (FY) 2016 Results for the CMS Hospital-Acquired Conditions (HAC) Reduction Program https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheetsitems/2015-12-10-2.html Accessed March 18, 2016.

[5] Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Policy Changes and Fiscal Year 2016
Rates. 80 FR 49325. August 17, 2015. Available at http://federalregister.gov/a/2015-19049 Accessed March 18, 2016.

[6] National Quality Measures Clearinghouse. Total hip arthroplasty (THA) and/or total knee arthroplasty (TKA): hospital-level risk-standardized complication rate (RSCR) following elective primary THA and/or TKA. Agency for Healthcare Research and Quality. https://
www.qualitymeasures.ahrq.gov/content.aspx?id=49201 Accessed March 18, 2016.

[7] Adapted from Septimus E et al. Approaches for Preventing Healthcare-Associated Infections: Go Long or Go Wide? Infect Control Hosp Epidemiol. 2014; 35(7): Suppl 2:S10-4.

[8] Kim HY et al. The effects of chlorhexidine gluconate bathing on health care-associated infection in intensive care units: A meta-analysis. J Crit Care. 2016 Apr;32:126-37.

[9] Huang SS et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013 Jun 13;368(24):2255-65. Erratum in N Engl J Med. 2013 Aug 8;369(6):587. N Engl J Med. 2014 Feb 27;370(9):886.

[10] Marschall J et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Sep;35 Suppl 2:S89-107.

[11] Association for Professionals in Infection Control and Epidemiology, Inc. (APIC).Guide to Preventing Central Line-Associated Bloodstream Infections. 2015. Washington DC

[12] APIC. Guide to the Elimination of Orthopedic Surgical Site Infections. Washington DC, 2010. APIC; Guide for the Prevention of Mediastinitis Surgical Site Infections Following Cardiac Surgery. Washington
DC, 2008; Anderson DJ. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update. SHEA/IDSA Practice Recommendation. Infect Control and Hosp Epidemiol. 2014;35(6):605-627.

[13] Hetem DJ, Bonten MJ. Clinical relevance of mupirocin resistance in Staphylococcus aureus. J Hosp Infect. 2013 Dec;85(4):249-56.

[14] Caffrey AR et al. Low adherence to outpatient preoperative methicillin-resistant Staphylococcus aureus decolonization therapy. Infect Control Hosp Epidemiol. 2011 Sep;32(9):930-2.

[15] Bebko SP et al. Effect of a preoperative decontamination protocol on surgical site infections in patients undergoing elective orthopedic surgery with hardware implantation. JAMA Surg. 2015 May;150(5):390-5

[16] Phillips M et al. Preventing surgical site infections: a randomized, open-label trial of nasal mupirocin ointment and nasal povidone-iodine solution. Infect Control Hosp Epidemiol. 2014 Jul;35(7):826-32.

[17] Maslow J et al. Patient experience with mupirocin or povidone-iodine nasal decolonization. Orthopedics. 2014 Jun;37(6):e576-81.

[18] Lanker Klossner B et al. Nondevelopment of resistance by bacteria during hospital use of povidone-iodine. Dermatology. 1997;195 Suppl 2:10-3.

[19] Torres EG et al. Is Preoperative Nasal Povidone-Iodine as Efficient and Cost-Effective as Standard Methicillin-Resistant Staphylococcus aureus Screening Protocol in Total Joint Arthroplasty? J Arthroplasty. 2016 Jan;31(1):215-8.