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Friday, December 23, 2016 Written by Jorge P. Parada, MD, MPH, FACP, FIDSA, Prof. of Medicine, Stritch School of Medicine Loyola University Chicago

Increase Revenue and Improve Patient Safety

How Loyola University Hospital has Profitably Succeeded Against 2 HAIs

Patient Safety: Increased Accountability and Never Events

Hospital administrators are all too aware of increasing requirements for hospitals to be transparent and accountable for patient safety. Data can now be easily compiled and compared across regions, states, and even countries. This provides strong bases for national patient safety goals and lists of Never events. Never events are outcomes that should never occur, and if they do, the hospital literally pays: for associated testing, drugs, and lengthened hospital stays, because the insurance companies and government will refuse to foot the bill for additional costs that should not have been incurred. Additionally, failing to meet national safety goals can mean being cited or losing accreditation — also an expensive proposition.

HAIs are a key source of skyrocketing costs

If all these factors weren't enough, the rise of the internet and social media has enabled widespread publication of this data, impacting consumer choices regarding healthcare providers, and ultimately impacting hospital revenues. Measures that increase cost efficiency while increasing patient safety are clearly to everyone's benefit. In this three-part series of articles, we explore some key steps Loyola University Hospital has taken to meet the challenges of both patient safety and revenue.

MRSA a clear target. Loyola's starting point:

When healthcare-associated infections are discussed, MRSA is a popular topic. MRSA is staph: methicillin-resistant Staphylococcus aureus. It is a bacteria that typically lives on the skin and is also the leading cause of skin and soft tissue infections. In hospitals, post-op wound infections and invasive measures (breathing tubes, catheters, etc.) provide a multitude of opportunities for invasive MRSA infections.

The associated costs of MRSA are approximately $3.2 to 4.2 billion annually, associated with increases in:

  • Average length of stay
  • Increased costs (treatment, protective measures, etc.)
  • Mortality

MRSA is a still-growing problem in the United States. In recent years, MRSA incidence has continued to climb, and Figure 1 shows the 566% increase in MRSA infections presenting to Loyola University Medical Center over the six years 2002–2007. Over the course of screening for MRSA at Loyola, more than 100,000 patients have been screened and 1 in 15 was found to be carrying MRSA upon admission.

High rates of MRSA infection are fixable. That has been proven. In the 1960s, Denmark, Holland, other EU countries saw MRSA rates rising, and took measures to drive them down. This contrasts with what occurred in the United States where when MRSA infection rates climbed little was done in response.

Speed Counts

Traditionally, the approach to infection control has been reactive. No action was taken until a positive blood or wound culture was obtained. Culture time to result was a few days, and during that time the patient's MRSA infection went unrecognized and the patient could be a source for MRSA to be spread throughout the hospital by healthcare workers — who, it is well recognized, are imperfect in their hand hygiene practices. Worse, traditionally cultures were only taken when deemed necessary because of infection. The 1 in 15 MRSA rate mentioned earlier? Many of the patients carrying MRSA were only colonized, not infected. Without screening for asymptomic carriers of MRSA, we only find the tip of the iceberg — patients with flagrant infections — but miss the bulk of patients with MRSA. This is a major reason the key to controlling and reducing the spread of MRSA is rapid identification of all patients with MRSA, so that isolation and treatment can be implemented immediately.

Implementation

At Loyola University Medical Center, the challenge rapid and accurate identification of patients with MRSA was addressed by implementing a universal surveillance system for all patients being admitted to hospital. Key to Loyola's success was using the GeneXpert, which provides far more sensitive results than culture and decreased the time to result was from days to only two hours. In addition to the universal surveillance for all hospital admissions, Loyola also conducted preliminary studies with the Emergency and Orthopedic Departments.

ER testing

Loyola's emergency room performed a study to see how rapid MRSA screening compared to culture in an ER setting, and if it would have an impact. There was initial concern that it might slow down or create a bottleneck in the ER, where speed is critical. However, the results of the study were quite positive:

  • No bottleneck or increase in stay
  • 25% greater ideal antibiotic choice
  • Increased physician and patient satisfaction that they were leaving the ER knowing if they had MRSA or not

Orthopedics

The Orthopedics Department also conducted a study on the impact of rapid MRSA screening. This department performs a large number of elective knee replacements and elective hip replacements. Because these are elective surgeries, patients shop extensively for their doctor, and are extremely interested in the infection rates they find online.

People with MRSA have an even higher rate of surgical site infections than people who don't. By identifying the people with MRSA before their surgery, the Orthopedics Department was able to treat them pre-operatively. The results:

  • No increase in pre-surgery prep time
  • Decreased rates of post-surgical infection

While each of the three populations (main hospital, ER, Orthopedics) had certain specific issues of interest, they unanimously found the rapid screening to be demonstrably valuable.

Total Results

Looking at the two years before Loyola University Hospital implemented universal surveillance through the first 16 months of data, there was a 2/3 drop in surgical site infections (Figure 2). Over 200 MRSA infections were prevented.

Financial

  • Hard savings of more than 1.5 to 2 million dollars per year
  • Revenue opportunities: 1,200 patient days saved, making those beds available for other paying patients
  • MRSA education/clinic brings in revenue
  • Tangential: great publicity from media attention to the universal surveillance program and from being the recipient of a hospital leadership award

Patient Safety and Quality of Care

  • Over 200 cases of hospital-associated MRSA avoided
  • Surgical site infections overall decreased by 1/3
  • MRSA surgical site infections decreased by 50%

Rapid and highly sensitive universal screening proved key in Loyola's successful campaign against MRSA — a prevalent and costly HAI. In this series' next article, we'll look at Loyola's C. difficile efforts, and the impact of rapid screening on a very different type of challenge.