Widespread Benefits of Added Infection Control Staffing and Quality & Safety Collaboration

Background: Infection control (IC) programs often have fewer than the recommended minimum of one IC practitioner (ICP) per 250 beds. 

Objective: Measure the impact of added staffing on IC outcomes and effectiveness.

 

Methods: Tertiary referral hospital, growing from 239 to 328 (33 to 52 ICU) beds from Jun'01 – Sep'09, adding a 2^nd ICP in Aug'03.  Prospective surveillance was conducted for numerous IC outcomes, including catheter-related bloodstream infection (CRBSI) and ventilator-associated pneumonia (VAP) in all ICUs; hospital-acquired (HA) MRSA infection & colonization in ICUs and medical-surgical floors; HA-VRE infection & colonization; C. difficile infection (CDI); and surgical site infections (SSI), including MRSA SSI.  We also measured alcohol-based hand rub (ABHR) consumption; hand hygiene (HH) compliance; adequacy of room cleaning; Surgical Care Improvement Project (SCIP) Appropriate Care Score (ACS); and healthcare worker influenza vaccination.  Rates were calculated per 1000 device-days, patient-days, or 100 procedures, as appropriate.  Analysis used PEPI 2.0, first comparing time series before and after adding a 2^nd ICP in Aug'03, and then with process control to study trends.

 

Results: Influx of MRSA and VRE from the community increased 2- to 3-fold.  Bed:ICP ratio changed from 239:1 to 120:1, then 160:1.  Collaboration with Quality & Safety (Q&S) personnel blossomed but was not quantified.  HH rose from ~40% to 96%; ABHR consumption from 0 to 29 L/1000 pt-days; adequate room cleaning from 40% to 82%; SCIP ACS from 72% to 96%; Flu vaccination to 74%.  A stewardship program kept antimicrobial expenditures to 2% growth vs 74% for other pharmaceuticals.

In reversal of generally increasing trends, each IC measure improved after hiring a second ICP (Figure).  Process control analyses revealed further improvements; all but HA-VRE were statistically significant: CRBSI rates dropped 81% to 1.42; VAP by 74% to 3.3; HA-MRSA by 44%; SSI decreased 17% and MRSA SSI by 46%; CDI by 44% (each p<0.0001). 

Expected infections, based on pre-intervention rates, minus observed episodes yielded averted infections.  Improvements averted an estimated 243 CRBSI, 223 VAP, 333 MRSA infections, 25 CDI, and 117 SSI, including 49 MRSA SSI.  Using published estimates, this corresponds to 9 to 26 deaths and $2-3 Million in costs avoided per year. Annual IC program costs were < $250,000, suggesting a return-on-investment of 8-12:1.

 

Conclusions: Adding personnel produced widespread improvements by shifting from surveillance and reporting to active intervention.  Quality Improvement collaboration added further manpower and expertise.  Our augmented IC program averted major morbidity & mortality, saved millions of dollars, and was cost-effective.