In January 1998 the staff at Village North Retirement Community in suburban St. Louis noticed changes in their patients. Residents were less alert, losing their appetites, coughing and suffering malaise.
After three or four patients contracted high fevers, the nursing home called the infection-control SWAT team from system headquarters, which sent nasal swabs from the patients to the state laboratory for identification. The verdict: Type A Sydney influenza.
"That strand was not covered by the vaccine," says charge nurse Lois Miller, the home's liaison to the infection-control team. "We got some interventions in right away. We restricted our visitors and restricted admissions to the health center. We put 'stop' signs up. We initiated amantadine antiviral prophylaxis for our symptomatic and asymptomatic residents.
"And with the Infection Control Consortium, we were able to get through this within a couple of weeks," she says.
The Infection Control Consortium operates out of the headquarters of BJC Health System, Village North's parent. It's unusual for a nursing home to have access to the kind of infection control services a big hospital can offer, points out Maureen Dunn, the home's administrator. In this instance, it paid off handsomely. To keep a resident at Village North costs $108 a day; to hospitalize a Village North patient whose influenza progresses to pneumonia costs $300 to $600 a day.
This kind of prevention is exactly what Denise Murphy and Victoria Fraser, M.D., had in mind four years ago when they proposed creating an integrated infection-control program for St. Louis-based BJC. The newly formed system of 13 hospitals, six nursing homes and miscellaneous clinical units didn't want drug-resistant bacteria to spread horizontally through multiple locations.
"The seamless delivery of healthcare must not be seamless for contagious organisms," Fraser wrote in her 1995 proposal. She suggested that BJC create its own systemwide indicators and customize its data collection to analyze infection sites, and costs, causes and outcomes of nosocomial infections.
Murphy, BJC's director of infection control, tallied the results of that effort. For 1998, two years after the systemwide Infection Control Consortium was founded, Murphy can document excess patient treatment costs of $5.8 million from five typical nosocomial infections: surgical-site infections from coronary artery bypass grafts, hip replacements, knee replacements, bloodstream infections and ventilator-associated pneumonia.
Murphy calls this "the business of infection control." In many hospitals, infection control is regarded as a backwater, of no particular operational or financial significance. Murphy's approach has been to quantify the damage financially.
"Talking about it isn't good enough," she says. "You have to be able to show good data to administrators and physicians to gain credibility. If they believe you have a credible infection-control program, they will fight to get you the resources you need."
At a time when the system was downsizing, BJC administrators put their money where Murphy's mouth was. They raised the system's number of infection-control practitioners to 23 in 1998, up from 15 in 1996. Fourteen are certified in infection control, and eight of the system's 13 hospitals have a trained epidemiologist heading the infection-control program. All the infection-control personnel now have computers, compared with 47% in 1996. "You can't do infection control without them," Murphy says.
On June 23, Murphy will spread the news at the conference of the Association for Professionals in Infection Control and Epidemiology in Baltimore. She thinks every integrated hospital system should save money the way BJC has.
Ed Case, BJC's acting chief executive officer and the system's former chief financial officer, was among the persuaded. He regards this infection-control program as one of the distinct advantages of the integrated system framework. "We had specific talent in infection control," he says. "One of the things we wondered was how we could take that expertise and spread it across a larger base."
In 1996 BJC conducted a controlled study. For 18 months the system tracked patients who contracted infections vs. those who didn't, and broke down their costs on a component basis. "Many times the cost of (treating) an infection is two to three times greater than normal treatment," Case says.
The costs of one surgical- site infection, for example, make sophisticated infection control suddenly sound very reasonable. "If you think a bedsore is gross, you should see a deep chest infection," Murphy says. The chest has to be reopened and the sternum debrided to get the infection out.
The excess cost is a minimum $20,000 per case and can easily hit $50,000-a year's salary for an infection-control nurse. Often a provider receives no extra reimbursement for treating the nosocomial infection. At those rates, it's easy to understand how BJC can project the cost savings from interventions against surgical-site infections at four of its hospitals at more than $2.1 million in 1997 and 1998.
Tracking infections, Case says, is like a detective story. You have to examine all the circumstances and analyze the clues that lead you to the root cause. A centralized infection-control SWAT team, as BJC refers to it, can bring a broad range of experience and education to a specific infection site, "whereas the on-site people may not have seen this specific type of bacteria in their environment."
The SWAT team intervention paid off in the Village North nursing home. In 1998 two patients were hospitalized as a result of the influenza outbreak. "This past season," Murphy reports, "they put all those interventions in place the minute they got their first case of influenza. They never got an outbreak." This time, not a single patient had to be hospitalized.