Economics and preventing hospital-acquired infection

To Analyze and Evaluate the Rate of Compliance of Hand Hygiene Practices in a Tertiary Care Hospital: Initiation of Quality Improvement Program and Clinical Audit

INTRODUCTION

Health care as a service organization is associated with hospital-acquired infection which is drawing attention. There are concerns raised by patients, attenders, stake holders, insurers, government agencies, and regulatory bodies. The study aims to evaluate the awareness and the rate of compliance with hand hygiene.

METHODS

The audit methodology implemented is a concurrent medical record audit. The period of the audit was conducted for 6 months. A random sampling method was incorporated. The sample size was determined as 20% of the staff had been involved.

RESULTS

The Total average level of awareness of hand hygiene and adherence to policy is 93.6%. The average of all the 3 categories of compliance at 5 levels of hand hygiene in percentage is 82.3%.

DISCUSSION

Hand hygiene practices if stringently implemented will minimize the cross-transmission of infection in health care facilities. By knowing the awareness level and compliance level are measured with standardized training modules.

APPLICATIONS

Create awareness on hand hygiene and provide training with respect to the effectiveness of implementation. Incorporate hand hygiene steps as well as in the audit process.

CONCLUSIONS

There is a requirement for training with respect to the effectiveness of the implementation of the techniques. The level of care and quality of services can be made better by incorporating quality improvement programs (QIPs). By regular audits, we can raise the service quality and benchmark it.

Topical Drug Delivery in the Treatment of Skin Wounds and Ocular Trauma Using the Platform Wound Device

Topical treatment of injuries such as skin wounds and ocular trauma is the favored route of administration. Local drug delivery systems can be applied directly to the injured area, and their properties for releasing therapeutics can be tailored. Topical treatment also reduces the risk of adverse systemic effects while providing very high therapeutic concentrations at the target site. This review article highlights the Platform Wound Device (PWD) (Applied Tissue Technologies LLC, Hingham, MA, USA) for topical drug delivery in the treatment of skin wounds and eye injuries. The PWD is a unique, single-component, impermeable, polyurethane dressing that can be applied immediately after injury to provide a protective dressing and a tool for precise topical delivery of drugs such as analgesics and antibiotics. The use of the PWD as a topical drug delivery platform has been extensively validated in the treatment of skin and eye injuries. The purpose of this article is to summarize the findings from these preclinical and clinical studies.

Evaluating the environmental microbiota across four National Health Service hospitals within England

Hospital surfaces contaminated with microbial soiling, such as dry surface biofilms (DSBs), can act as a reservoir for pathogenic micro-organisms, and inhibit their detection and removal during routine cleaning. Studies have recognized that such increases in bioburden can hinder the impact of disinfectants and mask the detection of potential pathogens. Cleanliness within healthcare settings is often determined through routine culture-based analysis, whereby surfaces that exhibit >2.5 colony-forming units (CFU) per cm² pose a risk to patient health; therefore, any underestimation could have detrimental effects. This study quantified microbial growth on high-touch surfaces in four hospitals in England over 19 months. This was achieved using environmental swabs to sample a variety of surfaces within close proximity of the patient, and plating these on to non-specific low nutrient detection agar. The presence of DSBs on surfaces physically removed from the environment was confirmed using real-time imaging through episcopic differential interference contrast microscopy combined with epifluorescence. Approximately two-thirds of surfaces tested exceeded the limit for cleanliness (median 2230 CFU/cm²), whilst 83% of surfaces imaged with BacLight LIVE/DEAD staining confirmed traces of biofilm. Differences in infection control methods, such as choice of surface disinfectants and cleaning personnel, were not reflected in the microbial variation observed and resulting risk to patients. This highlights a potential limitation in the effectiveness of the current standards for all hospital cleaning, and further development using representative clinical data is required to overcome this limitation.

Cost effectiveness of temporary isolation rooms in acute care settings in Singapore

Objectives

To estimate the change to health service costs and health benefits from a decision to adopt temporary isolation rooms that are effective at isolating the patient within a general ward environment. We assess the cost-effectiveness of a decision to adopt an existing temporary isolation room in a Singapore setting.

Method

We performed a model-based cost-effectiveness analysis to evaluate the impact of a decision to adopt temporary isolation rooms for infection prevention. We estimated changes to the costs from implementation, the number of cases of healthcare associated infection, acute care bed days used, they money value of bed days, the number of deaths, and the expected change to life years. We report the probability that adoption was cost-effective by the cost by life year gained, against a relevant threshold. Uncertainty is addressed with probabilistic sensitivity analysis and the findings are tested with plausible scenarios for the effectiveness of the intervention.

Results

We predict 478 fewer cases of HAI per 100,000 occupied bed days from a decision to adopt temporary isolation rooms. This will result in cost savings of $SGD329,432 and there are 1,754 life years gained. When the effectiveness of the intervention is set at 1% of cases of HAI prevented the incremental cost per life year saved is $16,519; below the threshold chosen for cost-effectiveness in Singapore.

Conclusions

We provide some evidence that adoption of a temporary isolation room is cost-effective for Singapore acute care hospitals. It is plausible that adoption is a positive decision for other countries in the region who may demonstrate fewer resources for infection prevention and control.

A study of clinical and economic burden of surgical site infection in patients undergoing caesarian section at a tertiary care teaching hospital in India

Background

Caesarian section is one of the most commonly performed surgeries in India. Determination of the incidence as well as the clinical and financial burden of post caesarian surgical site infection (SSI), is of critical importance for all the stakeholders for rational and fair allocation of resources.

Methods

This study was a prospective observational case-control study. The mean direct and indirect cost of treatment for the cases were compared with the control patients. An unpaired t-test was used to compare the mean between the two groups.

Results

Out of 2024 patients, who underwent caesarian section during the study period, 114 had acquired incisional surgical site infection (ISSI), with the infection incidence being 5.63%. The total cost of illness due to post caesarian ISSI was almost three times higher compared to the non-infected matched control group. (P<0.0001). An average length of hospital stay in the ISSI patient group was 10 days longer than that in the control group (P<0.0001) and importantly total length of antimicrobial therapy(LOT) in patients with ISSI was also almost three times higher than the control group (P<0.0001).

Conclusion

The development of post caesarian SSI imposes a significant clinical as well as a financial burden. The study highlights the necessity of taking effective preventive measures to decrease the incidence of SSI.

Evaluation of Patients' Adverse Events During Contact Isolation for Vancomycin-Resistant Enterococci Using a Matched Cohort Study With Propensity Score

IMPORTANCE

Although contact isolation has been widely recommended for multidrug-resistant organisms, contact isolation has raised some concerns that it may bring unintended patient harms.

OBJECTIVE

To compare adverse events between a contact isolation group with vancomycin-resistant Enterococcus (VRE) and a matched comparison group using a relatively large data set from full electronic medical records (EMR) and propensity score-matching methods.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, matched cohort study was conducted at Seoul National University Bundang Hospital (SNUBH) in Korea, a tertiary, university-affiliated hospital that has 1337 inpatient beds. Participants included a total of 98 529 hospitalized adult patients (aged ≥18 years) during 2015 to 2017.

EXPOSURES

Contact isolation in a single or shared double room.

MAIN OUTCOMES AND MEASURES

As adverse contact isolation-related outcomes, falls and pressure ulcers were included. All relevant EMR data were extracted from the SNUBH clinical data warehouse. Risk factors for adverse events were included in the propensity score model based on literature reviews, such as Braden scale score and Hendrich II fall risk score. A fine stratification and weighting (FSW) and a 1:10 nearest neighbor (NN) propensity score matching as a sensitivity analysis were adopted to compare adverse events between the 2 groups for the observation period from the study entry date and the exit date. Time-to-event analyses with a Cox proportional hazard model were conducted in December 2021.

RESULTS

For comparison of outcomes in wards, 177 patients (mean [SD] age, 67.38 [14.12] years; 98 [55.4%] female) with VRE and 93 022 patients (mean [SD] age, 56.44 [16.88] years; 49 462 [53.2%] female) without VRE were included and no difference was found in basic characteristics from the FSW (VRE contact isolation [n = 172] vs comparison [n = 69 434]) as well as from the 1:10 NN (VRE contact isolation [n = 168] vs comparison [n = 1650]). Among 177 patients with VRE contact isolation, 8 pressure ulcers and 3 falls occurred during their hospital stays; incidence rates of adverse events were 2.5 and 0.9 per 1000 patient-days, respectively (pressure ulcer incidence rate from the FSW: 2.53 per 1000 patient-days [95% CI, 1.09-4.99 per 1000 patient-days]; pressure ulcer incidence rate from the 1:10 NN: 2.54 per 1000 patient-days [95% CI, 1.10-5.01 per 1000 patient-days]; fall incidence rate from the FSW: 0.87 per 1000 patient-days [95% CI, 0.18-2.54 per 1000 patient-days]; fall incidence rate from the 1:10 NN: 0.87 per 1000 patient-days [95% CI, 0.18-2.55 per 1000 patient-days]). The hazard ratios for adverse events showed no statistically significant differences for both groups: 1.42 (95% CI, 0.67-2.99) for pressure ulcer and 0.66 (95% CI, 0.20-2.13) for fall from the FSW.

CONCLUSIONS AND RELEVANCE

In this cohort study, no association was found between the likelihood of adverse events and contact isolation using propensity score-matching methods and closely related covariates for adverse events.

The cost-effectiveness of temporary single-patient rooms to reduce risks of healthcare-associated infection

BACKGROUND

The use of single rooms for patient isolation often forms part of a wider bundle to prevent certain healthcare-associated infections (HAIs) in hospitals. Demand for single rooms often exceeds what is available and the use of temporary isolation rooms may help resolve this. Changes to infection prevention practice should be supported by evidence showing that cost-effectiveness is plausible and likely.

AIM

To perform a cost-effectiveness evaluation of adopting temporary single rooms into UK National Health Service (NHS) hospitals.

METHODS

The cost-effectiveness of a decision to adopt a temporary, single-patient, isolation room to the current infection prevention efforts of an NHS hospital was modelled. Primary outcomes are the expected change to total costs and life-years from an NHS perspective.

FINDINGS

The mean expected incremental cost per life-year gained (LYG) is £5,829. The probability that adoption is cost-effective against a £20,000 threshold per additional LYG is 93%, and for a £13,000 threshold the probability is 87%. The conclusions are robust to scenarios for key model parameters. If a temporary single-patient isolation room reduces risks of HAI by 16.5% then an adoption decision is more likely to be cost-effective than not. Our estimate of the effectiveness reflects guidelines and reasonable assumptions and the theoretical rationale is strong.

CONCLUSION

Despite uncertainties about the effectiveness of temporary isolation rooms for reducing risks of HAI, there is some evidence that an adoption decision is likely to be cost-effective for the NHS setting. Prospective studies will be useful to reduce this source of uncertainty.

Estimating the excess bed days and economic burden of healthcare-associated infections in Singapore public acute-care hospitals

We estimated the annual bed days lost and economic burden of healthcare-associated infections to Singapore hospitals using Monte Carlo simulation. The mean (standard deviation) cost of a single healthcare-associated infection was S$1,809 (S$440) [or US$1,362 (US$331)]. This translated to annual lost bed days and economic burden of 55,978 (20,506) days and S$152.0 million (S$37.1 million) [or US$114.4 million (US$27.9 million)], respectively.

The Clinical and Economic Burden of Norovirus Gastroenteritis in the United States

BACKGROUND

Although norovirus outbreaks periodically make headlines, it is unclear how much attention norovirus may receive otherwise. A better understanding of the burden could help determine how to prioritize norovirus prevention and control.

METHODS

We developed a computational simulation model to quantify the clinical and economic burden of norovirus in the United States.

RESULTS

A symptomatic case generated $48 in direct medical costs, $416 in productivity losses ($464 total). The median yearly cost of outbreaks was $7.6 million (range across years, $7.5-$8.2 million) in direct medical costs, and $165.3 million ($161.1-$176.4 million) in productivity losses ($173.5 million total). Sporadic illnesses in the community (incidence, 10-150/1000 population) resulted in 14 118-211 705 hospitalizations, 8.2-122.9 million missed school/work days, $0.2-$2.3 billion in direct medical costs, and $1.4-$20.7 billion in productivity losses ($1.5-$23.1 billion total). The total cost was $10.6 billion based on the current incidence estimate (68.9/1000).

CONCLUSION

Our study quantified norovirus' burden. Of the total burden, sporadic cases constituted >90% (thus, annual burden may vary depending on incidence) and productivity losses represented 89%. More than half the economic burden is in adults ≥45, more than half occurs in winter months, and >90% of outbreak costs are due to person-to-person transmission, offering insights into where and when prevention/control efforts may yield returns.

Urinary tract infection in patients with hip fracture

INTRODUCTION

Urinary tract infection (UTI) is a frequent complication of hip fractures. The Danish national clinical guideline for hip fracture recommends early and systematic mobilisation after surgery and that indwelling catheters are not used perioperatively.

AIMS

The aim of this study was to describe the number of patients who received nursing care to prevent UTIs in accordance with the recommendations from the national Danish clinical guidelines. Specifically, the aim was to report the number of patients developing UTIs during admission, have indwelling catheters removed and being mobilised with 24 hours after surgery.

METHODS

This prospective study included 65 patients. Data were collected on mobilisation and catheter use with a chart designed for this study. Sterile intermittent catheterisation was used to collect urine samples on admission and at discharge. Urine samples were sent for analysis at the microbiology laboratory. The urine sample was positive for UTI if the test showed 10⁴ CFU/ml bacteria.

RESULTS

A total of five patients contracted nosocomial UTI during their hospital stay (7.7%), while 29.2% of patients had a positive urine culture on admission and were treated for UTI. At discharge, 20% of the patients had a positive urine sample but no symptoms. Postoperatively, 52.3% of the patients were mobilised within 24 hours.

CONCLUSION

The incidence of nosocomial UTI was similar to what has been found in other studies (95% [CI], 0.03-0.17]). The percentage of patients with nosocomial UTI was 7.7%. Nursing care related to hygienic performance of catheterisation or intermittent catheterisation adhered to the Danish national clinical guidelines, and 52.3% of the patients were mobilised within 24 h after surgery, which showed low adherence to the guidelines.

How Long-Term Acute Care Hospitals Can Play an Important Role in Controlling Carbapenem-Resistant Enterobacteriaceae in a Region: A Simulation Modeling Study

Typically, long-term acute care hospitals (LTACHs) have less experience in and incentives to implementing aggressive infection control for drug-resistant organisms such as carbapenem-resistant Enterobacteriaceae (CRE) than acute care hospitals. Decision makers need to understand how implementing control measures in LTACHs can impact CRE spread regionwide. Using our Chicago metropolitan region agent-based model to simulate CRE spread and control, we estimated that a prevention bundle in only LTACHs decreased prevalence by a relative 4.6%-17.1%, averted 1,090-2,795 new carriers, 273-722 infections and 37-87 deaths over 3 years and saved $30.5-$69.1 million, compared with no CRE control measures. When LTACHs and intensive care units intervened, prevalence decreased by a relative 21.2%. Adding LTACHs averted an additional 1,995 carriers, 513 infections, and 62 deaths, and saved $47.6 million beyond implementation in intensive care units alone. Thus, LTACHs may be more important than other acute care settings for controlling CRE, and regional efforts to control drug-resistant organisms should start with LTACHs as a centerpiece.

The impact of healthcare associated infections on mortality and length of stay in Singapore-A time-varying analysis

OBJECTIVE

Methods that include the time-varying nature of healthcare-associated infections (HAIs) avoid biases when estimating increased risk of death and excess length of stay. We determined the excess mortality risk and length of stay associated with HAIs among inpatients in Singapore using a multistate model that accommodates the timing of key events.

DESIGN

Analysis of existing prospective cohort study data.

SETTING

Seven public acute-care hospitals in Singapore.

PATIENTS

Inpatients reviewed in a HAI point-prevalence survey (PPS) conducted between June 2015 and February 2016.

METHODS

We modeled each patient's admission over time using 4 states: susceptible with no HAI, infected, died, and discharged alive. We estimated the excess mortality risk and length of stay associated with HAIs, with adjustment for the baseline characteristics between the groups for mortality risk.

RESULTS

We included 4,428 patients, of whom 469 had ≥1 HAI. Using a multistate model, the expected excess length of stay due to any HAI was 1.68 days (95% confidence interval [CI], 1.15-2.21 days). Surgical site infections were associated with the longest excess length of stay of 4.68 days (95% CI, 2.60-6.76 days). After adjusting for baseline differences, HAIs were associated with increased hazards of in-hospital mortality (adjusted hazard ratio [aHR], 1.32; 95% CI, 1.09-1.65) and decreased hazards in being discharged (aHR, 0.75; 95% CI, 0.67-0.84).

CONCLUSIONS

HAIs are associated with increased length of hospital stay and mortality in hospitalized patients. Avoiding nosocomial infections can improve patient outcomes and free valuable bed days.

Cost-effectiveness of an Environmental Cleaning Bundle for Reducing Healthcare-associated Infections

BACKGROUND

Healthcare-associated infections (HAIs) remain a significant patient safety issue, with point prevalence estimates being ~5% in high-income countries. In 2016-2017, the Researching Effective Approaches to Cleaning in Hospitals (REACH) study implemented an environmental cleaning bundle targeting communication, staff training, improved cleaning technique, product use, and audit of frequent touch-point cleaning. This study evaluates the cost-effectiveness of the environmental cleaning bundle for reducing the incidence of HAIs.

METHODS

A stepped-wedge, cluster-randomized trial was conducted in 11 hospitals recruited from 6 Australian states and territories. Bundle effectiveness was measured by the numbers of Staphylococcus aureus bacteremia, Clostridium difficile infection, and vancomycin-resistant enterococci infections prevented in the intervention phase based on estimated reductions in the relative risk of infection. Changes to costs were defined as the cost of implementing the bundle minus cost savings from fewer infections. Health benefits gained from fewer infections were measured in quality-adjusted life-years (QALYs). Cost-effectiveness was evaluated using the incremental cost-effectiveness ratio and net monetary benefit of adopting the cleaning bundle over existing hospital cleaning practices.

RESULTS

Implementing the cleaning bundle cost $349 000 Australian dollars (AUD) and generated AUD$147 500 in cost savings. Infections prevented under the cleaning bundle returned a net monetary benefit of AUD$1.02 million and an incremental cost-effectiveness ratio of $4684 per QALY gained. There was an 86% chance that the bundle was cost-effective compared with existing hospital cleaning practices.

CONCLUSIONS

A bundled, evidence-based approach to improving hospital cleaning is a cost-effective intervention for reducing the incidence of HAIs.

Could the prevention of health care-associated infections increase hospital cost? The financial impact of health care-associated infections from a hospital management perspective

BACKGROUND

The financial burden health care-associated infections (HAIs) have on patients, payers, and hospitals is not clear. Although patient safety is the highest priority, administrators require data to justify the expense of HAI reduction programs.

METHODS

Chart review was performed to identify HAIs for patients discharged from Stanford Hospital. Using a t test, we tested whether patients with an HAI will have a different daily total hospital cost and length of stay than patients without an HAI. We calculated the change in hospital profit related to HAIs by comparing patients with and without an HAI in the same admit All-Patient Refined Diagnosis Related Group and complexity score.

RESULTS

Between October 1, 2015 and September 30, 2018, there were 78,551 inpatient discharges and 1,541 HAIs identified. Daily total hospital cost and length of stay for patients with an HAI versus patients without an HAI was $6,433 ($6,251, $6,615) versus $6,604 ($6,557, $6,651) (P = .073), and 26.30 days (24.89, 27.71) versus 5.69 (5.64, 5.74) (P < .001).

DISCUSSION

For each HAI eliminated, data suggests that hospital's cost and revenue would increase $25,008 and $1,518,682, respectively, by backfilling beds with new patients at a 4.62:1 ratio. The reduction of HAIs is profitable for hospitals.

CONCLUSIONS

Data from this study suggest that the more HAIs you eliminate and the more capacity you build for the hospital, the higher the total hospital costs will go. This is an essential shift to the current paradigm that will allow for the accurate and continued funding of HAI reduction programs. Although hospital cost appears to increase as HAIs are reduced, hospital profits rise even more.

HIV-associated comorbidities as mediators of the association between people living with HIV and hospital-acquired infections

BACKGROUND

Hospital-acquired infections (HAIs) lead to poor health outcomes in hospitalized patients and may be disproportionately affecting the aging population of people living with HIV (PLWH). This study determined the association between HIV and HAIs, and analyzed the potential mediating effects of comorbidities.

METHODS

The Louisiana Hospital Inpatient Discharge Database for the years 2011-2015 was used. All patients with at least 1 HAI diagnosis within this source population were included as cases in the case-control study, and a 1:1 ratio of controls was randomly selected from the same hospitals.

RESULTS

Of the 1,852,769 eligible hospital discharges that occurred from 2011 through 2015, there were 7,422 patients with at least 1 HAI. Marginal logistic regressions of the case-control sample showed a strong association between HIV and central line-associated bloodstream infections (CLABSIs), but an inverse association between HIV and any HAI. However, the mediation analyses revealed that having at least 1 comorbidity mediates the association between HIV and CLABSIs.

DISCUSSION

The unexpected inverse association between HIV and HAI could be attributed to the sample size of the exposed group of patients, or it could be explained by the mechanisms of treatment for HIV patients.

CONCLUSIONS

This study found that people living with HIV are at an increased risk of developing a CLABSI, which is consistent with the published literature. The mediation analyses indicated that having at least 1 comorbidity mediated the association between HIV and CLABSI diagnosis.

Point prevalence surveys of health-care-associated infections: a systematic review

Health-care-associated infections (HAIs) are considered a serious public health issues that contribute substantially to the global burden of mortality and morbidity with respect to infectious diseases. The aim is to assess the burden of health-care-associated infections by collation of available data from published point prevalence surveys (PPS) on HAIs to give future guidance. Study protocol and methodology were designed according to preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Published research papers that conducted a point prevalence survey of HAIs in hospital settings by following the structured survey methodology employed by European Centre of Disease Prevention and Control (ECDC) were included. Of 1212 articles, 67 studies were included in the final analysis conducted across different countries. Overall, 35 studies were conducted in Europe, 21 in Asia, 9 in America, and 2 in Africa. The highest prevalence of HAIs was recorded in a study conducted in adult ICU settings of 75 regions of Europe (51.3%). The majority of the studies included HAI data on urinary tract infections, respiratory tract infections, and bloodstream infections. Klebsiella pneumonia, Pseudomonas aeruginosa and E. coli were the most frequent pathogens responsible for HAIs. PPS is an useful tool to quantify HAIs and provides a robust baseline data for policymakers. However, a standardize surveillance method is required. In order to minimize the burden of HAIs, infection prevention and control programs and antibiotic stewardship may be effective strategies to minimize the risk of HAIs.

A single-arm study to evaluate skin tolerance, effectiveness and adherence to use of an alcohol-based hand rub solution among hospital nurses

Background:

Hand hygiene is considered as the most important strategy for preventing healthcare infections.

Objective:

In this single-arm study, skin tolerance, effectiveness and prolonged efficacy, and adherence to use an alcohol-based hand rub (ABHR) solution among hospital nurses was evaluated.

Methods:

Nurses were recruited in the main hospital of Molise Region, Central Italy. Skin reactions during 12-week follow-up were self-reported by nurses and, when occurring examined by hospital dermatologist. Samples were collected from palms and fingertips before and after ABHR, also at random times during work.

Results:

Dermatological reactions were not reported by 20 nurses (15 female and 5 male, aged 30–59 years) after product use. Microbial counts decreased by 99% (2Log10) in 75%, with higher reduction in palm than fingertips (99% vs 70% respectively). Analysis of six randomly collected samples after 10–20 and 30–40 min from the last use showed a satisfactory prolonged efficacy.

Discussion:

Beyond high effectiveness to reduce transient microbiota, no skin reactions were observed, likely due to the camomile, thyme and eucalyptus extracts contained within the gel. This study, addressing technical questions of a commercialised product, provides useful information for public health authorities faced with a choice of hand disinfectants, evaluating cost-effectiveness and cost-benefit in the light of the huge amount of these products needed at hospital level.

Development and pilot of a multicriteria decision analysis (MCDA) tool for health services administrators

INTRODUCTION

Health administration is complex and serves many masters. Value, quality, infrastructure and reimbursement are just a sample of the competing interests influencing executive decision-making. This creates a need for decision processes that are rational and holistic.

METHODS

We created a multicriteria decision analysis tool to evaluate six fields of healthcare provision: return on investment, capacity, outcomes, safety, training and risk. The tool was designed for prospective use, at the beginning of each funding round for competing projects. Administrators were asked to rank their criteria in order of preference. Each field was assigned a representative weight determined from the rankings. Project data were then entered into the tool for each of the six fields. The score for each field was scaled as a proportion of the highest scoring project, then weighted by preference. We then plotted findings on a cost-effectiveness plane. The project was piloted and developed over successive uses by the hospital's executive board.

RESULTS

Twelve projects competing for funding at the Royal Brisbane and Women's Hospital were scored by the tool. It created a priority ranking for each initiative based on the weights assigned to each field by the executive board. Projects were plotted on a cost-effectiveness plane with score as the x-axis and cost of implementation as the y-axis. Projects to the bottom right were considered dominant over projects above and to the left, indicating that they provided greater benefit at a lower cost. Projects below the x-axis were cost-saving and recommended provided they did not harm patients. All remaining projects above the x-axis were then recommended in order of lowest to highest cost-per-point scored.

CONCLUSION

This tool provides a transparent, objective method of decision analysis using accessible software. It would serve health services delivery organisations that seek to achieve value in healthcare.

Chlorhexidine versus saline in reducing the risk of catheter associated urinary tract infection: A cost-effectiveness analysis

BACKGROUND

Catheter associated urinary tract infections are one of the most common infections acquired in hospital. A recent randomised control study demonstrated the benefit of using chlorhexidine (0.1%) for meatal cleaning prior to urinary catheter insertion, by reducing both catheter associated asymptomatic bacteriuria and infection. These findings raise the important question of whether a decision to switch from saline to chlorhexidine was likely to be cost-effective. The aim of this paper was to evaluate the cost-effectiveness of adopting routine use of chlorhexidine for meatal cleaning prior to urinary catheter insertion METHODS: The outcomes of this cost-effectiveness study are changes to health service costs in $AUD and changes to quality adjusted life years from a decision to adopt 0.1% chlorhexidine for meatal cleaning prior to urinary catheter insertion as compared to saline. Effectiveness outcomes for this study were taken from a 32 week stepped wedge randomised controlled study conducted in three Australian hospitals.

RESULTS

The changes in health costs from switching from saline to 0.1% chlorhexidine per 100,000 catheterisations would save hospitals AUD$387,909 per 100,000 catherisations, prevent 70 cases of catheter associated urinary tract infections, release 282 bed days and provide a small improvement in health benefits of 1.43 quality adjusted life years. Using a maximum willingness to pay for a marginal quality adjusted life year threshold of AUD$28,000 per 100,000 catherisations, suggests that adopting chlorhexidine would be cost effective and potentially cost-saving.

CONCLUSION

The findings from our work provide evidence to health system administrators and those responsible for drafting catheter associated urinary tract infections prevention guidelines that investing in switching from saline to chlorhexidine is not only clinically effective but also a sensible decision in the context of allocating finite healthcare resources.

Combining dietary phenolic antioxidants with polyvinylpyrrolidone: transparent biopolymer films based on p-coumaric acid for controlled release

Polyvinylpyrrolidone (PVP) has probably been one of the most utilized pharmaceutical polymers with applications ranging from a blood plasma substitute to nanoparticle drug delivery, since its synthesis in 1939. It is a highly biocompatible, non-toxic and transparent film forming polymer. Although high solubility of PVP in aqueous environment is advantageous, it still poses several problems for some applications in which sustained targeting and release are needed or hydrophobic drug inclusion and delivery systems are to be designed. In this study, we demonstrate that a common dietary phenolic antioxidant, p-coumaric acid (PCA), can be combined with PVP covering a wide range of molar ratios by solution blending in ethanol, forming new transparent biomaterial films with antiseptic and antioxidant properties. PCA not only acts as an effective natural plasticizer but also establishes H-bonds with PVP increasing its resistance to water dissolution. PCA could be released in a sustained manner up to a period of 3 days depending on the PVP/PCA molar ratio. Sustained drug delivery potential of the films was studied using methylene blue and carminic acid as model drugs, indicating that the release can be controlled. Antioxidant and remodeling properties of the films were evaluated in vitro by free radical cation scavenging assay and in vivo on a murine model, respectively. Furthermore, the material resorption of films was slower as PCA concentration increased, as observed from the in vivo full-thickness excision model. Finally, the antibacterial activity of the films against common pathogens such as Escherichia coli and Staphylococcus aureus and the effective reduction of inflammatory agents such as matrix metallopeptidases were demonstrated. All these properties suggest that these new transparent PVP/PCA films can find a plethora of applications in pharmaceutical sciences including skin and wound care.

ROS mediated antibacterial activity of photoilluminated riboflavin: A photodynamic mechanism against nosocomial infections

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Riboflavin undergoes intersystem conversion under photoillumination.

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Interacts with molecular oxygen and generates ROS.

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Generated ROS disrupts E. coli cell membranes.

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Ultimately killing E. coli.

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Mechanism can be used to kill E. coli on hospital ware causing nosocomial infections.

Nosocomial infections are a major threat to modern therapeutics. The major causative agent of these infections is multidrug-resistant gram-negative bacteria, which impart high morbidity and mortality rate. This has led to an urge for the development of new antibiotics. Antimicrobial photodynamic therapy is a promising strategy to which till date no resistant strain has been reported. Since the efficacy of photodynamic therapy largely depends on the selection and administration of an appropriate photosensitizer, therefore, the realization of clinically active photosensitizers is an immediate need. Here, by using E. coli as a study model we have demonstrated the antimicrobial photodynamic potential of riboflavin. Intracellular ROS formation by DCFH-DA assay, lipid peroxidation, protein carbonylation, LDH activity was measured in treated bacterial samples. Enzymatic (SOD, CAT, GSH) antioxidants and non-enzymatic (GSH) was further evaluated. Bacterial death was confirmed by colony forming assay, optical microscopy and scanning electron microscopy. The treated bacterial cells exhibited abundant ROS generation and marked increment in the level of oxidative stress markers as well as significant reduction in LDH activity. Marked reduction in colony forming units was also observed. Optical microscopic and SEM images further confirmed the bacterial death. Thus, we can say that photoilluminated riboflavin renders the redox status of bacterial cells into a compromised state leading to significant membrane damage ultimately causing bacterial death. This study aims to add one more therapeutic dimension to photoilluminated riboflavin as it can be effectively employed in targeting bacterial biofilms occurring on hospital wares causing several serious medical conditions.

Assessing the opportunity costs of patients with multidrug-resistant organisms in hospitals

OBJECTIVES

The concept of opportunity cost can be applied to the utilization of hospital beds with special focus on patients colonized or infected with multidrug-resistant organisms. Blocked beds due to isolation measures or increased length of stay may result in opportunity costs if newly arriving patients have to be rejected and the hospital is confronted with revenue foregone. However, the amount of these costs is unclear, since different approaches are used in the literature to determine the respective costs. Our paper develops a concept to assess opportunity costs from the perspective of a hospital.

METHODS

The analysis is two-stage. In a first step, the probability of rejecting a patient due to over-occupancy in a hospital is calculated with a queuing model and a Monte Carlo simulation taking various assumptions into account. In a second step, the amount of the opportunity costs is calculated as an expected value applying a stochastic approach based on a potential patient pool.

RESULTS

Opportunity costs will occur only with a probability that is influenced, among others, by current bed occupancy rates. They have to be measured by average net revenue foregone, i.e., by the difference between average revenue foregone and average costs avoided.

CONCLUSIONS

Previous studies have a tendency of overestimating the occurrence or the size of opportunity costs with regard to the use of hospital beds. Nonetheless, its influence on the hospital budget is crucial and should be determined exactly.

Economic evaluation of interventions designed to reduce Clostridium difficile infection

INTRODUCTION

Healthcare decision-makers are increasingly expected to balance increasing demand for health services with a finite budget. The role of economic evaluation in healthcare is increasing and this research provides decision-makers with new information about the management of Clostridium difficile infection, from an economic perspective.

METHODS

A model-based economic evaluation was undertaken to identify the most cost-effective healthcare intervention relating to the reduction of Clostridium difficile transmission. Efficacy evidence was synthesised from the literature and was used to inform the effectiveness of both bundled approaches and stand-alone interventions, where appropriate intervention combinations were coupled together. Changes in health outcomes were estimated by combining information about intervention effectiveness and its subsequent impact on quality of life.

RESULTS

A bundled approach of improving hand hygiene and environmental cleaning produces the best combination of increased health benefits and cost-savings. It has the highest mean net monetary benefit when compared to all other interventions. This intervention remains the optimal decision under different clinical circumstances, such as when mortality rate and patient length of stay are increased. Bundled interventions offered the best opportunity for health improvements.

CONCLUSION

These findings provide healthcare decision-makers with novel information about the allocation of scarce resources relating to Clostridium difficile. If investments are not made in interventions that clearly yield gains in health outcomes, the allocation and use of scarce healthcare resources is inappropriate and improvements in health outcomes will be forgone.

An Effective Surrogate Tracer Technique for S. aureus Bioaerosols in a Mechanically Ventilated Hospital Room Replica Using Dilute Aqueous Lithium Chloride

Finding a non-pathogenic surrogate aerosol that represents the deposition of typical bioaerosols in healthcare settings is beneficial from the perspective of hospital facility testing, general infection control and outbreak analysis. This study considers aerosolization of dilute aqueous lithium chloride (LiCl) and sodium chloride (NaCl) solutions as surrogate tracers capable of representing Staphylococcus aureus bioaerosol deposition on surfaces in mechanically ventilated rooms. Tests were conducted in a biological test chamber set up as a replica hospital single patient room. Petri dishes on surfaces were used to collect the Li, Na and S. aureus aerosols separately after release. Biological samples were analyzed using cultivation techniques on solid media, and flame atomic absorption spectroscopy was used to measure Li and Na atom concentrations. Spatial deposition distribution of Li tracer correlated well with S. aureus aerosols (96% of pairs within a 95% confidence interval). In the patient hospital room replica, results show that the most contaminated areas were on surfaces 2 m away from the source. This indicates that the room’s airflow patterns play a significant role in bioaerosol transport. NaCl proved not to be sensitive to spatial deposition patterns. LiCl as a surrogate tracer for bioaerosol deposition was most reliable as it was robust to outliers, sensitive to spatial heterogeneity and found to require less replicates than the S. aureus counterpart to be in good spatial agreement with biological results.

Effects of operational decisions on the diffusion of epidemic disease: A system dynamics modeling of the MERS-CoV outbreak in South Korea

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Development of a macro-level health system dynamics model.

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Performance measurements of epidemic disease diffusion and patient-care performance from an operational perspective.

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Comparison of economic and optimal patient room design performance under different infectivity scenarios.

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Comparison of secondary infection outcomes under different ER occupancy circumstances.

We evaluated the nosocomial outbreak of Middle East Respiratory Syndrome (MERS) Coronavirus (CoV) in the Republic of Korea, 2015, from a healthcare operations management perspective. Establishment of healthcare policy in South Korea provides patients’ freedom to select and visit multiple hospitals. Current policy enforces hospitals preference for multi-patient rooms to single-patient rooms, to lower financial burden. Existing healthcare systems tragically contributed to 186 MERS outbreak cases, starting from single “index patient” into three generations of secondary infections. By developing a macro-level health system dynamics model, we provide empirical knowledge to examining the case from both operational and financial perspectives. In our simulation, under base infectivity scenario, high emergency room occupancy circumstance contributed to an estimated average of 101 (917%) more infected patients, compared to when in low occupancy circumstance. Economic patient room design showed an estimated 702% increase in the number of infected patients, despite the overall 98% savings in total expected costs compared to optimal room design. This study provides first time, system dynamics model, performance measurements from an operational perspective. Importantly, the intent of this study was to provide evidence to motivate public, private, and government healthcare administrators’ recognition of current shortcomings, to optimize performance as a whole system, rather than mere individual aspects.

The health and economic burden of bloodstream infections caused by antimicrobial-susceptible and non-susceptible Enterobacteriaceae and Staphylococcus aureus in European hospitals, 2010 and 2011: a multicentre retrospective cohort study

We performed a multicentre retrospective cohort study including 606,649 acute inpatient episodes at 10 European hospitals in 2010 and 2011 to estimate the impact of antimicrobial resistance on hospital mortality, excess length of stay (LOS) and cost. Bloodstream infections (BSI) caused by third-generation cephalosporin-resistant Enterobacteriaceae (3GCRE), meticillin-susceptible (MSSA) and -resistant Staphylococcus aureus (MRSA) increased the daily risk of hospital death (adjusted hazard ratio (HR) = 1.80; 95% confidence interval (CI): 1.34–2.42, HR = 1.81; 95% CI: 1.49–2.20 and HR = 2.42; 95% CI: 1.66–3.51, respectively) and prolonged LOS (9.3 days; 95% CI: 9.2–9.4, 11.5 days; 95% CI: 11.5–11.6 and 13.3 days; 95% CI: 13.2–13.4, respectively). BSI with third-generation cephalosporin-susceptible Enterobacteriaceae (3GCSE) significantly increased LOS (5.9 days; 95% CI: 5.8–5.9) but not hazard of death (1.16; 95% CI: 0.98–1.36). 3GCRE significantly increased the hazard of death (1.63; 95% CI: 1.13–2.35), excess LOS (4.9 days; 95% CI: 1.1–8.7) and cost compared with susceptible strains, whereas meticillin resistance did not. The annual cost of 3GCRE BSI was higher than of MRSA BSI. While BSI with S. aureus had greater impact on mortality, excess LOS and cost than Enterobacteriaceae per infection, the impact of antimicrobial resistance was greater for Enterobacteriaceae.

Making change easy: A peer-to-peer guide on transitioning to new hand hygiene products

This report summarizes our experiences planning and implementing the transition to a new commercial line of hand hygiene products and their dispensing systems in a large academic health care facility in Toronto, Canada. Our lessons learned are organized into a practical guide made available in 2 different formats: this article and an illustrated peer-to-peer guide (http://www.baycrest.org/wp-content/uploads/HCE-PROG-HH_HighQuality.pdf).

Potential economic burden of carbapenem-resistant Enterobacteriaceae (CRE) in the United States

OBJECTIVES

The Centers for Disease Control and Prevention considers carbapenem-resistant Enterobacteriaceae (CRE) an urgent public health threat; however, its economic burden is unknown.

METHODS

We developed a CRE clinical and economics outcomes model to determine the cost of CRE infection from the hospital, third-party payer, and societal, perspectives and to evaluate the health and economic burden of CRE to the USA.

RESULTS

Depending on the infection type, the median cost of a single CRE infection can range from $22 484 to $66 031 for hospitals, $10 440 to $31 621 for third-party payers, and $37 778 to $83 512 for society. An infection incidence of 2.93 per 100 000 population in the USA (9418 infections) would cost hospitals $275 million (95% CR $217-334 million), third-party payers $147 million (95% CR $129-172 million), and society $553 million (95% CR $303-1593 million) with a 25% attributable mortality, and would result in the loss of 8841 (95% CR 5805-12 420) quality-adjusted life years. An incidence of 15 per 100 000 (48 213 infections) would cost hospitals $1.4 billion (95% CR $1.1-1.7 billion), third-party payers $0.8 billion (95% CR $0.6-0.8 billion), and society $2.8 billion (95% CR $1.6-8.2 billion), and result in the loss of 45 261 quality-adjusted life years.

CONCLUSIONS

The cost of CRE is higher than the annual cost of many chronic diseases and of many acute diseases. Costs rise proportionally with the incidence of CRE, increasing by 2.0 times, 3.4 times, and 5.1 times for incidence rates of 6, 10, and 15 per 100 000 persons.

Positive impact of infection prevention on the management of nosocomial outbreaks at an academic hospital

Aim: Infection prevention (IP) measures are vital to prevent (nosocomial) outbreaks. Financial evaluations of these are scarce. An incremental cost analysis for an academic IP unit was performed. Material & methods: On a yearly basis, we evaluated: IP measures; costs thereof; numbers of patients at risk for causing nosocomial outbreaks; predicted outbreak patients; and actual outbreak patients. Results: IP costs rose on average yearly with €150,000; however, more IP actions were undertaken. Numbers of patients colonized with high-risk microorganisms increased. The trend of actual outbreak patients remained stable. Predicted prevented outbreak patients saved costs, leading to a positive return on investment of 1.94. Conclusion: This study shows that investments in IP can prevent outbreak cases, thereby saving enough money to earn back these investments.

Economic burden of antibiotic treatment of healthcare-associated infections at a tertiary care hospital ICU in Goa, India

Antibiotics to treat healthcare-associated infections (HCAIs) contribute to a substantial proportion of drug expenditure in intensive care units (ICUs). Our study aimed to determine the common HCAIs in our hospital ICU, to assess the antibiotics prescribed and the mean antibiotic cost per HCAI. All adult patients, admitted to the ICU over a 1-year period, were included in the study. HCAIs were determined according to CDC definition. The incidence of HCAIs in the ICU was 16%. Ventilator associated pneumonia (50%) was the most common HCAI, followed by urinary tract infection (35.6%). The total cost of antibiotic treatment for HCAIs in ICU over a 1-year period was approximately Rs. 2 million (US$32,000); the mean antibiotic cost per HCAI was calculated as Rs. 17,000 (US$255). HCAIs in the ICU thus put a significant economic burden on the patient and the healthcare network and should be prevented by implementing recommended infection control guidelines.

An Economic Model: Value of Antimicrobial-Coated Sutures to Society, Hospitals, and Third-Party Payers in Preventing Abdominal Surgical Site Infections

Background

While the persistence of high surgical site infection (SSI) rates has prompted the advent of more expensive sutures that are coated with antimicrobial agents to prevent SSIs, the economic value of such sutures has yet to be determined.

Methods

Using TreeAge Pro, we developed a decision analytic model to determine the cost-effectiveness of using antimicrobial sutures in abdominal incisions from the hospital, third-party payer, and societal perspectives. Sensitivity analyses systematically varied the risk of developing an SSI (range, 5%–20%), the cost of triclosan-coated sutures (range, $5–$25/inch), and triclosan-coated suture efficacy in preventing infection (range, 5%–50%) to highlight the range of costs associated with using such sutures.

Results

Triclosan-coated sutures saved $4,109–$13,975 (hospital perspective), $4,133–$14,297 (third-party payer perspective), and $40,127–$53,244 (societal perspective) per SSI prevented, when a surgery had a 15% SSI risk, depending on their efficacy. If the SSI risk was no more than 5% and the efficacy in preventing SSIs was no more than 10%, triclosan-coated sutures resulted in extra expenditure for hospitals and third-party payers (resulting in extra costs of $1,626 and $1,071 per SSI prevented for hospitals and third-party payers, respectively; SSI risk, 5%; efficacy, 10%).

Conclusions

Our results suggest that switching to triclosan-coated sutures from the uncoated sutures can both prevent SSIs and save substantial costs for hospitals, third-party payers, and society, as long as efficacy in preventing SSIs is at least 10% and SSI risk is at least 10%.

Researching effective approaches to cleaning in hospitals: protocol of the REACH study, a multi-site stepped-wedge randomised trial

Background

The Researching Effective Approaches to Cleaning in Hospitals (REACH) study will generate evidence about the effectiveness and cost-effectiveness of a novel cleaning initiative that aims to improve the environmental cleanliness of hospitals. The initiative is an environmental cleaning bundle, with five interdependent, evidence-based components (training, technique, product, audit and communication) implemented with environmental services staff to enhance hospital cleaning practices.

Methods/design

The REACH study will use a stepped-wedge randomised controlled design to test the study intervention, an environmental cleaning bundle, in 11 Australian hospitals. All trial hospitals will receive the intervention and act as their own control, with analysis undertaken of the change within each hospital based on data collected in the control and intervention periods. Each site will be randomised to one of the 11 intervention timings with staggered commencement dates in 2016 and an intervention period between 20 and 50 weeks. All sites complete the trial at the same time in 2017. The inclusion criteria allow for a purposive sample of both public and private hospitals that have higher-risk patient populations for healthcare-associated infections (HAIs). The primary outcome (objective one) is the monthly number of Staphylococcus aureus bacteraemias (SABs), Clostridium difficile infections (CDIs) and vancomycin resistant enterococci (VRE) infections, per 10,000 bed days. Secondary outcomes for objective one include the thoroughness of hospital cleaning assessed using fluorescent marker technology, the bio-burden of frequent touch surfaces post cleaning and changes in staff knowledge and attitudes about environmental cleaning. A cost-effectiveness analysis will determine the second key outcome (objective two): the incremental cost-effectiveness ratio from implementation of the cleaning bundle.

The study uses the integrated Promoting Action on Research Implementation in Health Services (iPARIHS) framework to support the tailored implementation of the environmental cleaning bundle in each hospital.

Discussion

Evidence from the REACH trial will contribute to future policy and practice guidelines about hospital environmental cleaning. It will be used by healthcare leaders and clinicians to inform decision-making and implementation of best-practice infection prevention strategies to reduce HAIs in hospitals.

Trial registration

Australia New Zealand Clinical Trial Registry ACTRN12615000325505

Efficacy of commercially available wipes for disinfection of pulse oximeter sensors

BACKGROUND

This study examined the effectiveness of commercially available disinfecting wipes and cosmetic wipes in disinfecting pulse oximeter sensors contaminated with pathogenic bacterial surrogates.

METHODS

Surrogates of potential biological warfare agents and bacterial pathogens associated with hospital-acquired infections (HAIs) were spotted on test surfaces, with and without an artificial test soil (sebum), allowed to dry, and then cleaned with different commercially available cleaning and disinfecting wipes or sterile gauze soaked in water, bleach (diluted 1:10), or 70% isopropanol. The percentage of microbial survival and an analytical estimation of remaining test soil on devices were determined.

RESULTS

Wipes containing sodium hypochlorite as the active ingredient and gauze soaked in bleach (1:10) were the most effective in removing both vegetative bacteria and spores. In the presence of selective disinfectants, sebum had a protective effect on vegetative bacteria, but not on spores.

CONCLUSIONS

The presence of sebum reduces the cleaning efficiency of some commercially available wipes for some select microbes. Various commercial wipes performed significantly better than the designated cleaning agent (70% isopropanol) in disinfecting the oximetry sensor. Cosmetic wipes were not more effective than the disinfecting wipes in removing sebum.

Cost-Effectiveness of a National Initiative to Improve Hand Hygiene Compliance Using the Outcome of Healthcare Associated Staphylococcus aureus Bacteraemia

BACKGROUND

The objective is to estimate the incremental cost-effectiveness of the Australian National Hand Hygiene Inititiave implemented between 2009 and 2012 using healthcare associated Staphylococcus aureus bacteraemia as the outcome. Baseline comparators are the eight existing state and territory hand hygiene programmes. The setting is the Australian public healthcare system and 1,294,656 admissions from the 50 largest Australian hospitals are included.

METHODS

The design is a cost-effectiveness modelling study using a before and after quasi-experimental design. The primary outcome is cost per life year saved from reduced cases of healthcare associated Staphylococcus aureus bacteraemia, with cost estimated by the annual on-going maintenance costs less the costs saved from fewer infections. Data were harvested from existing sources or were collected prospectively and the time horizon for the model was 12 months, 2011-2012.

FINDINGS

No useable pre-implementation Staphylococcus aureus bacteraemia data were made available from the 11 study hospitals in Victoria or the single hospital in Northern Territory leaving 38 hospitals among six states and territories available for cost-effectiveness analyses. Total annual costs increased by $2,851,475 for a return of 96 years of life giving an incremental cost-effectiveness ratio (ICER) of $29,700 per life year gained. Probabilistic sensitivity analysis revealed a 100% chance the initiative was cost effective in the Australian Capital Territory and Queensland, with ICERs of $1,030 and $8,988 respectively. There was an 81% chance it was cost effective in New South Wales with an ICER of $33,353, a 26% chance for South Australia with an ICER of $64,729 and a 1% chance for Tasmania and Western Australia. The 12 hospitals in Victoria and the Northern Territory incur annual on-going maintenance costs of $1.51M; no information was available to describe cost savings or health benefits.

CONCLUSIONS

The Australian National Hand Hygiene Initiative was cost-effective against an Australian threshold of $42,000 per life year gained. The return on investment varied among the states and territories of Australia.

Extra length of stay and costs because of health care-associated infections at a German university hospital

BACKGROUND

Health care-associated infections (HAIs) can be associated with increased health care costs. We examined extra length of hospital stay (LOS) and associated per diem costs attributable to HAIs in a large academic medical center.

METHODS

Data for analysis were acquired in a preinterventional phase of a prospective cohort study (ALERTS) conducted over 12 months in 27 general and 4 intensive care units at Jena University Hospital. HAIs were identified among patients hospitalized for ≥48 hours with at least 1 risk factor for HAI and new antimicrobial therapy; the diagnosis was confirmed by U.S. Centers for Disease Control and Prevention criteria. Extra LOS was estimated by multistate modeling, and associated extra costs were based on average per diem costs for clinical units sampled.

RESULTS

Of a total of 22,613 patients hospitalized for ≥48 hours, 893 (3.95%) experienced 1,212 episodes of HAI during 12 months. The associated mean extra LOS ± SEM in general units was 8.45 ± 0.80 days per case and 8.09 ± 0.91 days for patients treated in both general and intensive care units. Additional costs attributable to HAIs were €5,823-€11,840 ($7,453-$15,155) per infected patient.

CONCLUSION

HAIs generated substantial extra costs by prolonging hospitalization. Potential clinical and financial savings may be realized by implementing effective infection prevention programs.

Annual Antibiotic Related Economic Burden of Healthcare Associated Infections; a Cross-Sectional Population Based Study

So far, too little attention has been paid to total burden of healthcare associated infections (HAIs) in Iran. In the present study, we aimed to assess the rate of HAIs, as well as economic burden of hospitalization and antibiotic related cost associated with HAIs in ICU at training Taleghani hospital in Iran and to compare our results with national nosocomial infections surveillance (NNIS) system. This research to date for the first time has tended to focus on the economic burden of HAIs rather than epidemiology of HAIs evaluation. The total of 474 patients was followed up in this study. Overall, the rate of HAIs was 19.2 % in which ventilator associated pneumonia (VAP) was dominant HAIs and followed by urinary tract infection (UTI). Importantly, mortality rate increased significantly in infected patients. The highest total hospitalization economic burden and antibiotic related cost were observed for patients having blood stream infection (BSI). The results demonstrated significant differences between antibiotic related cost in patients and uninfected patients. Antibiotic related absolute extra cost for HAIs was 2.09 PPP$ per day. Estimation of direct annually HAIs associated economic burden of antibiotic and Total hospitalization was 433,382.4 PPP$ and 705,024 PPP$ respectively in Iran at intensive care unit (ICU). The most obvious findings were a strong relationship between relatively heavy antibiotic related financial burden, higher mortality rate, longer hospitalization time, and HAIs emergence on the Iranian national health system. It also reflects, more fundamentally a shift toward the need for comprehensive thinking about HAIs at ICU ward from Iran's hospitals. On the question of the research found that: With the implementation of policies and strategies to reduce hospital infections, which will benefit; Patient, Society, and/or national health system?!

Urinary catheter indwelling clinical pathogen biofilm formation, exopolysaccharide characterization and their growth influencing parameters

Self-reproducing microbial biofilm community mainly involved in the contamination of indwelling medical devices including catheters play a vital role in nosocomial infections. The catheter-associated urinary tract infection (CA-UTI) causative Staphylococcus aureus, Enterobacter faecalis, and Pseudomonas aeruginosa were selectively isolated, their phenotypic as well as genotypic biofilm formation, production and monomeric sugar composition of EPS as well as sugar, salt, pH and temperature influence on their in vitro biofilm formation were determined. From 50 culture positive urinary catheters S. aureus (24%), P. aeruginosa (18%), E. faecalis (14%) and others (44%) were isolated. The performed assays revealed their varying biofilm forming ability. The isolated S. aureus ica, E. faecalis esp, and P. aeruginosa cup A gene sequencing and phylogenetic analysis showed their close branching and genetic relationship. The analyzed sugar, salt, pH, and temperature showed that the degree of CA-UTI isolates biofilm formation is an environmentally sensitive process. EPS monosaccharide HPLC analysis showed the presence of neutral sugars (ng/μl) as follows: glucose (P. aeruginosa: 44.275; E. faecalis: 4.23), lactose (P. aeruginosa: 7.29), mannitol (P. aeruginosa: 2.53; S. aureus: 2.62; E. faecalis: 2.054) and maltose (E. faecalis: 7.0042) revealing species-specific presence and variation. This study may have potential clinical relevance for the easy diagnosis and management of CA-UTI.

Cost-effectiveness of national mandatory screening of all admissions to English National Health Service hospitals for meticillin-resistant Staphylococcus aureus: a mathematical modelling study

BACKGROUND

In December, 2010, National Health Service (NHS) England introduced national mandatory screening of all admissions for meticillin-resistant Staphylococcus aureus (MRSA). We aimed to assess the effectiveness and cost-effectiveness of this policy, from a regional or national health-care decision makers' perspective, compared with alternative screening strategies.

METHODS

We used an individual-based dynamic transmission model parameterised with national MRSA audit data to assess the effectiveness and cost-effectiveness of admission screening of patients in English NHS hospitals compared with five alternative strategies (including no screening, checklist-activated screening, and high-risk specialty-based screening), accompanied by patient isolation and decolonisation, over a 5 year time horizon. We evaluated strategies for different NHS hospital types (acute, teaching, and specialist), MRSA prevalence, and transmission potentials using probabilistic sensitivity analyses.

FINDINGS

Compared with no screening, mean cost per quality-adjusted life-year (QALY) of screening all admissions was £89,000-148,000 (range £68,000-222,000), and this strategy was consistently more costly and less effective than alternatives for all hospital types. At a £30,000/QALY willingness-to-pay threshold and current prevalence, only the no-screening strategy was cost effective. The next best strategies were, in acute and teaching hospitals, targeting of high-risk specialty admissions (30-40% chance of cost-effectiveness; mean incremental cost-effectiveness ratios [ICERs] £45,200 [range £35,300-61,400] and £48,000/QALY [£34,600-74,800], respectively) and, in specialist hospitals, screening these patients plus risk-factor-based screening of low-risk specialties (a roughly 20% chance of cost-effectiveness; mean ICER £62,600/QALY [£48,000-89,400]). As prevalence and transmission increased, targeting of high-risk specialties became the optimum strategy at the NHS willingness-to-pay threshold (£30,000/QALY). Switching from screening all admissions to only high-risk specialty admissions resulted in a mean reduction in total costs per year (not considering uncertainty) of £2·7 million per acute hospital, £2·9 million per teaching, and £474,000 per specialist hospital for a minimum rise in infections (about one infection per year per hospital).

INTERPRETATION

Our results show that screening all admissions for MRSA is unlikely to be cost effective in England at the current NHS willingness-to-pay threshold, and our findings informed modified guidance to NHS England in 2014. Screening admissions to high-risk specialties is likely to represent better resource use in terms of cost per QALY gained.

FUNDING

UK Department of Health.

Cost analysis of hospitalized Clostridium difficile-associated diarrhea (CDAD)

Aim:Clostridium difficile-associated diarrhea (CDAD) causes heavy financial burden on healthcare systems worldwide. As with all hospital-acquired infections, prolonged hospital stays are the main cost driver. Previous cost studies only include hospital billing data and compare the length of stay in contrast to non-infected patients. To date, a survey of actual cost has not yet been conducted.

Method: A retrospective analysis of data for patients with nosocomial CDAD was carried out over a 1-year period at the University Hospital of Greifswald. Based on identification of CDAD related treatment processes, cost of hygienic measures, antibiotics and laboratory as well as revenue losses due to bed blockage and increased length of stay were calculated.

Results: 19 patients were included in the analysis. On average, a CDAD patient causes additional costs of € 5,262.96. Revenue losses due to extended length of stay take the highest proportion with € 2,555.59 per case, followed by loss in revenue due to bed blockage during isolation with € 2,413.08 per case. Overall, these opportunity costs accounted for 94.41% of total costs. In contrast, costs for hygienic measures (€ 253.98), pharmaceuticals (€ 22.88) and laboratory (€ 17.44) are quite low.

Conclusion: CDAD results in significant additional costs for the hospital. This survey of actual costs confirms previous study results.

Cost-benefit analysis from the hospital perspective of universal active screening followed by contact precautions for methicillin-resistant Staphylococcus aureus carriers

OBJECTIVE To explore the economic impact to a hospital of universal methicillin-resistant Staphylococcus aureus (MRSA) screening. METHODS We used a decision tree model to estimate the direct economic impact to an individual hospital of starting universal MRSA screening and contact precautions. Projected costs and benefits were based on literature-derived data. Our model examined outcomes of several strategies including non-nares MRSA screening and comparison of culture versus polymerase chain reaction-based screening. RESULTS Under baseline conditions, the costs of universal MRSA screening and contact precautions outweighed the projected benefits generated by preventing MRSA-related infections, resulting in economic costs of $104,000 per 10,000 admissions (95% CI, $83,000-$126,000). Cost-savings occurred only when the model used estimates at the extremes of our key parameters. Non-nares screening and polymerase chain reaction-based testing, both of which identified more MRSA-colonized persons, resulted in more MRSA infections averted but increased economic costs of the screening program. CONCLUSIONS We found that universal MRSA screening, although providing potential benefit in preventing MRSA infection, is relatively costly and may be economically burdensome for a hospital. Policy makers should consider the economic burden of MRSA screening and contact precautions in relation to other interventions when choosing programs to improve patient safety and outcomes.

Incidence and Costs of Clostridium difficile Infections in Canada

Background.  Limited data are available on direct medical costs and lost productivity due to Clostridium difficile infection (CDI) in Canada. Methods.  We developed an economic model to estimate the costs of managing hospitalized and community-dwelling patients with CDI in Canada. The number of episodes was projected based on publicly available national rates of hospital-associated CDI and the estimate that 64% of all CDI is hospital-associated. Clostridium difficile infection recurrences were classified as relapses or reinfections. Resource utilization data came from published literature, clinician interviews, and Canadian CDI surveillance programs, and this included the following: hospital length of stay, contact with healthcare providers, pharmacotherapy, laboratory testing, and in-hospital procedures. Lost productivity was considered for those under 65 years of age, and the economic impact was quantified using publicly available labor statistics. Unit costs were obtained from published sources and presented in 2012 Canadian dollars. Results.  There were an estimated 37 900 CDI episodes in Canada in 2012; 7980 (21%) of these were relapses, out of a total of 10 900 (27%) episodes of recurrence. The total cost to society of CDI was estimated at $281 million; 92% ($260 million) was in-hospital costs, 4% ($12 million) was direct medical costs in the community, and 4% ($10 million) was due to lost productivity. Management of CDI relapses alone accounted for $65.1 million (23%). Conclusions.  The largest proportion of costs due to CDI in Canada arise from extra days of hospitalization. Interventions reducing the severity of infection and/or relapses leading to rehospitalizations are likely to have the largest absolute effect on direct medical costs.

Healthcare-associated infections, medical devices and biofilms: risk, tolerance and control

Biofilms are of great importance in infection control and healthcare-associated infections owing to their inherent tolerance and 'resistance' to antimicrobial therapies. Biofilms have been shown to develop on medical device surfaces, and dispersal of single and clustered cells implies a significant risk of microbial dissemination within the host and increased risk of infection. Although routine microbiological testing assists with the diagnosis of a clinical infection, there is no 'gold standard' available to reveal the presence of microbial biofilm from samples collected within clinical settings. Furthermore, such limiting factors as viable but non-culturable micro-organisms and small-colony variants often prevent successful detection. In order to increase the chances of detection and provide a more accurate diagnosis, a combination of microbiological culture techniques and molecular methods should be employed. Measures such as antimicrobial coating and surface alterations of medical devices provide promising opportunities in the prevention of biofilm formation on medical devices.