Pennsylvania Patient Safety Advisory Demonstrating Return on Investment for Infection Prevention and Control ABSTRACT of new infection prevention and control programs if Healthcare-associated infections (HAIs) represent the return on investment is not realized within a cer- 4.5 infections for every 100 hospital admissions tain time frame.3 An infection control business case and account for an estimated 99,000 deaths in the analysis of the excess cost of HAIs and of the excessive United States each year. In 2007, the Pennsylvania length of stay can help gain needed resources and Health Care Cost Containment Council reported physician support.4 Practical methods are needed to hospital charges of $35,168 in cases without an HAI engage healthcare executives in evaluating the true to $191,872 in cases with an HAI, with a difference cost of HAIs in their organizations. Hospital lead- of 15.3 days in the average length of stay. Effective ers’ awareness that HAIs impact their patients may infection prevention and control programs demon- not always lead to understanding the extent of the strate a valuable return on investment by releasing financial burden of HAIs or the cost-effectiveness of hospital resources for alternative uses and beds for infection prevention and control programs. Organi- new admissions. The Centers for Disease Control zations may have inadequate methods to investigate and Prevention estimates that the $45 billion annual the true cost of HAI in their institutions. Executives direct cost of HAIs could be significantly reduced by and clinicians in hospitals with HAI rates at or below as much as $31.5 billion with well resourced, quality nationally published rates may become complacent, infection prevention and control programs. Organiza- accepting that a certain degree of patient harm from tions may have inadequate methods to investigate the infections is an unavoidable price of caring for older, true cost of HAIs or the cost-effectiveness of infection sicker patients. Common misconceptions about HAIs prevention and control program. This article provides need to be dispelled. These misperceptions include practical methods to engage healthcare executives in (1) the fallacy that the incidence of HAI in most insti- evaluating the cost of HAIs in their organization and to tutions is insignificant; (2) the erroneous belief that dispel common misperceptions about the significance additional cost of HAIs is largely offset by reimburse- of HAIs, reimbursement, and cost savings associated ment, making cost savings associated with reduction with effective HAI reduction programs. Using these of HAIs not worth the investment, and (3) the misper- methods will assist hospital epidemiologists to develop ception that HAIs are an expected outcome of treat- a compelling business case for infection prevention ing an older, sicker patient population with escalating and control programs. (Pa Patient Saf Advis 2010 use of invasive procedures.5 Sep;7[3]:102-7.) Economic Burden of HAI HAIs consume resources, prolong patients’ hospital Introduction stays, and are only partially reimbursed at best. Healthcare-associated infections (HAIs) account for An economic analysis of central line-associated blood- about 1.7 million infections and 99,000 deaths in stream infections (CLABSIs) at Allegheny General the United States each year. This number represents Hospital in Pennsylvania from 2002 to 2005 exam- 4.5 infections for every 100 hospital admissions.1 The ined hospital revenues and expenses in 54 cases of Centers for Disease Control and Prevention (CDC) patients with CLABSIs in two intensive care units March 2009 report on the direct medical costs of (ICUs). The average payment for a case complicated HAIs estimates that $35.7 to $45 billion in 2007 dol- by CLABSI was $64,894, and the average expense was lars is added to the nation’s annual healthcare costs $91,733 with a gross margin of minus $26,839 per to treat these infections. These estimates reinforce the case and a total operating loss of nearly $1.5 million need for a renewed focus on sustainable HAI preven- from the 54 cases.6 tion and surveillance processes.2 Resources are needed In addition to revenue loss, there are hidden costs to sustain the momentum of infection prevention. and lost financial opportunities associated with HAIs. Increasing resources requires establishing a business For example, when patients are brought back to the case for infection prevention and control programs. operating room (OR) for an incision and drainage of An important function of the hospital epidemiologist a postsurgical site infection, both the surgical suite and the infection preventionist (IP) is to demonstrate and the OR team are tied up, and new cases cannot the value of infection prevention and control pro- be scheduled. Primary procedures are often reim- grams to healthcare executives. The most important bursed at a higher rate than follow-up procedures. 4 aspect of a business case for prevention is reduction of The 2007 Pennsylvania Health Care Cost Contain- harm and loss of life. But from a financial health per- ment Council (PHC4) report on HAIs in Pennsylva- spective, boards, executives, and healthcare managers nia hospitals shows that the average charge for care are interested in cutting costs and getting maximum grew from $35,168, with an average length of stay of value for expenditures. They may not see the benefit 4.4 days, for cases without an HAI to $191,872 for Page 102 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 3—September 2010 Pennsylvania Patient Safety Advisory those cases with an HAI, with an average length of the Association for Professionals in Infection Control stay of 19.7 days. PHC4 reported that in almost all and Epidemiology (APIC),5 a business case exists if cases, hospitals do not receive full reimbursement the intervention realizes a financial return on invest- of charges; on average, in 2006 and 2007, hospitals ment through hospital profit, loss reduction, or cost statewide were paid approximately 27% of established avoidance in a reasonable time frame. Comparing the charges (see Table).7 cost of an infection prevention and control program The misconceptions regarding the financial signifi- or intervention to the benefits—lowering rates of HAI cance of HAIs are dispelled by the CDC in its 2009 and preventing harm and death—is the best method report on the direct medical costs of care related to for justifying the investment in prevention efforts. secondary infection diagnosis, increased length of Return on Investment stay, and expensive HAI outbreaks. The report also describes additional cost components, which reflect Possibly the greatest opportunity to demonstrate a the socioeconomic consequences of HAIs such as positive return on investment in infection prevention indirect and intangible costs of HAIs related to and control is by decreasing patients’ hospital length diminished quality of life (e.g., permanent disability, of stay and releasing those beds to new patients, con- lost wages).2 sequently increasing volume, revenue, and reimburse- ment.11 This opportunity reinforces the evidence that CDC reports that the cost of HAIs per patient (based financial investments in infection prevention and on the 2007 consumer price index) ranges from control programs offer good value and that resources approximately $20,000 to $25,000.8 Diagnosis-related to implement best practice strategies at the bedside group (DRG) based reimbursement is not increased should be made available.8 In assessing the extent when a patient develops an HAI, as there are no to which HAIs are preventable, CDC estimates that specific DRG codes available for HAIs. Hospitalized effective infection control programs could prevent up patients may be covered by Medicare and Medicaid, to 70% of infections. This can translate into potential which in most cases reimburse fixed amounts based savings nationwide of up to $31.5 billion of the $45 on diagnosis. The hospital then has to absorb the billion expenditures attributed to HAIs.2 additional costs associated with HAIs, while the HAIs The components of a high-quality infection preven- simultaneously prevent the hospital from taking new tion and control program include sufficient staff with admissions with reimbursable conditions.5,9 The time to conduct risk-adjusted surveillance; staff edu- Centers for Medicare and Medicaid Services (CMS) cation; isolation and outbreak management; report regulations, effective in 2008, now refuse reimburse- review and development; employee health activities; ment to hospitals for the excess costs of certain types tasks intended to meet regulatory requirements, of infections. (See “The Department of Health and including public reporting tasks; clinical implemen- Human Services Action Plan to Prevent Healthcare- tation of evidence-based best practices; and process Associated Infections.”) improvement activities. Program resource needs The current legal and regulatory landscape has include trained IPs, clerical support, at least a part- changed in a large part due to the success of hospitals time epidemiologist, physician champion and clinical across the country with HAI prevention programs. nurse liaison hours, supplies, data mining support, HAIs that were previously thought of as defensible and education.11,12 Successful infection control pro- are now considered to be preventable adverse events. grams are supported by clinicians, physicians, and IPs will play a larger role in protecting their hospitals executives in an organizationwide culture of safety. against liability in the future.10 The average cost for staffing that includes two IPs, Based on recent guidelines from the Society for one member of clerical support staff, and a part- Healthcare Epidemiology of America (SHEA)3 and time medical director is estimated at $300,000.13 Table. Pennsylvania Healthcare Cost Containment Council Hospital-Acquired Infections, 2007 Report Highlights INFECTION AVERAGE LENGTH NUMBER RATE PER MORTALITY OF STAY (IN DAYS) AVERAGE CHARGE 2007 CASES OF CASES* 1,000 CASES Number Percent Mean Median Mean Median Statewide 1,578,600 17.7 35,120 2.2% 4.7 3.0 $37,943 $20,111 Cases with a hospital- 27,949 N/A 3,416 12.2 19.7 15.0 $191,872 $87,655 acquired infection Cases without a hospital- 1,550,651 N/A 31,704 2.0 4.4 3.0 $35,168 $19,748 acquired infection * The number of cases with infections represents the number of hospitalizations in which the patient contracted a hospital-acquired infection as identified and reported by the hospital. Source: Pennsylvania Health Care Cost Containment Council (PHC4). Hospital-acquired infections in Pennsylvania in 2007 [online]. 2009 Jan [cited 2010 Apr 21]. Available from Internet: http://www.phc4.org/reports/hai/07/default.htm. Vol. 7, No. 3—September 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 103 Pennsylvania Patient Safety Advisory through the appropriate selection of products and The Department of Health and expensive technology, avoidance of regulatory cita- Human Services Action Plan to Prevent tions14 and fines for lack of progress in decreasing Healthcare-Associated Infections infection rates,15 and enhancement of the organiza- The U.S. Department of Health and Human tion’s image by minimizing the threat of outbreaks, Services (HHS) released an action plan in resistant pathogens, employee injuries from blood- January 2009, which estimates that 80% of all borne pathogens, HAI disclosures, sentinel events, healthcare-associated infections (HAIs) in hos- and malpractice claims.10,16 Many infection preven- pitals in the United States fall into one of four tion practices can improve quality without much of categories of infections: (1) catheter-associated a financial investment. These include nurse-driven urinary tract infections (CAUTI), (2) surgical-site catheter removal protocols, proper equipment disin- infections (SSI), (3) intravascular catheter-related fection, hand hygiene, process and outcome measure- bloodstream infections (CLABSI), or (4) ventila- ment, and accountability standards for compliance. tor-associated pneumonia (VAP). The plan further states that hospital length of stay for patients Success Models infected with methicillin-resistant Staphylococcus aureus (MRSA) has tripled since 2000.1 HHS has Hospitals across the country are taking an aggressive developed targets and metrics in a five-year plan stance against HAIs, demonstrating that infections aimed at eliminating infections, including Clos- are not an expected outcome of treating older, sicker tridium difficile infections and MRSA. patients and that hospitals have a significant opportu- nity to improve their bottom line by eliminating HAIs.5 HHS prioritized recommendations for prevention of these infections based on evidence-based A 2004 Johns Hopkins Hospital study on the effects best practices outlined in related Healthcare of a multifaceted infection control intervention pro- Infection Control Practices Advisory Commit- gram on CLABSI found that implementation of sim- tee (HICPAC) recommendations. HAIs will ple, inexpensive interventions prevented 43 CLABSIs be identified through the Centers for Disease and eight deaths and saved nearly $2 million in addi- Control and Prevention’s National Healthcare tional costs to the hospital.17 Safety Network (NHSN) reporting modules and from administrative and discharge data. As of Pennsylvania’s public reporting mandate necessitates October 1, 2008, the Centers for Medicare and support for hospitalwide surveillance of HAIs in Medicaid Services no longer provides additional acute care hospitals. Across the state, HAIs dropped payment for hospital cases with secondary diag- nearly 7.8% from 2006 to 2007. According to PHC4’s noses of CAUTI, CLABSI, and selected SSI when latest study, 27,949 patients contracted an infection the condition was not present on admission. during their hospitalization in 2007—a decrease from These conditions were selected by three criteria: (1) high cost, high volume, or both; (2) assign- 30,237 patients in 2006. This represents a drop in the ment to a diagnosis-related group that has a infection rate of 7.8%, from 19.2 infections per 1,000 higher payment when present as a secondary cases in 2006 to 17.7 per 1,000 cases in 2007.7 diagnosis; and (3) could reasonably have been St. Christopher’s Hospital for Children in Philadel- prevented through the application of evidence- phia implemented a modified neonatal ventilator care based guidelines.2 bundle, decreasing the ventilator-associated pneu- Notes monia (VAP) rate in the neonatal ICU from 3.9 (10 1. U.S. Department of Health and Human Services cases) per 1,000 ventilator days in 2006 to 0.3 (1 case) (U.S. HHS). HHS action plan to prevent health- per 1,000 ventilator days in 2008.18 CDC estimates care-associated infections [online]. [cited 2010 the cost of one case of VAP to be $28,508.2 Feb 1]. Available from Internet: http//www.hhs. gov/ophs/initiatives/hai/infection.html. Making the Business Case for 2. Centers for Medicare and Medicaid Services. Infection Prevention Hospital-acquired conditions (HAC) [online]. 2008 Oct [cited 2010 Apr 21]. Available An Administrator’s Perspective from Internet: http://www.cms.hhs.gov/ Administrators see infection prevention and control HospitalAcqCond/. programs as cost centers because the costs cannot be passed onto anyone else. Infection prevention’s value to the organization is based on how well HAIs are This cost could be financed by avoiding fewer than prevented and controlled. There are a number of ways nine surgical-site infections (SSI), based on the in which that value is added; for example, reducing CDC 2009 direct cost estimates of $34,670 per SSI.2 HAI damage to the hospitals’ operating budget can Another study of 28 U.S. hospitals estimated that the also reduce legal liability. The public’s demand for hospitals’ financial loss due to HAIs was 4.3 times accountability for public safety has increased, giving greater than the amount the hospitals invested in IPs the advantage of more leverage as they represent prevention in 2005.9 best practices. The primary cost of HAIs to the hos- Examples of cost savings associated with a well- pital is the loss of bed days due to prolonged length resourced, quality infection control program include of stay. The loss of higher paying, new admissions the expertise of an IP to eliminate supply waste represents the gross costs of HAIs and the value of Page 104 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 3—September 2010 Pennsylvania Patient Safety Advisory prevention. For example, an intervention that short- medical record documentation, and having sufficient ens a patient’s stay in intensive care or lessens the time for surveillance investigation.20 need for surgery is a plus because the hospital gets Steps to Completing an Infection Control Business more productivity out of the existing facility. Admin- Case Analysis istrators want to know what comprises an effective Before asking for more support and presenting infec- infection prevention and control program, the costs tion control programs to management, it is important and savings to the hospital, how much to invest, and to accurately and comprehensively identify the key what else could be done with the resources released issues in the organization and where best to direct through HAI prevention. They want the informa- efforts. For example, focus on which types of infec- tion in a timely fashion for budget consideration—at tions are more prevalent, locations where endemic that time, there will be competition with every other infection rates are particularly high, or locations department in the hospital. Administrators can be where surveillance and prevention efforts have been greatly influenced by a physician champion—physi- sporadic or lacking.4 cians control 85% of healthcare spending in the United States, and they control the number of Focus the hospital executive team’s attention on the patients coming into the institution.4 number of infections avoided and the dollars saved by infection control interventions that have been success- A January 2010 survey of 203 senior hospital execu- ful in the past. Identify a patient group (e.g., intensive tives across the United States found that, despite care patients), the infection prevented, and all reason- current severe financial constraints, hospitals of all able strategies that might prevent that type of infec- sizes are employing sophisticated budget strategies in tion.8 Develop clinical practice priorities based on the a commitment to reduce infection rates. Surveyed Department of Health and Human Services (HHS) hospital executives anticipate that focus on patient action plan, which have the potential to decrease safety is a key component of an organization’s strategy HAIs based on: (1) supporting scientific evidence that to enhance its reputation in select specialties. Infec- the recommended practice is effective, practical, and tion prevention and control was identified as one of urgent; (2) recognized gaps in current implementation the top five categories with the highest budget growth of the practice (full versus partial implementation); potential. However, the report also found that just and (3) the “bundling” or implementation of several one-third of respondents are willing to increase spend- practices at the same time to ensure the effective- ing to reduce errors and infection rates.19 ness of the action plan.21 Assessment of adequate From an IP Standpoint resources for an infection prevention and control pro- gram includes identification of the scope of patient When making the business case for increased populations being served, the number of trained and infection prevention and control resources, data certified IPs in the facility, the types of programs in gathered for the infection prevention and control which the IP is involved, and a practice analysis. This committee should be shared with people who analysis describes the frequency and estimated hours decide how resources are allocated. Be prepared to required each week for infection prevention and con- discuss which interventions require minimal or no trol activities and identifies areas of the program that financial investment (e.g., standardization of work may be underresourced.11 processes, compliance with checklists, teamwork, communication, collaborative efforts) and which are The process of completing a business case can be cost-effective. Any information about the excess num- divided into practical steps to analyze how HAIs are ber of days and costs attributable to HAIs is likely impacting the organization’s bottom line, calculate to be favorably received, as administrators are often the economic value of reducing HAIs using the facil- receptive to information on the number of beds occu- ity’s internal data, and assist the hospital epidemiolo- pied by patients with HAIs.4 gists and IPs in justifying and expanding the infection prevention and control programs. In a 2008 survey of IP challenges to maintaining a In an effort to enhance the attention and resources quality infection prevention and control program, dedicated to the zero-tolerance culture regarding HAIs 30% of the 930 respondents suggested that executives and to calculate the estimated value (i.e., excess cost) and physicians are their most important resources to of eliminating HAIs in the organization, APIC and meet HAI challenges; of those looking for leadership, SHEA recommend the following methods:3,5 only half indicated that these executives and physi- cians are leading the charge against infections in their Prepare an executive summary. Start with a facilities. Fifty-seven percent cited regular infection statement of purpose. Describe the intervention prevention and control agenda discussion at board requested, explain why it should be pursued, and meetings, but only 15% said leadership provided feed- review the financial implications of not pursuing it. back and recommendations. Survey respondents also Identify a financial partner. Infection prevention and indicated challenges in the areas of engaging infor- control specialists need to work with the financial mation technology support, measuring compliance, specialists in the organization to identify which ser- providing adequate staffing, removing indwelling vices provided were attributable to the infection and urinary catheters, ensuring appropriate physician the cost of that service. Vol. 7, No. 3—September 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 105 Pennsylvania Patient Safety Advisory Frame the problem. Select an HAI or a population Identify process defects and institute changes. within the last year to be analyzed. Select a number Institute necessary systems or practice strategies of cases (e.g., 10) of patients who acquired a CLABSI where indicated. or select a class of HAI for the last year. Develop Measure results. Collecting outcomes, costs, and potential solutions based on these cases. implementation data allows comparison with units Meet with key administrators or physician leaders. where the intervention has not yet been implemented. Before the start of the analysis, obtain agreement Prospectively collecting cost and outcome data once that the issue is of institutional concern and has programs are in effect can illustrate stable outcome the support of leadership. Administrators can help rates or continued improvement associated with the to identify individuals or departments that may be intervention. affected by the proposal and also help identify the A sample business plan is available at http://www. critical costs and factors that should be included. ihi.org/NR/rdonlyres/EEC35DF1-0324-4C69-A401- Determine the costs associated with the infection 05BD178E555E/2735/YumaBusinessPlanTemplate.pdf. of interest. Emphasize the complications that would Conclusion not have occurred during a hospital stay without the HAI. With the financial advisor, identify actual or CDC estimates that as much as $31.5 billion of the estimated costs and reimbursement, and calculate the $45 billion annual direct cost of HAIs could be saved difference between profits with and without an HAI. with an effective infection program, which would Use available hospital administrative data for the significantly reduce the economic burden. Reimburse- amount of costs that are reimbursed, or use estimates ment is currently affected by the determination that from literature. An alternative method of calculat- some infections can reasonably be prevented through ing the attributed cost of an HAI is to multiply the application of evidence-based practices. The evidence mean increase in length of stay for HAI cases by the is compelling that taking action to invest in an effec- mean daily cost for a hospital stay. For example, if the tive infection control program can have a profound average daily cost for a patient intubated in ICU was positive impact on the organization’s bottom line $3,000 a day and the average increase in the length of and reputation, prevent the catastrophic effects of stay was seven days due to a VAP, the increased cost HAI, and improve patient safety and satisfaction. would be $21,000. Estimate additional revenue gained Hospital success stories highlight the opportunities by filling the additional bed days available. for all organizations to make zero HAIs a target, and many protocols can be implemented without much Determine which costs can be avoided through of an investment. Application of practical guidelines reduced infection rates. Use proposed or actual past to develop an infection prevention and control busi- reduced infection rates or published data. Calculate ness case will assist hospital IPs and epidemiologists the gross margin for the case by subtracting the to justify and expand much-needed programs. The expenses from the reimbursement. Compare the gross true investment is the organizational commitment margin for the case to the gross margin of similar from healthcare leaders and clinicians to engage in a cases without an HAI. Analysis of your organization’s fresh approach to providing patient care in a culture costs is more credible than general estimates from of safety and to set the goal number of HAIs at zero. studies. (An example of this calculation can be This requires acknowledging the high-risk nature of found at http://www.premierinc.com/safety/topics/ the organization’s activities, as well as investing in guidelines/downloads/09-hai-whitepaper.pdf.) infection prevention programs, allocating resources Calculate the financial impact. Subtract the upfront needed for optimal programs, and making infection and future outlay costs from the estimated cost prevention an institutionwide priority. savings. Determine the annual cost of an infection Notes prevention and control program, as well as the salary and benefits of the IP. When looking at a specific 1. Klevens RM, Edwards JR, Richards CL Jr, et al. project or intervention, estimate the percent of IP Estimating health care-associated infections and deaths time needed to support the project based on his or in U.S. hospitals, 2002. Public Health Rep 2007 Mar-Apr; her hourly rate. Include the additional reduced costs 122(2):160-6. and benefits expected from impact of the infection 2. Scott RD. The direct medical costs of healthcare- control intervention on other processes or other types associated infections in U.S. hospitals and the benefits of preventable infections of prevention [report online]. 2009 Mar [cited 2010 Apr 21]. Available from Internet: http://www.cdc.gov/ Make the business case. Once the analysis of the ncidod/dhqp/pdf/Scott_CostPaper.pdf. HAIs in the organization is completed, use this information to target an area that has significant 3. Perencevich EN, Stone PW, Wright SB, et al. Raising opportunity for improvement and then set the standards while watching the bottom line: making a target for elimination of this HAI. Develop an business case for infection control. Infect Control Hosp implementation plan, determine current support for Epidemiol 2007 Oct;28(10):1121-30. the initiative, and answer anticipated questions before 4. Stone PW, Hedblom EC, Murphy DM. The economic presenting the initial findings to critical stakeholders. impact of infection control: making the business case for Page 106 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 3—September 2010 Pennsylvania Patient Safety Advisory increased infection control measures. Am J Infect Control 13. O’Reilly K. Many hospitals cut back on infection control 2005 Nov;33(9):542-7. efforts [online]. Am Med News 2009 Jun 22 [cited 2010 Apr 21]. Available from Internet: http://www.ama-assn. 5. Murphy DM, Whiting J. Association for Professionals org/amednews/2009/06/22/prsa0622.htm. in Infection Control and Epidemiology (APIC). Dispelling the myths: the true cost of healthcare- 14. Medical Care Availability and Reduction of Error associated infections. [briefing online]. 2007 Feb 9 (MCARE) Act. 40 P.S. § 1303.408 (2007). [cited 2010 April 21] Available from Internet: http:// 15. Health Care Facilities Act. 35 P.S. § 448.817 (1992). www.premierinc.com/safety/topics/guidelines/ downloads/09-hai-whitepaper.pdf. 16. Dunagan WC, Murphy DM, Hollenbeak CS, et al. Making the business case for infection control: 6. Shannon RP, Patel B, Cummins D. Economics of pitfalls and opportunities. Am J Infect Control 2002 central line-associated bloodstream infections. Am J Med Apr;30(2):86-92. Qual 2006 Nov-Dec;21(6 Suppl):7S-16S.7 17. Berenholtz SM, Pronovost PJ, Lipsett PA. Eliminating 7. Pennsylvania Health Care Cost Containment Council catheter-related bloodstream infections in the intensive (PHC4). Hospital-acquired infections in Pennsylvania care unit. Crit Care Med 2004 Oct;32(10):2014-20. [online]. 2009 Jan [cited 2010 Apr 21]. Available from 18. Successful reduction of ventilator-associated Internet: http://www.phc4.org/reports/hai/07/ pneumonia. Pa Patient Saf Advis [online] 2009 Jun default.htm. [cited 2010 Apr 21]. Available from Internet: http:// 8. Graves N. Economics and preventing hospital-acquired www.patientsafetyauthority.org/ADVISORIES/ infection. Emerg Infect Dis 2004 Apr;10(4):561-6. AdvisoryLibrary/2009/Jun6(2)/Pages/63.aspx. 9. Anderson DJ, Kirkland KB, Kayre KS. Underresourced 19. L.E.K. Consulting. Hospitals apply surgical precision hospital infection control and prevention programs: to budgets, brace to support healthcare reform [online]. penny wise,pound foolish? Infect Control Hosp Epidemiol L.E.K. Consult Exec Insights 2010 Jan [cited 2010 Apr 2007 Jul;28(7):767-73. 21]. Available from Internet: http://www.lek.com/ UserFiles/File/Executive_Insights/Volume_XII_ 10. Hsieh S. Hospitals fight off infections and lawsuits. Issue_4_LEK_Hospital_Purchasing_Survey_Executive_ Mass Med Law Report [online] 2009 Feb [cited 2010 Insights.pdf. Apr 21]. Available from Internet: http://mamedicallaw. com/blog/2009/02/01/hospitals-fight-off-infections- 20. Association for Professionals in Infection Control and and-lawsuits/. Epidemiology (APIC). APIC-Premier survey on HAI prevention strategies [online]. 2008 [cited 2010 Feb 1]. 11. Association for Professionals in Infection Control Available from Internet: http://www.premierinc.com/ and Epidimiology (APIC). IP program evaluation tool about/news/08-sep/SurveySummary_09122008.pdf. [CD-ROM]. .Prevention Strategist 2010;3(1). 21. U.S. Department of Health and Human Services (U.S. 12. Rutala WA, Weber DJ. Cost and cost benefit of HHS). HHS action plan to prevent healthcare-associated infection control [presentation online]. 2005 Dec [cited infections [online]. [cited 2010 Feb 1]. Available from 2010 Apr 21]. Available from Internet: http://www.unc. Internet: http://www.hhs.gov/ophs/initiatives/hai/ edu/depts/spice/resource.html#Slides. infection.html. Vol. 7, No. 3—September 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 107 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 7, No. 3—September 2010. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2010 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our Web site at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s Web An Independent Agency of the Commonwealth of Pennsylvania site at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.