CEO SUMMARY: Probably the most challenging infections for hospitals to control and reduce are methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. diff). The laboratory at one New York hospital introduced algorithms to screen for the presence of each infection. In the past five years, the hospital not only cut costs by almost $3 million and improved quality, but also did fewer tests for these two infectious diseases. The contribution of the laboratory at John T. Mather Memorial Hospital demonstrates how labs can leverage lab testing to deliver increased value.
EVER SINCE BEING NAMED one of Medicare’s original “Never Events” in 2008, hospital acquired infections (HAIs) have become a high-profile target for early detection and prevention in hospitals throughout the United States.
No one disputes the size of the problem. The Centers for Disease Control and Prevention estimates that, each year, there are 1.7 million hospital acquired infections causing about 100,000 deaths annually. On average, a single case of HAI incurs costs of up to $38,000. Moreover, each year, one in seven Medicare beneficiaries experiences a “never event” such as an HAI.
These are huge numbers. In 2008, innovative hospital labs recognized the potential to help their parent hospitals and health systems reduce and prevent HAIs. That’s because of the essential role that laboratory testing plays in helping clinicians identify patients with HAIs and then guide the selection of appropriate therapies.
One first-mover in this regard was the 248-bed John T. Mather Memorial Hospital in Port Jefferson, New York. During 2007, its laboratory leaders had put a plan on the table to use state-of-the-art rapid molecular technologies specifically to improve detection and treatment of methicillin-resistant Staphylococcus aureus (MRSA). In 2010, a similar plan was implemented for Clostridium difficile (C. diff).
“Every hospital laboratory has the opportunity to improve those statistics,” stated Denise Uettwiller-Geiger, Ph.D., DLM(ASCP), Director of Laboratory Services and Clinical Trials at Mather. “At the same time, new diagnostic technologies are giving us faster and more accurate ways to identify these infectious diseases. It is why the lab is well-positioned to collaborate with other departments to cut these infection rates.”
The lab at the Mather Hospital runs 2.3 million tests annually. It has 72 FTEs including clerical staff, accessioners, and
phlebotomists. Among those 72 FTEs are about 30 clinical laboratory scientists who work in three shifts, 24 hours a day, seven days a week.
The program that Geiger’s lab team implemented addressed two HAIs that are among the most vexing for hospitals. One interesting benefit of this program was that it led to reduced testing, even as costs declined by almost $3 million and patient outcomes improved for these two infectious diseases. For this reason, the success of the Mather lab provides a road map for boosting the contribution of lab testing to achieving more effective HAI control that other labs will find useful.
Pathologists and lab administrators understand why MRSA and C. diff were made a priority. Treatment of MRSA is becoming ever tougher, making early detection essential. In the case of C. diff, inci- dence of this disease is at historic highs in the United States, according to the CDC. The diarrhea it causes is linked to 14,000 deaths annually nationwide.
“Of course every hospital has protocols to address both of these infections, which is why, over the last few years, we wanted to improve our test results for MRSA and C. diff by providing actionable information more rapidly to our clinicians,” recalled Geiger. “For MRSA, we started by seeing what technology was available for screening patients.
There are many different approaches, including universal screening and targeted screening for high-risk patients. Some hospitals screen everyone with nasal swabs, but this method can be costly.
“Instead, we thought it might be more cost effective to do targeted rapid MRSA screening for high-risk patients,” she explained. “These would be patients in intensive care and critical care units, nursing home patients coming to the hospital, and surgical patients needing hip or knee replacements.
“Not only is it important to screen patients to improve patient care, but also one MRSA infection can cost upwards of $35,000,” Geiger noted. “And we know that, starting in 2006, the New York State Department of Health commenced collecting data on HAIs. Also, two years later, the Medicare program stopped paying hospitals to treat patients with HAIs. All of these reasons made it imperative that we had an effective screening program here at Mather.
“We track our MRSA and C. diff infection rates using typical benchmarks,” added Geiger. “We gather the number of infected patients per 1,000 patient care days and we report this rate as a percentage of hospital occupancy.
“Before our MRSA program began, we had 74 MRSA infections in 2007,” she said. “That gave us an infection rate of 0.90 per 1,000 patient care days, based on 91% occupancy.
“In March 2008, we worked with infection prevention specialists, infectious disease clinicians, nursing, and the information technology department to track and reduce infections,” noted Geiger. “In that first year of 2008, the number of MRSA infections went down to 48, which reduced our rate to 0.59 per 1,000 patient care days, representing a 35% decrease in MRSA infections.
“From there, it continued to decline significantly,” she stated. “If we compare the infection rate from our base year of 2007 to 2012, we had a dramatic reduction in MRSA infections of 76% and we also had an associated cost avoidance that dropped our costs by 76% as well,” observed Geiger. “You can see that the savings potential is significant if the hospital can avoid just one case of MRSA.
“In the case of C. diff, our program was a bit different,” she continued. That is because the primary testing was not molecular and we didn’t need an algorithm to identify which patients would be screened. “But, for C. diff, we did need to identify a rapid-screening method,” observed Geiger. “We decided to use an enzyme immunoassay (EIA) because it is convenient and easy to use.
“The EIA incorporates a rapid flow membrane technology that allows us to do the analysis of both the glutamate dehydrogenase (GDH) and toxin A and B simultaneously,” she said. “This testing can be done on demand in 60 minutes or less.
“Before we started using the EIA to identify C. diff in May 2010, we had an algorithm that involved performing three sequential tests on samples that came from all patients experiencing symptoms of C. diff infection. The previous test identified toxin A and B but not the GDH. Because of the improved sensitivity and specificity of our new test methodology, we immediately recognized that we did not need to do three serial samples.
C. diff Testing Approach
“Another approach to C. diff testing is with polymerase chain reaction (PCR),” added Geiger. “But this method is costly when applied to each sample. Our decision was to reserve PCR testing for a specific subset of patient samples.
“In our base year of 2009, we had 70 C. diff infections. Last year we had 26 infections, which is 0.34 per 1,000 patient care days (compared with 0.95 per 1,000 patient care days in 2009). These numbers show that, when you compare the base year of 2009 to 2012, we had a decrease in C. diff infections of 63%,” she explained.
“In 2012, we screened 1,522 samples, and 75% were reportable immediately as antigen and toxin negative. We also had 12% that were reported immediately as antigen and toxin positive,” Geiger said. “The remaining 13% of specimens represented a subset of patients who were antigen positive, meaning they were GDH positive but toxin A and B negative.
For this 13% (which was 203 samples) we used PCR testing,” Geiger commented. “So now we can calculate how much was saved using this stepwise approach in our lab testing algorithm.
“If we did 100% of the samples with PCR, which is what the molecular testing experts recommend, that would have cost
$40 per test on 1,522 samples for a total of $61,000,” she calculated. “But because we use EIA to stratify those 87% of the specimens that did not require PCR testing, we saved almost $35,000. By using EIA testing for most of the samples, the costs totaled just $18,000.
“However, this story gets even better!” she added. “In 2009 we ran three sequential tests on each sample. In that year, we did 3,300 C. diff tests,” noted Geiger. “Then, in 2010, we implemented our algorithm and eliminated serial sampling. That cut the number of samples tested down to 1,774. For 2012, we did only 1,522 of these tests, representing a drop of 51% from the base year.
“These data show that we are doing less testing, even as we cut our hospital’s infection rates and reduced its costs as well,” she stated. “Our lab performs less testing even as our hospital achieves a reduction of more than 63% in the infection rate.
“All of this was done as part of a hospital-wide initiative started in 2008,” added Geiger. “It is called the ‘Voyage to Excellence’ and it is our mission to be the best community hospital in New York State. This rating is measured in different ways by such metrics that include our infection rates and patient experience scores. Notably Mather is ranked second on Long Island, according to one report.
“Overall, our lab’s engagement with the program to reduce hospital acquired infections is a compelling story because it shows what is possible when our laboratory collaborates with other departments,” emphasized Geiger. “It also shows that the lab can play a bigger role in managing care when it becomes more effective at using the data and the new diagnostic technologies we have in our clinical laboratory.”
If we compare the infection rate from our base year of 2007 to 2012, we had a dramatic reduction in MRSA infections of 76% and we also had an associated cost-avoidance that dropped our costs by 76% as well,” observed Geiger.
Mather Lab Shares Lessons Learned
OVER A MULTI-YEAR PERIOD, the laboratory at John T. Mather Memorial Hospital has made significant contributions to reducing hospital acquired infections (HAIs), including MRSA and C. difficile. There are several useful lessons learned during this time.
“First, we showed that the lab can and should play a vital role in the reduction of hospital acquired infections,” observed Denise Uettwiller-Geiger, Ph.D., DLM (ASCP), Mather’s Director of Laboratory Services and Clinical Trials. “Second, our lab delivered substantial value in a performance-driven health care system by helping to control total costs. Even though the lab represents only 2% to 3% of total healthcare costs, we have a significant role in controlling spending as we showed with this infection control effort.
“A third lesson is that—to be successful in an effort like this—the lab needs the support of clinical leadership within the hospital,” she continued. “For the MRSA initiative, in particular, that leadership was important. To develop the MRSA screening program, our lab team worked closely with the chief medical officer and we made a presentation to the board of directors. In that way, the program had a lot of visibility.
“Similarly, we needed that support from leadership to acquire new equipment, which included a molecular testing platform,” said Geiger. “This was essential if we were to deploy new diagnostic technology.
“Fourth, in addition to getting leadership support, our lab needed to work collaboratively with staff from a number of departments,” she concluded. “After all, infection control programs require interdisciplinary team effort. Our lab team worked closely with senior hospital leadership, infectious disease professionals, pharmacists, nursing management and staff, physicians, environmental services, information technology, and finance.”