Budgeting for hand hygiene

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Elizabeth Newman
Elizabeth Newman

One of my former colleagues, who had moved to the healthcare sector from television, shared with me the story of how she began her new job and was told, “Oh, yeah, you can figure out the budget, right?”

She has learned by trial and error and has sometimes felt overwhelmed with the task. She's surely not alone. Many nurses or administrators have been in similar positions, with limited training and a lot on the line when it comes to their budget. 

With additional financial challenges for skilled nursing, due in no small part to proposals such as the White House budget slating SNF decreases, I'm sympathetic to how it's tempting to avoid wanting to make big investments. But vendors complain that purchasers tend to lose foresight when considering products or systems that will reduce future costs, and sometimes they are right. This is something that administrators with limited budget-related training and experience need to keep in mind, so that they don't save a penny today but lose far more in the long run. 

One area to focus on in this regard is reducing healthcare-associated infections. A study from the Columbia University School of Nursing and the World Health Organization, published in the American Journal of Infection Control this week, supports the idea that at least some long-term care facilities can do better.

In the study, around 186 facilities — hospitals, ambulatory and long-term care — in 42 states and Puerto Rico participated in an examination of their hand hygiene strategies. (It's worth noting that 2,238 facilities were invited, which is its own story about how many healthcare organizations are reluctant to be examined in this area.) While 77.5% of facilities reported alcohol-based sanitizers were available at every point of care, that means almost one in five are missing this strategy to reduce healthcare-associated infections. It's of course possible these are facilities where staff is religious about using soap and water — which should be noted is the preferred method for cutting down on norovirus — but I doubt it.

Facilities in the APIC study also reported that senior leaders, including the medical director and director of nursing, weren't making a clear commitment to support hand hygiene improvement, according to the researchers.

That's disappointing, as we know that proper hand hygiene is a tried-and-true way to keep residents and patients healthy (just ask the anti-vaxxers about the need for better hand washing rather than higher immunization rates). It can be harder to see how hand hygiene translates to the overall bottom line.

Let's start with a 2013 review in JAMA Internal Medicine that discusses how HAIs cost the government $9.8 billion annually, and that each C. diff infection case costs $11,285. Catheter-associated urinary tract infection costs $896. It's estimated that around 20% of HAIs are preventable.

Still, you may reason, while it's troubling when a resident gets C. diff, it's probably not going to result in a $12,000 reimbursement denial (yet). Fair enough, but it will cost you in extra laundry and disinfectants, extra time for housekeeping to clean, and time spent trying to make sure the resident doesn't become so sick or dehydrated they'll end up in the emergency room. Let's not even start with how unhappy your hospital partner may be when they hear news of an outbreak and how that may impact referrals. Evoking C.diff-laden diarrhea is not the way to a hospital CEO's heart.

This brings us back to walking your facility with your director of nursing and pinpointing areas where more alcohol-based sanitizers are needed. Let's assume it's cheaper and easier to install these units rather than more sinks. In our example, let's say each unit costs $50, and you want to add 100 units. That $5,000 can't come out of petty cash, of course, and you also will need to estimate how much it will cost to keep each unit filled. However, this may be a drop in the bucket compared to what your facility could save if it reduced its HAI rate by 20%.

These sanitizers, of course, are effective only if they are being used. As Jean Fleming pointed out in 2009 McKnight's column, most people, including staff, are trained early on to wash their hands after using the toilet, and it can be expected that they'd use proper hand hygiene before, for example, adjusting a catheter. The problem is that acts like taking a temperature, touching a bedrail or removing clothing don't provoke the same “ew” factor. If there simply is no money for hand hygiene products, you may have to go back to the basics: Remind staff how long it takes to properly wash hands, let them know they're being monitored and, above all, make sure senior leaders treat this as a priority.

Elizabeth Newman is Senior Editor at McKnight's. Follow her @TigerELN. 

Daily Editors' Notes

McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Marty Stempniak.