Follow Cindi Crosby, Vice President, Global Medical Affairs at CareFusion, as she discusses trends in infection prevention practices.

  • Close this author

    Dr. Cindi Crosby

    “The secret to success is never giving or accepting excuses.”

Dr. Cindi Crosby

Vice President, Global Medical Affairs

Cindi’s work in CareFusion’s Medical Affairs Department represents the perfect culmination of a career that has always focused on combining education with research to improve patient care. From her start working in a bone marrow transplant unit at a university medical center to her recent honorary appointment as a research associate in infectious disease in the Department of Microbiology at Queen Elizabeth Hospital in the UK, Cindi’s primary focus has been the clinical application of infection control products to improve patient health outcomes. But Cindi has also always understood the importance of building networks to share information and solve problems. Her education and background as a microbiologist has helped her assemble effective global partnerships with key thought leaders in infection prevention, and she has built on this further by publishing and speaking to share information with those who care for patients. As the company works to tell the story of how all CareFusion products work together for safe and effective healthcare, Cindi looks forward to extending our global partnerships with thought leaders and healthcare providers for the benefit of patients around the world. In addition to her professional commitments, Cindi is highly involved with charitable animal and human health organizations in infection prevention.

Dr. Crosby began her career with an associate degree in Animal Science from Southern Utah State College. She earned her bachelor's degree in Biology, Human Emphasis and Microbiology from the University of Utah and completed her doctorate in Microbiology- Healthcare Associated Infections at Aston University in Birmingham, United Kingdom. She has an extensive list of professional affiliations in infection prevention, nursing, and microbiology organizations and has a patent pending from her research.

Read Bio
Dr. Cindi Crosby - Vice President, Global Medical Affairs

The pay-for-performance (P4P) movement in the U.S. healthcare system is not new, but the Patient Protection and Affordable Care Act (PPACA) has the potential to usher in the largest federal expansion of P4P to date. Even if legal and political challenges result in the repeal of PPACA, momentum continues as insurance companies and healthcare systems strive to improve health outcomes and reduce costs.

As seen in Healthcare Purchasing News.

The pay-for-performance (P4P) movement in the U.S. healthcare system is not new, but the Patient Protection and Affordable Care Act (PPACA) has the potential to usher in the largest federal expansion of P4P to date.  A provision of PPACA mandates pilot testing of P4P for certain Medicare providers, beginning no later than January 1, 2016. Even if legal and political challenges result in the repeal of PPACA, momentum for P4P continues as insurance companies and healthcare systems strive to improve health outcomes and reduce costs.

Pros and Cons

Proponents of P4P focus on the logic behind providing incentives to healthcare organizations and providers to meet measurable process improvements or clinical outcomes, such as better management of chronic diseases or reducing infection rates.  At first glance, these P4P objectives seem reasonable and desirable in terms of improving clinical outcomes.  But detractors of P4P cite a number of problems, including the assumption that financial incentives (or disincentives tied to poor performance) will affect important clinical outcomes associated with morbidity and mortality. (See “Effect Of Pay For Performance On The Management And Outcomes Of Hypertension In The United Kingdom: Interrupted Time Series Study.”) A study published online in New England Journal of Medicine (March 28, 2012) found that hospitals participating in the Medicare Premier Hospital Quality Incentive Demonstration (HQID) had  no decrease in 30-day mortality compared to control hospitals over a six-year period.  The authors noted that P4P effects on mortality did not differ significantly among conditions for which outcomes were explicitly linked to incentives (i.e., acute myocardial infarction and CABG) and those not linked to incentives (i.e., congestive heart failure and pneumonia).  (See “The Long-Term Effect of Premier Pay for Performance on Patient Outcomes.”) As expected, a quick scan of the medical literature shows an evolution from primarily positive articles in the early and mid-2000s, when P4P was a broad goal yet to be widely implemented, to more recent restrained views of actual P4P program outcomes.

Thorny Issues Surrounding Data Collection

In infection control, one of the more hotly debated issues related to P4P concerns the accuracy of data collection, including using accurate definitions and correcting for errors.  An example of this was illustrated by Patricia W. Stone in her article, “Economic Burden of Healthcare-associated Infections: An American Perspective.” In her article, Dr. Stone references the Medicare reform initiative that withholds reimbursement payment for HAIs and notes that, initially, administrative billing records were the primary mechanism used to identify HAIs. It was soon determined that billing records are unreliable indicators of infection occurrences, so additional diagnostic criteria were added. Stone suggests, however, that even the additional criteria do not completely dispel concerns about the accuracy of HAI identification in this population of patients.

Related to the issue of accuracy is the lack of any formal auditing practice to verify data gathered within the same healthcare institution or between institutions within the same healthcare system. Variations in data collection methods, and failure to identify erroneous data, could result in unfair penalties against under-resourced institutions.

Adjustments for Sicker Patients

Finally, there are concerns that P4P programs may not include mechanisms for adjusting for sicker patient populations.  On the New England Journal of Medicine Career Center website, John A. Fromson was recently quoted as follows:

“Pay-for-performance (P4P) incentives have the potential to improve the quality of care for our patients, but could also be exploited to simply control cost and improve the bottom line. Meaningful, standardized, evidence-based measures that do not penalize physicians for treating patients with significant co-morbidity and take into account variations in practice settings will have to be developed if P4P is to be fully integrated into medical practice.” (See “Physician Pay-for-Performance Programs Taking Hold.”)

Obviously, healthcare providers who treat patients who are sicker (and who usually have more sick patients) will see poorer overall health outcomes than those who treat healthier patients. These providers must not be financially penalized for taking on more risk. Perhaps a risk stratification structure is necessary to adjust for these differences in patient populations. For example, this might include grouping providers by patient population and adjusting outcome measures by underlying health condition.

Stepping Back

P4P sounds like a fair, evidence-based method for improving patient health by using measurable outcomes and recognized standards. But pilot programs and an extensive review period to evaluate and fine-tune definitions and methodologies are needed before P4P programs are widely implemented, particularly in infection control. At a minimum, infection control P4P measures should:

  • Use the same recognized definitions of infection to ensure that accurate infection rates are recorded.
  • Use similar or the same infection prevention interventions to get apples-to-apples comparisons among providers and institutions. For example, will barrier precautions and surveillance cultures both be required to reduce infections from multi-drug-resistant organisms?
  • Recognize and adjust for differences in resources and patient populations. This would help avoid unfair penalties for providers and institutions in more impoverished areas or with sicker patients.
  • Include an auditing mechanism to identify errors in data collection and outcomes.

These steps would promote data accuracy and consistency for comparison. With these and other improvements, P4P programs may eventually provide another tool for evaluating outcomes to improve patient health.

Read More

Dr. Cindi Crosby - Vice President, Global Medical Affairs

For the past 20 years I have attended many conferences, both national and international, on the topic of healthcare-associated infections (HAIs). The fundamental debate still continues, however, as to the actual frequency of HAIs. Most infectious disease physicians, infection preventionists and epidemiologists agree that HAIs are under-reported. Why? Could it be in the way we conduct our surveillance?

As seen in Infection Control Today.

For the past 20 years I have attended many conferences, both national and international, on the topic of healthcare-associated infections (HAIs). The fundamental debate still continues, however, as to the actual frequency of HAIs. Most infectious disease physicians, infection preventionists and epidemiologists agree that HAIs are under-reported. Why? Could it be in the way we conduct our surveillance?

Today, most HAI surveillance is passive, relying on data retrospectively gathered from medical records. Conversely, active surveillance involves prospective steps to identify patients who have or who may develop HAIs, using standardized definitions of infection, pre-determined criteria, and protocols that result in risk-adjusted HAI incidence rates.

Implementing and maintaining an active surveillance system requires personnel and financial resources, and so it’s often crucial to justify the investment with improved patient outcomes. Outcomes may then be used to develop targeted intervention programs. At a high level:

• Active surveillance may be most directly associated with monitoring and controlling the risk of outbreaks of drug-resistant pathogens, such as methicillin-resistant Staphylococcus aureus (MRSA).
• Increasingly, active surveillance has been used to identify patients at high risk for infections associated with surgery and hospitalization in intensive care units (ICUs).

Here are several more detailed examples of published outcomes from active surveillance programs:
Active surveillance to decrease MRSA isolates
Healthcare institutions are acutely aware of the rise in drug-resistant pathogens. In 1980, MRSA accounted for about 2 percent of all S. aureus HAIs. By 2006, it accounted for more than 60 percent.1 In response, some hospitals initiated active surveillance testing of patients considered high-risk for active MRSA infections or colonization. One hospital system using passive and ICU-targeted surveillance recorded no change in MRSA isolates over a three-year period. They implemented an active surveillance program to universally screen all patients upon admission for nasal colonization with MRSA.2 Patients found to be colonized received treatment with mupirocin nasal ointment and periodic bathing with antisepsis soap. For each year after initiation of active universal screening, the hospital recorded decreases in MRSA and total S. aureus clinical isolates compared to each of the prior three years of passive surveillance (P < 0.0001). The author of this study suggests that the decrease in MRSA isolates correlates with decreased disease.
Active surveillance to decrease surgical site infections
Active surveillance may be particularly useful in identifying surgical site infections (SSIs), which can develop up to 30 days after a patient is discharged. In one study of SSI rates identified passively by neurosurgeons,surgeons missed 36 percent of SSIs using passive surveillance, as evidenced by results from active surveillance performed by infection control professionals.3 Under-reporting HAIs with passive surveillance has been shown to be more likely among certain types of surgical patients during the post-discharge period. In a Dutch study of post-discharge SSI rates for various surgeries, more SSIs were identified with a recommended active surveillance protocol (43 percent) than with passive surveillance (25 percent).4  This study also demonstrated that for common surgeries including appendectomy, knee prosthesis surgery, mastectomy and hysterectomy, most SSIs developed after discharge and were underestimated when passive surveillance was used.
Active surveillance of device-associated infections
Patients at risk for device-associated infections such as catheter-associated urinary tract infections (CAUTIs) and ventilator-associated pneumonia (VAP) may benefit from active surveillance designed to identify risk factors that are unique to a particular patient population or hospital unit. An active surveillance program undertaken at Alexandria University Hospital in Egypt included an objective to identify etiologic and antibiotic resistance patterns associated with CAUTIs in the facility’s four ICUs.5 During a 13-month study period, 757 patients in the ICU who had existing urinary catheters or who were catheterized after ICU admission were monitored. The overall infection rate was 15.7 CAUTIs per 1,000 catheter days, with the following risk factors identified:

• Female gender
• Previous catheterization within the same hospital admission
• Admission to the chest unit
• Patient age 40 or older
• Prolonged duration of catheterization
• Prolonged hospital and ICU stay

In addition, the pathogen profile was identified, including Candida (51 percent), Gram-negative pathogens (33.5 percent), and Gram-positive organisms (15.4 percent). The prevalence of extended-spectrum beta-lactamase-producing organisms included E. coli (78.6 percent) and K. pneumoniae (56 percent). Investigators concluded that existing infection control policies were inadequate, and a tailored intervention to address these specific risk factors and microorganisms is now being designed.

Active surveillance was also used to guide evidence-based VAP prevention strategies in one tertiary medical-surgical trauma ICU in Saudi Arabia.6 VAP cases were diagnosed according to predefined criteria, and VAP microbiology, risk factors, and outcomes were recorded. The intervention program resulted in a decrease in VAP infection from 19.1 to 6.3 per 1,000 ventilator days from 2003 to 2009.  Active surveillance identified the following risk factors for VAP:

• Accidental extubation
• Trauma versus medical diagnosis
• Chronic obstructive pulmonary disease
• Neuromuscular blockade

The most common isolated pathogens were Gram-negative organisms. Investigators realized a reduction in VAP rates with active surveillance, reporting, and evidence-based preventive strategies and identified modifiable risk factors to be included in additional interventions.
Of note, another active surveillance testing program designed to identify MRSA colonization and institute contact isolation of affected patients in two Michigan hospitals also resulted in a decrease in VAP in both hospitals, although MRSA infection decreased in only one hospital.7 The investigators concluded that active surveillance testing with contact precautions was effective in reducing both VAP and MRSA in their facilities.
Economic consequences of surveillance
These studies are just a few examples of successful active surveillance programs that resulted in reduced infection rates. But even if active surveillance is shown to improve patient outcomes, are we prepared to actively capture HAI data? I would speculate that many institutions are not. A common objection to implementing active surveillance is the cost of labor and economic resources, particularly during a time when healthcare institutions are under pressure to reduce the cost of care. Those providers who are not taking steps to lower the risk and incidence of HAIs, however, may be taking an even greater financial risk.  Extended lengths of stay, antibiotic days, and readmissions are costly and create longer-term economic pressure. In a study by Dimick et al. (2004), median total hospital costs for patients with and without post-operative infection alone were $13,083 vs. $ 5,044, a statistically significant result.8

The difference between passive and active surveillance may seem like an academic debate among infection control professionals, but the consequences in terms of patient morbidity and costs of care are real and affect everyone.

___________________________________________________

References

1. Hall G, Flayhart D. Active surveillance culture as a promising new tool. Infection Control Today. Available at: http://www.infectioncontroltoday.com/articles/2006/02/approaches-to-infection-control.aspx. Accessed on February 15, 2012.
2. Hacek DM, Paule SM, Thomson RB Jr, Robicsek A, Peterson LR. Implementation of a universal admission surveillance and decolonization program for methicillin-resistant staphylococcus aureus (MRSA) reduces the number of MRSA and total number of S. aureus isolates reported by the clinical laboratory. J Clin Microbiol. 2009;47:3749-52.
3. Heipel D, Ober JF, Edmond MB, Bearman GM. Surgical site infection surveillance for neurosurgical procedures: a comparison of passive surveillance by surgeons to active surveillance by infection control professionals. Am J Infect Control. 2007;35:200-2.
4. Manniën J, Wille JC, Snoeren RLMM, van den Hof S. Impact of postdischarge surveillance on surgical site infection rates for several surgical procedures: results from the Nosocomial Surveillance Network in The Netherlands. Infect Control Hosp Epidemiol. 2006:27:809-16.
5. Talaat M, Hafez S, Saied T, et al. Surveillance of catheter-associated urinary tract infection in 4 intensive care units at Alexandria university hospitals in Egypt. Am J Infect Control. 2010;38:222-8.
6. Al-Dorzi HM, El-Saed A, Rishu AH, et al. The results of a 6-year epidemiologic surveillance for ventilator-associated pneumonia at a tertiary care intensive care unit in Saudi Arabia. Am J Infect Control. 2012. [Epub ahead of print]
7. Martinez-Capolino C, Reyes K, Johnson L, et al. Impact of active surveillance on methicillin-resistant Staphylococcus aureus transmission and hospital resource utilization. J Hosp Infect. 2010;74(3):232-7.
8. Dimick JB, Chen SL, Taheri PA, Henderson WG, Khuri SF, Campbell DA Jr. Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J Am Coll Surg. 2004;199:531-7.

 

 

Read More

Dr. Cindi Crosby - Vice President, Global Medical Affairs

Many of us know that silver is often used in hospital products because of its antimicrobial properties. Like silver, copper and copper alloys also have bactericidal, fungicidal and some virucidal properties that make it a good fit for the hospital environment. In fact, copper is the first solid antimicrobial material registered with the U.S. Environmental Protection Agency and is increasingly evaluated for use on door handles, bathroom fixtures and bed rails in hospitals, where microorganisms can collect and be transmitted from person-to-person.

Many of us know that silver is often used in hospital products because of its antimicrobial properties. Like silver, copper and copper alloys also have bactericidal, fungicidal and some virucidal properties that make it a good fit for the hospital environment. In fact, copper is the first solid antimicrobial material registered with the U.S. Environmental Protection Agency and is increasingly evaluated for use on door handles, bathroom fixtures and bed rails in hospitals, where microorganisms can collect and be transmitted from person-to-person. This transmission of microorganisms that cause infection contributes to hospital-acquired infection (HAIs). It’s estimated that bacteria on Intensive Care Unit (ICU) room surfaces are responsible for up to 80 percent of patient infections, leading to increased illness, longer hospital stays, higher costs of care and even death. Finding ways to reduce transmission of microorganisms is therefore an important focus for healthcare providers and a reason for strong interest in the use of copper.

In July, early results released from a multi-site clinical trial in the U.S. demonstrated that the use of antimicrobial copper surfaces in ICU rooms resulted in a 40.4 percent reduction in the risk of acquiring an HAI. The study, funded by the U.S. Department of Defense (DOD), was designed to determine the efficacy of antimicrobial copper in reducing the level of disease-causing microorganisms (pathogens) in hospital rooms, and whether such a reduction would lower infection rates. Researchers at three hospitals involved in the study replaced commonly touched items including bed rails, overbed tray tables, nurse call buttons and IV poles with antimicrobial copper versions. Rooms with copper surfaces had a 97 percent reduction in surface pathogens, which is the same level achieved after conducting the cleaning regimen used after a patient vacates a room. This DOD study confirmed others that have also reported reduced levels of pathogens on hospital surfaces made of copper.

Laboratory testing has shown that antimicrobial copper products that are regularly cleaned can kill more than 99.9 percent of microorganisms, including antibiotic-resistant bacteria such as MRSA, VRE and other bacteria that can cause fatal infections, as well as viruses that cause influenza. In addition to its use as surface material, copper is being evaluated for use in biocides, in external fixation pins used in orthopedic surgery, and as a coating or impregnated substance in gloves, filters, and fibers used in fabrics like clothing and mattresses.

As hospitals look for ways to reduce the risk of HAIs and improve the overall safety and quality of patient care, I expect we’ll begin to see more studies of this kind that help identify novel ways to redesign products and procedures to avoid preventable errors and infections.

Read More

Dr. Cindi Crosby - Vice President, Global Medical Affairs

Healthcare-associated infections (HAIs), also known as nosocomial infections, are infections that patients acquire while receiving treatment for medical or surgical conditions. HAIs occur in all healthcare settings. Common causes of HAIs include contamination of medical devices such as catheters and ventilators; transmission of microorganisms from healthcare worker to patient, or from patient to patient; and overuse of antibiotics, resulting in resistant organisms.

Healthcare-associated infections (HAIs), also known as nosocomial infections, are infections that patients acquire while receiving treatment for medical or surgical conditions. HAIs occur in all healthcare settings. Common causes of HAIs include contamination of medical devices such as catheters and ventilators; transmission of microorganisms from healthcare worker to patient, or from patient to patient; and overuse of antibiotics, resulting in resistant organisms.

HAIs are very serious, causing substantial morbidity and even death. In the United States, an estimated 2 million patients acquire HAIs annually, and between 44,000 and 98,000 patients die from HAIs. In the United Kingdom, an estimated 5,000 deaths occur annually due to HAIs. The most common HAIs include pneumonia, urinary tract infections, surgical site infections, and bloodstream infections.

In addition to causing serious morbidity and mortality, HAIs are expensive, resulting in longer hospital stays and increased use of medical resources. In the United States, HAIs account for an estimated $17 to 29 billion in additional healthcare costs each year. In the United Kingdom, the annual cost to the National Health Service is approximately £1 billion.

To illustrate the risks of HAIs and demonstrate concrete actions that can be used to reduce these risks, the U.S. Department of Health and Human Services released Partnering to Heal, a computer-based, video-simulation training program on infection control practices for clinicians, health professional students, and patient advocates. This powerful video demonstrates how easily pathogens can be spread in the healthcare environment and how even minor communication and infection control lapses in the hospital can increase risks for patients. Users assume the identity of one of five main characters, including a physician, a nurse, an infection preventionist, a medical student, and a patient’s family member. Each character is given the opportunity to make decisions about preventing HAIs and learn about creating a “culture of safety” to prevent patients from getting sicker.

To watch the HHS Partnering to Heal training video online and learn about practices that can reduce HAI risks, go to: http://www.hhs.gov/ash/initiatives/hai/training/partneringtoheal.html.

Read More