Becker's Clinical Quality & Infection Control

36 Executive Briefing earn back incentive payments based on their performance scores that may be less than, equal to, or greater than the re- duction that was held in that year. Poorly performing hospitals receive reduced payments while higher performing hospitals are rewarded with incentive payments. In fiscal year 2016, 1806 hospitals will receive a positive adjustment to their pay- ments, while 1235 will receive a negative adjustment averag- ing around 0.3 percent of their total $455,000 payment. 3 In the Hospital-Acquired Condition Reduction program, hospitals in the lowest-performing quartile are subject to a 1 percent reduction in Medicare payments. The HAC scores include similar measures for HAIs as the VBP. For fiscal year 2016, 758 of 3,308 hospitals will have their payments cut by 1 percent, an increase from 724 hospitals in 2015. 4 Table 1 provides details of the programs and changes for fiscal years 2017-2020, which have performance periods from 2015 onwards. 5 With the shift towards payments based on quality of care provided, these ACA programs result in additional financial penalties for poorly performing hospitals, beyond the costs for additional treatments resulting from HAIs that they might already bear. What's more, there are significant financial incentives available for hospitals reporting HAI levels below national averages. The combined features of penalties and payments, and the emphasis placed on HAIs in the HAC pro- gram, make it clear that hospitals can benefit exponentially from tackling HAI rates. However, there are a number of tools and strategies available to healthcare organizations to help mitigate the risk of patient infections. Approaches to Preventing HAIs To prevent the spread of HAIs, healthcare facilities should focus on a horizontal infection prevention approach, which is most appropriate to address the growing concern of multi- drug resistant organisms such as methicillin-resistant Staph- ylococcus aureus, vancomycin-resistant enterococci, carbap- enem-resistant Enterobacteriaceae, and others that cause serious infections which are extremely difficult and costly to treat. Within that horizontal approach, strategies to specifical- ly target the pathogens that cause the most HAIs can be very effective. One useful strategy is skin and nasal decolonization. Vertical and Horizontal Approaches to Preventing HAIs 7 Pathogen-specific vertical approaches • Active surveillance testing • Contact precautions • Decolonization of patients Non-pathogen specific horizontal approaches • Daily environmental cleaning and disinfection • Standard precautions (e.g. hand hygiene) • Universal use of gloves and gowns • Universal decolonization • Antimicrobial stewardship Decolonization Methods Patient bathing with chlorhexidine gluconate is an effective approach to reducing HAIs, particularly CLABSIs. A recent meta-analysis of studies in critically ill patients showed that daily CHG bathing resulted in a 55 percent reduction in the risk ratio for CLABSI compared to the normal standard of care, as well as significant reductions in MRSA and VRE infec- tions. 8 Daily bathing and nasal decolonization of ICU patients can also reduce the rate of all bloodstream infections. 9 The 2014 Society for Healthcare Epidemiology of America and the Infectious Disease Society of America recommendations include the daily bathing of all ICU patients with CHG to reduce the risk of CLABSI. 10 CHG bathing is also included as an optional recommendation for a central line maintenance bundle in an implementation guide released by the Associa- tion for Professionals in Infection Control and Epidemiology. 11 The skin and nasal decolonization component of the preoper- ative bundle has also been key to preventing SSIs. In general, there are two decolonization strategies that are effective when employed prior to surgery: targeted decolonization in which patients are screened for S. aureus or MRSA and under- go skin and nasal decolonization, or universal decolonization, in which all patients are decolonized prior to surgery, thus avoiding timely and costly screenings. According to APIC guidelines and SHEA/IDSA Practice Recommendations, the strategy of skin and nasal decoloni- zation prior to surgery and implementation of this pre-oper- ative decolonization protocol is a good practice that can be implemented prior to any major invasive surgical procedures, including colon surgeries, hysterectomy, and arthroplasty. 12 Up to now, mupirocin ointment, applied twice daily for five days prior to surgery, has been the most common agent used for nasal decolonization. However, the search for a one-time, easy-to-apply antiseptic for decolonization has been prompt- ed by concerns about resistance of S. aureus and MRSA to mupirocin 13 and the risk of decolonization failure due to pa- tient non-compliance with the five day mupirocin application regimen. 14 Povidone Iodine: An Antiseptic Alternative for Nasal Decolonization Povidone iodine has emerged as an effective antiseptic alternative to mupirocin that can address concerns about re- sistance. Its usage also aligns with national antimicrobial stew- ardship initiatives that aim to address the growing problem of multi-drug resistant organisms. As products are designed to be applied to patients by healthcare workers, compliance may also be increased. Studies evaluating the efficacy of povidone iodine for nasal decolonization, when used as part of a decolonization bundle that includes CHG bathing and CHG oral rinse, have shown positive results. A 2015 study showed that implementing this decolonization regimen resulted in a 70 percent decrease in SSI following joint arthroplasty, compared to patients who did not undergo a decolonization regimen. 15 In patients under- going orthopedic surgeries, povidone iodine was shown to be as effective as mupirocin when used for nasal decoloni- zation. 16 Additionally, a study has also shown that patients decolonized with povidone iodine experienced fewer ad- verse events compared to those using mupirocin. 17 Allaying concerns about resistance, studies to date have not yet shown that bacteria develop resistance to povidone iodine. 18 There are also financial savings resulting from the use of povidone iodine as part of a universal decolonization proto- col prior to surgery. When used in a universal decolonization protocol including CHG bathing and compared to a targeted

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