August 24, 2005
Surgical site infections are the most common hospital-based infections, representing 14 to 16 percent of all hospital nosocomial infections. In addition to the obvious health concerns, these infections also can be quite costly -- adding days to hospital stays, raising treatment costs, and increasing the likelihood of readmission.
In HFMA's September 2004 issue of Managing the Margin, Girard Senn, RN, CNAA, managing principal of perioperative and cardiovascular services for Premier, Inc., Oak Brook, Ill., explains that many providers may not be aware that some strategies to prevent these infections also can present significant -- and unnecessary -- clinical variation and financial drain.
Skin Preparation Options
Skin preparation options are probably not high on the organization's list of costly supplies; yet inefficient use of or investment in unproven products can lead to substantial cost.
Alcohol. According to guidelines for prevention of surgical site infections from the Association of periOperative Registered Nurses (AORN), alcohol remains the most effective and rapid-acting skin antiseptic when properly applied. The highly effective and classic combination of 70 percent alcohol, 1 percent iodine, and 29 percent water that is painted on the surgical site is also the least expensive skin preparation option available. For a total hip replacement procedure, cost is about $1.12 per patient -- far less than other typical options.
Other antiseptic agents. Several other antiseptic agents are available for preoperative preparation of skin at the incision site. AORN notes that adequate comparison of the effects of these preoperative skin antiseptics on surgical site infection risk has not occurred in well-controlled, operation-specific studies. At the higher-cost end of the skin-preparation product continuum are swabs containing alcohol and chlorhexidine gluconate (CHG). Cost is typically at least $6 per swab. Many providers find when they start looking at the hospital's usage rates, staff frequently use two or more of the swabs on each patient. Using these swabs inefficiently can double or even triple the cost of preoperative skin preparation per patient to about $20.
Drapes. Preoperative skin preparation may include using an antiseptic-impregnated adhesive drape and using a sterile (versus a "clean") surgical skin preparation kit. However, AORN states that neither of these modifications has been shown to represent an advantage. Providers that use iodine-impregnated adhesive drapes add between $5 and $30 in costs per patient -- and still do not improve the likelihood of reducing surgical site infections.
Showering. Preoperative showering practices also may present opportunities to improve processes and reduce costs. To quote the AORN's prevention guidelines: "Even though preoperative showers reduce the skin's microbial colony counts, they have not definitively been shown to reduce surgical site infection rates."
Initiating Change
To support efficient and cost-effective clinical practice changes in skin preparation options, the healthcare financial manager should be persuasive, not directive. There are several actions you can take:
- Ask the materials manager to provide a report on the percentages of various skin preparation types that are purchased and used and the costs for each. (Although somewhat difficult to ascertain, also included should be an estimate of the cost of custom surgical packs that do not show up in regular supply audits.)
- Ask the OR director to tally how many skin preparations are used per procedure. Compare this information with cost data obtained from the materials manager's report and discuss significant trends with the OR director.
- Recommend sharing this information with the OR staff. Individuals are most inclined to adopt cost-savings efforts when they are included in discussions and provided with meaningful supportive information to make informed decisions.
Clinical staff can appreciate that variation in preoperative skin preparation practices that is without scientific support does not serve patients well, places demands for constant adaptation on the surgical nursing staff, and is unnecessarily costly.
SOURCE:
"Achieving Preoperative Savings," by Girard F. Senn, RN, CNAA. From the September 2004 issue of HFMA's Managing the Margin newsletter.
Additional Resources
- Comprehensive listing of HFMA programs, publications, tools, and reports related to cost control.
If you have questions or comments about HFMA Wants You to Know, contact editor Laura Noble.
HFMA Wants You to Know ISSN: 1540-0697. Volume IV, Issue 16. Copyright 2005, Healthcare Financial Management Association. All rights reserved.