Clinical PotpourriDo cost savings from reductions in nosocomial infections justify additional costs of single-bed rooms in intensive care units? A simulation case study
Introduction
The critically ill patients in intensive care units (ICUs) are susceptible to infection, making the risk nosocomial infections much greater in ICUs than in other hospital departments [1], [2], [3]. Nosocomial infections are associated with substantial morbidity and mortality [1], [4]. Although recent efforts to improve health care quality and safety in the United States and around the world have led to major progress in preventing nosocomial infections, studies continue to show that there is still a considerable room for improvement in preventing the hundreds of thousands of nosocomial infections that occur every year [5], [6], [7].
Some efforts to control nosocomial infections focus on changing the behaviors of those involved in patient care; others focus on standardizing the clinical best practices for preventing infections. Examples of behavioral strategies include education and performance feedback [8] as well as teamwork and decision making by physician-led multidisciplinary teams [9], [10]. Clinical practices include screening at hospital admission, standard isolation measures (eg, hand hygiene, personal protective equipment, respiratory hygiene and cough etiquette, cleaning and disinfection of equipment and environment, and waste disposal), and transmission-based isolation measures (eg, contact, droplet, and airborne isolation) precautions during hospital stay [11]. In recent years, hospitals have also used decolonization strategies, such as the use of daily chlorhexidine bathing [12], [13], [14], and used nasal mupirocin [14], [15] for controlling transmission of multidrug-resistant organisms.
However, given the multifactorial nature of these infections, no single intervention is likely to be sufficient. Multiple interventions, including those that focus on the physical environment, are necessary to mitigate risk [16], [17]. A growing body of evidence demonstrates that nosocomial infection rates can be reduced through changes in facility design and operation, including the use of single-patient rooms, air filtration devices, antibacterial surfaces, cleanable surfaces, and properly located hand-cleaning rubs and sinks [11], [18], [19], [20].
Although there are studies that have not demonstrated no significant differences in highly endemic infections between single-patient and open-bay rooms [21], [22], many other studies have specifically shown the benefits of single-patient rooms in preventing environmental contamination and interrupting transmission of pathogens in adult [23], [24], [25], [26], [27], [28], [29], [30] and pediatric [31], [32] ICU settings. A recent quasiexperimental study of 176 hospitals found that after controlling for known predictors of nosocomial infection rates, including use of a surgical mask, use of antiseptic soap, enhanced environmental cleaning, admission screening, occupancy rate, and staffing level, the routine use of private rooms for colonized and infected patients was independently associated with a lower rate of nosocomial infections [30]. Overall, the conventional wisdom seems to be in favor of the added benefit of single-patient rooms. In light of such evidence, the current infection control [11] and facility design [33], [34] guidelines in the United States recommend single-bed rooms over open-bay rooms, citing better infection control, specifically when transmission-based precautions are necessary. Nevertheless, single-bed rooms require additional space and possibly higher construction costs as well as higher operation and maintenance costs (eg, heating and cooling loads, cleaning, disinfection, and support services). Such costs, however, can potentially be offset by the costs avoided due to lower rates of infection. Contrasting the long-term costs of single-patient vs open-bay room can provide a valuable tool for facility planning, financial evaluations, and resource allocation in hospitals.
Few peer-reviewed studies have investigated the return on investment from improving facility design and operation [35], [36], and none have been performed in ICU settings. Therefore, this study aimed to investigate whether, from a hospital perspective, the costs savings from reductions in nosocomial infections can justify the additional construction and operation costs of single-bed rooms in ICUs. We use the reported results from a previous comparative study of nosocomial infections in patients in single-patient and open-bay ICU rooms to estimate the return on investment in such rooms.
Section snippets
Materials and methods
This study uses, as an exemplary setting, the assessment by Bracco et al [24] of a medical-surgical ICU in Canada. Bracco et al provided detailed information regarding the specific design and operation features implemented in the facility and a schematic drawing of the floor plan for calculating construction and operating costs. With these data, as well as external evidence on the costs associated with particular ICU design and operation interventions, we performed a probabilistic
Deterministic analysis
Our calculations indicated that the numbers of cases of MRSA acquisition, Pseudomonas species acquisition, and Candida species colonization in single-bed rooms vs bay rooms were reduced by 1.5 (4.1 vs 2.6), 1.5 (3.8 vs 2.3), and 9.4 (37.8 vs 28.4) per year, respectively. Given the additional costs of each incident (Table 1), $418 269 in spending would be avoided through infection reduction in this ICU if all patients hosted in bay rooms were admitted to single-bed rooms. Using deterministic
Discussion
We found that although single-patient rooms are more costly than open-bay rooms to build and operate, they are also more effective in avoiding costs associated with nosocomial infections. The financial feasibility of single-bed room becomes apparent considering that current rate for cost of capital in US health care sector is approximately 6% [45]. Our probabilistic analysis indicates only a 4.87% chance that the IRR would be less than 6% resulting in a negative NPV. As such, although different
Conclusions
The simulated case study presented in this article indicated that although single-patient rooms are more costly to build and operate, they can result in substantial savings compared with open-bay rooms by avoiding costs associated with nosocomial infections. Together with studies that have shown the efficacy of single-bed rooms in controlling ICU nosocomial infections, our study showed that facility design and operation can support good hospital practice in a cost-effective way. Incorporation
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