Impacto dos custos, infraestrutura para higienização das mãos e magnitude das infecções relacionadas à assistência à saúde em hospital de referência em Minas Gerais

Abstract

Background: The principal focus of all efforts to control and prevent healthcare-associated infections (HAIs) is the inherent necessity to measure the burden of these infections as well as the risks and costs associated. Objectives: This study aimed to map the prevalence of HAIs caused by epidemiologically important pathogens in the hospital environment, as well as to evaluate the direct costs and reimbursement by the Brazilian government associated with critical patients, in a Tertiary Referral Hospital in Brazil. Additionally, the Hospital's infrastructure diagnosis for HAI control was performed, mainly related to hand hygiene. Methods: In 2017, a point prevalence survey was carried out in all clinics at the hospital, through systematic screening of patients' medical records and visits to clinics. A case study (patient with HAI present at the time of the prevalence survey) versus control (patients who had not yet acquired HAI on the "corresponding day") was paired to assess risk factors, total mortality and hospitalization costs. Cases and controls were matched for hospitalization clinic, age, sex and time of risk. For the calculation of reimbursement, the total amount charged for each hospitalization to the Unified Health System (SUS) was obtained through the Hospital Billing Sector and for the calculation of direct costs, those related only to the adult ICU care were included, through an annual survey (2018). A Monte Carlo simulation was carried out, with 50,000 simulations, of the direct annual cost of patients with HAI admitted to the adult ICUs in 50 federal university hospitals in Brazil, covering three prevalence scenarios. The diagnosis of the hospital's infrastructure was focused on 4 essential areas: hospital infection control service, sterilization service, microbiology laboratory and, mainly, on resources for hand hygiene. Results: 423 patients were included, in which the total prevalence of patients with HAI was 19.6%, being especially high in the adult ICU (50.0%). The prevalences of bloodstream infections (BSI), pneumonia (PNM) and urinary tract infection (UTI) were 32.6%, 22.4% and 21.4%, respectively, mainly caused by Enterobacteriaceae, Gram-negative bacilli (BGN) non-fermenters and E. coli in those with microbiological evidence (60.2%), respectively. The use of invasive devices was an independent risk factor for HAI. It was observed that the presence of central venous catheter, mechanical ventilation and urinary catheter increases the risk for BSI, PNM and UTI by 9.5; 16.0 and 9.5 times, respectively. In addition, the patient's presence in the adult ICU was strongly related to the development of pneumonia (OR: 4.2408). In total, 45.6% of the patients received at least one antimicrobial. Of all antimicrobials used to treat infection, only 48.6% of patients were based on microbiological results. This study demonstrated an average proportion of the number of patients per sink of 3.42 ± 2.33, with a compliance rate (CI) of 91% and the number of patients per alcoholic dispenser of 1.61 ± 1.12 patient / dispenser (CI = 86%). However, evaluating the performance of hand hygiene by indirect methodology, the rate of adherence to the practice of hand hygiene was 10% and 15% in the ICUs and other clinics, respectively. This study revealed that the cost of reimbursement for hospitalization of patients with HAIs was 75% higher than patients without HAIs, even higher among patients with infection by resistant phenotypes. 41% of the total reimbursement amount for hospitalization of all patients included in the study was allocated to patients with HAI, however the number of patients with HAI corresponded to 19.6% of the total. When the direct cost was assessed, extremely high values were observed when the same comparison was made, with the direct cost being 111.5% higher than the reimbursement value (US $ 11776 x US $ 5569, respectively) for the patient with HAI. From the Monte Carlo simulation, an additional direct cost of US $ 2,824,817 was observed for each 1% increase in the prevalence of HAIs. Conclusion: This study provides alarming data on HAIs as well as the costs involved, with high rates of infections that have a worse prognosis (sepsis and pneumonia), caused mainly by multidrug-resistant BGN, significantly associated with the patient's presence in the ICU, as well as the use of mechanical ventilation and central venous catheters. Although the hospital evaluated has adequate infrastructure and resources for hand hygiene, performance in the practice of hand hygiene was extremely low.