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Building a Business Case for Control of Multidrug Resistant Organisms (MDROs)
Hospital Authority Convention 2012 May 8, 2012
Tom R. Talbot, MD MPH Associate Professor of Medicine and Preventive Medicine
Vanderbilt University School of Medicine Chief Hospital Epidemiologist
Vanderbilt University Medical Center
Objectives • Review briefly the rising challenge regarding
multidrug resistant organisms (MDROs)
• Discuss the approach to making a business case for MDRO prevention programs including a review of – The clinical consequences of MDROs – The financial consequences of MDROs – Putting it all together
Multidrug-Resistant Organisms (MDROs): Background
• Infectious agents that are resistant to key antimicrobials. May include resistance to: – One or more antimicrobials – All but one antimicrobial or class – All antimicrobials and classes – Three or more antimicrobial classes*
• Limited treatment options • Associated morbidity/mortality
*Management of MDRO in Healthcare Settings, 2006 HICPAC
S = Sensitive (Antibiotic will treat) R = Resistant (Antibiotic will NOT treat)
Different Antibiotic Options
MDR GN
What options do we have to treat this patient?
Examples of MDROs
• Methicillin-resistant Staphylococcus aureus • Vancomycin-resistant Enterococci • MDR Gram-negative bacilli
– Carbepenemase-resistant Enterobacteriaceae (CRE) – New Delhi metallo-β-lactamase (NDM-1)
• Clostridium difficile
MRSA
VRE
MDR GN
C diff
http://www.chp.gov.hk/en/epidemiology/29/97/119/564.html
Source of the MDRO • Colonized or infected patient • Colonized or infected healthcare worker • Contaminated environment • Spontaneous mutation
Dubberke ER et al Am J Infect Control 2007;35:315+
X
X X X
X
X
X
X
C. difficile recovered from 83% of “dirty surfaces C. difficile recovered from 67% of “clean” surfaces
Reducing Transmission of MDROs in Healthcare Settings
• Administrative measures and adherence monitoring • Education and training of healthcare personnel • Surveillance (know the scope of the problem) • Infection control precautions
– Basic strategies – hand hygiene, isolation precautions – Enhanced strategies – active surveillance testing
• Environmental measures • Judicious use of antimicrobial agents
*Management of MDRO in Healthcare Settings, 2006 HICPAC
General Recommendations: Environmental Measures
• Clean and disinfect surfaces in close proximity to patient and high-touch surfaces more frequently than minimal-touch surfaces
• Dedicate non-critical equipment to use on individual patients colonized or infected with MDROs
• Prioritize room cleaning of patients on contact precautions
• ? Audit cleaning practices • Use advanced room cleaning techniques?
*Management of MDRO in Healthcare Settings, 2006 HICPAC
Judicious Use of Antimicrobial Agents/ Antimicrobial Stewardship
• Processes designed to measure and optimize the appropriate use of antimicrobials
• Achieved by selecting the appropriate agent, dose, duration of therapy and route of administration
• Implement systems to prompt clinicians to use appropriate agents – Provide antibiograms at least annually
• Implement process for review and feedback of prescribed antimicrobials
*Management of MDRO in Healthcare Settings, 2006 HICPAC
Active Surveillance Testing • Practice of culturing asymptomatic patients
for the presence of MDRO (colonized) • Prevalence of MDRO may be greater than
anticipated, even if there have only been a few clinical cases
*Management of MDRO in Healthcare Settings, 2006 HICPAC
Making the Business Case for MDRO Prevention
• Should address the following: – What is the extent of the problem? – Will the proposed program effectively address the
problem? – Is the program aligned with institutional
goals/values?? – What is the cost of the program? – What are the potential unintended consequences of
the program?
Making the Business Case for MDRO Prevention
• Should address the following: – What is the extent of the problem? – Why is it a problem worth addressing?
• Disease burden • Clinical consequences • Financial consequences
Clinical Consequences of MDROs
• How much of a clinical impact does acquiring an MDRO infection have on your patients?
• Depends upon several factors -- – How much disease is present? – How severe of an outcome will a
patient will have if he/she becomes infected?
Assessing the Burden of an MDRO
Proportion # of isolates of MDRO x
100 Total # of isolates
Ex: 62% of Staphylococcus aureus isolates in Q2 were
MRSA
Rate # of isolates of MDRO
Unit of time
Ex: 3.7 MRSA isolates per 100 hospital admissions in Q2
Two methods to measure:
Proportion •Impacted by changes in non-MDRO isolates
Rate •Independent of changes in non-MDRO isolates •Can accurately evaluate impact of new procedures or policies
Two methods to measure:
Assessing the Burden of an MDRO
Assessing the Burden of an MDRO at Your Facility: Some Sample Data
98 sensitive
2 MDRO
48 sensitive
2 MDRO
18 sensitive
2 MDRO
18 sensitive
4 MDRO
135 sensitive
15 MDRO
If examine proportions: MDRO burden interpreted as a 4 year increase followed in year 5 by a decline.
If examine rates: MDRO
burden steady for 4 years and then sharp increase
Clinical Consequences of MDROs
• How much of a clinical impact does acquiring an MDRO infection have on your patients?
• Depends upon several factors -- – How much disease is present? – How severe of an outcome will a
patient will have if he/she becomes infected?
• Patients with an MDRO infection will have limited treatment options compared to those with a more antibiotic-susceptible infection.
• For some MDROs, only 1 or 2 antibiotics are left for treatment, and these often have toxic side effects.
Clinical Consequences of MDROs
• Studies examining several different types of MDROs have noted an increased risk of death in patients with an MDRO infection.
• This risk is still present when comparing patients with MDRO infection to those with infection due to a more susceptible strain of the same bacteria.
• This may be due to increased virulence of the MDRO, delays in antibiotic therapy that will treat the organism, underlying patient illnesses, or all of the above.
Clinical Consequences of MDROs: Mortality
• Patients with and MDRO infection have an increased risk of death compared to patients with infection due to a susceptible strain: – MRSA Bloodstream Infection 2X Risk – MRSA Ventilator-Associated Pneumonia 2X Risk – Any MRSA Infection 2X Risk
– VRE Bloodstream Infection 2-2.5X Risk – ESBL Producer Bloodstream Infection 2X Risk – MDR Acinetobacter Bloodstream Infection 4X Risk
Clinical Consequences of MDROs: Mortality
Cosgrove SE et al Clin Infect Dis 2003;36:53+
MRSA and Mortality: Bacteremia
MRSA
Engemann JJ et al CID 2003;36:592+
MRSA and Mortality: Surgical Site Infections
MRSA
Mortality Associated with KPC-Producing Organisms
p<0.001
p<0.001
20 48 12 38
OR 3.71 (1.97-7.01) OR 4.5 (2.16-9.35)
Patel et al. Infect Control Hosp Epidemiol 2008;29:1099-1106
MDR GN
• Multiple studies with several different types of MDROs have shown that MDRO-infected patients also have – d length of hospitalization – d risk of ICU admission – d ICU length of stay
Clinical Consequences of MDROs: Morbidity
The Costs of MDROs: Economic Impact
• Increasing number of studies on costs of MDROs • Methodology varies widely • Examine “cost” definitions closely
– “Cost” vs. “Charge” – Include fixed costs (e.g. nursing)?
• Ask for help from finance colleagues – The “Our Own Data” syndrome
Assessing the Costs of MDRO Infections
• Fixed costs – Accrue regardless of case volume
• Physical plant costs • Equipment • Base-level staffing
– Prevention of outcome may not prevent these costs • e.g. Still need to support nurse staffing even if
MDROs reduced
• Variable costs – Per case expenses
• Supplies • Medications • Variable staffing
– If decreased nurse-to-patient staffing with MDRO + patients, may be impacted by prevention programs
Assessing the Costs of MDRO Infections
Making the Business Case for MDRO Prevention
• Should address the following: – What is the extent of the problem? – Will the proposed program effectively address the
problem? • Include studies that show impact of prevention
efforts on outcome • Important to identify facilities of similar
composition to your own
MRSA
Robicsek A et al Ann Intern Med 2008;148:409+
• Observational: no control arm
• Changes in time to obtain study results
• Single health system
Making the Business Case for MDRO Prevention
• Should address the following: – What is the extent of the problem? – Will the proposed program effectively address the
problem? – Is the program aligned with institutional
goals/values?? • Does it further the mission of the organization? • Is the issue the focus of an external group?
External Interest/ Requirements
Making the Business Case for MDRO Prevention
• Should address the following: – What is the extent of the problem? – Will the proposed program effectively address the
problem? – Is the program aligned with institutional
goals/values?? – What is the cost of the program?
• Direct and indirect
Costs of an MDRO Prevention Program
• Supplies (e.g. PPE, alcohol gel, reagents) • Equipment (e.g. AST PCR, environmental
cleaning tools) • Personnel (e.g. technician, ID pharmacist)
Cost Effectiveness Studies?
Making the Business Case for MDRO Prevention
• Should address the following: – What is the extent of the problem? – Will the proposed program effectively address the
problem? – Is the program aligned with institutional
goals/values?? – What is the cost of the program? – What are the potential unintended consequences of
the program?
Diekema D et al CID 2007;44:1101+
Adverse Consequences of Contact Precautions
Decreased healthcare contacts
Patients examined less frequently each day
Patients have vital signs checked less often
More adverse events
Psychological symptoms (depression)
Wenzel RP et al ICHE 2008;29:1012+
Look for Other Solutions/Perspectives
• Define the owners, stakeholders, key leaders • Ask for help/perspectives
– Especially finance leaders • ? Impact of reduced LOS and better throughput • Local cost data on HAIs/MDROs??
• Get the input of potential resistors early
Making the Business Case for MDRO Prevention – Words of Wisdom
Making the Business Case for MDRO Prevention – Words of Wisdom (II)
• Understand potential barriers • Be honest with impact and cost of program • Note the societal impact but emphasis varies
depending on your audience • Describe how you will analyze the program’s
impact
Components of an MDRO Prevention Program Business Case Proposal
A business case proposal should contain the following key components: 1. Background of the problem/impact 2. Definition of the MDRO Prevention Program 3. Benefits of the MDRO Prevention Program 4. Implementation strategies 5. Pilot testing logistics and timeframe 6. Financial analysis 7. Recommendations 8. Next steps 9. Measurable goals/outcomes 10. Time points of assessment
Putting It All Together