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