The Cost of Antibiotic Resistance: What Every Healthcare

Client name/ Presentation Name/ 12pt - 1

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The Cost of Antibiotic Resistance:What Every Healthcare Executive

Should KnowJCR National Infection Prevention

and Control Conference2009

Mastering Powerful and Practical Infection Prevention Strategies

August 21-22Arlington, Virginia

© Ortho!McNeil!Janssen"Pharmaceuticals,"Inc." May"2009 02AXXX


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Presented by:

– Stephen G. Weber, MD, MS– Medical Director, Infection Control and Clinical

Quality – University of Chicago Medical Center

– JCR Consultant

– Barbara M. Soule, RN, MPA, CIC– Practice Leader, Infection Prevention and Control

Services– Joint Commission Resources / Joint Commission

International


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Why did we create this toolkit?– Patients and Hospitals in Peril– The Problem of Antibiotic Resistance and

Multidrug Resistant Organisms (MDROs) is Increasing

– Leadership is not aware and their understanding of the issue and leadership is mandatory!

– TJC 2009 National Patient Safety Goal aimed to prevent infections


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Development of the Toolkit– Ortho-McNeil sponsorship and JCR

development– Steering Committee

– Nationally recognized thought leaders participated in steering committee and production of tools and content

– Toolkit concept tested by senior executives of ~ 30 organizations of varying size and complexity with feedback to authors

– Full process – 18 months


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Toolkit OverviewEach chapter contains:

– Compelling question for leaders– Illustrative case study– Comprehensive evidence-based background

information summarizing research, challenges and interventions

– Illustrative figures and tables, success stories, helpful hints, links to other resources

– Tools applicable to each topic– Key concepts and take-home messages– CEO and senior executive messaging


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Chapter 1: Antibiotic Resistance: Patients and Hospitals in Peril

Why is the issue of antibiotic resistance important to you and your organization?

– Provides background on the growing problem of MDROs and rationale for MDRO control

– Over past 2 decades, incidence of infections among hospital patients caused bymultidrug-resistant organisms (MDROs) has continued to rise despite widespread control efforts 1

– Driven by 2 major factors– Antibiotic misuse or overuse by physicians– Horizontal transmission in health care facilities

National Nosocomial Infections Surveillance System: National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through 2004, issued October 2004. Am J Infec Control. 32:470-485, Dec. 2004.


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– MDROs pose significant challenges to the health care system, including clinical and financial burdens !


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– CD tools include–Sample Risk Assessment Matrix*–Risk Assessment Primer–Considerations for Enhanced Risk

Assessment –Dashboard for MDRO Reporting–Competency Questions–CEO Talking Points



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SAMPLEMDRO RISKASSESSMENT MATRIX


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Chapter 2 - The Clinical Consequences of Antibiotic Resistance

– How many patients at your institution died last year as a resultof infection with multi-drug resistant organisms?

– Designed to help senior leaders understand the burden of MDROs at their institution

– Highlights the clinical consequences associated with MDRO infection to help leaders

– Understand the clinical impact of MDROs– Prioritize and promote prevention strategies

– Assesses the frequency of MDROs through proportion and incidence rates

– Discusses patient morbidity and mortality risks associated with several types of MDROs


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Mortality Risk for MRSA Compared to MSSA

1.9 1.8

3.6

2.2

0

0.5

1

1.5

2

2.5

3

3.5

4

BloodstreamInfections

Ventilator-AssociatedPneumonia

Surgical SiteInfections

All Infections &Long-Term Mortality

Odd

s/H

azar

d R

atio

for M

orta

lity

The specific mortality outcome for each infection type is as follows: bloodstream infections and ventilator-associated pneumonia = in-hospital mortality; surgical site infection = 90-day post-operative

mortality; all infections = 12-month mortality in those surviving to hospital discharge.

Odds or hazard ratio

of 1 or lower =

No increase in risk


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– CD tools include–MDRO Burden Calculator–Competency Questions*–CEO Talking Points*

Chapter 2: The Clinical Consequences of Antibiotic Resistance


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Chapter 3 - The Financial Impact of Antibiotic ResistanceHow much did it cost your hospital last year to prevent and manage infections caused by multidrug-resistant organisms?

– Discusses specific issues regarding the financial impact of MDROs

– Measuring the impact of antibiotic resistance– How antibiotic resistance leads to increased financial

costs– Control of MDROs can be embraced as not only a clinical

priority for the organization but a financial one as well


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Chapter 3 - The Financial Impact of Antibiotic Resistance

The primary driver of increased costs isan increase in length ofHospitalization !


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Variation of costs for treatment from infections fromresistant vs sensitive organisms


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– CD tools include–MDRO Burden Calculator*–Competency Questions–CEO Talking Points

Chapter 3: The Financial Impact of Antibiotic Resistance


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MDRO Burden Calculator

Patient Population for Analysis

MDRO Infection for Analysis

2007 2008

A. Number of non-duplicate isolates of specific pathogen of interest

40 20

B. Number of non-duplicate isolates of pathogen resistant to specific antibiotic of interest

30 15

C. Proportion of resistant isolates representing true infection (%)

100.0 100.0

D. Number of admissions 1500 1500

E. Inpatient mortality (%) 5.1 5.1

F. Average length of stay 6.5 6.5

G. Average cost per hospital day $6,200 $6,200

H. Proportional increased risk of death associated with infection with resistant pathogen

2.0 2.0

I. Proportional estimated increased length of stay associated with resistance

1.8 1.8

Reporting Period 2007 2008 Change

Proportion of isolates that were MDROs 75.0% 75.0% 0.0%

Rate of MDROs per 100 admissions 2.00 1.00 -1.00

No. of excess deaths due to MDRO 3.06 1.53 -1.53

No. of excess hospital days due to MDRO 156.0 78.0 -78.00

Costs associated with excess hospital days $967,200 $483,600 -$483,600

Time Periods for Analysis

Medical Intensive Care Unit

MRSA bloodstream infection

2 . 0

1. 0

0 . 0

0 . 5

1.0

1.5

2 . 0

2 . 5

2 0 0 7 2 0 0 8

3 . 1

1.5

0 . 0

0 . 5

1. 0

1. 5

2 . 0

2 . 5

3 . 0

3 . 5

2 0 0 7 2 0 0 8

15 6 . 0

7 8 . 0

0

2 0

4 0

6 0

8 0

10 0

12 0

14 0

16 0

18 0

2 0 0 7 2 0 0 8


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Chapter 4 - Transmission Control to Prevent the Spread of MDRO

– How frequently do clinicians in your organization wash their hands before seeing a patient? Are you ready to deploy the most aggressive and cutting edge measures to prevent the spread of MDRO?– Identifies, describes and evaluates the key strategies to

prevent MDRO transmission in hospitals– Hand hygiene– Isolation precautions– Environmental hygiene– Active surveillance– Decontamination


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Chapter 4 - Transmission Control to Prevent the Spread of MDRO

– CD tools for Chapter 4 include –Active Surveillance Checklist–Marketing and Promotional Ideas–Executive Rounding Checklist–Hand Hygiene Monitoring Tool–Competency Questions–CEO Talking Points


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Active Surveillance Checklist– Active surveillance Checklist– The following is meant to serve as a practical tool for leaders tasked with developing and implementing an active surveillance

program. In addition to identifying the essential steps to ensure that the program is both effective and efficient, notes are provided (in italics) to specifically highlight the rationale for each step and to identify particular pitfalls that may be associated with the completion (or omission) of each step.

– Pre-planning– Identify population targeted for screening

– May be driven by external expectations or mandates.– If internally-driven, should be informed by institutional risk assessment (incorporating prevalence, severity of infections and trends).– Potential pitfalls in this step include the delineation of a population or program scope that is not appropriate for the goal of the program

(see #2).– Identify goals of program

– Without a clearly-defined goal, an active surveillance program cannot be examined for performance effectiveness and cannot be appropriately compared to other clinical and non-clinical programs to properly evaluate the appropriateness of continued institutional support.

– Complete performance assessment for current interventions/practices– The effectiveness of active surveillance is dependent on the application of evidence based measures to ensure that such pathogens

are not disseminated to other vulnerable patients.– Prior attention must be given to correcting poor adherence with hand hygiene, isolation precautions, etc to expect there to be an impact

with deployment of active surveillance.– Screening Logistics– Who will be screened?

– Specify target population as has been previously discussed– When will subjects be screened?

– The minimal standard for screening patients entails collection of specimens at the time of admission to the hospital or targeted unit. – A more comprehensive approach is to periodically collect additional surveillance specimens from those patients not found to be

colonized at admission. – One clear benefit to the collection of follow up swabs is the capacity to use the frequency of new acquisition events as a more precise

measure of the effectiveness of the active surveillance program in general.


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Chapter 5 - Antibiotic StewardshipIs antibiotic misuse promoting the spread of MDROs and unnecessarily increasing costs at the institution?

– Examines the structure, functions, and benefit of implementing an Antibiotic Stewardship Program (ASP)

– Published guidelines for antibiotic stewardship by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America state that one of the critical elements for reducing antibiotic resistance is an ASP


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– Improve clinical outcomes by optimizing:– Antimicrobial selection– Dose and route of administration– Duration of therapy

– Minimize unintended consequences of antimicrobial use, including:– Toxicity– Emergence of resistance (“collateral damage”)– Excess costs

Dellit TH, et al. Clin Infect Dis. 2007;44:159-177.

Antimicrobial Stewardship: Aims


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Do You Know What You’re Spending to Treat Resistant Organisms?

– Expenditures for drug classes used to treat resistant organisms greatly increased from 2004 to 2007

– In contrast, expenditures for older drug classes (eg, penicillins, fluoroquinolones) decreased over the same period

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* Anti-MRSA drugs: vancomycin, daptomycin, linezolid, quinupristin-dalfopristinData on file. Ortho-McNeil-Janssen Pharmaceuticals, Inc.

CarbapenemsAnti-MRSA Drugs*GlycylcyclinesPenicillinsFluoroquinolones


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ASP: Potential Savings


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Chapter 5 -Antibiotic Stewardship

– CD tools for Chapter 5 include–Antibiogram Template*–Proactive Strategies for ASPs–Antibiotic Audit Form–Competency Questions–CEO Talking Points


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Antibiogram Template

ISOLATES FROM ALL ADULTS

# Is

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Gram-negative

Escherichia coli 526 98 34 43 90 79 92 91 56 100 84 100 93 82 70

Klebsiella pneumoniae 254 100 0 77 89 86 90 89 89 100 92 100 93 91 86

Klebsiella oxytoca 34 100 0 76 85 59 91 91 91 100 100 100 85 100 97

Enterobacter aerogenes 58 100 0 0 x 0 93 x 98 95 100 95 x 100 98

Enterobacter cloacae 109 100 0 0 x 0 94 x 76 83 87 96 x 85 76

Serratia marcescens 107 98 0 0 x 0 97 x 94 99 99 100 x 87 91

Proteus mirabilis 93 100 68 78 81 76 81 81 59 100 80 97 100 82 68

Acinetobacter baumannii 162 27 56 10 0 7 19 23 5 23 7

Pseudomonas aeruginosa 668 96 55 76 65 0 82 74 88 86

Stenotrophomonas maltophilia 57 100 98

Gram-positive

Streptococcus pneumoniae 38 97* 58 55 100

ER isolates only 33 100* 84 76 100

Enterococcus faecalis 203 98 70** 78** 94

Enterococcus faecium 162 9 84** 45** 23

Staphylococcus aureus 762 47 53 59*** 35 97 47 96 94 100

ER isolates only 384 35 72 78*** 27 99 35 100 96 100

Staphylococcus coagulase-neg. 510 26 32 44 27 71 27 89 56 100

Streptococcus agalactiae 33 100 61 42 100 100


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Chapter 6 - Challenges on the Path to Higher PerformanceIs your organization ready to implement the changes needed to control MDROs?

– Discussion of most common pitfalls, or “Leadership Challenges” that threaten improvement initiatives related to antibiotic resistance

– Guidelines for how senior leaders can overcome each specific challenge

– Aim is to ensure that risk- and performance-assessment activities are not wasted due to the inability or unwillingness of key stakeholders to commit to the plan


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Challenges on the Path to Higher Performance– CD tools for Chapter 6 include

–Project Prioritization Matrix*–Eight Dimensions of Capacity for Change –Assessing Structures and Systems –Project Charter Template –Sustainability Rating Scale –CEO Talking Points


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Project Prioritization Matrix

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Chapter 7 - Call to ActionWhy you? Why now?– The job of controlling and eradicating MDROs is the job of many,

but the responsibility must ultimately be borne by organization executives

– Patients are angry and are demanding accountability and transparency. Payers and legislators are working in their support

– With all this in mind, can the healthcare leader afford not to take action?

– CD tools for Chapter 7 include– Health Care Executive Checklist – Metrics for Senior Leaders


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Role of the CEO– Insist on data to understand the costs of antibiotic use or misuse in

terms of cost of drugs, incidence of MDROs, risk to patients multidrug resistant infections and potential cost savings.

– Once stewardship program has been approved, provide collaborative but firm guidance to support the work

– Engage physician champions and leadership from the pharmacy– Use an incremental approach as appropriate to prevent failure– Spread the desired behaviors throughout the medical staff

prescribers– Leave the non-adapters to last – peer pressure will help eventually– Keep the issue visible among medical and pharmacy staff– Acknowledge achievements


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JCR Plan for Dissemination and Improvement– Deliver the information into the “right

hands” – senior leaders; you– In depth audio presentations of each of

the major chapters with specific instructions about the using the tools– 6 audio conferences– Chapter focused blogs


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What’s Next?

– Formation of learning communities for support in improvements – Call for Participation– 4-6 Organizations– Use toolkit to improve performance and reduce

antibiotic resistance and MDROs– Use metrics to document care improvements and

decrease in financial expenditures– Disseminate and advance learnings


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Questions?

– [email protected]– [email protected]– [email protected]

Documents

The Cost of Antibiotic Resistance: What Every Healthcare