The Cost of Antibiotic Resistance: What Every Healthcare Executive Should Know

The Cost of Antibiotic Resistance: What Every Healthcare Executive Should Know JCR National Infection Prevention and Control Conference 2009 Mastering Powerful and Practical Infection Prevention Strategies August 21-22 Arlington, Virginia Client name/ Presentation Name/ 12pt - 1 Ortho!McNeil!Janssen"Pharmaceuticals,"Inc." May"2009 02AXXX

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 Client name/ Presentation Name/ 12pt - 2

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 Client name/ Presentation Name/ 12pt - 3

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 Client name/ Presentation Name/ 12pt - 4

Toolkit Overview Each 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 Client name/ Presentation Name/ 12pt - 5

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 by multidrug-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, Client Dec. name/ 2004. Presentation Name/ 12pt - 6

Chapter 1: Antibiotic Resistance: Patients and Hospitals in Peril MDROs pose significant challenges to the health care system, including clinical and financial burdens! Client name/ Presentation Name/ 12pt - 7

Chapter 1: Antibiotic Resistance: Patients and Hospitals in Peril CD tools include Sample Risk Assessment Matrix* Risk Assessment Primer Considerations for Enhanced Risk Assessment Dashboard for MDRO Reporting Competency Questions CEO Talking Points Client name/ Presentation Name/ 12pt - 8

SAMPLE MDRO RISK ASSESSMENT MATRIX Client name/ Presentation Name/ 12pt - 9

Chapter 2 - The Clinical Consequences of Antibiotic Resistance How many patients at your institution died last year as a result of 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 Client name/ Presentation Name/ 12pt - 10

Mortality Risk for MRSA Compared to MSSA Odds/Hazard Ratio for Mortality 4 3.5 3 2.5 2 1.5 1 0.5 0 1.9 1.8 Bloodstream Infections Ventilator- Associated Pneumonia 3.6 Surgical Site Infections 2.2 All Infections & Long-Term Mortality Odds or hazard ratio of 1 or lower = No increase in risk 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. Client name/ Presentation Name/ 12pt - 11

Chapter 2: The Clinical Consequences of Antibiotic Resistance CD tools include MDRO Burden Calculator Competency Questions* CEO Talking Points* Client name/ Presentation Name/ 12pt - 12

Chapter 3 - The Financial Impact of Antibiotic Resistance How 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 Client name/ Presentation Name/ 12pt - 13

Chapter 3 - The Financial Impact of Antibiotic Resistance The primary driver of increased costs is an increase in length of Hospitalization! Client name/ Presentation Name/ 12pt - 14

Variation of costs for treatment from infections from resistant vs sensitive organisms Client name/ Presentation Name/ 12pt - 15

Chapter 3: The Financial Impact of Antibiotic Resistance CD tools include MDRO Burden Calculator* Competency Questions CEO Talking Points Client name/ Presentation Name/ 12pt - 16

MDRO Burden Calculator Patient Population for Analysis MDRO Infection for Analysis Medical Intensive Care Unit MRSA bloodstream infection Time Periods for Analysis 2007 2008 2.5 A. B. C. Number of non-duplicate isolates of specific pathogen of interest Number of non-duplicate isolates of pathogen resistant to specific antibiotic of interest Proportion of resistant isolates representing true infection (%) 40 20 30 15 100.0 100.0 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. I. Proportional increased risk of death associated with infection with resistant pathogen Proportional estimated increased length of stay associated with resistance 2.0 2.0 1.8 1.8 2.0 1. 5 1. 0 0.5 0.0 3.5 3.0 2.5 2.0 1. 5 1. 0 0.5 0.0 2.0 1. 0 2 0 0 7 2 0 0 8 3.1 1. 5 2 0 0 7 2 0 0 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 18 0 15 6. 0 16 0 14 0 12 0 10 0 7 8. 0 80 60 40 20 0 2 0 0 7 2 0 0 8 Client name/ Presentation Name/ 12pt - 17

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 Client name/ Presentation Name/ 12pt - 18

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 Client name/ Presentation Name/ 12pt - 19

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. Client name/ Presentation Name/ 12pt - 20

Chapter 5 - Antibiotic Stewardship Is 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 Client name/ Presentation Name/ 12pt - 21

Antimicrobial Stewardship: Aims 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. Client name/ Presentation Name/ 12pt - 22

Do You Know What You re Spending to Treat Resistant Organisms? Hospital IV Expenditures ($ millions) 550 500 450 400 350 300 250 200 150 100 50 0 2004 2005 2006 2007 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 Carbapenems Anti-MRSA Drugs* Glycylcyclines Penicillins Fluoroquinolones * Anti-MRSA drugs: vancomycin, daptomycin, linezolid, quinupristindalfopristin Data on file. Ortho-McNeil-Janssen Client Pharmaceuticals, name/ Presentation Inc. Name/ 12pt - 23

ASP: Potential Savings Client name/ Presentation Name/ 12pt - 24

Chapter 5 -Antibiotic Stewardship CD tools for Chapter 5 include Antibiogram Template* Proactive Strategies for ASPs Antibiotic Audit Form Competency Questions CEO Talking Points Client name/ Presentation Name/ 12pt - 25

Antibiogram Template ISOLATES FROM ALL ADULTS Gram-negative # Isolates Amikacin Ampicillin Ampicillin/sulbactam Aztreonam Cefazolin Cefepime Ceftriaxone Ciprofloxacin Clindamycin Ertapenem Erythromycin Fluconazole Gentamicin Imipenem Methicillin/Nafcillin Minocycline Penicillin Piperacillin/tazobactam Streptomycin Tetracycline Tobramycin Trimethoprim/sulfamethox Vancomycin 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 Client name/ Presentation Name/ 12pt - 26

Chapter 6 - Challenges on the Path to Higher Performance Is 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 Client name/ Presentation Name/ 12pt - 27

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 Client name/ Presentation Name/ 12pt - 28

Project Prioritization Matrix Project Example Project 1 Project 2 Project 3 Project 4 1 = Low 3 = Medium 9 9 = High Fit with organization mission/goals 1 = No/Very low risk 3 = Moderate risk High risk to staff or patients 3 9 = High risk 1 = Low volume 3 = Moderate Volume High volume 9 = High Volume 1 = Low or not related 3 = Moderately related 9 = Directly related; element of performan Related to a standard required for accreditation 1 = Low or not related 3 = Moderately related 9 = Directly related Related to a law/government regulation 1 = Low or not related 3 = Moderately related Related to National / International Patient Safety Goal 9 = Directly related 1 = None 3 = Few Complaints from patients/staff 9 = Several 1 = None 3 = Mild Potential future cost savings if implemented 3 9 1 9 3 9 1 1 9 3 60 0 0 0 0 9 = Strong effect Tracer / measurement shown deficiency 1 = None 3 = Somewhat, inconclusive 9 = Strong evidence Identified as a problem in literature 1 = Low or few 3 = Moderate resources 9 = Large amount Needed resources to address problem Client name/ Presentation Name/ 12pt - 29 1 = Slim to none 3 = Moderate potential 9 = Large potential 1= More than 18 months 3 = 6 to 18 months Project Payback Period 9 = Less Than 6 months Priority Score (Max = 108; Min = 12)

Chapter 7 - Call to Action Why 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 Client name/ Presentation Name/ 12pt - 30

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 Client name/ Presentation Name/ 12pt - 31

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 Client name/ Presentation Name/ 12pt - 32

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 Client name/ Presentation Name/ 12pt - 33

Questions? bsoule@jcrinc.com nfinis@jcrinc.com sweber@jcrinc.com Client name/ Presentation Name/ 12pt - 34