Antibiotic-Resistant Pathogens: More Than a Bug, Potential Business Chaos
Reports of exotic infectious diseases crossing the border into the US always raise alarm bells and make headlines, evidenced by the Ebola crisis in 2014 and the spread of the Zika virus this year. Many organizations have adopted protocols to mitigate the spread of these viruses within their hospitals, and governmental organizations such as the CDC have released frequent updates for both patients and providers who may encounter these conditions. Yet the disease burden from exotic pathogens is relatively small when compared to the less discussed threat from antibiotic-resistant (AR) bacteria.
The CDC estimates that 2 million people become infected with these pathogens each year, resulting in 23,000 deaths. These bacteria include 18 pathogens of particular concern, among them Clostridium difficile, carbapenem-resistant Enterobacteriaceae (CRE) and Neisseria gonorrhoeae.
Think antibiotic-resistant pathogens are a problem just for infectious disease or your chief quality officer? Not so fast: if it hits your organization, there are potentially dire financial consequences. AR strains are of particular concern in health care settings due to a susceptible patient population and antibiotic use that can inadvertently contribute to AR selection. Despite well-known risks associated with AR infection and efforts to prevent bacterial spread within health care settings, compliance with established protocols is historically low, with some reports finding hand hygiene compliance as low as 10% to 40%. As health care continues to march down the road to value-based payment, hospitals and health systems risk the health of their patients and organizational bottom lines if AR infections take hold.
Know the Financial Risks
The risk of infection is well known among health system staff and administrators. Penalties for 30-day readmissions and hospital-acquired conditions provide incentive for organizations to implement infection control measures that can limit the spread of all pathogens, including AR strains. More recent efforts to improve management of infections include the Bundled Payments for Care Improvement (BPCI) initiative for sepsis. Sepsis discharges have risen 99% from 2007 through 2013, though some of this growth may be attributed to advances in early detection of sepsis. Early detection of sepsis may improve outcomes for patients, yet management of diagnosed sepsis has improved little in that time. This bundled payment initiative focuses on the acute event of severe sepsis, including early detection of sepsis cases and emphasis on effective management in the 6 hours postdiagnosis. This payment initiative also includes a postdischarge period, so effective management and follow-up for patients with sepsis will be key. Innovation in care management will need to account for the challenges that treatment of AR pathogens poses.
There are more serious risks for organizations that have a lapse in infection controls. As health care becomes more complex, with patients being touched by an increasing number of staff and highly sensitive equipment being used, compliance with hygiene protocols is ever more essential. This fact is illustrated starkly in recent reports of unit closures and contaminated equipment that impact not only the hospital’s bottom line but the organization’s reputation in the market. In one instance in 2013, the CDC identified an outbreak of CRE infections associated with duodenoscopes that resulted in at least 6 deaths. Although device manufacturers must work to develop effective protocols to clean their devices, hospitals and health systems are still responsible for ensuring these protocols are effective and executed thoroughly. A key aspect of this control is knowing what AR pathogens may be present and designing cleaning measures to target those pathogens.
AR pathogens can be especially challenging to eradicate once established within a unit or device and may require closure or removal of equipment from use to fully eradicate the AR pathogen. This has been reported several times in a particularly sensitive unit: the neonatal ICU. Due to the highly invasive care patients in this unit receive, the spread of AR pathogens between patients is tragically easy. When an AR infection is detected, neonates may be transferred to other hospitals and the unit closed.
Innovate to Mitigate Risk
With AR pathogens on the rise and traditional infection control measures challenging to implement, some organizations are exploring novel approaches. Antibiotic stewardship boards, rapid infection testing and revised hand hygiene compliance strategies are just a couple of operational measures that hospitals and health systems deploy, while other organizations have leveraged new technology to help address this problem.
Many organizations are beginning to incorporate rapid polymerase chain reaction (PCR) diagnostics into their infection control strategy. Advances in molecular diagnostics have made this highly sensitive diagnostic less expensive and more automated for many key pathogens. This technology facilitates effective antibiotic stewardship through differentiation of bacterial from viral infections in near real-time, reducing the number of patients who receive broad spectrum antibiotics. Additionally, PCR antimicrobial-resistant testing, combined with rapid detection, allows for prompt identification and containment of AR infections.
Several organizations, including the Joint Commission and the Association for Professional Infection Control and Epidemiology, have developed handbooks to support hand hygiene programs. These tools emphasize metrics tracking, engaging a multidisciplinary team and implementing accountability measures with feedback. The key to effective hand hygiene programs is process improvement—testing new initiatives to isolate effective strategies and deselect strategies that aren’t.
The University of Iowa has developed 2 tools to objectively track and improve both hand hygiene compliance and monitoring. Their mobile app, iScrub, provides a convenient platform to record hand hygiene compliance metrics electronically. In addition, they seek to remove the human observation step from hand hygiene compliance efforts by developing a sensor to monitor hand hygiene behaviors among all staff members. New developments in materials science may also provide a new route to AR control. Recent studies have found surfaces embedded with copper oxide have antimicrobial properties, which have been demonstrated to be effective against methicillin-resistant Staphylococcus aureus and other AR strains. This material is being tested in health care settings to determine the potential effects on reducing hospital-acquired infections.
Standardize, From the Top
Hospitals and health systems may evaluate a variety of approaches to reduce the impact of AR pathogens, but one of the biggest challenges to overcome is complacency. Building institutional will to drive program success will be required to reduce the spread of AR pathogens and to deploy antimicrobial stewardship to prevent the selection of AR. To build this institutional support, consider the following:
- Build the business case. Efforts to reduce the impact of AR infection will be increasingly important as payers continue to emphasize and reward high-quality care. Hospital quality teams can assist in identifying potential risks.
- Work with physician champions and nurse leaders to implement processes. Process improvement requires involvement from all staff, and physician leaders can help ensure that infection control is prioritized during care delivery. Partnerships between all clinical teams and support staff can help maintain morale while promoting infection control measures.
- Track infections and compliance. Measuring effects of AR control efforts and acting on metrics will help improve processes. Work with teams to obtain feedback on potential barriers and challenges to deployment and develop strategies to streamline adoption.