We are entering one of the most active, interesting and challenging times in the history of infection prevention and control. In this special section we explore a number of critical issues that will define the future of the field and establish new precedents in how healthcare-associated infections (HAIs) are identified, dealt with and hopefully eradicated in the process.
MRSA on Our Minds
The general publics recent fixation on the community-acquired strain of methicillin-resistant Staphylococcus aureus (MRSA) has cast new light on the importance of education about this multi-drug resistant organism (MDRO). While we know that MRSA is the most common healthcare-associated infection (HAI) and that it increases not only patient morbidity and mortality but also hospital costs, the prevalence of this MDRO is startling to even the most veteran of infection prevention practitioners (IPPs). According to data provided by the Association for Professionals in Infection Control and Epidemiology (APIC), MRSA accounts for more than 60 percent of Staphylococcus aureus infections (in 1972, MRSA accounted for just 2 percent of all staph infections reported to the Centers for Disease Control and Prevention (CDC)). The cost associated with MRSA infections is staggering as well; the MRSA death rate has been estimated to be more than 2.5 times higher than infections from Staphylococcus aureus that are susceptible to methicillin. In economic terms, an analysis of 55 studies concluded that the cost of a MRSA infection was $35,367 compared with $13,973 for a non-MRSA infection.1
The presence of MRSA in the community is not surprising given the fact that approximately one-third of the human population is colonized with S. aureus bacteria. Of those, about 1 percent has MRSA, says the CDC. Today, according to the National Institute of Allergy and Infectious Diseases, S. aureus has evolved to the point where experts refer to MRSA in terms ranging from a considerable public health burden to a medical crisis. The challenge for IPPs is helping educate others about the two categories of MRSA infection hospital associated (HA) or community associated (CA) that are becoming confused in the minds of the general public and members of the mainstream media. The criteria for HA-MRSA vs. CA-MRSA are familiar to IPPs but not to the masses, and therein lies the necessity for constant communication about the critical differences. The news of the deaths from MRSA of several youths triggered a panic among parents, teachers and members of the public that is slow to subside. Exacerbating the fear and misinformation is some members of the media, and so IPPs must remain the voice of reason in the midst of a maelstrom of reports containing fact and fiction.
Distinguishing between HA-MRSA and CA-MRSA is taking on new importance. A study published Oct. 17, 2007, in the Journal of the American Medical Association (JAMA), which estimated that 94,000 invasive drug-resistant staph infections occurred in the U.S. in 2005, established a baseline for MRSA infection estimates.2 Equally important, the study emphasized that the majority of the MRSA infections were healthcare-associated specifically, the study found about 85 percent of all invasive MRSA infections were associated with healthcare settings, of which two-thirds surfaced in the community among people who were hospitalized, underwent a medical procedure or resided in a long-term care facility within the previous year. In contrast, about 15 percent of reported infections were considered to be community-associated. Experts arrived at the new national estimate by projecting from the number of invasive MRSA cases from nine U.S. sites, including the state of Connecticut; the Atlanta metropolitan area; the San Francisco Bay Area; the Denver metropolitan area; the Portland, Ore., metropolitan area; Monroe County, N.Y.; Baltimore City, Md.; Davidson County, Tenn.; and Ramsey County, Minn. All the sites were part of CDCs Active Bacterial Core surveillance program, which actively tracks a number of pathogens in the United States.
Elizabeth A. Bancroft, MD, SM, of the Acute Communicable Disease Control department of the Los Angeles County Department of Public Health, was among the public health officials who testified before Congress in November 2007 about CA-MRSA. In her testimony, she emphasized the need for healthcare practitioners to be very clear in separating the two strains when conversing about MRSA: The media have commonly confused the two strains of MRSA, conferring the attributes of healthcare MRSA (invasive disease and high rate of death) to that of community MRSA. Much of the recent media has focused on deaths due to MRSA in school children. However, according to the CDC study, the lowest rate of invasive MRSA occurs in school age children 2 to 17 years and the death rate in children with community MRSA was estimated to be 0, though obviously there can be exceptions.
Bancroft made her case further in a 2007 article in JAMA in which she stated, Healthcare-associated and community-associated MRSA have different clinical and molecular epidemiology. Healthcare-associated MRSA is associated with invasive disease, healthcare exposure, and multi-drug resistance. Community-associated MRSA has been primarily reported in young, healthy individuals with no recent healthcare exposure. The strains have generally been sensitive to non-lactam antibiotics, although most have had genes for the Panton-Valentine leukocidin and other enterotoxins that may make these strains more virulent. Healthcare-associated MRSA is typified by a USA100 pulse-field electrophoretic pattern, while USA300 is the most commonly reported community-associated MRSA pattern in the United States. Complicating the issue is that patients can unknowingly be colonized with MRSA and therefore have onset of disease away from the source of exposure. Furthermore, molecular studies reveal that either strain can appear in both locations.3
In addition to confusing the two MRSA strains, there is danger in how data is interpreted. While data is a tool that enhances knowledge, misinterpretation of the data can undermine its value and skew assertions. Members of the infection prevention community are asking that people maintain a reasonable perspective on the dangers of MRSA and the threat it poses. Bancroft is among those encouraging others to keep a level head about the data causing a furor. A CDC study published Oct. 17, 2007, in JAMA presented the alarming data that helped fuel the MRSA fire; this study said that the rate of invasive MRSA (resistant staph that has gotten to the blood, spinal fluid or other deep body sites) was greater than the combined rate of invasive disease caused by group A strep (the so-called flesh eating disease) and resistant pneumococcal disease. The study also said that invasive MRSA rates were poised to exceed those of HIV/AIDS. Bancroft points out that the estimated number of deaths caused by MRSA is only half of the estimated number of deaths caused by influenza in the United States each year (36,000 deaths).
The true magnitude of the total burden of MRSA in the U.S. healthcare population has been virtually unknown; however, a massive MRSA data dump occurred in June 2007 with the publishing of the results of APICs study, National Prevalence Study of Methicillin-Resistant Staphylococcus aureus (MRSA) in U.S. Healthcare Facilities.4 Conducted in October and November 2006, this national MRSA prevalence study was the most comprehensive MRSA study of its kind and provided new information about MRSA. Data showed that 46 out of every 1,000 patients in the study were either infected or colonized with MRSA a rate between eight and 11 times greater than previous MRSA estimates. The study is significant because it provides data on MRSA colonization as well as infection, and is more representative of all sizes and types of U.S. healthcare facilities than any study ever conducted (1,237 facilities provided data).
The study presented a number of key findings:
- The total number of patients with MRSA colonization/infection was 8,654. The overall MRSA rate (infection and colonization, HAMRSA and CA-MRSA) was 46.3 per 1,000 inpatients. For states with reporting from >5 facilities, the MRSA rate ranged from 16-91 per 1,000 inpatients. The clinical culture positive MRSA rate (i.e., including only infections) ranged from 16 to 48 (average of 34) per 1,000 inpatients.
- From the detailed data provided on 7,944 patients with MRSA: 54 percent were male, 46 percent were female; 67 percent were on the medical service; 81 percent of patients were detected by clinical cultures; 19 percent were detected by active surveillance cultures; 77 percent were detected <48 hours within admission; 23 percent were detected >48 hours within admission; 37 percent had skin and soft tissue infections only (most commonly seen with CA-MRSA); 63 percent had infections at sites other than skin or soft tissue (e.g., blood, pneumonia, urinary tract); <30 percent of isolates susceptible to clindamycin and <20 percent susceptible to levofloxacin.
The MRSA issue is getting the attention of legislators. Last November, the Committee on Oversight and Government Reform held a hearing, Drug- Resistant Infections in the Community: Consequences for Public Health, to examine the public health consequences of MRSA infections outside of the healthcare setting. Chairman Henry Waxman (D. Calif.) observed during the testimony, We will hear two messages from our expert witnesses: one reassuring and one worrisome. The reassuring message is that there are simple steps that we can take to protect ourselves and our children from MRSA infections. We can limit the spread of MRSA with basic measures like frequent handwashing and keeping wounds covered. Also reassuring is the fact that doctors already have drugs that can treat MRSA, and more are in development. The worrisome message is that MRSA is a symptom of a larger problem of drug-resistant infectious disease. This is not a new problem. But in recent years, antibiotic use has increased, which has led to more drug resistant bacteria. According to the CDC antibiotic resistance has been called one of the worlds most pressing public health problems.
The committee says it will hold future hearings on other aspects of the growing threat posed by drug-resistant infectious diseases. In the spring, the committee will hold a hearing on hospital-associated infections, as well as look at the root causes of antibiotic resistance.
Capitol Hill Gets Serious About Infections: Public Reporting
Last year, the Government Accounting Office (GAO), in its goal is to make recommendations to Congress, conducted a series of interviews with stakeholders, including infection prevention professionals and epidemiologists, to discuss federal requirements and guidelines related to infection prevention and control strategies implemented in hospitals. Industry experts believe a report will be forthcoming in early- to mid-2008.
In the meantime, the spotlight has been on a number of pieces of federal legislation that have been introduced recently, including:
- HR 1174: Healthy Hospitals Act of 2007. This bill, sponsored by Rep. Tim Murphy (R-PA) strives to amend the Social Security Act to require public reporting of HAI data by hospitals and ambulatory surgery centers (ASCs); establish a pilot program to provide incentives to hospitals and ASCs to eliminate the rate of occurrence of HAIs. This bill is sitting in committee as of press time.
- S 692: VA Hospital Quality Report Card Act of 2007. This bill, sponsored by Barack Obama (D-IL), strives to establish a hospital quality report card initiative to report on healthcare quality and HAIs in Veterans Affairs hospitals. This bill is sitting in committee as of press time.
The call for greater transparency in healthcare has resulted in a number of actions, including a movement toward increased mandatory public reporting of infections and adverse events. Currently, 19 states mandate public reporting of HAIs; two states have voluntary reporting, one state reports to the state level only, and four states have study bills right now. States that have already released HAI data to the public are Pennsylvania, Florida, Missouri and Vermont.
Legislation pertaining to MRSA in particular has been increasing. In 2006, legislation was introduced in Illinois and Maryland to require screening of MRSA and VRE (VRE in Maryland only), with a provision for reporting to the state health department. While the Maryland bill did not pass, the Illinois bill went on to the 2007 legislative session. Two bills came before the Illinois governor last summer: HB 378/SB 233 mandated that all hospitals screen for MRSA in ICU patients and other high-risk patients, and provide decolonization therapy if colonized; HB 92 mandates that all healthcare facilities comply with the CDCs MDRO guidelines, and recommends tests to determine, control and prevent MDRO infections. There has also been MRSA reporting legislation in Minnesota, Pennsylvania, Tennessee and Texas, which has called for the screening of high-risk patients, as well as reporting to state departments of health. The Texas bill is a pilot program to research and implement procedures for the reporting of MRSA cases. The commonwealth of Virginia signed into law emergency legislation requiring labs to report invasive MRSA isolates; the bill was likely a response in part to the deaths of several youths from MRSA infections.
Last October, Sen. Richard Durbin (D-IL) introduced legislation to require the Agency for Healthcare Research and Quality (AHRQ) to develop infection prevention guidelines for hospitals, which would also have to report infection rates to the CDC. The bill, called the Community and Healthcare- Associated Infections Reduction (CHAIR) Act, was introduced Oct. 30, 2007, and addresses public awareness, research, reporting and prevention efforts. This legislation builds on what hospitals are already doing and what infectious disease experts and government agencies agree is critical to reducing the emergence of these infections, said Durbin in a press release. We have a national responsibility to improve the prevention, detection, and treatment of community and healthcare-associated infections.
APICs Public Policy Committee says that the CHAIR Act now aligns with two goals within the organizations strategic plan: that ICPs be recognized as a separate and distinct profession whose members are positioned for leadership roles in healthcare, and that APIC will ensure that appropriate standards and measures are set by which infection prevention and control programs are evaluated by regulatory agencies, healthcare executives, payers and consumers.
While supporting meaningful public reporting of HAI data (see APIC Position on Mandatory Public Reporting of Healthcare-Associated Infections at www.apic.org), the organization has been calling for better standardization of the practice instead of a fragmented state-by-state approach. In 2005, the Society of Healthcare Epidemiologists of America (SHEA) published its position paper on public disclosure of HAIs, to reflect the growing demand for transparency by consumer groups and lawmakers. SHEA notes, The impetus for these laws is complex. Support comes from consumer advocates, who argue that the public has the right to be informed, and from others who view HAI as preventable and hope that public disclosure would provide an incentive to healthcare providers and institutions to improve their care. With these new state laws, the focus of attention is not directly on individual providers, but rather on healthcare facilities, which will be mandated to collect and report hospital-level performance indicators.
The debate over public disclosure often pits consumers, insurance carriers, and health maintenance organizations against healthcare providers. The payers want performance data made available so that they can be better purchasers of healthcare services. Healthcare providers are concerned that the data may be flawed and misleading. Personnel at healthcare institutions also are concerned about the additional cost for resources that will have to be expended to collect the required data. The stakes may be even higher because the results of these analyses can conceivably be used by health plans to choose among competing providers or incorporated into the reimbursement process (pay for performance). These laws mandating HAI reporting are not revolutionary, but are simply the latest development in the movement to improve the quality of medical care and to hold healthcare providers more accountable.
Also in 2005, published in the May 2007 issue of AJIC, was the paper, Guidance on Public Reporting of Healthcare-Associated Infections: Recommendations of the Healthcare Infection Control Practices Advisory Committee, which outlines the essential elements of a public reporting system for HAIs. The HICPAC paper also explored the consequences of mandatory reporting systems: mandatory public reporting that doesnt incorporate sound surveillance principles and reasonable goals may divert resources to reporting infections and collecting data for risk adjustment and away from patient care and prevention; such reporting also could result in unintended disincentives to treat patients at higher risk for HAI. In addition, current standard methods for HAI surveillance were developed for voluntary use and may need to be modified for mandatory reporting. Lastly, publicly reported HAI rates can mislead stakeholders if inaccurate information is disseminated. Therefore, in a mandatory public report of HAI information, the limitations of current methods should be clearly communicated within the publicly released report.
APIC and SHEA share similar concerns about another topic that has stirred up controversy in the infection prevention community active surveillance. In its position paper, Legislative Mandates for the Use of Active Surveillance Cultures to Screen for MRSA and VRE, the groups declared that although reducing the burden of resistant pathogens is of preeminent importance, the organizations do not support legislation to mandate use of active surveillance cultures to screen for MRSA, VRE or other resistant pathogens. Many infection prevention experts insist that to assert that active surveillance culturing is the single most important infection prevention intervention and would be applied to all patients in all settings would be premature and preempt scientific evidence and risk assessment analysis. What most people can agree on for now is that we have not heard the last of this debate in 2008, and that the topic could create a dangerous precedent if included in federal legislation.
Antimicrobial Resistance in the Legislative Spotlight
Members of Congress are also considering subjects such as the challenge of antimicrobial/antibiotic resistance. Public health experts have linked the emergence of antimicrobial resistance in the United States to the increased use and abuse of antibacterial agents. For example, from 1980 through 1992, there was a 48 percent increase in the antibiotic prescribing rate for children by office-based physicians.5 One of the most glaring instances of growing resistance is Streptococcus pneumoniae; prior to 1980, more than 99 percent of all strains of S. pneumoniae were susceptible to penicillin, but by the mid-1990s, 40 percent of clinical isolates from the bacteria demonstrated intermediate or high-level resistance to the same drug.
The focus on community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has subsequently directed increasing attention on the issue of antimicrobial resistance. Elizabeth Bancroft makes the case that antimicrobial resistance is an increasing problem outside of hospitals.
Historically, Bancroft notes, Most community outbreaks have involved skin or soft tissue infections, and little has been reported on invasive infections originating outside healthcare settings. Few health departments or jurisdictions have systematic surveillance programs for antimicrobial resistance. Of the list of reportable diseases in the United States, only three are specifically observed for being caused by antimicrobial-resistant organisms (drug-resistant Streptococcus pneumoniae, vancomycin-intermediate S. aureus, and vancomycin-resistant S. aureus). However, she cites Klevens and colleagues data suggesting the rate of invasive MRSA in the United States in 2005 is at 31.8 per 100,000.1
To put this number into context, Bancroft notes that the estimated rate of invasive MRSA is greater than the combined rate (in 2005) for invasive pneumococcal disease (14.1 per 100,000), invasive group A streptococcus (3.6 per 100,000), invasive meningococcal disease (0.35 per 100,000), and invasive H influenzae (1.4 per 100,000). Klevens and colleagues(2) report that among 5,287 patients hospitalized with MRSA during 2005, there were 988 deaths; based on these data, the authors estimate that were 18 650 deaths in patients with invasive MRSA in the United States in 2005. Bancroft emphasizes, If their projection is accurate, these deaths would exceed the total number of deaths attributable to human immunodeficiency virus/AIDS in the United States in 2005.1
A CDC study revealed that 6 percent of CA-MRSA was invasive. In another study, 9 percent of children hospitalized in 2003 for community-associated MRSA had invasive disease. Bancroft cautions that various studies have their limitations, especially when individuals are likely to extrapolate data beyond the confines of the cases presented. For example, in the study by Klevens, et al. Bancroft notes that the data are based on a more robust surveillance system however, community-associated MRSA rates in skin infections vary considerably by geographic region, and it is unknown whether the surveillance sites in this report represent the distribution of MRSA in the United States.1
Bancroft also points to the possibility for error in attributing the source of MRSA. The presence of a healthcare risk factor does not preclude acquisition of a community strain of MRSA from exposure in the community, yet by surveillance definitions those cases would be classified as healthcare-associated, she writes. Moreover, if healthcare risk factors were not recorded in hospital charts, cases classified as community-associated might have acquired their MRSA from a healthcare setting or some other unidentified nosocomial source, such as a healthcare worker in the home. In addition, mortality data were collected from patient charts, and there are no data to firmly establish that MRSA was the actual cause of death.1
Bancroft says that more than half of MRSA cases had the USA100 genotype, and were among patients who had healthcare risk factors but a community onset of disease. She writes, It appears that what happens in the hospital does not stay in the hospital. Patients are discharged from healthcare facilities with MRSA colonization that likely is often unidentified and only later develop invasive MRSA disease. More research is needed to determine the risk factors for developing invasive disease after hospital discharge and the prevention measures necessary to decrease infection. Working vigorously to decrease transmission of MRSA in healthcare facilities may decrease both nosocomial and community-onset MRSA that occurs in persons with prior healthcare exposure.1
A number of clinicians are reporting an increase in the community of the number of infections with significant antimicrobial-resistant pathogens, the types formerly seen only in healthcare facilities. Bancroft notes, Old diseases have learned new tricks. Consequently, new collaborations between the public health and medical communities are needed to identify and control antimicrobial resistance. It is not practical for public health departments to perform surveillance for MRSA or other highly prevalent resistant organisms without a robust system of electronic laboratory reporting. In the meantime, population surveillance can be achieved by public health personnel working with hospitals and laboratories in their jurisdictions to develop aggregate antibiograms. Clinicians also should be encouraged to report to the health department any new trends in antibiotic resistance that they identify.1
Bancroft emphasizes that collaborative efforts are needed to determine how to control HA-MRSA and community-onset MRSA, and how to prevent CA-MRSA from entering the hospital. She says that prudent us antibiotic use is one important measure, as are additional resources to enforce infection prevention in healthcare facilities.
The issue of antimicrobial resistance has renewed attention in Congress presently and is being addressed by two new pieces of legislation; the Strategies to Address Antimicrobial Resistance (STAAR) Act (HR 3697) was introduced in the House of Representatives in late September by Rep. Jim Matheson (D-UT) and Mike Ferguson (R-NJ), while in early November, the cerned about the additional cost for resources that will have to be expended act was introduced in the Senate by Sens. Sherrod Brown (D-OH) and Orrin Hatch (R-UT).
The bill in part builds upon the work of the Antimicrobial Resistance Task Force (created by Congress in 1999 but whose authority expired in 2006) by enhancing authority, funding, and personnel to execute a coordinated federal response to antimicrobial resistance. This interagency task force had developed the Public Health Action Plan to Combat Antimicrobial Resistance, but the plan was not implemented due to a lack of authority and funding. The STAAR Act provides for the creation of the new Office of Antimicrobial Resistance, which will execute a coordinated federal response to antimicrobial resistance. An advisory board will be created to allow outside experts from domestic and international health communities to contribute to the effort. The bill also calls for the creation of a federal blueprint for antimicrobial resistance led by the National Institutes of Health and CDC, in collaboration with other federal agencies and the new Office of Antimicrobial Resistance.
The STAAR Act has the potential to save thousands of lives, says Donald Poretz, MD, president of the Infectious Diseases Society of America (IDSA), which strongly supports the legislation. Infectious diseases physicians have watched in dismay for years as the antibacterials and other antimicrobials we rely upon to treat our patients have lost their power. Poretz adds, IDSA has been warning that the bad bugs are getting ahead of us. We are glad to see Congress is listening. But we need this legislation to pass soon. It takes years to develop a new drug, and to strengthen and implement new control strategies. These bad bugs are not waiting.
To make matters worse, there are very few new drugs in the pipeline to replace the failing ones, because the pharmaceutical industry now finds developing new antibiotics less appealing than developing drugs for chronic conditions like heart disease. We are in danger of slipping backward to the era before antibiotics, Poretz adds. The STAAR Act gets us back in the fight by enhancing federal leadership, encouraging expert input, and by improving our grasp on resistance and ways to control it.
Currently, there is little capacity to rapidly and effectively monitor, assess and address the spread of new or particularly virulent resistant microbes. The STAAR Act addresses this problem by establishing a sentinel surveillance system through CDC, encompassing at least 10 geographically-distributed sites to track and confirm (in near-real time) the emergence of resistant pathogens. These sites will conduct epidemiological, interventional, basic and clinical research to study the development of antimicrobial resistance and enhance the capacity to prevent, control and treat resistant organisms. The bill would also establish a national isolate collection capacity under which CDC would serve as a national repository for samples of emerging pathogens with a focus on pathogens that show new or atypical patterns of resistance.
Its a different world versus even five years ago, says Neil Fishman, MD, chair of IDSAs Antimicrobial Resistance Work Group. In addition to MRSA, multi-drug resistant bugs like Klebsiella have cropped up and spread practically before anyone has had the chance to examine them under the microscope, much less do anything to stop their spread. The network will be CDCs extra eyes and ears looking out for resistant bugs around the nation and finding ways to prevent their spread.
1. Bancroft EA. Antimicrobial resistance: Its not just for hospitals. JAMA. 2007;298:1803-1804.
2. Klevens RM, Morrison MA, Nadle J, et al. Invasive methicillinresistant Staphylococcus aureus infections in the United States. JAMA. 2007;298(15):1763-1771.
3. Bancroft EA. Antimicrobial resistance: Its not just for hospitals. JAMA. 2007;298:1803-1804.
4. Association for Professionals in Infection Control and Epidemiology (APIC). Summary of MRSA Prevention Guidelines. Accessed at www.apic.org
5. Quinonez JM. The Continuing Saga of Antimicrobial Resistance. Accessed at: http://www.medscape.com/viewarticle/495300
The Issues ICPs Face in 2008
A Q&A with Kathy Warye
By Kelly M. Pyrek
ICTcaught up with Kathy Warye, chief executive officer of the Association for Professionals in Infection Control and Epidemiology (APIC) to discuss the top issues on the minds of infection prevention professionals for the coming year.
Q: How has the recent frenzy over both hospital- and community-acquired methicillin-resistant Staphylococcus aureus (MRSA) created an opportunity for ICPs to educate people about multi-drug-resistant organisms (MDROs) as well as about what they do for a living?
A: As far as MRSA is concerned, with every negative incident there is a silver lining in terms of being able to build greater awareness of the work that infection prevention and control professionals (IPCPs) do and how important it is to make sure they are adequately resourced and supported in their institutions. That is not a consistent situation across the country. I think the increased awareness on the part of the public and state and federal lawmakers, is a continuing wake-up call for healthcare administrators in terms of how they view infection prevention and control programs, how high up on the list of priorities they are, and how well resourced they are.
Q: Reports about MRSA from the media have been a mixed bag, with some half-truths creeping in. How do IPCPs deal with that?
A: (Media attention) is something that any of us can be subjected to at any time. MRSA has become of great interest to the general public, and clearly there are media outlets that will use it to sensationalize the situation and draw attention to their broadcasts and articles. However, it is a wonderful opportunity for us to present the facts in terms of the increasing prevalence of MRSA, and to focus public and legislative attention on what might be done to improve how infection prevention programs are managed and resourced in healthcare facilities. Many media outlets reported on our MRSA prevalence study, and the more we can get the information out there, the better.
Q: An IPCPs job isnt getting any easier these days, is it?
A: In terms of the increasing challenges to IPCPs in general, weve seen for a number of years now a growing number of tasks for which they are responsible. The list has moved well beyond surveillance to things such as emergency preparedness. As another example, every IPCP I know is involved in some sort of construction project that requires input from infection control. Now we have the growing incidence of MRSA and other resistant microorganisms; this situation cant continue as it is, or all of us, including patients, will be in an increasing amount of danger in healthcare facilities. APIC has created a task force to evaluate IPCP staffing in healthcare facilities. Certainly we dont want to take a one-size-fits-all approach, and we are not going to promote any particular ratio, but instead put forward formulas and other guidance for administrators and IPCPs in terms of what adequate staffing may look like in a number of different situations.
Q: How can IPCP staffing needs be addressed in present and future projects and even in legislation at the state and federal levels?
A: We have already had two opportunities to work closely with Sen. Durbins staff on the pending legislation, the CHAIR Act of 2007. Its a negotiation process, and you never know particularly when it comes to resources how your assertions are going to be received. We have had two conversations with them, first supporting the fact that we do believe that public reporting will lead to greater transparency, and if the data is properly collected and used, that could lead to improvements in patient safety and in patient outcomes. But none of that will happen without adequately resourcing infection prevention and control programs. We have stressed that at every opportunity to Durbins staff; we have also had a conversation with Sen. Clintons staff. Denise Graham and Lisa Tomlinson from APICs government relations team have been working very assertively at the state level as well, to ensure that wherever the opportunity exists, we can have that conversation and get legislation that is as supportive as possible of IPCPs and what they need to accomplish.
Q: How can IPCPs help with these advocacy efforts?
A: There is a role that every IPCP can and should play by recognizing what a tremendous opportunity the legislation and the public and media awareness has provided to us as a community, and capitalizing on that. Its an opportunity to create much greater awareness about a vital but probably not terribly well known profession in our healthcare institutions today. Its a tremendous opportunity to help people understand how our programs support patient and healthcare worker safety. I would encourage them to understand and appreciate the opportunities, not only for APIC, as their professional association, but for each of them in their institution and in their community. Without this individual grassroots approach, APIC would not be nearly as effective. We would like our members to understand the results of our MRSA prevalence study; to understand the risk that MRSA presents in their institution; to conduct their risk assessments; to understand the economic consequences of those infections; to undertake the critical economic analysis of infection prevention; and use at the facility level this opportunity to create more robust, better-resourced infection prevention programs. And we will do the same, as we have been all along, at the national level.
Q: Many IPCPs say they still do not know how to make the business case for infection prevention; what are your thoughts on this?
A: I made a presentation on the economics of infection prevention to one of our chapters about a month ago. I asked the audience of about 200 people how many of them were actively engaged in a project to determine the economic impact of healthcare-associated infections (HAIs) and only a few hands went up. Then I asked how many of them would like to be involved in doing this kind of work, and every hand went up. I asked them what the problem was, and there were two issues. The first issue was understanding how to do this because even though theyre data experts, understanding reimbursement and related financial issues is not their field of expertise; it requires a partnership with a financial executive or accountant at the hospital.
I suspect the real problem is time. They said even if we learn how to do this, it takes us away from vital activities such as being out on the floor and managing the interventions that save lives. So whenever they are challenged with the choice of doing the work that protects patients or doing this work that is more economic in nature, they will always choose the work that protects patients. As long as healthcare administrators continue to misunderstand this issue, were going to continue to have a gap in terms of what we need to protect patients, and the resources that are available to do so.
Q: It seems as though the infection prevention community is demonstrating great ownership of its challenges, addressing issues proactively instead of reactively. APICs MRSA prevalence study is a good example of this, dont you agree?
A: Absolutely. I think we have barely scratched the surface in terms of our understanding of MRSA transmission and how prevalence is changing, so it is an opportunity for additional research, some of which APIC will undertake. We will conduct another MRSA prevalence study in about a year from now to see what changes have taken place in the environment. The study is a starting point in terms of research; its something APIC is going to be involved in, in a very substantive way, for as long as I can foresee. Were also trying to create a variety of resources, like the MRSA elimination guide, that can help our members understand these problems from a multi-dimensional perspective.
We conducted a recent media awareness/public education campaign called Skin is the Source, to educate people about how skin is an often-overlooked source of bacteria that can contribute to acquiring an HAI. Were employing a variety of methodologies, not just the type of things members may be familiar with coming from APIC, such as the scientific and technical documents and guidelines. We are reaching out through the media to the general public to build greater awareness of the profession, of the vital role IPCPs play, and what members of the public can do to protect themselves from acquiring an HAI.
We are also in the process of conducting a mini e-mail survey of our members to determine what, if anything, has changed in their institution since the first MRSA prevalence study was conducted. We are trying to get a sense of how much change the study precipitated, and we will be coming out with some data from that project shortly. It doesnt have the scientific rigor of the MRSA prevalence study, but it will give us a quick snapshot of what is changing. There also is a growing amount of interest in a prevalence study on Clostridium difficile. We have a growing body of evidence that C. diff is increasing in prevalence, just as we did with MRSA, so wed like to get ahead of this one to the extent possible.
Q: Healthcare institutions are facing new CMS regulations this fall; what impact will that have on IPCPs?
A: The profession is coming into its own just as CMS is about to make new requirements from healthcare facilities. The three infections that are conditions that will no longer be reimbursed are creating a lot of angst in the healthcare community. Those who are desirous of taking greater ownership of their work and who want to be empowered to declare the value of their infection prevention program are taking advantage of the with them, first supporting the fact that we do believe that public reporting new requirements as an opportunity for them to go to their administrators and CFOs. They can let them know the unique body of knowledge and skills they bring to the situation, and that their infection prevention program is their institutions most significant resource in terms of understanding how to eliminate infections and protect the institution from negative financial consequences. I hope IPCPs will use this opportunity to create awareness for what they do and be a partner in the financial health of their institutions.
Q: Do you have an update for us on the status of standardizing public reporting measures?
A: APIC was the organization that initially recommended that there be a national approach to public reporting, as opposed to a state-by-state approach, and helped the National Quality Foundation (NQF) create a project to develop a set of national standards. The NQF is going to be reviewing those standards, which are in the final stages of approval, within the next month or so. The timing is perfect, considering the Durbin bill and other pieces of legislation making their way through Congress presently.
Q: Theres a lot of talk about making active surveillance mandatory. What are your concerns?
A: While APIC is in favor of public reporting, we are not in favor of legislation that would mandate active surveillance, primarily because its a one-size-fits-all approach to a very complicated problem. Its entirely possible that an institution doesnt have a MRSA problem. If they do, to hardwire the expenditure of resources around one particular microorganism, we think, is very unwise. Today its MRSA and tomorrow it could be XDR-TB. An institution has to commit a certain amount of resources to active surveillance, which is costly. Plus, we would rather not see our government legislators become actively involved in determining how healthcare is delivered in an institution meaning the actual specifics of how infection prevention and control is deployed as a discipline. What we are in favor of is broader-based legislation that would create a foundation for more robust and effectively resourced infection prevention and control programs that would be capable of tackling any pathogen or problem whether its MDROs or pandemic influenza. We think that would be a far more beneficial approach. We are trying to use the legislative opportunities that are before us as a means of accomplishing that broader goal.
Q: What words of additional wisdom do you have for IPCPs?
A: I would say to them that this is their time to shine. What will be required for us to be successful is for each IPCP to use the opportunity presented by the greater awareness on the part of the general public, regulators, legislators and the media, to promote, expand, and resource their infection prevention programs appropriately. Its going to take each of them understanding that opportunity and using it effectively to advance the profession, to advance the process, and to advance patient safety nationwide.
A Q&A with Suzanne Pear
Making the Business Case for Infection Prevention
By Kelly M. Pyrek
Its more important than ever for infection control professionals to overcome their reticence about tackling the economics of their work and do the math. The costs associated with hospital-acquired infections (HAIs), particularly methicillin-resistant Staphylococcus aureus (MRSA), can be calculated in terms of impact on hospitals bottom lines as well as the toll on human life. An audit of published HAI reports, and interventions conducted by infection prevention professionals from 1990 to 2000, revealed the mean cost attributable to an MRSA infection was approximately $35,367.1 A price tag cannot so easily be placed on lives lost due to infections, and that is why a number of organizations from the public and private sectors have launched initiatives to support the compelling call for infection prevention. Legislation related to halting HAIs has been introduced or is being developed in an increasing number of states, and at the federal level, beginning in October 2008, the Centers for Medicare and Medicaid Services (CMS) will reduce diagnosis related group (DRG) acuity payments for several conditions related to HAIs occurring during a hospital stay.
ICTsat down with Suzanne Pear, RN, PhD, CIC, associate director for infection prevention practices for Kimberly-Clark Health Care, to discuss the importance of addressing these economic imperatives.
Q: Many ICPs indicate that they do not know how to make a business case for infection prevention; what are the ramifications of this trend?
A: According to a recent ICT online poll, 73 percent of ICPs dont know how to make an effective business case for infection control and prevention to their hospital administrator, which is surprising to me. It does seem that they are unsure of themselves and dont realize that they do have the skills and are actually using those skills now. For instance, with any type of new product evaluation, ICPs have to make a business case for or against adopting the new product or practice.
They have to be able to evaluate the benefits, risks and cost effectiveness of whether to adopt or not adopt those practice changes. Most ICPs have done this many times over in one form or another. ICPs may think that formalizing data and information as an effective business case to the hospital administrator is something different that entails skills they havent used or acquired. But in reality, they have those skills and are using those skills.
Q: It is simply because many ICPs feel as though they dont have a right to speak to their administrator or they feel as though they dont know what to say? What is the root of this insecurity?
A: I was fortunate enough to have a champion during my 30 years of practice with the Department of Veterans Affairs. I never feared any kind of overt or covert reprisal for speaking out, which is a good thing considering that ICPs are the messengers who often times have a message that no one wants to hear. Additionally, I was truly blessed with my hospitals epidemiologist who was my mentor and always there to back us up. A physician champion is absolutely critical in empowering ICPs. I didnt really value what I had until I saw that other organizations and ICPs did not have that. Without that support, you dont have that confidence going forward.
Q: Are there other stakeholders who are important to this mission critical? A lot of ICPs feel that they are in it alone, which is very much not the case. Do you agree?
A: At least half of the institutions in this country have less than 100 beds. Most ICPs are either by themselves or are doing multiple jobs and infection control is only part of their job. This makes it difficult for the ICP to truly be an expert, which can contribute to their lack of confidence. People who are not in the practice of infection prevention and control dont appreciate how complex that job is and the number of skills it requires. From the scientific to the human relations skills and everything in between, many ICPs may not have the opportunity or ability to perfect their practice and become the experts that they need to be with such a complex position. On the upside, ICPs should recognize that they have resources such as APIC, publications like Infection Control Today, and the Internet. The value of the ICT poll tells the organizers of APIC chapters that there is a need for hands-on practice in developing the business case as well as presenting it, which may be the biggest challenge for ICPs. Presenting your position can be very daunting and if you dont have a physician champion or a high level champion, that can really put you at a disadvantage.
Q: With the emphasis on risk management and the greater awareness in general of what is going on in healthcare, is it getting any easier to speak to the administrators? Are they any better educated than they used to be?
A: What may be still an issue is the language being used. I personally fell in love with statistics and charts, graphs and numbers. What I thought was important was not necessarily what the administrators thought was important. The ICP needs to find out what keeps their administrators up at night. Find out what gets their attention and what their concerns are. After that, ICPs should couch infection prevention in those terms so that its a win/win. I would also learn the language and speak the language personalize the data as much as possible. I assumed that numbers got everyones juices flowing. ICPs are just one of many people who are coming to the administrators everyday with data. I think that there should be a local chapter that offers classes that allows them to share the wealth of knowledge and education within the chapters face to face.
Q: Do you think that the recent public reporting and public discloser helps add increased scrutiny and pressure on this entire situation? Does it perhaps even strengthen what the ICP has been telling their administration?
A: In the past many people were clueless of what I did and what my job entailed. The public knowledge about HAIs is very important and I am very pleased that the cover is off. I have a lot of concerns in the inability for the public and legislators to really understand what the numbers mean and the accurate comparison made between facility to facility. For example, Denise Murphy recounted when Barnes-Jewish Hospital started reporting their statistics on HAIs, they were penalized because they did such an efficient job at surveillance. The more surveillance you perform the more infections youre going to find. Unfortunately the quickest way to lower your infection rate is to quit looking for infections. There are in many situations pressures put on ICPs not to find those infections. I am fearful that we will see this reaction happen more and more in the future.
Q: Does this crunching of the numbers help or hurt the move toward humanizing infections?
A: You have to recognize that you are dealing with physicians who are scientists, administrators who are executives; they are use to wanting and demanding all of this data. You should always have the data to back up anything you are saying whether its the possible outcome of an intervention or an outbreak. You have to provide the numbers to the stakeholders. You owe it to the patient to humanize the data. You need to talk about what those infections would mean if you had an outbreak. What would the demographics be? How many people, families, deaths? Those are facts that need to be known as well as the numbers. We have to realize what our business culture is and develop that as a plan.
Q: What are the essentials that ICPs should include when making their cases heard?
A: Most important is getting the numbers especially the financial numbers that are relevant to your institution. Speak to what the reimbursements are in your institution and where the operating losses are coming from. Get on a first name basis with the people who are collecting the data and who can retrieve it for you so that you can make convincing, relevant comparisons or discussions about the situation. Personalize it about the patient and especially personalize it about the institution so that whomever you are talking to can relate. Talk to them about what is happening right now to their own patient, etc. Personalize the data as much as possible and on as many levels as possible.
Q: Are you a fan of the electronic surveillance systems and all of the informatics and more automatic systems that are out there? Any thoughts on tools and technology that can make this process easier for ICPs?
A: I think that the current technology may help ICPs in getting through the mountains of information and data. If these software packages can be used to merge the data that enables the C-suite to see what exactly is happening and where their losses are associated with HAIs, that is great. APIC has a series of Webinars on elimination of MRSA transmissions. One Webinar by Dr. Robicsek titled, Designing a program to eliminate MRSA transmission part 2: making the business case, demonstrates the steps that they took. The team gathered local data from their healthcare system to bring to their executives so the C-suite would finance a MRSA prevention intervention, which ultimately paid for itself. Dr. Robicsek goes through the steps that could be applicable to situations in terms of making the business case.
Q: Do you agree that we need more tools that help analyze the data and do you think the industry is heading in the right direction?
A: MRSA is an excellent case in point where the public concern about the infectious bacteria is huge and a lot has to do with the lack of understanding and education on MRSA. If we dont have the data to be able to understand the situation ourselves how useful can we be? The only concern that I have is that sometimes there is not unity in the major voices in how we should proceed. The more that these organizations work together for the common good, educating the public and having interventions that work, the better off we will all be.
Q: What are the most significant impediments to ICPs being able to make their case to administrators and other stakeholders?
A: Most ICPs are by themselves and are doing multiple tasks along with infection prevention. There are a number of skills that are required that executives so the C-suite would finance a MRSA prevention intervention, which ultimately paid for many people dont realize or appreciate. ICPs have organizations like APIC and ICT to help them, but there needs to be some hands on practice on making a business case.
Q: As a company collectively, is there a campaign or effort to help in this regard? Helping ICPs make the business case?
A: We are sponsoring an intervention with the CDC that will show a large benefit to the public in terms of infection prevention.
Q: In the APIC white paper, Dispelling the Myths: The True Cost of Healthcare-associated Infections, do you agree that there is a lot of misinformation out there relating to making this business case?
A: When our healthcare system received a C for service that was certainly the case. Administrators then talked numbers instead of people who were getting sick and dying. Administrators were saying that since the costs were being recovered and we were getting more money its not a big deal. The administrators started paying more attention when they got the DRG reimbursement program. Even then they felt that the complication and co-morbidity coding was again not an issue. What they didnt realize was how poorly and under-reimbursed CMS (DRGs were). Even without a complication sometimes the facility loses money, but with a complication they really do lose money. The one benefit of the pay-for-performance that CMS has started is getting the administrators attention. If administrators dont get the message now that HAIs are extremely cost prohibitive and how they undermine the net operating profit, I dont think there is anything else you can do. The message should be loud and clear. If you want to have a viable institution thats financial stable you are going to have to prevent HAIs.
1. Stone PW, Larson E, Kawar LN. A systematic audit of economic evidence linking nosocomial infections and infection control interventions: 1990-2000. Am J Infect Control. 2002;30:145-152.
1. Cosgrove SE, Qi Y, Kaye KS, Harbarth S, Karchmer AW, Carmeli Y. The impact of methicillin resistance in Staphylococcus aureus bacteremia on patient outcomes: Mortality, length of stay, and hospital charges. Infect Control Hosp Epidemiol. 2005;26:166-174.
2. Noskin GA, Rubin RJ, Schentag JJ, et al. The burden of Staphylococcus aureus infections on hospitals in the United States: An analysis of the 2000 and 2001 Nationwide Inpatient Database. Arch Intern Med. 2005;165:1756-1761.