On 10/13/2009 Karen Iversen - JCR said:

Thank you to everyone for participating today - we look forward to our next interactive blog on Tuesday, October 27th!

On 10/13/2009 Stephen Weber said:

Candace: Sorry I missed your question at first. The learning modules on the web site really walk you through each of the various sections of the toolkit. I really think the modules supplement the toolkit very nicely. Take a look!

On 10/13/2009 Stephen Weber said:

Patricia: The highly resistant gram negatives are really on the rise, don't you think? Unfortunately - our experience in prevention is also growing at this time so we really do not have the same evidence base to back us up as for MRSA, C. difficiel, VRE, etc. That said - I would be very cautious about embarking on a dedicated program to pre-screen patients. First of all, the methods have not been as well worked out as they have for VRE or MRSA active surveillance programs (e.g. are stool or peri-rectal cultures preferred). Next - how the results are managed are also not clear. You also bring up one of the most daunting challenges - which is whether or when patients colonized or infected with these potentially lethal pathogens can come off of precautions. At this time - we do not have clear evidence or guidance as to when it is safe to discontinue precautions for these patients. For clinicians who question this logic - remind them that the best way to avoid these precautions is to prevent their patients from ever acquiring these pathogens in the first place.

On 10/13/2009 Stephen Weber said:

Janice: You are right when you point out that this toolkit was specifically designed with acute care hospitals in mind. Really - this is where some of the best evidence in MDRO control originates. That said - as some of the other questions reveal - the same aims and approaches can often be modified just slightly to fit in other care settings (LTCF and ambulatory centers in particular). I know I sound like a broken record - but focus on risk assessment, performance assessment and maximize best practices and I think you will see benefits.

On 10/13/2009 Stephen Weber said:

Molly: Why not re-orient employees? I mean - it strikes me that some of the materials that are covered at annual competency and certification sessions can be quite a bit less crucial than what we are talking about in this session. That said - like most - your resources are probably stretched and to expect a solo infection preventionist to constantly re-orient staff would obviously pull him/her away from other important activites. Why not invest in some brief training modules that can be created once (by the IC program) and then "train the trainers" to adapt the key messages to be applied in a variety of care settings?

On 10/13/2009 Patricia said:

I have a question about the ESBL gram neagatives like Klebsiella pneumoniae. We are seeing an increase in our patients and wondered what you recommned for control measures beyond Contact precautions. Would you pre-screen, and how long would you keep a patient in isolation?

On 10/13/2009 Stephen Weber said:

Pauline: I suppose I am biased when I say that I believe that ALL senior leaders need to know about MDRO! Realistically though, which specific members of the management team can actually help direct resources to MDRO control will probably vary from hospital to hospital. I do aim for the CEO at most centers because to have him/her engaged and articulating an institutional commitment to MDRO can be a real difference-maker. Sometimes a testimonial from an affected patient (particularly if they happen to be a member of the board of trustees!) can really help. One more practical step is to look at the quality/safety report card or dashboard that the senior leaders review at their meetings. Campaign hard to get some MDRO measure onto this kind of report (an example is included in the toolkit).

On 10/13/2009 Janice W. said:

I work in an ambulatory health care setting. This toolkit is geared toward hospitals - can I still apply some of this content?

On 10/13/2009 Molly said:

That's good advice, Dr. Weber. Thanks. One other question: Do you advise re-orienting ALL employees in IC periodically?

On 10/13/2009 Candace P. said:

You have self-paced learning modules on this website - what is the difference between these learning modules and the MDRO toolkit?

On 10/13/2009 Pauline said:

The MDRO Toolkit's CD has "CEO" talking points at the end of every chapter - the toolkit also talks about the need to have Senior Leaders "on board". What are the best forums to meet w/Senior Leaders? Exactly which Sr. Leaders should know about MDRO?

On 10/13/2009 Stephen Weber said:

Isabel: One sneaky way to look at the impact of your orientation session is to go back to those employees at 1 month, 6 months and 1 year and ask them about some of the materials covered. Obviously - this gives you a direct measure of knowledge retained. Perhaps more importantly though - that assessment (even if done informally at the bedside) allows you to reinforce some of the key messages and reminds a new(ish) employee that this material remains important - even after they are on the job. You mgiht be surprised by the results!

On 10/13/2009 Stephen Weber said:

Gavin - you have just added evidence to the fact that you cannot gather more than two people to speak about infection control these days without bringing up H1N1. This isn't the focus here but I think we can illustrate an important point! Infection prevention, whether targeting MDRO or H1N1 is really not complicated. The focus needs to be on the basics, as I have said. For both H1N1 and MDRO: e.g. hand hygiene and following recommended isolation precautions (no matter the environment in which the patient is seen). While you might think this is overly simplistic - I would counter that it is also empowering. One does not need a new PCR method or a staff of 40 to prevent infection. You need providers expect of themselves and their co-workers the highest standard of care. Maximize these basics and you will achieve gains not just with H1N1 or MDRO, but most all infections.

On 10/13/2009 Isabel said:

Thank you for your response, Dr. Weber. Regarding my previous orientation question - how do we know that the HR orientation to IC was effective? Is there a measure we should consider?

On 10/13/2009 Stephen Weber said:

Molly: Thanks for expanding on Isabel's question. When thinking about a more broad scope for new employee orientation - think further about tailoring the content to your own institutional risk assessment. If C. difficile is your number one problem - focus there (because this message will be reinforced particularly among clinicians once they are out on the wards and in the clinics). For H1N1 and other timely matters - keep the message simple and straightforward. Our new employees will only retain a small fraction of all of the important materials shared at orientation - focus on very basic messages and action items and then refer them to accessible resources and expertise within the center that can be responsive to more specific (and even esoteric questions).

On 10/13/2009 Gavin K. said:

What are some key messages you would recommend educating patients and their families in regards to H1N1?

On 10/13/2009 Stephen Weber said:

Isabel: Make orientation realistic and personal for all staff. Frankly - I'm not certain that every employee in my hospital needs to know every detail of CDC guidelines for every MDRO. That said - what EVERYONE needs to know is how critical basic measures such as hand hygiene and isolation precautions can be. We leave a lot of opportunity to prevent MDRO "on the table" because we fail to hit anything close to 100% adherence to these basic measures. One thing that has proven useful at many centers is to collect testimonials from patients who have been affected by MDRO (some of this is available in generic form online). Believe me - as compelling an orator as your lead infection preventionist or senior ID doc may be, to hear from a Mom who had a child who acquired an MDRO infection is going to be much more pwerful. There are some tricky issues to manage in identifying such folks (risk management can help!), but the benfit can be incredible. Everyone in the hospital needs to know that infection prevention IS his or her job!

On 10/13/2009 Molly said:

Isabel, I was going to ask the same thing. Our administration has asked us to revise our orientation too--especially now with H1N1 and everything. I too am interested in the response.

On 10/13/2009 Stephen Weber said:

Thanks Christina. The expense of MRSA SSI vs. MSSA is still largely driven by length of stay. John Engemann and colleagues from Duke published a very thoughtful analyisis on this issue which you may want to reference: Clin Infect Dis. 2003 Mar 1;36(5):592-8.

On 10/13/2009 Isabel J. said:

All of our new employees receive orientation training on IC - however we're looking to revise this. What must every new employee know about IC - regardless of their dept?

On 10/13/2009 Christina V. said:

Why is it more costly to treat patients with SSI due to MRSA than it is to treat patients with SSI due to MSSA?

On 10/13/2009 Stephen Weber said:

Selma: This is a trick question I think! The most important elements of a great IC program are truly hospital-specific, depending on the needs and risks at that center. All kidding aside though - I think there are some important components. First - you need dedicated expertise on site. This does not mean everyone will have a fullt-ime epidemiologist and 10 preventionists. Rather - that there is staff available who really are charged to think exclusively about infection prevention. Healthcare-associated infections annually have been said to account for more US deaths than HIV, breast cancer and motor vehicle accidents combined. It is time that IC no loner be seen as a part time job. Next, and perhaps most importantly is that the institution engage in meaningful and constructive risk assessment. The toolkit provides a number of resources to help with this process. When going to leaders to say you want to build a program - they should rightly demand that you have carefully considered how these precious resources will be allocated. This is where risk assessment comes in. Once you have started a number of initiatives (hand hygiene and device related infections are often low-hanging fruit) - you must engage in equally rigorous performance assessment. What's working and what is not? At the end of the day - I advise "start up" programs to focus on initiatives (1) that have high impact across a wide range of pathogens (again - hand hyigiene and device related infections), (2) that can be measured in a standardized fashion and (3) for which an evidence base of appropriate interventions are already available. Good luck

On 10/13/2009 Stephen Weber said:

Sandra - before answering your excellent question I do want to add the caveat that your general observation has been upended by the epidemic of so-called community-associated MRSA in the last decade or more. These MDRO infections really can uniquely affect patients without convention risk factors for MDRO. That said - I would still agree that patients with co-morbidities are at higher risk for colonization and infection with MDRO in general. Does this mean that this is entirely related to some magical impact of diabetes, cancer or heart disease on these patients and pathogens. No - rather it is a very useful reminder that in most cases - the risk is driven for these individuals not entirely due to their underlying disease - but rather the frequent and often intense contact with the healthcare system that results from their necessary and appropriate medical care. Folks with other co-morbid conditions tend to be mroe frequently hospitalized, tend to have more invasive procedures performed and (perhaps most importantly) tend to receive a lot of antibiotics (when compared with a healthy population). All of these more direct risks really drive the incidence of resistance. To me, this is a sobering reminder of the importance of enhancing transmission control and antimicrobial stewardship programs in all settings in which care is provided.

On 10/13/2009 Selma D. said:

What are the elements you would consider that make up a good IC program?

On 10/13/2009 Stephen Weber said:

Fred - great question. The short answer is - Absolutely! As MDROs proliferate - prescribers are compelled to make us of antibiotics that are in essence custom-built to treat these aggressive pathogens. These newer pharmaceutical agents are generally newer and more expensive (often because they are still on patent through the original manufacturer). Moreover - where older antibiotics have been put into use again to treat MDROs - we often find ourselves compelled to monitor patients closely (sometimes with frequent blood draws or clinic visits) to avoid toxicity. Not only do these more expensive agents get used to treat patients with confirmed MDRO infections, prescribers (understandably) start to use these products more routinely just in case there is a chance that an MDRO might be involved. It really adds up!

On 10/13/2009 Sandra Rojas said:

Why are patients with comorbities at a higher risk of resistance infections as opposed to someone coming into the hospital with no significant med history?

On 10/13/2009 Fred Hunt said:

Is there a connection w/increased pharmacy costs and antibiotic resistance?

On 10/13/2009 Stephen Weber said:

Thanks for your question Jessie. I suspect that the senior executives (especially the CFO) at your center may provide an even more comrpehensive answer. The bottom line is that the hospital needs to look at finances exclusively from their perspective (as opposed to the viewpoint of the payer, the patient or even society as a whole). That's how they will ultimately (try to) balance the books. Costs provide a common denominator to all of this accounting. Charges may be more unpredictible. For example - the amount reimbursed from a given charge to a patient (or payer) may be quite different than the original charge itself (sometimes quite a bit lower). IN essence, the costs provide a more realistic view of the money that is transacted. Of course, no matter how you count it (costs v. charges) MDRO remain expensive to hospitals (and that's not even considering the human and clinical toll!)

On 10/13/2009 Stephen Weber said:

Dolores: I certainly hope so! Thanks for your question. When you say the "costs of utilization" I presume you mean to include all of the costs (length of stay, supplies, staffing, pharmacy costs, etc). These are the more dircet costs that should show up pretty readily on the bottom line. If that is not the case at your center - you need to start looking at some of the less direct economic impacts. These might include reporting standards. Do you need to publically report MRSA rates in your jurisdiction? Will such reporting affect your public perception or market share? Is there an entrepreneurial plaintiff's bar in your city that is on the lookout for hospitals where they are hearing about a lot of MDRO cases? Also remember that the costs of an outstanding infection control program don't need to be simply weighed against the benfit in terms of MDRO reduction. There are other gains to be made in most centers (e.g. device related infections, etc)

On 10/13/2009 Jessie Nombrowski said:

Why does leadership tend to look at costs rather than charges?

On 10/13/2009 Stephen Weber said:

Thanks Lisa for this challenging question about decolonization. Decolonization is really attractive to many knowledgeable clinicians because it seems like such a rational and targeted approach to managing MDRO surgical site infections. Now the evidence has been surprisingly mixed on this subject with arguably the best evidence coming from the cardiac surgery literature. For now - most view this practice as a decision best made locally. A review of the microbiology of pathogens detected from confirmed cases of SSI can be helpful in this regard. For example, some centers have a surprising proportion of SSI caused by pathogens apart from MRSA and even S. aureus. In these centers - I would focus my performance efforts away from decolonization targeting just one pathogen. Where MRSA remains a problem - I would only consider decolonization as ONE PART of a comprehensive SSI prevention program. You might also make sure that periop antibiotic prophylaxis is more custom-tailored for colonized patients, you might stress appropriate hair removal and skin preparation and you might focus on issues of post-op care (including appropriate hand hygiene), etc. One cautionary note for the use of mupirocin for widespread prophylaxis is to keep an eye out for resistance -as this can quickly limit any benefit you might get from attempts at decolonization

On 10/13/2009 Dolores Heist said:

How can we still help leadership understand the cost of MDROs, even if we don't see a major increase in costs due to increase in length of utilization?

On 10/13/2009 Stephen Weber said:

Lisa - as a doctor I guess I can point out that one might re-phrase your question to ask "how do you change a doctor's mind about anything?" That said - the issue of limiting post op antibiotics should become an easier "sell" to even your most reluctant docs as time goes on. We hope that most of our providers are evidence driven and for this issue the evidence is mounting. Given the pay for performance standards about limiting post op antibiotics - many hospitals have had great success on this measure. Many of them now are starting to publish and report their (favorable) experiences. Tap into this evidence. The other issue to bear in mind is to try to avoid getting bogged down trying to convince a small (but often vocal) minority of docsa as to the wisdom of this approach. Cultivate your early adopters to really achieve high rates of compliance for the majority of providers. Before long - those who were originally reluctant will begin to feel like the outliers.

On 10/13/2009 Lisa said:

I work at a surgery hospital. We have many patients coming in for elective procedures with a known hx of MRSA, many probably CA. Wouldn't decolonization be beneficial in this population who are about to have surgery?

On 10/13/2009 Stephen Weber said:

Ann - you are in good company with these issues. Whiel the toolkit was primarily developed to address issues in the acute care setting, we all realize that issues regarding MDRO control do nto stop at the hospital doors! LTCF like yours are really motivated to be doing everything possible to limit the economic and clinical impact of the pathogens. One think I like to stress with leaders in all settings is to make certain that any active surveillance program is well thought out not just in terms of logistics and resources, but also aims and consequences. The toolkit features an active surveillance checklist which walks people through this. In the situation you describe - what has been recommended and adopted at many facilities is to stratify patients/residents into those at highest risk of tarnsmission (for whom more stringent precautions are appropriate) and those at lower risk. This might be one way to explain the policies to the staff and avoid some of the consequences you mention.

On 10/13/2009 Lisa said:

How do you change the thought processes of doctors you continue to feel the need to continue antibiotics for > 24hours post-op

On 10/13/2009 Stephen Weber said:

Larry - thanks for your question. It sounds like you are asking about the costs of the prevention/control program itself, right? To that end - the greatest expense is of course associated with staffing. However - bringing on experts in infection prevention and control really can pay important dividends to the organization. When adequately resources and empowered, not only can an effective IC team avoid the costs with MDRO, but also the expense of other preventable healthcare-associated infections (including many device related infections). Further, in a world of pay for performance and public reporting - the IC team can really be shown to add value in many circumstances.

On 10/13/2009 Ann said:

We have started testing our LTC residents for MRSA colonization & now know their colonization status. We encourage our LTC pts to be active & out of bed. It is upsetting to some employees that pts "have MRSA" & are out and about. This results in providers wanting to decolonize & give antibiotics more frequently. Ann

On 10/13/2009 Stephen Weber said:

Gwen - Thanks for your question. Your are right in identifying the patient's clinical status as far and way the #1 factor in driving the economic cost of resistance. Even in the most simplistic analysis - the increased length of stay associated with MDRO really drives costs. In terms of other factors, it really depends on one's economic perspective. For the hospital - it is the expense of isolation supplies and even additional staffing. Acquisition costs for antibiotics to treat MDRO may also be much higher. For the payer - it may be the cost of care after hospitalization. Some of these patients require home IV antibiotics or the decline in functional status associated with some MDRO infections can mandate transfer to a LTCF.

On 10/13/2009 Ann said:

We are testing for MRSA colonization in our LTC unit & therefore discovering the colonization status of residents. We encourage our LTC residents to be active & out of bed. It is upsetting to some employees to know residents have MRSA and are mobile. This results in providers wanting to decolonize or give antibiotics when the patient is not ill. Thanks Ann

On 10/13/2009 Larry F. said:

How you do begin to quantify (in dollars) all the prevention and control resources you have in regards to antibiotic resistance?

On 10/13/2009 Gwen Milano said:

In addition to the patient's clinical status, what other factors influence the economic impact of antibiotic resistance?