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Leah Myrick

Infection Costs and HAIs

Infection Costs and HAIs 150 150 Leah Myrick

Multifaceted Cost of Infection

Depending on who you are and what you do, the phrase, “infection costs” could have different meanings.
It could be taken literally: the financial burden of infections. You could take a more philosophical approach, the cost to the person suffering from infection (physically, mentally, psychologically). It could reflect a more “jaded” image of the physical and mental stress of a caregiver. Whatever your first impression, it’s easy to recognize that the cost of an infection is a price all of us would rather not pay, especially when that price tag includes the loss of life.

Searching for Answers

I recently posted the question, “how much do you think an infection costs in a hospital or LTC/SNF?” to a popular social media group made up of fellow nurses and healthcare workers. I wanted to know what others in the medical field, particularly nurses, thought infection costs involved. Unfortunately, most just read the question and moved on, but the few who did answer, posed their own questions: “what do you mean?” and “I’m confused?”. The costs of infections are not even on the radar for most nurses; but ask “how do you prevent the spread of infection?” and get a flood of “handwashing” among other answers. The result of my little experiment? I learned that sometimes, it’s more about asking the right question and that nurses do contribute to lessening the burden of infections costs. Nurses can, and do, impact infection costs whether it be financial, physical or philosophical by aiding in the prevention of Healthcare Associated Infections (HAIs).

The Life of a Nurse

I am a nurse by trade and I remember being a new nurse with my “save the world, no matter the costs” outlook. After all, how do you put a price tag on someone’s life or well-being? However, as my profession and, by necessity, position grew; I began to understand the nuances of running a business as well. If my co-workers and I wanted to be paid, there had to be money made. I’ve come to recognize while saving money may not be the only answer, it’s something we can all contribute to. Saving money on infection costs by decreasing the spread of infection is one way to do it.

Food For Thought

As a SmartSteward team, we have looked at the question of infection costs. We’ve brain-stormed and discussed measuring the cost of infection, what’s involved, and researched what others have found. Unfortunately, there is little data on the costs of infections. Most studies are hospital based and use retrospective studies looking at reimbursement data of diagnostic and medication costs. However, we came up with a much broader definition of the costs of infections. The literal costs of the financial burden of caring for someone with an infection, including: extra medication and treatment costs, the use of more equipment or devices, the costs of diagnostic data such as lab tests, cultures, and/or x-rays, increased doctor’s visits, maybe even a specialist or consult is included. However, the most costly, financially and otherwise, is the extra time, effort, stress, and sometimes escalation of the healthcare staff. When a patient becomes ill with a HAI, it sets off a series of events including speaking with the doctor, the family, providing extra care, establishing any precautions that may be needed, ordering new and/or different medications and/or diagnostic testing, and the list goes on and on. Someone has to initiate and carry out all of those tasks while caring for the patient and, sometimes, the family as well. This is a burden healthcare staff readily accept, it’s what we are here for; but it also means increased time and stress which may lead to burn-out, staff turn-over, and increased over-time.

The Real Costs of Infections

As Hamlet said, “Ay, there’s the rub” (Hamlet, 2015), infection costs are not limited to medications, treatments, labs, or x-rays. No, it’s embodied in the “boots on the ground” caregivers that are working hard to, not only care for the patient and family, but prevent the HAI from spreading to anyone else. This is where the real financial costs lie for a facility: The increased time spent by the nursing staff and the increased burden on the staff leading to more costly turn-over, over time and burnout. Ethically, the ultimate price to pay for infection is loss of life. I could list statistics of HAI death rate, the rate of HAI and the rate of those infections that result in death or debility; but to my nurse’s heart, any loss of life is too high a price to pay, especially when it is preventable.

Increased Costs of Resistance

While infection costs as a whole does not have enough reliable data, one of the aspects of infection costs has been recorded more than most: HAIs of the resistant variety. Some studies have shown that antimicrobial resistance increase overall infection costs and we have found this to be true in our own data by about 10x. When looking at the average cost of a non-resistant versus a resistant organism, the costs rise with the need for more expensive antibiotics, I.V. antibiotics (I.V. supplies), more testing, and isolation precautions. How do you combat antibiotic resistance? The easy answer: stop using antibiotics, but obviously, the full answer is more complicated. Antibiotics are great, when used properly and only when needed; but antibiotics can actually cause infection as well as other complications.

What does it all mean?

Why is the SmartSteward team researching the costs of infections and how it impacts facilities? Because we want to be the answer to the follow-up question: “how do we reduce the costs of infections?” Through our 24/7/365 surveillance system with notification of potential outbreaks as well as the ability for the Infection Control and Prevention Officer (ICPO) to monitor all infection events quickly and easily; SmartSteward can enable the ICPO to detect and prevent the spread of HAIs. In addition, the SmartSteward software decreases the time spent on gathering and processing data thereby allowing the ICPO to process and use surveillance data in real time. SmartSteward also has a one-of-a-kind recommendation engine for prescribing antibiotics as well as a feedback system for the prescribers creating a “one-stop shop” for antimicrobial stewardship that leads to a reduction in resistance.

Opening Doors to The Future

Infection costs, antibiotic resistance and antimicrobial resistance costs are not unheard of. Government agencies, such as the Centers for Disease Control and Prevention (CDC), the Centers for Medicaid and Medicare (CMS), and even the World Health Organization (WHO) continue to address the growing problem of infection costs. The most recent move by CMS began in 2014 with initiating rule and regulation changes surrounding infection control and prevention and antibiotic stewardship. The changes did not happen quickly, but has been spread out over the course of years culminating this year. However, as more information, guidelines, and regulations come from the continued rise in infection and antibiotic resistance awareness, payment and regulatory systems will continue to depend on the decline of infection rate and resistance in each facility. Without constant and consistent surveillance and tools for antibiotic stewardship, this is nearly impossible. SmartSteward is your all-in-one infection control and prevention and antibiotic stewardship partner in regulatory compliance and costs saving.

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Hamlet by William Shakespere. (2015). Retrieved on 13 September 2019 from https://www.williamshakespeare.net/hamlet.jsp

Manipulating Antibiotic Resistance

Manipulating Antibiotic Resistance 150 150 Leah Myrick

“War of the Worlds”

October 30th, 1938.  Imagine a slower, simpler time before the internet, smart phones, and television.  It’s Halloween night and Orson Welles is presenting an adaptation of “The War of the Worlds” by H.G. Wells (reference).  Unfortunately, your family is one of the dozens that miss the announcement that the show is for entertainment only and by the end of the hour long show, everyone has been thrown into a panic thinking the world is coming to an end.  Some call the radio station while others call the police. The Mercury Theater has just caused wide-spread panic over it’s listening area by faking an alien invasion! In the end, though, humanity is saved by the very thing that makes us sick.

Bacteria, the hero?

Bacteria, bacterium, classified as prokaryotes, single-cell organisms that lack a nucleus, and yet, they can bring a grown man to his knees (or kill alien invaders) (reference).  In the “War of the Worlds”, it was the bacteria our bodies have acclimated to fight that defeated the entire alien army (reference). Bacteria are microscopic, but they are mighty in numbers and adaptability.  Bacteria can adapt to almost any condition, there are bacteria that live in anaerobic (without air) conditions, some thrive in extreme heat or cold, while others have learned to adapt to the ever changing world of antibacterial drugs.

Antibiotics, the antagonist?

The first modern antibiotic, Penicillin was discovered in 1928 by Dr. Alexander Flemming (reference).  Mass-production began in the early 1940’s and by the time the U.S. began using Penicillin to treat troops during World War II, it was being heralded as a miracle drug (reference).  By the late 1940’s, it was being introduced into agriculture to boost poultry production (reference). Despite Dr. Flemming’s caution that bacteria could start mutating to resist Penicillin if not used cautiously, the first resistant strains of bacteria were already being identified in the mid to late 1940’s (reference).  According to Harvard Magazine, resistant staph infections in hospitals rose from 14 percent in 1946 to 59 percent in 1948 (reference).  The trend of antibiotic resistance has continued and, with it, the emergence of “superbugs” or Multidrug Resistant Organisms (MDRO).  The overuse and misuse of antibiotics, not just to treat humans, but in agriculture as well, has led those microscopic, one-celled organisms to do what they do best: survive.

Setting the stage for change 

Fortunately, we know more now about bacteria and antibiotics then we did in the 1940’s.  As Maya Angelo once said, “I did then what I knew best, when I knew better, I did better.” (reference).  We now know better, so we must do better. The Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), as well as many more agencies and organizations across the world have recognized the current and potential threat of antibiotic resistance.  There are new mandates, recommendations, education, and regulations being put into place, but some are too little, too late. In order to make a difference, the healthcare community is going to have to become proactive and change the environment in which bacteria lives (or dies).

The Plot Thickens…

We know that we can change the tide of antibiotic resistance.  Just as we have forced bacteria into creating or mutating a resistance, we can “turn down” the pressure so to speak of  antibiotics being used in a specific area by decreasing or eliminating the use of certain antibiotics. The idea is that we are creating a better, safer environment for the bacteria and will, therefore, decrease the need to create a resistance.  “When there is a concerted effort made by all of a facility’s physicians and nurses to coordinate together intelligently, resistance and its complications can be controlled,” Dr. Robert Yancey, ID and Antibiotic Stewardship Expert.

The Plot Twist!

How does that work, exactly?  Simply, bacteria are everywhere, they are on everybody, in the environment, can live in different conditions.  However, as “normal flora” and “healthy flora” can live outside the body for a period of time, so can “Superbugs” and MDRO’s.  They are in the environment and, therefore, spread to others. If you imagine a building as a petri dish with a few isolated areas of MDROs or Healthcare Acquired Infections (HAI), we know these infections will spread unless there is some intervention.  This is why isolating infected patients and environmental cleaning, handwashing , and observing infection control guidelines are so important. Now imagine there are antibiotics introduced into that petri dish, the bacteria may respond to those antibiotics at first, but just like with the introduction and overuse of Penicillin, the bacteria develops a resistance.  When antibiotics are overused and misused in a facility (building = petri dish), a resistance builds in that environment, not just in the affected person. Though we isolate those that already have MDRO’s, not every person that has bacteria in or on them are isolated and, therefore, bacteria and the antibiotics used to treat them are not isolated.  

Crescendo

What can you do?  As in antibiotic stewardship, everyone has a role.  However, the most important roles as it pertains to manipulating bacterial resistance are the information gatherer, the information giver or reporter, and the prescriber.  The information gatherer and reporter (giver) is typically the nurse caring for a resident or client. Nurses are expected to know and understand how to assess a resident, identify what is wrong, gather data such as vital signs, assessment findings, and lab reports and call the physician.  The physician then has to rely on what the nurse is telling him or her and make the best possible decision with the information given, and they already know. This isn’t ideal for manipulating antibiotic resistance. The physician isn’t going to have the latest and greatest antibiotic prescribing guidelines nor are they going to have an up to date facility antibiogram in their back pocket.  The nurse isn’t expected to know what an antibiogram is, much less how to report it to the prescriber and he or she is not expected to know about any resistance “brewing” in the facility. This makes antibiotic resistance manipulation difficult at best, impossible at worst.  

Problem. Solved.

How is manipulation of antibiotic resistance a solution if it’s difficult, hopeless possibly impossible to attain?  Because there is a solution that makes it not only attainable, but easy. SmartSteward enables the nurse and prescriber to be equipped with the most up to date antibiogram, the most proficient prescribing and a recommendation engine that automatically gives the top 3 antibiotic choices while removing the threat of prescribing antibiotics that are developing a resistance in the facility.  By using these tools, doctors and nurses can truly work together in a concerted effort to control resistance and it’s complications.

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Be an Antibiotic Stewardship Warrior

Be an Antibiotic Stewardship Warrior 150 150 Leah Myrick

Antibiotic resistance… two words that strike fear into the hearts of healthcare providers all over the world.  Antibiotic resistance isn’t a “new” problem, it began with the first introduction of antibiotics. When Penicillin was introduced in 1942, the first case of Penicillin resistance was noted in the late 1940’s.  Fast forward to 2003 and the introduction of Daptomycin then the speed in which bacteria formed a resistance increased dramatically with the first case of resistance within just 1 year. Antibiotic resistance is a “hot topic” in today’s culture.  Whispers can be heard everywhere, not just in healthcare facilities; but the daycare down the street or our sweet little elderly neighbor two doors down. This widespread problem isn’t just spoken of in quiet corners of the doctor’s lounges in big metropolitan hospitals or discussed in hushed tones among the top infectious disease doctors in Atlanta any more.  No, these days, it is front page news.  

In November of 2017, the President of the United States addressed it in a Presidential message in which he states, “My Administration is, therefore, committed to implementing the National Action Plan for Combating Antibiotic-Resistant Bacteria. This plan provides a roadmap to identify instances of antibiotic resistance, stop the spread of resistance, and improve the prescribing and use of antibiotics”. (Presidential, 2017)  The Centers for Disease Control and Prevention (CDC) has addressed the growing problem by developing multiple tools that were laid out in prior Leading Age Newsletters, including a January, 2014 article introducing the CDC’s (then new) LTC Infection Control website (Munley, 2015) and an October, 2015 article about the CDC releasing the Core Elements of Antibiotic Stewardship for Nursing Homes (New, 2014).  

What can we do about this urgent issue? 

 The most common answer is antibiotic stewardship, but what is antibiotic stewardship?  The CDC defines antibiotic stewardship as, “a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.”(The Core, 2017).  This is a very general definition and often results in healthcare providers acknowledging that something must happen, but scratching their heads as to how, or how it applies to them.  The executive summary of the above mentioned National Action Plan sums it perfectly by stating, “All of us who depend on antibiotics must join in a common effort to detect, stop, and prevent the emergence and spread of resistant bacteria.” (National, 2015).

We all remember the “recycling” presentation in grade school where a presenter came in and we all circled around sitting “criss cross applesauce” and listened as they told us the dangers of producing trash and litter.  They told us about how we can “be the change” and start recycling all the trash we possibly could. They pumped us full of sugar and sent us home to tell our moms and dads (and anyone else who would listen) about the dangers of trash and the glorious benefits of recycling.  We all became “recycling warriors” for about a day then, as most children do, was distracted by the next thing that came along and it fell to the wayside. But look at us now with our recycling bins in front of our houses on recycling day and being good, productive members of society.  It’s time for us (a little older and, hopefully, a little smarter) to become “Antibiotic Stewardship Warriors”.  

What does an “Antibiotic Stewardship Warrior” look like? 

An Antibiotic Stewardship Warrior understands that not all illness requires an antibiotic to get better.  They understand that a healthy body (plenty of rest, good food, staying hydrated, and having a healthy lifestyle) is important to our immune health.  They learn to listen to their body and their physician, and the importance of a good trusting relationship with their physician to stay healthy and avoid illness.  They know to stay home when they’re sick and avoid other people who may be sick and, of course, to wash their hands.  

 As a healthcare community, we must become an army of “Antibiotic Stewardship Warriors”, so how does the healthcare community really affect change through antibiotic stewardship?  This is THE question, but it has many answers. The greatest and most useful tool that we can all use is education. Educate our patients, residents, clients, family members, and visitors as well as our own family and friends.  We can also, “know our role”. All roles, from being a patient to a prescriber, have a responsibility to being good stewards of antibiotics and to only use them when necessary. The CDC gives guidance through their LTC Core Elements of Antibiotic Stewardship for Nursing Homes that includes: Leadership Commitment, Accountability, Drug Expertise, Action, Tracking, Reporting, and Education.  Antibiotic stewardship gives each one of us, from leadership to patient, a responsibility and role. Of course, the best way to affect change is to have an infectious disease expert that specializes in antibiotic stewardship to review each antibiotic ordered, give expert advice on prescribing and help change prescribing habits. This would have been an expensive and unrealistic option for many facilities, until technology stepped in to provide another option.

Enter SmartSteward

SmartSteward is a software solution to the challenges of effecting change through antibiotic stewardship.  It is an infection control and prevention and antibiotic stewardship software solution that uses technology to provide recommendations and feedback for expert level antibiotic stewardship.  SmartSteward offers a HIPPA-compliant, time management friendly solution to nurses and doctors to communicate and easily share patient information, along with other tools including a proprietary expert-level antibiotic recommendation engine to positively impact the rampant overuse and misuse of antibiotics.  The future of healthcare is looking to technology to bring safer, better, and more timely solutions to the bedside for every patient. Through advancements in machine learning and artificial intelligence to communication and prescribing solutions; healthcare is turning to technology to help solve some of its more pressing concerns.  SmartSteward is an example of how technology is aiding the healthcare team to combat the rising concern of antibiotic resistance bacteria.

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