This morning I attended an event organized by the Committee to Reduce Infection Deaths (RID) at the Harvard Club of New York.
RID's Chairman and Founder as well as former Lt. Governor of New York State Betsy McCaughey, Ph.D. hosted the forum entitled, "CRE and Other High-Mortality Superbugs: How to keep care in our hospitals and nursing homes safe." CRE stands for Carbapenem-resistant Enterobacteriaceae and the emphasis of the presentations and roundtable discussion surrounded CRE and multi-drug resistant organisms (MDROs), in general.
A pool of public health leaders present reflected diverse perspectives on how the complex task of preventing healthcare-associated infections (HAI) needs to be approached. The scope of the conversation varied by touching upon the following: How do we quantify the problem? How do we address the flaws and hurdles inherent in compiling the data required? What avenue is most desirable to curtail this burden? What are the conflicts? What measures have proven to ensure patient safety? What is the highest priority in terms of new technology needed in this battle?
Betsy McCaughey, Ph.D. (pictured at the top of this article) began by underscoring her main goal is "to save lives by leveraging information-- actionable information to the people who can make a difference." She acknowledged the vital role technological innovation needs to play as "our most important partner" in combating this issue-- specifically, she referenced self-cleaning devices and development of rapid assays. Her priorities include acquiring adequate data (e.g. how, where, how many), vigorous disinfection of patient rooms as room assignment plays a crucial part in contracting HAIs, screening patients with CRE as they enter the hospital so as to identify the "silent carriers" and calling for a "battle plan" for combating CRE. She spoke of success in Israel and the nation's precipitous reduction of CRE rates after implementing "vigorous cleaning and screening everyone."
John Jernigan, M.D., M.S. is the director of the Office of HAI Prevention Research and Evaluation of the Centers for Disease Control and Prevention (CDC)’s Division of Healthcare Quality Promotion (DHQP). Dr. Jernigan's efforts concentrate on a regional approach to controlling HAIs and MDROs. It is his contention it is not a problem individual facilities can solve by themselves. Due to the "dense network of patient sharing" between healthcare institutions, patients colonized or infected serve as reservoirs for transmission. "Understanding connectedness" and being aware of neighboring facilities will help decipher new approaches to minimizing the spread via patient sharing-- hospitals more highly connected have higher infection rates. By generating "a matrix of inter-facility patient sharing"--e.g. using Medicare billing data-- then "can merge the data to see how" it "relates to infection rates."
According to Dr. Jernigan, by "characterizing the drivers of outbreaks over time, we can then determine prevention efforts." In addition, a longer length of hospital stay contributes significantly to the problem. Though the goal is to promote prevention everywhere, it is also important-- especially if resources are limited-- to target those facilities where stays are traditionally protracted. Long-term studies are currently underway in Chicago and Orange County to see if can diminish MDRO rates. He says the science is relatively early, so we will need to adapt but concludes with "think regionally when thinking of control of antibiotic resistance." (See his Morbidity & Mortality Weekly Report here).
I have repeatedly written about the vital need to stop one-size-fits-all approaches to complicated medical conditions and how important regional nuance is to solving these and more problems. See Top Cause of Death: Geography.
Jacqueline Reuben, MHS ,--Infectious Disease Epidemiologist, D.C. Hospital Association-- presented her study findings on "Healthcare Antibiotic Resistance Prevalence." Her work detailed in the preceding blue link explored CRE prevalence across the District of Columbia. She spoke of the challenges of screening: requiring written patient consent, attending approval, funding issues, need plan if colonized, perianal location optimal for testing not so ideal for patient preference, adding to staff responsibilities etc. Due to the many hurdles of getting hospitals and staff on board and the nature of the study, the team opted to de-identify patients which served to somewhat ease their path-- now could do verbal consent, etc. CRE overall prevalence in D.C. was 5.1%. Long-term care facilities and critical care environments had higher rates. To sum up, "a lot of action ensued as a result of identifying prevalence. CRE is now reportable in the District as a result." An advisory group featuring multiple disciplines and a workshop were created as the approach for CRE and patient transfer needs to be a collaborative endeavor.
Lawrence Muscarella, Ph.D. is a patient safety expert on the contamination of medical devices. He believes CRE infections are higher than what has been reported and proceeded to speak on "Risk of CRE Infections from Contaminated Endoscopes." He contends if we keep reimbursing hospitals for problems, then the problems will continue. Dr. Muscarella focused on notable trends in infection prevention, risk factors, recent outbreaks and recommendations to avoid CRE infections. He sources the CDC to assert more healthcare-associated outbreaks have been linked to contaminated flexible endoscopes than to any other type of reusable medical devices. He clarified they can be difficult to clean which makes them more prone to CRE, among the issues are accessibility to reusable valves and heat-sensitivity (so cannot be steam sterilized). Dr. Muscarella recommends disposable products if can't be thoroughly cleaned and disinfected as well as changing the process--- e.g. culturing endoscope for clearance before use again. He urges enhanced measures, more resources, proper handwashing and cleaning along with active surveillance.
Rheuters journalist Ryan McNeill gave a brief presentation about a multi-part series he participated in called "The Uncounted: What a team of reporters learned during a year investigating the public health system." As a self-described "data journalist," he concentrated on the difficulty of data access from hospital and governmental agencies. His team's hypothesis before setting out to take on their project was that "far more people are dying than the CDC reports."
Patricia Stone, PhD, RN, FAAN is the Director of the Center for Health Policy at Columbia University's School of Nursing. Her talk highlighted the "State of the Art of Infection Prevention in Nursing Homes." Dr. Stone identifies the use of antibiotics and patient transfer as problematic. She reports that despite a lack of solid numbers we know infection and antibiotic resistance is a big issue in nursing homes. In states where reporting HAIs is mandatory or voluntary, there is progress. It is important to recognize these long term care facilities are a heterogeneous group--the discussion shifted to how some have patients on mechanical ventilation while others are living environments that feel like home. Dr. Stone underscored the need for collaboration, education, improved understanding in general and with respect to the conflict of quality of life, and that more needs to be done including but not limited to looking at action plans to reduce antibiotic resistance.
Emery Stephens-- Founder and CEO, Enterprise Analysis Corporation-- detailed "A Retrospective Outcome Study on Multi Drug Resistant Organisms." He emphasized the biggest problem is a lack of diagnostics. As everyone focuses on developing new antibiotics-- which is clearly valuable, he asserts creating diagnostic tools that cut wait time from 72 hours to 4 hrs will revolutionize how we intervene on this issue and change the current tide.
The forum concluded with the presentation of RID's 2nd Ignaz Semmelweis Award to Evan Jones the Chairman of OpGen, a diagnostics company, for its "innovative superbug screening methods." Mr. Jones spoke of this as an "extremely personal issue" recognizing how universal HAIs are to families.
He is optimistic about innovations that hold the promise of saving lives and says "there is hope and good work" is being done showing "some rates coming down." He further states "when these levers are put in place there is progress going on." Though more work needs to be done, high colonization rates and rates of MDROs in long-term care facilities are two areas for improvement-- e.g. shorten length of stay, rapid assays not culture-based.
I was fortunate to speak with John J. Connolly, Ed.D. (President & CEO of Castle Connolly Medical Ltd.) and many others dedicated to making an impact in this arena. Congresswoman Carolyn Maloney (NY-12) attended.
My Take Home Points...
Reduction of medical error and HAIs is a strong interest of mine (See 10 Ways to Save Your Life or the Life of a Loved One), so I was particularly enthused to participate in today's activities. The diversity of points of view from policy expert to researcher to academic to industry leader contributes to a meaningful dialogue and genuine collaboration.
In a time where collecting data for data's sake appears to be an incessant norm in medicine and healthcare today, there was an acknowledgement of its limitations. As I routinely say, "good information can save lives and bad information can end them." Much data for prevention strategies is taken from death certificates and I have previously written of their flaws. The document is no panacea--- it does not tell an entire clinical picture. The medical record and accessing the clinician is more useful.
There is room to narrow the gap between its high priority status for the journalist or researcher and its competing priority for the often overburdened practitioner. Data entry has usurped much autonomy and quality of care for physicians today. Speaking with suffering families, caring for sick patients and routinely high volumes, endless paperwork and fragmented electronic medical records are a mere few examples of a physician's priorities (see here). Solving the issue of getting good data needs to be addressed comprehensively, not in a vacuum. Ignoring the realities of medical practice today impedes progress. The role of data entry specialists outside of the physician is one to be further explored --this has its challenges too (for another article, ha!).
The sentiments of Emery Stephens and Dr. Jernigan especially resonated while all of the speakers substantially provoked thought. A more rapid detection tool for identifying what bug is causing the infection would dramatically improve the situation. It would prompt a cascade of positive effects. For example, a patient in the emergency room could be started swiftly on the correct treatment and be appropriately assigned a room-- thereby reducing time and ability to transmit to others. Also, the regional approach for so many reasons serves best to identify and fix the problem at its source as opposed to band-aid it temporarily.
Much more needs to be done, but great work is taking place. I would also be interested in an improved system of educating hospital and care facilities' visitors. This was not addressed today and needs to be a part of the discussion. Educating the public about infection control measures when visiting a loved one can be just as crucial as training hospital employees. The systems are not uniform between institutions and often families get no instruction outside of a note on a door indicating "contact precautions" or signs in the lobby "if you have a cough, first stop to see the clerk." There is much room for improvement in this realm.