CEO SUMMARY: Most laboratorians struggle to get clinicians to pay close attention to the potential for lab data to improve healthcare outcomes. At Northwestern Memorial Hospital, the laboratory acqired in-house molecular typing test capability as one cornerstone for an aggressive infection control program. Physicians, nurses, med techs, pharmacists and even maintenance staff now regularly participate in the infection control effort. Northwestern’s modest investment in expanding its lab’s capability now generates $2.5 million in annual savings–a yearly 10-1 payoff from its investment!
HERE’S AN UNUSUAL STORY about laboratory data and outcomes improvement. It is unusual for several reasons, most of them familiar to hospital-based laboratory executives.
During the last three years, the provider team at Chicago’s Northwestern Memorial Hospital mounted an effective effort to stomp out nosocomial infections. By itself, this is not uncommon. All hospitals pay attention to nosocomial infections and launch campaigns to reduce or eliminate them.
But it is how Northwestern went about attacking nosocomial infections that makes this a particularly outstanding story. It is a story that demonstrates how clinical laboratory data can drive significant improvement in healthcare outcomes, while at the same time reducing costs by a substantial amount.
It’s a story with several heroes, or more properly, champions. After all, teamwork was the secret behind this success. But one unusual twist to the story is that the catalyst of all this change was a laboratorian.
It was this laboratorian who designed the “attack plan” on hospital infection rates and sold it to administration. He obtained funding to build the necessary laboratory infrastructure and generated enthusiasm among his hospital colleagues. In that respect, he lit the match. It was the hospital team which maintained the fire.
Another aspect of this story which makes it unusual is the the laboratory became an integral and accepted part of the infection SWAT team. Clinicians and professional staff welcome its contribu- tions, and rely upon clinical laboratory data as an essential tool for changing clinical practices to the benefit of Northwestern’s patients.
As most laboratorians know, it is difficult to get doctors to look at laboratory data with the suggestion that such data provides relevant insight into ways they might improve their practice of medicine. Directly or indirectly, physi-cians don’t like to feel as if their clinical practices are under criticism. The harmony between doctors and laboratorians on the Northwestern infection control effort proves that both groups can benefit from each other’s talents and clinical contributions.
Given these unusual circumstances, it makes the Northwestern story all the more interesting. The protagonist is a microbiologist. Meet Lance Peterson, M.D., Director of Microbiology at Northwestern Memorial Hospital’s pathology department. He is also Professor of Medicine and Pathology at Northwestern University (separate but affiliated organizations).
It was Dr. Peterson’s brainstorm to attack nosocomial infections using a different approach. When he arrived at Northwestern in 1992, conditions were ripe for ideas he had developed over the years.
“Prior to coming to Northwestern, I was at the VA hospital in Minneapolis,” said Dr. Peterson. “A colleague, Dr. Dale Gerding, and I were doing academic work in infectious diseases and how to control them.
Infectious Disease Organisms
“We both appreciated a basic fact about infectious disease,” he continued. “If you know that the organisms are the same, then the likely mode of transmission is from person to person. If you know that the organisms are different, then some other factor is causing the increased rate of infection.
“Our frustration was that existing labo- ratory technology made it time-consuming and expensive to identify the organisms,” added Dr. Peterson. “It became obvious that, if a laboratory could identify organisms in a timely manner, then infection control efforts could become significantly more productive. But existing laboratory technology could not support these goals.”
By the time Dr. Peterson arrived at Northwestern in 1992, things had changed. “New molecular technology for genetic typing was emerging. Most importantly, Northwestern had a long history of monitoring outcomes, infection rates, costs, and a variety of other useful information. This type of information was unavailable at my prior hospital.”
Northwestern’s extensive data base was essential to proving the benefits of an enhanced infection control program. Dr. Peterson explains, “With good information covering prior years, it permits us to demonstrate the effectiveness of the program. The cost analysis demonstrates that money invested in infection control was repaid in multiples by reduced infection rates.”
Dr. Peterson is referring to the fact that historical infection control data and costs were used to convince hospital administrators to invest in laboratory infrastructure. As the laboratory came on-stream, it was used to show the cost-effectiveness of the laboratory.
“That’s right,” confirmed Dr. Peterson. “It took about eight to 12 months to write the business plan and get administration to approve it. Gary Noskin, M.D. is an infectious disease practitioner and Medical Director of the hospital’s infection control and prevention department. He was committed to this project from the start and helped with this process. We proposed expanding some lab space, acquiring the necessary instruments, and adding two employees.”
Northwestern’s administration supported the initiative. “We proposed this as a two-year financial trial,” he said. “‘Here’s the cost, here’s the projected outcomes, and if we don’t improve things, then we’ll quit.’ The administration encouraged us to proceed.”
According to Dr. Peterson, the two-year proposal required about $250,000 per year. “Of this money, about $60,000 was spent on remodeling. Another $80,000 went towards equipment. The balance represents consumables, additional salaries, and the like.”
By the end of two years, the microbiology project was returning $2.5 million per year in identifiable savings! But more on that later.
The essence of Dr. Peterson’s game plan for enhancing infection control was rapid typing, done by the lab on-site. If organisms could be identified rapidly, then the source of infections could be tracked and stopped.
“Speed is the key,” commented Dr. Peterson. “By definition, you can’t identify organisms rapidly enough if the hospital is sending specimens to outside labs for testing. Having in- house capability is what makes our program successful.”
Monday Morning Meetings
As the new laboratory came on-line, the infection control SWAT team began to take shape. “Obviously everyone on staff needs to help with the effort. We have meetings every Monday morning,” said Dr. Peterson. “These working sessions only last about 30 to 45 minutes. In attendance are physicians, infectious disease practitioners, infection control practitioners, pharmacists, laboratorians, and anyone else with useful ideas to contribute.
“It was in the fall of 1994 that the laboratory begin molecular typing and these Monday meetings were launched,” he noted. “To show the team nature of our project, within months the pharmacy joined us. As successes mounted, people become more excited about contributing to the project.”
Now entering its fifth year of operation, Northwestern’s new infection control program has evolved into a broad-based effort and it is laboratory data which drives much of the team’s response.
“Typing in the laboratory tells us one of two things,” said Dr. Peterson. “Either the organisms are related or they are not. If related, then we look for ways that it could spread, maybe by conducting a surveillance investigation.”
“If they are not related, then we look for something else,” he continued. “Was there new antibiotic use? Did nursing practices change? For example, there was an outbreak of Candida krusei on one of the oncology floors. The literature says this would be the result of too much use of fluconazole.
“However, we typed the strains. They were all the same. If the fluconazole was stopped on all the patients, these bacteremias would still be present. It was being passed between a few patients. Our solution was to enhance gowns and gloves worn by the staff on the ward. The infections disappeared within a month and we were not required to change the prophylaxis.
“This demonstrates what a powerful tool laboratory data can be,” he continued. “It reinforces intuitive thinking and doesn’t replace the infection control practitioners, but makes them more effective. It also gives them additional time to intervene, which further enhances the end result.”
Technology used in the special microbiology laboratory is not complex. “We do some PCR, but most of our tests are run using gel electrophoresis,” said Dr. Peterson. “We will take the whole bacterial genome, cut it up into smaller pieces and run it a simple one-dimensional gel electrophoresis process. We end up with 30 to 50 bands.
“The interesting thing is that med techs who do this full time get very good at identifying the organism by its basic footprint,” he continued. “Our cost per test is very modest, particularly with the pay-off in reduced rates of nosocomial infection.”
Success at Northwestern’s team is undisputed. Since Northwestern had good data prior to this project’s start, administration was able to measure improvements in outcomes and the direct cost of the project. The numbers are impressive.
“The baseline nosocomial rate at Northwestern was already half of the national average when we launched this project in 1994-95,” noted Dr. Peterson. “So we started from a tightly-managed position. Nonetheless, during 1998, the hospital infection rate remains now at 5.3per 1,000 patient days. This is about a 23% reduction from our starting rate.
“This also occurred at a time when our patient population was becoming increasingly sick,” he added. “We calculate that some 750 patients were prevented from acquiring infections in the first three years of the enhanced infection control program. This represents 3,000 patient days and cumulative savings of $7.5 million!”
This is a remarkable testimony to the power of laboratory data to improve healthcare outcomes and save significant sums of money. For Northwestern’s administration, adding in-house DNA- typing capability to the microbiology laboratory has been a big winner.
“Our experience might be called revolutionary in one sense,” said Dr. Peterson. “This type of infection control effort, keyed around in-house molecular typing capability, can and should be done by local hospitals.
“This cannot be done by referring tests out to a reference center,” he continued. “Such testing must occur immediately, while the patient is still in the hospital. This is a change in the thinking of most laboratorians from five years ago.
“But during that time, the industry has caught on. There is an increasing number of instruments and kits reaching the market that allow smaller hospital laboratories to do this kind of typing. The result is that both the capability and the economics of bringing this testing in-house support such a decision.”
THE DARK REPORT recommends that laboratory executives and pathologists look at Dr. Peterson’s microbiology effort as an unbeatable way for the laboratory to add value inside the hospital.
At a time of widespread budget cutbacks and pressure to cut costs, here is a blueprint that laboratorians can use to extend its influence and relevance to hospital care and operations.
Pharmacy, Maintenance Join In Infection Control
Momentum built as the infection control team demonstrated its effectiveness. Hospital ID pharmacist Mike Postelnick began active involvement in 1995.
His contribution was to recognize that antibiotics can sometimes actually nurture the growth of many bacteria. Postelnick’s input has caused physicians to reduce antibiotic use in favor of alternate treatments.
When studies by the infection control team indicated that a sink shortage was inhibiting hand-washing, maintenance officials were enlisted in a project to increase the number of sinks throughout the facility. In fact, the infection control team joined in the design phase of a new $580 million building. Staff-only sinks were installed next to the entries to 500 private rooms. Staff will have to walk by a sink to get to the patient.