"TDR Story Update"

Northwestern Hospital Laboratory Supports Reduced Infection Rate

On-site microbiology molecular typing lab now tracking antibiotic-resistant bacteria

THIS MONTH, ONE OF THE NATION’S most unique and effective nosocomial infection programs completes its seventh year of operation at Northwestern Memorial Hospital in Chicago.

This one-of-a-kind infection control effort is organized around the laboratory—specifically, in-house molecular typing within the microbiology department. Functioning as part of a multi-disciplinary team chartered to cut the rate of hospital infections, on-site molecular typing plays a key role in helping Northwestern achieve a nosocomial infection rate that is 57% below the national average.

Of equal importance, this lab-driven program is generating savings of $2.15 million per year from reduced infections, against annual lab costs of about $400,000! It’s a great demonstration of how hospital-based laboratories can add value that far outweighs the incremental cost of enhanced lab testing services.

Compelling Success Story

Ever on the prowl for examples of management excellence, THE DARK REPORT was first to bring this compelling laboratory success story to the attention of the lab industry (see TDR, February 1, 1999). A presentation at the 1999 EXECUTIVE WAR COLLEGE by Northwestern’s Prevention Epicenter Director Lance R. Peterson, M.D. was followed by extensive coverage in CAP Today. Lab administrators and pathologists were both impressed and excited about the way Dr. Peterson’s team used lab testing to improve a major benchmark of hospital quality while substantially reducing unnecessary costs.

Visit To Northwestern

To update this story, THE DARK REPORT recently visited Northwestern Memorial Hospital for a first-hand look at the infection control department and to learn about other hospitals which were emulating this groundbreaking nosocomial infection control program.

The visit was both encouraging and discouraging. The encouraging news was that, following the original five-year trial of the program, administration at Northwestern authorized this program to continue on a permanent basis. Additional resources have been funded and the micro lab is now also participating in studies with the Center for Disease Control (CDC) to track antibiotic-resistant bacteria.

The discouraging news is that only a couple of other hospitals in the United States use, like Northwestern, on-site molecular typing as part of a multi-disciplinary team effort to control nosocomial infections. According to Dr. Peterson, University of Iowa Medical Center in Ames, Iowa and Evanston Hospital in Evanston, Illinois are using on-site molecular typing to aggressively manage nosocomial infections.

Lab Industry’s Reticence

That short list of active nosocomial infection programs illustrates how reticent the laboratory industry is to proactively study the “best practices” of other labs and import those successful management innovations into their own institutions, particularly in an area as important as nosocomial infections.

“I believe one important factor which stifles innovation within our profession is the existing economic model of healthcare,” observed Dr. Peterson. “Because of the way costs and revenues are assigned, it makes it difficult for innovators to get funding to study their ideas in clinical settings, particularly if the study crosses clinical departments.

“For example, our nosocomial infection control program created additional costs for the laboratory,” he continued. “However, most of the direct expense reductions were realized in pharmacy and nursing. This situation is similar to other healthcare settings. Often it is difficult for one clinical service to ‘volunteer’ to add costs if the economic benefits actually flow into other clinical areas.”

Medical Errors Meeting

However, the current economic model of healthcare is under pressure to change the way it supports innovation. “In June, there was a national meeting in Chicago on the topic of medical errors in infectious disease,” stated Dr. Peterson. “Included among the participants were representatives from the Institute of Medicine (IOM) and General Motors Corporation’s health management team. There was keen interest by business and the IOM to address deficiencies in the existing economic model in healthcare and create more incentives and support for innovation that improves the quality of health services.

“Based on discussions and comments made at this recent meeting, I see signs that big employers intend to encourage more innovation among healthcare providers,” he added. “Now that medical errors have become a high- profile issue, there is greater awareness of barriers within the healthcare system which discourage innovation.”

Performance Measures At Northwestern Hospital

NORTHWESTERN’S INFECTION CONTROL program is organized around a weekly planning meeting that includes representatives from infection control, diagnostic microbiology (molecular epidemiology), pharmacy, and infectious diseases. Here are selected performance measurements:

•National hospital infection rate in 1995: 9.97 per 1,000 patient days.

•Northwestern Hospital infection rate in 1993-1994 (Pre-infection control project): 6.49 per 1,000 patient days.

•Northwestern Hospital infection rate from 1994 to present (During and after infection control project): 5.60 per 1,000 patient days.

•Northwestern calculates that, from 1994-99, the sustained rate reduction to <2.6% yearly suggests that predicted nosocomial infections were prevented in at least 2,600 patients during this time as compared to the average 700-bed U.S. hospital.

•Within Northwestern, the lower incidence of infections reduced inpatient days by 1,100 per year, triggering annual savings of $2.15 million (calculated using an average weighted daily cost per care of $1,907 for FY99).

Data taken from “New Technology for Detecting Multi-drug-Resistant Pathogens in the Clinical Microbiology Laboratory”; Peterson, Lance R. and Noskin, Gary A.; Emerging Infectious Diseases, Vol. 7, No. 2, March-April 2001, pages 306-311. Members of THE DARK INTELLIGENCE GROUP can request a copy of the February 1, 1999 issue of THE DARK REPORT which contains the story about Dr. Peterson and the Northwestern nosocomial infection control program.

Continuous Evolution

Within Northwestern Memorial Hospital, there has been a continuous evolution of the nosocomial infection control program. It was started with the goal of reducing the overall incidence of nosocomial infections by using on-site epidemiologic typing in collaboration with the infection control team.

As originally organized, the team “fingerprinted” bacteria by extracting genomic DNA. Using a gel-based methodology, results are available within 16- 24 hours. “We originally learned that genomic typing could readily separate possible episodes of nosocomial infection into groups of those that were likely, possible, and unlikely due to patient-to-patient transmission,” noted Dr. Peterson. “This allowed us to more quickly determine what type of intervention was likely to control an apparent outbreak.”

With the capability of doing on-site molecular typing, the microbiology lab is participating in other studies to identify and track infection-resistant bacteria. In particular, vancomycin-resistant enterococci (VRE) and methicillin-resistant staphylococci (MRSA) are seen with increasing frequency at referral centers like Northwestern.

In conjunction with the CDC, Northwestern’s Prevention Epicenter is now tracking patients known to have these bugs. The goal is to use molecular typing to learn how strains of the bacteria mutate and change over time. This is done in conjunction with the existing program to track and control infection outbreaks within the hospital. CDC grant money provides funding for this activity.

“It’s been seven years since we began to use to use on-site molecular testing to support Northwestern’s nosocomial infection control program,” stated Dr. Peterson. “Probably the single most important lesson we’ve learned is that reduced rates of infection are sustainable.

“As most healthcare providers know, it is common, once lots of attention is focused on a specific area of clinical service, to see significant improvement. However, as often as not, over time this improvement cannot be sustained. Our ability to sustain, over seven years, a consistently lower level of nosocomial infections is solid evidence that this is a valid approach that can be copied by other hospitals seeking improvement in this area.”

Labs Can Improve Value

The experience of on-site molecular typing at Northwestern Memorial Hospital provides a tangible demonstration of how laboratories can improve the quality/value/cost equation of healthcare.

Its laboratory was willing to innovate. It offered enhanced lab services designed to support specific clinical improvements. The result was a substantial reduction in the number of nosocomial infections. Besides savings that exceeded costs by 5-to-1, literally thousands of patients were spared the experience of an infection. That’s a win for the hospital, lab, physicians, nurses, and patients!

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