Dear Partnership (and potential partners),
It has been an exciting time since the last newsletter. The rate of hospitals officially joining PPP and qualifying for the two years of free Purell for use throughout their facilities has increased dramatically. The frequency of our being notified that you have already implemented the initial phases of active surveillance programs with plans to soon complete the program has also increased. Thanks and congratulations to all of you!
PPP in the News
PPP and the importance of having a program of active surveillance cultures that identifies the reservoir for spread throughout the health system was featured in the August 2001 issue of ICP Report. Check it out. Dr. Farr was quoted as saying that facilities that choose, as an institutional decision, to not have such a program will not be using CDC recommended contact precautions for 95% of the reservoir for spread of VRE. He said that putting the 5% that happen to be detected by routine clinical cultures into isolation represents a meaningless infection control effort. He added "that getting uptight about individual HCW's compliance" with hand hygiene and/or isolation precautions in such facilities is "the infection control equivalent of rearranging the deck chairs on the Titanic." In other words the infection control program needs to be helping the hospital administration steer the boat. If they have abdicated this responsibility, then they shouldn't expect individual clinicians to bail them out when the boat sinks.
PPP, or at least the concept underlying PPP, may soon be aired on NPR. The reporter, like the NBC News correspondent Robert Bazell, seemed to grasp why this makes sense and said she couldn't understand why hospitals weren't already doing something like this. To date, PPP has contacted no news organizations. They have contacted us.
At some point PPP will likely attempt to go around refusenik hospitals straight to the public through the media. Jefferson said that newspapers were more important than government because an informed citizenry was important for having sound policies. If hospitals won't choose to protect patients from the prolonged suffering, higher risk of death, and greater societal costs that come with letting these antibiotic resistant infections spread in an uncontrolled fashion inside the healthcare system, then the public deserves to know this.
Recent Letter from a 600 Bed Hospital Pleased with the Results of PPP Approach
Dear Barry,
Thanks for your inquiry. Your advice was on the money. As of yesterday, we had NO CASES of VRE in our SCU. I am in the process of analyzing our interventions. The results were so dramatic that we may have others jumping on your bandwagon. As I told you, there were some on our IC committee who were ready to abandon isolation for MRSA. I listened to the tape of your lecture at APIC on this subject; your argument is compelling. The results will need to be sustained, but we have seen a steady decline in our VRE since we've instituted a more aggressive program to control it.
Thank you so much for your advice, support, and interest.
Informational PPP Website Set to Go
Some of you have already been collecting infection control information of use to PPP participants from the UVA Infection Control website. There will soon (perhaps later today!) be an easier web address to retrieve information specific to PPP. PPP.everything had already been taken as web addresses, but our principal corporate sponsor GOJO suggested www.PPPsite.org, which will become the site's name. All of the materials for initial installation have been prepared. The web address has been purchased and becomes effective later today. We hope to have it loaded and ready for use later today (God willing and the [cyber] creek don't rise). Of note, the slides usually used in PPP presentations will be included on that address and can be downloaded for your personal use. A total of about 70 will be part of the initial installation. Some have asked if Dr. Farr's 2001 APIC presentation on this topic can be put on the website for use with the slides. We are not sure if this can be easily done, but APIC may still have the audio tapes. The title of the one hour talk was "The Value and Challenge of Isolation for Controlling MRSA and VRE Infections." Dr Farr has been asked to return to APIC 2002 to address the same topic.
Lancet Infectious Diseases Article on Controlling MRSA and VRE
Drs Farr, Salgado, Karchmer and Sherertz authored an article in the first issue of Lancet Infectious Diseases entitled "Can Antibiotic Resistant Nosocomial Infections Be Controlled?" Lancet has been asked for permission to put this article on the PPP website. If they agree you will be able to see it there. If not, it is available in the August 2001 issue of the journal and will soon be available with a larger set of references than would fit into the printed form on the Lancet website, http://infection.thelancet.com/.
Second Survey of Virginia and North Carolina Hospitals Regarding Control of MRSA and VRE
This survey was mailed on July 5th. Thanks to those who have already responded and to those who have been working on completing it. We understand that this is somewhat longer and more precise than the first one mailed in May 2000. One ICP said that it took her less than a half hour, but others have said it took longer. This probably depends in large part upon how information is stored. We sincerely appreciate your efforts to help us complete a mosaic of information that will better describe what is being done to control this problem throughout the two states. If you have questions/ problems with completion of the survey, please contact Cassy Salgado at phone # 434-924-2490, FAX 434-924-1225, or e-mail at CDS9Z@virginia.edu.
Letter That Helped Convince A Hospital to Join PPP
Many hospitals have gone through the PPP documents and have their ICC vote to join only to have the CEO then say something like the following: "Sure it's better for patient safety, but is it cheaper?" When one hospital notified PPP of this quandary recently, the following letter was sent which convinced the CEO that this is not only safer but cheaper over the long term. The hospital joined.
Thanks for your continuing work! Your answer about cost is correct. First they need to understand that there are significantly higher costs due to antibiotic resistant infections (not to mention prolonged suffering and significantly higher mortality) and there are other costs for preventing these infections. At present most healthcare facilities are experiencing continually rising costs due to infections with MRSA and VRE, which cost significantly more than infections due to antibiotic susceptible S. aureus and Enterococcus. Trying to minimize healthcare costs by not trying to prevent spread of these sometimes lethal infections to patients is "pennywise and pound-foolish."
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The University of Virginia has followed CDC guidelines in a responsible and epidemiologically meaningful way (i.e., doing cultures to see who has these pathogens and then preventing spread to others). As a result (as shown in the graph below), patients at UVA had lower rates of bloodstream infections (BSI) with vancomycin resistant Enterococcus (VRE) and methicillin resistant Staphylococcus aureus (MRSA) in 1999 than at other hospitals of comparable size and complexity (two hospitals in the graph below did not have records regarding the number of hospital-acquired MRSA BSIs). (MRSA=black, VRE=gray in the graph) The low rates at UVA (shown at far right in the graph below) would have been even lower if all facilities around us were following this same approach. As you know, a large majority haven't done this.
The higher rates of MRSA and VRE bacteremia at the hospitals of similar size and complexity resulted in excess annual costs of $1 million to $3 million as compared with UVA (this comparison used published studies of the median attributable excess costs due to MRSA and VRE bacteremias as compared with MSSA and VSE bacteremias, respectively). If the excess costs due to infections by these pathogens at other sites like pneumonia and wound infections had been included, the differences would have been still larger.
This approach (i.e., following the CDC guidelines) was recently used in all healthcare facilities (4 hospitals and 28 LTCF) in an entire health district (the Siouxland) in Iowa and almost completely controlled the problem there. The results were featured in the May 10, 2001 issue of the New England Journal of Medicine. The CDC official who organized and directed the Iowa public health initiative has asked that UVA try to encourage all hospitals in Virginia and North Carolina to follow the CDC guidelines. This would yield the same public health benefits for our patients that were achieved in Iowa but might also help to solve this difficult and worthy problem for the nation. The Board of Directors of the Society for Healthcare Epidemiology of America has resolved that success on such a large scale would require implementation of a regulation requiring that this approach be used.
This approach has already been used effectively in Denmark and Holland and now is being used in Belgium to control MRSA. The cost per capita in Denmark from keeping the rate of MRSA low is much lower than the cost per capita in the U.S. of allowing our high rate to keep growing even higher.
In the short term there will obviously be an increase in preventive costs by joining PPP because of the costs of cultures, gowns, gloves, etc. It should be made very clear, however, that current levels of cost in Central Virginia are much higher than they are in a place like Denmark or Holland, where the problem of MRSA has been controlled to a very low level. Once we start controlling the problem and infection rates start falling, our costs of both infections and prevention will go down to a lower level than our current (rising) level of cost for infections. The study by Chaix published in JAMA in the fall of 1999 concluded that doing active surveillance cultures and isolation would be cost effective if the infection rate fell by only 14%. We can obviously reduce the infection rate by much more than 14% (look at the graph comparing infection rates between UVA and other university hospitals in 1999 that weren't using this approach and at the graph showing virtually complete control of MRSA in Denmark). 3M contacted PPP and is now funding a new economic analysis that will go into a lot of mathematical detail, but it is pretty obvious even from from the graphs above that it is cheaper to detect colonized patients, stop spread and prevent the more costly infections.
PS You can also let them know that the frequency of hospitals in both states joining PPP and getting the free alcohol hand gel is going up.
PPS The benefits of the alcohol hand gel (other than being free for two full years) are that it is 1) kinder and gentler to workers' hands than soap and water handwashing making frequent use possible, 2) it is quicker to use than soap and water handwashing (making it more cost effective of clinicians' time), and 3) it removes significantly more problem pathogens (like MRSA and VRE) per unit of time than does soap and water handwashing (making it more effective for preventing spread through contaminated hands). The new hand hygiene guideline about to be published by CDC/SHEA/APIC et al will strongly push facilities to use this type of product.
